Key in Board paper title here

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Key in Board paper title here ...

PCT Board Meeting

     Agenda Item: 14

    Date: 30 July 2008

    From: Director of Commissioning

    and Service Development

    Market Management and Trends Report as at July 2008

Summary Sheet


     Discussion ?

    Information ?

    This report provides high-level information on the Purpose range of providers the PCT commissions. As it

    develops, it is intended to demonstrate how the


    ? Identifies emerging trends

    ? Commissions services from new and existing

    provider organisations

    ? Shapes the structure of supply

    ? Prioritises and redesigns services in the light

    of local need and stakeholder engagement


    ? Explores the impact of new policies and

    technologies on the services the PCT


    This report will not cover performance of providers

    against key targets as this is covered in the PCTs

    overall performance report although benchmarking

    of provider services will be included where this

    relates to emerging trends and the current and

    future supply of services.

    To ensure the organisation is fit for purpose as a Link to Strategic Objectives leading commissioner.

     To build effective working relationships, processes

    and structures

    To develop Service Level Agreements with

    providers that reflect ‘commissioning for quality’

    targets outlined in National Standards, Local Action.

    If you need this document in a different format telephone the PCT on 01275 546683

Board Paper Page 1 of 2


Domain 1 Safety Standard C3 NICE Interventional Link to Standards for Better Procedures Health

    Domain 2 Clinical and Cost Effectiveness Standard C5a NICE technology appraisals Domain 3 Standard C7d Openness, honesty, probity, accountability & effective use of resources

    Financial Implications The PCT is now starting work to revise its capacity

    plan for the next two years. This will provide a

    demand plan which will enable the PCT to then

    source capacity. A budget has been provided for procurement and this will enable the PCT to test the

    market where this is required or judged to be


    The work required to produce a comprehensive Risk Implications market management report on a regular basis

    currently exceeds the resources available within the commissioning and finance team. In the first

    instance, reporting will be limited to readily

    available information and thus this report will not

    provide a comprehensive review of market trends. The PCT is currently exploring opportunities to secure Market Analysis support from independent

    sources in partnership with other PCTs. This report will over time help to identify where Equality Issues access to services may be contributing to health

    inequalities. Indicators to highlight any need to

    stimulate new market entry or prompt

    reconfiguration of services or providers in relation to

    addressing health inequalities will be agreed with

    the Director of Public Health. This is a very

    complex process and it is expected that the

    outcome of the Joint Strategic Needs assessment

    that is nearing completion will inform this. There are no specific legal issues in relation to this Legal Issues report.

    Service issues and changes in the market will be Consultation and consulted on as and when necessary either through Communication specific service redesign projects or implementation

     groups or through discussions at PPI Forums and

    Health Overview and Scrutiny Committee’s. This report is presented to the Board 2 or 3 times Review of Progress per year with specific reports on market testing

     being reported as necessary on individual services. The PEC considers the service specifications for

    redesigned services and approves these prior to Board Paper Page 2 of 12


    offering services to the market. They also receive

    reports on the impact of new clinical policies and

    technologies on the services commissioned by the


    Market management issues are reviewed by the

    Executive Team as necessary at their weekly


    The LDP/PBC Group considers market

    management issues as they arise.

    The author has no interests to declare Declared Interests

    The Board is asked to note this report and comment Recommendations on its content.

    Appendix A Market Segment Analysis Appendices

Prepared by: Jeanette George, Director of Commissioning and Service Development

    Date: 16 July 2008

    Board Paper Page 3 of 12


     Meeting of the Board to be

     held on 30 July 2008

    Market Management Trends Report as at July 2008

    Agenda Item: 14

    1 Purpose

    The purpose of this report is to provide the Board with information on:

    ? The range of providers from which the PCT commissions and any shifts in

    the sectors from which services are provided.

    ? Emerging trends in the demand for services and the capacity available to

    deliver these.

    ? The application of our contestability framework and current and planned

    market testing.

