Information for public & partners

Transcription

1 Information for public & partners what is it? This introduction to World Class Commissioning (WCC) gives an insight into Shropshire County PCT s work as part of this ongoing national programme for all Primary Care Trusts. It will provide you with information about the programme, how the PCT is approaching it and our first year results. The results report is available separately on our web site Commissioning is the process through which Primary Care Trusts (PCTs) assess local health needs, identify the services required to best meet those needs, and then buy those services from potential providers World class commissioning (WCC) is a new, ground-breaking approach to this task. It takes best practice from this country, and from health systems around the world to help PCTs commission services in the most effective way WCC will help PCTs ensure delivery of better services which are more closely matched to local needs. It will result in better quality of care, improved health and well-being and a reduction in health inequalities across the community Working with partners is crucial to achieving these aims, and many organisations have already worked with us on our WCC plans to date. WCC is the first programme of its type in the world, and is on-going. This short introduction to WCC will briefly explain the approach being taken to improve the health of Shropshire people over the next five years and how we plan to continue working with partners to achieve that. There is a national assurance process for assessing each PCT s progress on WCC. Shropshire County PCT, like all other PCTs in England, is being evaluated against competencies which reflect national and international excellence in commissioning and cover a broad range of requirements. Several of the WCC competencies that the PCT is expected to meet are explicitly related to partnership working. These are: Competency two: work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities, and Competency five: manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements. For the PCT to meet all WCC competencies at a high level, successful partnerships need to be at the heart of all our work.

2 adding life to years and years to life As part of WCC we have reviewed our existing Vision for services in the light of latest information about local population health needs, and have focused our more detailed plans to implement that vision. The PCT s Vision, developed with input from public and staff in 2007, sets out what we want to achieve over the next few years, and identifies the six priority areas of: Tackling health inequalities Promoting mental health and well-being Vibrant community hospitals Supporting healthy lifestyle choices Delivering care closer to home Modern hospital care. We have developed a Strategic Plan covering the period to 2013, setting out how we are going to do this. All PCTs are required to produce such a plan as part of the WCC process, showing how we will improve both life expectancy and quality of life for the people we serve. Our Plan (available on our web site) includes all the local Developing Health and Healthcare Strategy work which is currently taking place, including the new models of care developed for the eight care pathways. from our vision to the strategic plan Assess population needs Identify health outcomes Establish phased initiatives Strategic Plan Worldclasscommissioning 10 year Vision >>> More detailed plans and outcomes >>> 5 year plan so, how healthy is shropshire? Information about the population and its health has been taken from the Joint Strategic Needs Assessment (JSNA), a document produced in partnership with Shropshire County Council. Shropshire people are generally slightly healthier and live slightly longer on average than the rest of the UK population but that generalisation hides a number of important Shropshire-specific health factors that the Plan has taken into account, including: Our Population Shropshire is one of the most sparsely populated counties in England, with a small number of people per square mile and more than a third living in rural places. The county is relatively well-off, but has pockets of significant deprivation, especially in Shrewsbury. We have a higher concentration of older people than most UK counties, and the proportion of older people in the population is set to increase significantly over the next ten years as people live longer and because Shropshire is a popular retirement area. All this makes it important to ensure people have access to a range of services close to home, with special emphasis on services for older people. Main Causes of Death Heart disease, stroke and cancer are still amongst the most significant causes of death, but are gradually reducing. Deaths from illnesses related to obesity and alcohol consumption are increasing.

