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Insight: Getting it right

Insight: Getting it right
4 June 2014



Systemising commissioning processes and utilising Right Care data has enabled two CCGs in Sefton to deliver improvements
Sefton is a borough just north of Liverpool and includes the towns of Southport in the north of the borough, Formby in the middle and Bootle in the south. It has two clinical commissioning groups (CCGs) – South Sefton, and Southport and Formby. The CCGs have a joint management team and are coterminous with Sefton Metropolitan Borough Council.
Sefton CCGs commission services for a population of 280,000 patients across 56 GP practices. (Southport and Formby CCG serves 121,000 patients and 20 GP practices, while South Sefton CCG serves 159,360 patients in 34 GP practices). 
In the summer of 2012 the CCGs started to work with Professor Matthew Cripps to explore systemising its commissioning processes. This involved two strands – firstly to develop robust systems and processes to commission services, and secondly to look at what the evidence was telling us.
Staff within the CCGs had a strong background of research, evidence-based healthcare and improvement methodology, so the concept of using evidence-based healthcare was not new to them. They were required, as part of the CCG authorisation, to establish a Programme Mangement Office (PMO). This sat well with the work we had started with Professor Cripps.
In November 2012, the two governing bodies approved the establisment of a PMO along with this approval came the authorisation to appoint a Transformational Change Manager. Between December 2012 and April 2013 we developed and tested our documentation – this included a business case proforma, a decision aid and refining our timetablining.
While the development of the business case proforma was fairly straightforward, we encountered more problems with our decision aid. This was mainly due to testing it’s sensitivity to the business cases that the PMO were likely to receive and was compounded by how few business cases were being submitted in the first few months.
Role of the PMO 
We wanted to ensure that the PMO was facilitative, so staff did not see any notable changes from the 1 April 2013, however we insisted that any bids for funding were submitted on the business case proforma. This took a few months to embed as the PMO and staff got used to the process and documentation. 
An example of where business cases were being submitted for approval was for the implementation of National Institute for Health and Care Excellence (NICE) approved drugs. While it is important to record that implementation has been approved, it wasn’t strictly necessary for the PMO to have a record and the PMO wouldn’t be tracking implementation. As a result it was agreed that these would not go through the case for change process, which also applied to procurements.
The PMO functions as a resource centre; supporting staff to develop commissioning intentions/cases for change and CCG planning documents. For cases for change this will typically involve supporting managers working through the case for change documentation, and work with patient and carer groups to seek their views. Supporting managers through this process enables smooth passage through the finances and resources committees. 
The PMO also supports managers in the preparation of the commissioning intentions ensuring that they are evidence based (using national data sources such as Right Care, Programme Budgeting, NICE guidance and other evidence sources) and fit with strategic objectives and planning documents. 
In addition to supporting managers develop cases for change and planning documents, the PMO tracks and monitors business cases, commissioning intentions and planning documents, and reports progress to the finance and resource committees. 
Commissioning for value (right care)
The other piece of work that we undertook with Professor Cripps was to look at where each CCG was an ‘outlier’ in terms of the outcomes it was achieving compared to other CCGs, and to understand why and what we could do about it. 
NHS Right Care and the Atlas of Variation were the first data sets that we looked at. Once we had identified the areas where we were outliers, we then started to look at other data sources such as Programme Budgeting, the Spend and Outcomes Tool (SPOT), different Health Profiles (eg. alcohol and mental health) and Advancing Quality Alliance (AQuA). We were then able to summarise the findings into a couple of pages for each CCG (there were some small differences within the disease headings). Table 1 shows the main disease headings where the CCGs were outliers. 
The next stage of the process was to share our findings with CCG Governing Body Members and managers; this was done at CCG Board Development Sessions, where the process was outlined and the outcomes presented to the GPs. A detailed discussion took place on each of the disease areas. Subsequent to the Board Development Sessions, the information was shared with at the CCG wider forum, where again the process and outcomes were presented to the membership.
As a result of these sessions the CCGs’ commissioning intentions have been developed and all of the above disease areas have been included for this year (2014/15). This is an improvement on the previous year; in 2013/14 South Sefton had 52 Commissioning Intentions and Southport & Formby had 47. For 2014/15 Southport and Formby have eight new commissioning intentions and are continuing with seven for 2013/14. In South Sefton there are now five main commissioning intentions.
The reduction in the number of commissioning intentions is significant, as while we were able to track and report on delivery through the PMO for 2013/14, there were so many for each CCG that it was difficult to intervene where commissioning intentions were not delivering as planned, as managers were likely to be responsible for nine or 10 commissioning intentions each. The advantages of having a smaller number of commissioning intentions is obvious, but perhaps more importantly the PMO can now not only report on the implementation of commissioning intentions but it can also support managers and let them know that they are doing a good job.
The future
Throughout 2014/15 the PMO will be able to be much more proactive in supporting managers implement their commissioning intentions and act as a resource for evidence and implementation tools. 
We are in the process of developing improvement methodology to drive implementation in South Sefton and we are fortunate that the consultant in community geriatric medicine who will lead some of this work was a health foundation quality improvement fellow for 2011/12.
While we shared our work around Right Care with the CCG members, what we were unable to do, mainly down to time constraints, is to have an in-depth discussion with all clinicians to understand why the CCGs are outliers. We plan to have this conversation with with CCG members in Autumn 2014 and get further answers.
Malcolm Cunningham is head of primary care and corporate performance at South Sefton, and Southport and Formby CCGs.

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