    ? How the PCT shapes the structure of supply and works with other

    commissioners, both practice based and other PCTs, to ensure best value

    delivery of services by our providers, both internal and external to the PCT.

    ? Service redesign priorities in the light of local need and stakeholder

    engagement activities.

    ? New policies and technologies and their impact on the services the PCT


    This report will not cover performance of providers against key targets as this is

    covered in the PCTs overall performance report although benchmarking of

    services will be included where this relates to emerging trends and the current and

    future supply of services.

    2 Understanding the Market

    2.1 Key Market Shifts

    The PCT is committed to allowing patients to be treated and cared for at home or

    as near to their homes as possible wherever this is possible within the resources

    available. We intend to do this through securing improvements to primary and

    community care services and facilities through Practice Based Commissioning,

    the new Primary Care Contracts, utilisation of new Primary Medical Services

    contracts (e.g. APMS and SPMS) and improved facilities, as agreed within

    ‘Shaping our Future’. We also expect to work with third sector partners to improve

    the arrangements we have with these and encourage innovative partnerships with

    this sector. The PCT should expect to see shifts between types of provider as

    services are redesigned to move care closer to patients and as a wider range of

    providers is offered to facilitate choice.

    Board Paper Page 4 of 12


The graphs and tables below show how the PCT has spent its money by sector

    since 2006/2007 compared with the plan for 2008/2009.

    Sector 2007/2008 2008/2009 Proportion of Proportion of

    Actual Plan total actual total planned

    expenditure expenditure ? 2007/2008 % 2008/2009 % Primary Care 60,799,150 64,123,550 23.4 24.9 Secondary Care 144,078,310 132,862,562 55.5 51.7 Tertiary Care Included in 5,562,045 Included in 2.2 (spec services) Secondary Secondary

    Care Care Independent 412,000 0.2 Sector (Shepton


    NHS Mental 16,476,292 16,051,471 6.3 6.2 Health (AWPT)

    Other Mental 5,861,656 4,257,169 1.7 2.3 Health

    NHS 15,179,274 14,537,948 5.8 5.7 Community


    Independent 4,717,068 6,807,976 1.8 2.6 Sector Non-

    Acute (CHC)

    Third Sector 2,678,062 2,647,906 1.0 1.0 Services 9,853,581 9,749,796 3.8 3.8 contracted by

    LA (LD/Free


    Total 259,643,393 257,012,423 100 100 Appendix A shows further analysis of this information.

The reduction in the PCTs investment in general and acute care provided by NHS

    Trusts was signalled in the PCTs operational plan approved by the Board in

    March 2008. This arises from:

    ? The reduced level of non-recurring funding required in 2008/2009

    compared with 2007/2008 to achieve access targets, in particular the

    18 week target

    ? The implementation of resource utilisation management schemes both

    the full year effect of schemes commenced in 2007/2008 and new Board Paper Page 5 of 12

    schemes planned for 2008/2009.


The Board also approved a range of developments which have contributed to

    these shifts in care. These include:

    ? Practice Based Commissioner led shift of anticoagulation services for some

    patients from hospital to primary care

    ? Expansion and development of the Community Matron model to cover the

    whole PCT to enable patients with chronic disease to be cared for closer to


    ? Increased investment in the PCT’s community services such as ICRT,

    Musculoskeletal Services

    ? Development of a Primary Care Mental Health Services

    ? Increased investment in Weston Hospice Trust to support the growth in care

    provided and a pilot to develop end of life care for people with heart failure. Other shifts have come about because of changes to national frameworks or


    ? The new national framework for Continuing Health Care means that the

    PCT will be investing considerably more in this area to meet demand in the

    light of new criteria.

    ? The development of the Choice agenda and the funding regime which

    enables resource to follow the patient.

    The PCT intends to develop a new way of working with the third sector in

    2008/2009. A national development programme is being launched to support

    improvements in the commissioning of services from third sector providers and

    four people from the PCT ; a senior commissioner, a non-executive director, a PPI

    manager and a Public Health professional have agreed to attend this. It is

    expected that this will form the basis of a team through which a commissioning

    plan can be developed to maximise the potential of third sector partnerships and

    develop this market segment.