3 Some key facts: Certain long term conditions are more common in Shropshire than the national average including high blood pressure, coronary heart disease, stroke and asthma Life expectancy is generally good apart from for men in the most deprived areas, whose life expectancy is now four years less than for men in the least deprived areas (for women the gap is only one year). Obesity and smoking rates are higher in deprived areas Smoking remains a major cause of illness and death and alcohol-related harm is increasing fast Alcohol-consumption is higher than average amongst young people, and so is the rate of obesity in reception class children. the world class commissioning challenge This picture of Shropshire health reinforces the need for the priorities in our Vision. Our new WCC Strategic Plan now identifies specific strategic goals which will address these particular health needs. We are then required to identify particular health outcomes, which can be measured. Our performance will be measured regularly on these. It is important to stress that these will not be our only areas of work over the next few years, but rather they will be a way of sampling our progress on some key topics. We have worked with partner organisations, including the County Council, to choose these outcomes from a national list. We ve also included our own local outcome the percentage of obese children in reception classes. The link between our strategic goals and the outcomes which we have proposed to be measured on is shown below (these may be subject to further minor changes): Strategic Goals Reduce health inequalities for men in deprived areas Improve healthy lifestyle choices in older people and improve the management of long term conditions Improve healthy lifestyle choices in children and young people re obesity and alcohol. Develop infrastructure and systems to support better access to local services Develop a sustainable and vibrant health care system in Shropshire WCC assurance outcomes Health inequalities (mandatory) Life expectancy (mandatory) Life expectancy for men Rate of smoking quitters % of coronary heart disease patients with controlled blood pressure Dementia outcome % of obese children in reception class (local outcome) Reduce the rate of hospital admission for alcohol-related harm Increase the % of people able to die at home Increase the % of stroke admissions receiving brain scan within 24 hours Our plans include specific projects and services to help achieve these outcomes over the next five years. They are described more in our Strategic Plan which is available on our website at (under publications).

4 World Class Commissioning year one results Following a significant amount of work during 2008, Shropshire County PCT has recently received formal feedback on our progress against the standards set in the WCC framework. That report is published on our web site alongside this briefing. Every PCT s progress on WCC is assessed through an annual assurance process. Because this is the first year of an ambitious and ongoing programme, no PCT is expected to score highly in this first year. The importance of the process, however, is to identify clearly the steps needed for each PCT to become world class at commissioning. Our assurance report highlights strengths in our approach to commissioning including strong partnerships with other organisations, an especially strong plan for developing the PCT as an effective organisation and progress on involving clinicians in our work (an area which the report recommends we develop more). It also provides insight and guidance into areas such as the need to develop our strategic plans to achieve more in preventing ill health, developing the ability of our community hospitals to improve health in local communities, promoting engagement of clinicians in our work and developing our capacity and capability to prioritise and innovate. We shall now be working with these recommendations to drive progress on our five year strategic plan and develop into world class commissioners. The context for these results is important. This is the first year of an ongoing programme in which all PCTs are developing their effectiveness as commissioners. The insights and guidance in the report help to set the path ahead for us, which will be challenging but can help deliver real benefits for our local population. Our results can be found on the Trust s website at under the news and publications sections. If you have any specific questions about World Class Commissioning or how Shropshire County PCT is working to become a world-class commissioning organisation, then please contact Jo Chambers, Chief Executive or Paul Tulley, Director of Strategic Planning and Commissioning on

5 Panel Report Shropshire County PCT 9 December 2008 Final Report

6 Overview The panel thanks the Board of Shropshire PCT for participating in this round of assessments for the World Class Commissioning assurance framework. We ask the PCT to accept this report in the spirit in which it is intended; a support tool on the journey to World Class Commissioning and as a considered perception of the organisation s strengths and weaknesses based on the insights the PCT gave the panel into its commissioning approach. The overall impression the panel developed during the process is that the PCT has good potential for improvement. The panel feels that the results from the competencies self-assessments largely match the panel s perceptions during the assurance process. We ask the PCT to consider four main recommendations as it positions itself to drive the transformation of health and health care in Shropshire. Adding life to years and years to life 2

7 Commentary (1/3) The panel fed back to the PCT on a number of positive areas identified through the process; partnerships, the open and cohesive attitude of the Board, the progress being made on clinical engagement and leadership, a good OD plan and a talented group of executive and non executive directors. The panel identified four main recommendations for early consideration by the PCT: 1. Strategy Observations: The panel acknowledges the strategic plan as a work in progress. The panel considered the strategic plan to be under ambitious in relation to upstream interventions and long term conditions management. The scale of upstream investment appears insufficient and disinvestment requirements are not explicitly laid out. There is good alignment of initiatives with the Darzi process but the impact of initiatives on health outcomes and inequality is unclear. Some but not all of the initiatives include the investment required. Recommendations: Develop the strategic plan to be clearer about the scale of upstream intervention necessary to achieve health outcomes and a sustainable financial position. Build on the good work carried out as part of the Darzi review process and be clearer about how community hospitals will support delivery of your key outcomes rather than being a priority in themselves. Up-scale the LTC management programmes and maximise the role of high quality primary care. Use medium-term outcome metrics to demonstrate and support delivery. Adding life to years and years to life 3

8 Commentary (2/3) 2. Finance Observations: Investment priorities must be clear even if this means identifying where investment will not be made. Finances underpinning the strategy are very tight and based on optimistic assumptions. Recommendations: Develop a more comprehensive 5 year plan based on the Wanless model to be clearer about the potential funding gap. Model the potential solutions, upstream interventions, changes in investment and productivity improvement required to close the gap. 3. Clinical Engagement Observations: You are now in a strong position to build clinical engagement based on the structures put in place to lead the Darzi work. There is a need for better alignment and engagement of PBC. Recommendations: We recommend that the PCT continues to develop and promote its shared leadership model of clinical engagement Adding life to years and years to life 4

9 Commentary (3/3) 4. Board Development Observations: The organisational development plan is very good The Board clearly accepts the leadership / engagement responsibility You are well placed to develop a membership model of community engagement should you choose to do so. Recommendations: Focus on the prioritisation of investment and the innovation and improvement competencies which will be key to meeting your financial challenges. Whatever model of public engagement you decide on there is a need for a subtle shift away from the provision of community hospitals as a priority towards a more granular focus on the communities they serve. Continue to build on your work to develop the capability and capacity of the organisation. Adding life to years and years to life 5

10 Local National Current Previous Upper Quartile SHROPSHIRE COUNTY PCT HEALTH OUTCOMES AND QUALITY COMPETENCIES GOVERNANCE Outcomes Selection Date: Sep-Oct National Median 100 th percentile Level 4 Strategic Priority Worst Value Best Value PCT Rate of Change Time period Level 1 1. Life expectancy 2. Health Inequalities M 73 F 87 M 0.5% CY 2004/06 F 1.0% 48 8 NA CY 2007 Local leader of NHS Collaborates with partners Strategy A 3. Life expectancy: Males % CY 2004/06 Patient and public engagement 4. Smoking quitters % FY 2007/08 Clinical leadership Finance 5. Uptake of influenza vaccinations by over 65s % FY 2007/08 Assess needs A 6. Percentage of stroke admissions given a brain scan within 24 hours % CY 2006 Prioritisation 7. Rate of hospital admissions per 100,000 for alcohol related harm % FY 2006/07 Stimulates provision 8. CHD controlled blood pressure 9. Percentage of all deaths that occur at home 10. Prevalence of obesity in primary school age children in reception Potential for improvement Local 0.1% FY 2007/ % CY 2006 NA Innovation Procurement and contracting Performance management The panel considers that the PCT has good potential for improvement over the next 12 months. The PCT has clearly embraced the challenges presented by world class commissioning and has produced a very good organisational development plan. A new management team is in place and, together with strong board leadership, this gives us confidence that the pace of organisational development will accelerate over the next 12 months. Board A Adding life to years and years to life 6

11 Local Local National National SHROPSHIRE COUNTY PCT HEALTH OUTCOMES AND QUALITY Outcomes Selection Date: Sep-Oct 2008 Outcomes National Average 100 th percentile 0 0% National median 100% Worst Best National Rate of Strategic Priority Indicator Value Value PCT Rate of Change Change Time period Previous Current Upper Quartile 1. Life expectancy Life expectancy 2. Health Inequalities Health inequality 3. Life expectancy: Males 4. Smoking quitters Life expectancy at time of birth, Years Multiple deprivation score Life expectancy at time of birth, Years Life expectancy for men Smoking quitters Rate per 100,000 population aged 16 and over 5. Uptake of influenza vaccinations by over Percentage uptake of influenza vaccinations by over 65s 65s CHD controlled BP M F M % M 0.6% 48 8 NA 0.0% CY 2007 CY 2004/ % 0.6% CY 2004/ % 8.4% FY 2007/ % -0.4% FY 2007/08 F Observations: The outcomes were developed through the JSNA, 1.0% F 0.5% collaborative 10-year vision, and a series of engagement exercises. Flu vaccine take up is a relatively short-term metric and not the best capture of your 5-year strategy One of your key strategy areas and largest financial investment is in dementia. CHD controlled BP is a relatively narrow measure of your CHD pathway and your wider LTC strategy 6. Percentage of stroke admissions given a Percentage of stroke admissions given a brain scan brain scan within 24 hours within 24 hours Flu vaccination over 65s 7. Rate of hospital admissions per 100,000 Rate of alcohol-related admissions per 100,000 for alcohol related harm Admissions for alcohol-related harm 8. CHD controlled blood pressure Deaths at home 9. Percentage of all deaths that occur at home 10. Percentage of patients with coronary heart disease, in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less Percentage of all deaths that occur at home Stoke admissions given brain scans in 24 hours Prevalence of obese children in reception Recommendations: % -25.1% CY % 8.4% FY 2006/ % 0.5% FY 2007/ % 3.0% CY % Recommend being ambitious with your metrics to reflect longer term outcomes measures and ensure they align to your strategic priorities. Consider adding a dementia metric to your list of outcomes Recommend choosing an overall metric for your vascular pathway such as CVD or CHD mortality. Consider a local metric for equity in life expectancy rather than an additional male life expectancy outcome. NA Be clear NA how your strategy for community hospitals contributes to your outcomes Adding life to years and years to life 7