    3 Emerging Trends

    3.1 Acute Services

    In November 2007’s market management report several capacity gaps were

    identified that would potentially impinge on the PCT’s ability to deliver an 18 week

    maximum wait from referral to treatment (RTT) by March 2008.

    The following list identifies the outcome of the action identified to address these


    ? Audiology The ‘one stop’ approach at Weston Area Health Trust (WAHT)

    and the waiting list initiatives and transfers have helped to bring the waiting

    times down under 6 weeks at the end of April 2008.

    ? Echocardiography The additional capacity undertaken by WAHT has

    ensured that at April 2008 our longest waiters were at 5 weeks.

    ? Endoscopy Additional capacity has been added across all acute trusts

    and there has been a marked improvement since November but we did not

    achieve 100% within the maximum wait time of 6 week for March 2008. All

    Board Paper Page 6 of 12


    acute trusts are having problems at various levels and the PCT has

    requested action plans from each which will be monitored over the coming


    ? Orthopaedics Action to make better use of the PCT’s own

    musculoskeletal (MSK) service and notification to GPs of pressures on

    Trauma and Orthopaedics (T&O) have helped some of the pressures on

    North Bristol Trust (NBT) but the Trust is still some way off the targets for

    delivery of 18 weeks. WAHT are actively looking to market their service and

    are undertaking detailed activity and population profiling work as part of the

    Weston Futures Project to target this capacity shortfall. The PCT will

    continue to inform GPs of all alternative providers to enable North

    Somerset patients to be treated as fast and safe as possible.

    The PCT have joined a BNSSG wide Orthopaedic Service Design Group

    which is looking at tackling some of the delays in the system. A BNSSG

    Orthopaedic Steering Group also meets monthly to assess where we can

    alleviate specific problems. This group, for instance, commissioned work to

    call and offer patients alternative provider appointments to reduce the

    number of patients waiting at NBT.

    Since April 2008, some additional capacity gaps have been identified. These


    ? University Hospitals Bristol (UHB) Diagnostics - UHB have had increased

    pressures on a number of diagnostic areas and have put together an action

    plan that will see the numbers of patients waiting reduced by the end of

    July 08. Neurophysiology remains a problem with a shortage of specialists

    sited as a key factor. The NSPCT is investigating our contractual position

    with UHB and will assess the possibility of commissioning alternative

    providers to provide relevant tests.

    ? Ophthalmology There is increased pressure on UHB ophthalmology

    service with a lack of outpatient appointments which reached 1 in 3 as at 13

    July 2007. The PCT joined a BNSSG Service Design Group in June that

    will look at ways to reduce the pressure on secondary care for specific

    problems like glaucoma. We are also looking to Independent Sector

    Treatment Centre (ISTC) providers as a potential short term solution for

    cataract surgery specifically.

    North Somerset has seen an increase in year on year referrals for outpatient

    appointments across all providers for the first quarter of 2008. This trend has been

    mirrored in our neighbouring PCT’s in South Gloucestershire and Bristol. We have

    instigated some patient level analysis of data and GP and other referrals are up

    year on year and on the last 6 months average. Further analysis of all patient level

    data and analysis of conversion rates will be undertaken to assess future impact

    of this increase.

    3.2 Other Services

    There are a number of emerging market trends that commissioners are

    exploring. These may have in-year effects but are more likely to inform

    commissioning plans for 2009/10 and beyond. Examples include:

    Board Paper Page 7 of 12


    ? Development of a wider range of options and providers for

    Continuing Health Care to respond to market shortages. A recent

    example has been in developing a package that provides additional

    input from community teams in response to difficulty sourcing

    independent domiciliary care due to a lack of providers in Pill/Ham


    ? The sourcing of secondary care from alternative providers where the

    PCT’s quality standards cannot be met.