12 Overview - Competencies PCT's Self Assessment Panel Assessment Competency Locally lead the NHS Level 2. Work with community partners 3. Engage with public and patients 4. Collaborate with clinicians 5. Manage knowledge and assess needs 6. Prioritise investment Top line introduction: The overview shows the PCT self assessment and panel assessment against the 10 competencies. The panel agreed with 25 of the PCT s 30 self-assessment ratings. The panel acknowledges that in many areas where it has adjusted self-assessment ratings, the PCT has made inroads into achieving the sub-indicators. 7. Stimulate market 8. Promote improvement and innovation 9. Secure procurement skills 10. Manage the local health system Adding life to years and years to life 8

13 Competency 1: Panel assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Are recognised as the local leader of the NHS Reputation as the local leader of the NHS Reputation as a change leader for local organisations Position as the local healthcare employer of choice PCT's Self Assessment Panel Assessment Rationale for scoring 1a Key stakeholders agree that the PCT is the local leader of the NHS (score of 5 out of 6). 25% of the Shropshire population is optimistic about the future of the NHS, which is slightly below the SHA average. 1b Key stakeholders agree that the PCT significantly influences decisions and actions (score of 5 out of 6). Staff satisfaction rates are on par with the SHA and national average. The PCT has a very strong OD plan which is based on 1c staff survey results, includes a gap analysis, and lays out a clear action plan. The PCT uses a chief executive hotline, team briefings, staff surveys, and talent management processes to improve the productivity and satisfaction of staff. Recommendations going forward The PCT should develop a clearer corporate identify as a commissioning organisation. Adding life to years and years to life 9

14 Competency 2: Panel assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Work collaboratively with community partners to commission services that optimise health gains and reduce health inequalities Rationale for scoring Creation of Local Area Agreement based on joint needs Ability to conduct constructive partnerships Reputation as an active and effective partner PCT's Self Assessment Panel Assessment 2a The PCT has contributed to a LAA based on the local needs of its population which is consistent with the health needs identified in the JSNA. The PCT shares targets with the LA for alcohol, childhood obesity, and learning disabilities. The LAA has been split into 4 blocks for delivery, one of which (health) is led by the PCT. 2b Key stakeholders agree that the PCT engages with their organisation to inform and drive strategy (score of 5 out of 6). The PCT and LA have produced a JSNA which is founded upon health needs. There is a Director of Joint Commissioning and a plan to appoint a joint Director of Public Health. 2c Key stakeholders somewhat agree that the PCT is an effective partner in delivering health outcomes (score of 4 out of 6). PBC agreement rate (50%) is on a par with the SHA and national average (49% and 52%, respectively). Delivery of certain milestones has been hindered by issues of engagement with PBC. Recommendations going forward The panel has identified the engagement and alignment of PBC as one of its four main recommendations. Adding life to years and years to life 10 10

15 Competency 3: Panel assessment PCT's Self Assessment Panel Assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Proactively build continuous and meaningful engagement with the public and patients to shape services and improve health Influence on local health opinions and aspirations Public and patient engagement Delivery of patient satisfaction Rationale for scoring 3a Key stakeholders agree that the PCT has proactively shaped the health opinions and aspirations of the local population (score of 5 out of 6). In addition to mass-market campaigns, the PCT has organised health fairs in town centres to improve the awareness of its population. The PCT is also planning expert patient programmes, compacts, and patient health groups. However, the PCT noted social marketing as a future capability need. 3b Public feedback has influenced the PCT s care closer to home, mental health promotion, and self-management programmes. Fewer survey respondents believe the PCT is very engaged with the local population (8%) than the SHA and national average (22% and 25%, respectively). The PCT primarily works with the public through large voluntary organisations. 3c The proportion of survey respondents who are optimistic about the future of the NHS has increased over the last two years (21% to 25%). The PCT gave themselves a Level 1 assessment because their patient feedback analysis is not systematic. Recommendations going forward The PCT has comprehensive plans in place and the panel supports the priority which the PCT is giving this competency in its OD plan. Adding life to years and years to life 11 11

16 Competency 4: Panel assessment PCT's Self Assessment Panel Assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Lead continuous and meaningful engagement of all clinicians to inform strategy and drive quality, service design and resource utilisation Rationale for scoring Clinical engagement Dissemination of information to support clinical decision making Reputation as leader of clinical engagement 4a The PCT is developing clinical engagement through a number of mechanisms; PEC, the clinical leaders forum and practice based commissioning. Roles, responsibilities, and accountability of clinicians are being clarified. The Board noted a need to build confidence in the PBC. The framework is in place for delegation but PBC have chosen not to take budgets to date. 4b Survey feedback regarding the quality, format, and frequency of information shared with the PBC is more negative than the SHA and national average. The PCT utilises data from the CBSA but recognises the need for improvement. 4c Key stakeholders somewhat agree that the PCT proactively engages clinicians to inform and drive strategic planning and service design. The PCT has 21 GPSIs and is working on service redesign through the clinical leaders forum. Recommendations going forward As discussed in the feedback overview, the panel recognises the improvement that the PCT has made in clinical engagement over the last 18 months. However it recommends continuing to strengthen this competency as a matter of priority, in particular alignment with PBC. Adding life to years and years to life 12 12

17 Competency 5: Panel assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Manage knowledge and undertake robust and regular needs assessments that establish a full under-standing of current and future local health needs and requirements Rationale for scoring Analytical skills and insights Understanding of health needs trends Use of health needs benchmarks PCT's Self Assessment Panel Assessment 5a A lot of work has gone into the JSNA which identifies local health needs and gaps in provision. However, it does not forecast future disease prevalence or the associated activity / finance impact. The PCT is considering using a prioritisation framework such as the Dudley model for prioritisation of health needs. 5b The JSNA and the Strategic Plan clearly present the mortality of CHD and cancer by deprivation quartile. The JSNA also includes a clear trend analysis of major diseases over time. The PCT has developed a peer group volunteers to explore the health needs of Eastern European migrant workers and the Chinese population. 5c The JSNA benchmarks disease prevalence against national targets. The Board reviews benchmarking data for its top-six targets, LAA targets, prison metrics, sexual health, and quality issues. Recommendations going forward Urgently recruit a strong Director of Public Health who can give an organisational focus on needs assessment, particularly focused upon future needs. Develop a common methodology for identifying needs, gaps in care, and drivers in performance by locality. Systematically use benchmarking in public health, provider activity (acute, mental health, 3 rd sector) as a method to drive behaviour change and performance improvements. Adding life to years and years to life 13 13

18 Competency 6: Panel assessment PCT's Self Assessment Panel Assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Prioritise investment according to local needs, service requirements and the values of the NHS Predictive modelling skills and insights Prioritisation of investment to improve population s health Incorporation of priorities into strategic investment plan Rationale for scoring 6a The PCT does not currently use scenario planning to support its financial forecasts. The Board recognises the challenge associated with predictive modelling and is establishing the infrastructure required. 6b The PCT currently does not have a prioritisation process for new investment. All initiatives considered for the Strategic Plan were approved by the Board. Meetings to develop and approve the Strategic Plan including the approval of initiatives were attended by members of the LA and the PBC. 6c The Board and Chairman do not consider disinvestment a viable option. Instead, the PCT plans to rely upon efficiency improvements and upstreaming care to maintain financial balance. Recommendations going forward We recommend undertaking the Wanless financial model to better understand the best and worst case financial scenarios facing the PCT. The role of the PCT is to make investment decisions and to understand trade offs between investments and this is a critical competency. We recommend that this be given very high priority as part of the OD plan. Adding life to years and years to life 14 14

19 Competency 7: Panel assessment PCT's Self Assessment Panel Assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Effectively stimulate the market to meet demand and secure required clinical and health and wellbeing outcomes Rationale for scoring Knowledge of current and future provider capacity Alignment of provider capacity with health needs projections Creation of effective choices for patients 7a The PCT has started to assess their market, but has not yet completed the work for the full range of providers. The PCT is also not systematically collecting and utilising patient feedback. 7b As discussed above, the PCT does not yet have the systems necessary to identify gaps in current or future provider capacity. The PCT is currently developing an approach which will inform decisions for increasing / decreasing capacity as deemed appropriate when it feeds through. 7c The number of patients who were offered a choice of hospital on their first appointment (44%) was on par with SHA and national average (44% and 46% respectively). However, the Board recognised a need to develop a set of criteria to focus on quality to facilitate understanding where quality and / or value-for-money are poor. Recommendations going forward The PCT should give priority to developing the capacity to systematically use patient feedback as part of the commissioning process. In order to be clear where best to focus the choice offers, the PCT should prioritise understanding the quality of services where there are no or limited options. The PCT should consider the use of personalised budgets as a tool for involving patients with LTC in creating the choice offer. Adding life to years and years to life 15 15

20 Competency 8: Panel assessment PCT's Self Assessment Panel Assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration Rationale for scoring Identification of improvement opportunities Implementation of improvement initiatives Collection of real time quality and outcome information 8a There are good examples of redesign across a range of services that meet the requirements of level 2. This includes patient involvement. 8b On the panel day, the Board was not able to articulate how metrics have been used to measure the impact of process improvement initiatives. Fewer survey respondents believed the PBC is improving patient care (8%) than the SHA and national average (15% and 18%, respectively). 8c The PCT identified the absence of clear quality and outcome metrics. Recommendations going forward Ensure systematic development and use of benchmarking to identify and prioritise improvement opportunities. Ensure redesigned pathways are subject to robust measurement through identification of a range of metrics and systematic monitoring. Adding life to years and years to life 16 16

21 Competency 9: Panel assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Secure procurement skills that ensure robust and viable contracts Understanding of providers economics Negotiation of contracts around defined variables Creation of robust contracts based on outcomes PCT's Self Assessment Panel Assessment Rationale for scoring 9a The PCT is in the process of developing its procurement strategy and is building their understanding of provider economics. The PCT also does not currently capture patient experience information data for each provider. 9b On the panel day, the Board was not able to articulate the process used to prepare for negotiations or the negotiation variables they employ. As the new directorate is established this will play a key role in the negotiation of contracts going forward. 9c Contracts include a dispute resolution section which details criteria for suspension / termination of the contract. However, the provided contracts do not include outcome metrics above and beyond the national contract. The Board discussed plans for improving this sub-competency going forward. Recommendations going forward The immediate priority within this competency is to establish clear quality and outcome metrics for your contracts in line with the CQUIN programme. Adding life to years and years to life 17 17

22 Competency 10: Panel assessment Competency Measure Level 1 Level 2 Level 3 Level 4 Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvement in quality and outcomes and value for money Use of real time performance information Implementation of regular provider performance discussions Resolution of ongoing contractual issues PCT's Self Assessment Panel Assessment Rationale for scoring The PCT is developing a dedicated contracts team which will be responsible for monitoring performance and ensure targets listed in contracts are realistic and achievable. The provided contracts did not include performance indicators, KPIs, or performance reports. 10a The Clinical Quality Review Meeting is attended by the Medical director and clinical governance leads. It is currently chaired by an Exec Director from Telford and Wrekin PCT. There are regular performance meetings with providers, including specific meetings to ensure action on high risk areas (18 weeks and A&E). Performance is monitored at Board level, including discussion on remedial actions. 10b Contracts indicate intervention procedures but do not include specific remedial actions. The PCT has demonstrated strong resolution of contractual issues in dentistry, 18 weeks, and A&E. This has included identifying alternative capacity and writing to GPs to advice on other providers. 10c Recommendations going forward The PCT should build this competency to enable it to work more systematically and proactively with all of its key providers. Adding life to years and years to life 18 18

23 Governance: Panel assessment on Strategy Panel assessment Assessment A Measure Red Amber Green a Vision and objectives b Initiatives to ensure delivery of strategic objectives c Consistency of financial plan with the strategy d Board challenge and ownership of the strategic plan e Achievement of milestones to date Rationale for scoring a The vision is under-ambitious in relation to upstream interventions. b Disinvestment requirements are not explicitly laid out. The impact of initiatives on health outcomes and inequality lacks clarity. The time needed to impact on health outcomes is unclear. It is uncertain whether or not these initiatives will address the Wanless challenge. Review of the strategy included participation from members of the LA and the PBC. Good alignment of initiatives with the Darzi process. c Link between financial investment on the initiatives and the impact upon health is unclear. Some but not all of the initiatives include the investment required. A significant portion of discretionary expenditure is allocated to the initiatives. d Clear involvement of the Board in the development of the strategy. The Board cannot adequately explain how the strategy addresses the highest priority health needs of the local population. e The PCT has mixed performance and does not have a track record of consistent delivery. Recommendations going forward The Strategic Plan needs to be developed to be clearer about the scale of upstream intervention necessary to achieve both health outcomes and a sustainable financial position. As part of this the PCT should review all baseline expenditure to ensure the best return on investment. There is considerable scope to build on the good work carried out as part of the Darzi review process but a need to be clearer about how community hospitals will support delivery of your key outcomes rather than a priority in themselves. Adding life to years and years to life 19 19

24 Governance: Panel assessment on Finance Panel assessment Assessment A Measure Red Amber Green a Sustainable financial position b Historical financial management c Robustness of planning assumptions Rationale for scoring a Forecast surpluses are only 0.15% of baseline and primarily non-recurrent. Contingencies are also low ( 600k) in 2009/10 but increase to approximately 1% after 2010/11. However, the PCT has not conducted sufficient scenario analyses to ensure they address likely financial challenges. b The PCT has been in a financial break-even position despite an 8m SHA top slice in 2006/07. c Uplift assumptions listed in financial plan for 2009/10 and 2010/11 were unrealistic. The financial plan lacks sufficient granularity in incidence and population growth rates to be credible. Recommendations going forward The PCT needs to develop a more comprehensive 5 year plan based on the Wanless model which will enable it to be clearer about the potential funding gap. Model the potential solutions, upstream interventions, changes in investment and productivity improvement required to close the gap. Adding life to years and years to life 20 20

25 Governance: Panel assessment on Board Panel assessment Assessment A Measure Red Amber Green a Organisation b Risk c Information d Performance e Delegation f Board interaction Rationale for scoring a Board was able to describe the separation between commissioning and provider functions. The Board has embraced what WCC is about and has constructed a strong OD plan. b The PCT has an ALE score of 3. The Board gave a consistent and credible list of risks facing the organisation. c The Board has a monthly, comprehensive performance report which is based upon timely information. d Currently rated red for three critical target measures (18 weeks, GP extended opening, A&E) e The PCT has proposed a framework for delegation to the PBC which has not yet been approved and tested. The responsibilities that are being devolved to the PBC are unclear. The role of the PBC in delivery of the strategic plan is unclear. f The Board has clearly played an active role in the development of the strategy. The Board does not demonstrate a good grasp of the tradeoffs that need to be made in regards to prioritisation. Recommendations going forward Future Board development should focus on developing the skills and behaviours of the Board to make investment decisions and trade offs. As part of the future work on clinical engagement there needs to be a clear alignment and understanding with PBC and their role in delivering the Strategic Plan. Adding life to years and years to life 21 21

26 Potential for Improvement Commentary PCT trajectory Although the PCT has scored at level 1 on 5 of the competencies, the panel considers that it has good potential for improvement over the next 12 months. The PCT has clearly embraced the challenges presented by world class commissioning and has produced a very good organisational development plan. A new management team is in place and, together with strong board leadership, this gives us confidence that the pace of organisational development will accelerate over the next 12 months. Areas for organisational development The PCT is facing a significant financial challenge. If the PCT is to have a long term financial plan which is sustainable it will need to strengthen its capability (at Board and executive level) to prioritise investment. This will require a focus on behaviours as well as the skills and tools necessary to support better investment decision making. There is also a need for a switch in focus away from the challenge of sustainable services and community hospitals towards commissioning to improve health outcomes. The other critical competency which requires development to support sustainability will be driving productivity gains through innovation and improvement. Finally, the delivery of the PCT strategy will be dependent on clinical alignment and engagement of PBC. We recommend that the PCT continues to develop and promote its shared leadership model of clinical engagement. Adding life to years and years to life 22 22