    ? Changes to the PCT’s contracted services arising from patient

    choice; for example, many more patients are choosing to attend

    Shepton Mallet Treatment Centre than planned.

    4 Contesting Services

    The Board approved the final version of the PCTs Commissioning Strategy in

    March 2008. This included a framework within which the PCT will contest the

    provision of health care services. The PCT will consider contesting services in the

    following situations:

    ? The end of the term of a previously awarded contract

    ? The commissioning of a new service for which there is no existing provider.

    This would include where new models of care are agreed and no single

    provider is able to provide the new model of care within existing contracts

    ? Where there are concerns about the quality, effectiveness, appropriateness

    or value for money of an existing service. This could be evidenced by

    actual performance of an existing provider or be predicted based on a

    range of indicators.

    The decision to contest a service will lie with the PCT but requests to contest

    services are expected to arise from a range of sources including:

    ? Practice Based Commissioners particularly where service quality or the

    mode of delivery is being challenged as a result of service redesign.

    ? Potential future providers wishing to enter the market. This could include

    third sector providers and social enterprise as well as independent sector


    ? Where providers express an intention to leave the market but are unable to

    do so without leaving a gap in health care provision,

    ? In the future, from ‘Community Petitioners’, if the model that has been

    signalled nationally is implemented

    The PCT’s procurement programme currently comprises of the following services:

    ? Procurement of Primary Care Mental Health Services separately reported

    to the Board

    ? Procurement of a new GP Led Health Centre and New GP Practice

    separately reported to the Board

    Board Paper Page 8 of 12


    ? Tendering of the Locality Health Centre contract separately reported to

    the Board

    ? Procurement of Independent Sector Treatment Centre Capacity Phase 2

    The Board was last updated on progress on this national contract last

    August in a closed session of the Board due to the need for commercial

    confidentiality. The procurement is designed to improve choice for patients

    and increase contestability of elective services. This procurement has now

    received Department of Health approval to proceed to financial close and

    this process is currently ongoing. The provider is UK Specialist Hospitals

    Ltd (UKSH). For North Somerset the facility that is most accessible is the

    Emersons Green NHS Treatment Centre. Building work is due to start this

    summer and the unit will open in autumn 2009. Local commissioners are

    now working together to agree priorities for the specific elective procedures

    required (based on a long list contained within the national framework


    The following areas are currently being considered under the Contestability

    Framework to determine whether services should be contested:

    ? Portishead Primary Care Resource Centre - the PCT is currently working

    with the Portishead GP Practice and the Woodspring PBC cluster to finalise

    the services that will be provided from the new Primary Care Resource

    Centre when it opens in Feb/March 2009. Many of the services fall within

    existing contractual arrangements and will simply relocate to the new

    facilities. Some services will be new services or result from redesigned

    pathways, and a procurement strategy will be agreed with the Project


    A forward programme of services that will be contested will be developed in

    coming months.

    5 New and emerging models of care and technologies, clinical guidelines and

    referral protocols NICE Technology Appraisals The PCT is legally obliged to provide funding and resources for medicines and

    treatments recommended by NICE’s Technology Appraisal Guidance. This

    guidance is normally required to be implemented within three months of the

    guidance being published. The PCT is part of the BNSSG NICE College which

    ensures that NICE Technology Appraisals are implemented in line with the

    guidance. Implementation plans are reviewed by a multi-disciplinary review group

    and are approved by the NICE College which reports to a BNSSG wide

    Commissioning Group. The PCT makes provision for the cost of this based on

    estimated costs of forthcoming appraisals. Investment over and above that

    provided for in earlier years is provided for in the PCT’s Financial Plans.

    Technology Appraisals published since the last report to the Board in November

    2007 are:

    TAG Name Date Published Implementation Date

    TA131: Asthma (in Nov 07 Feb 08 Implemented

    children) - corticosteroids

    Board Paper Page 9 of 12


    TAG Name Date Published Implementation Date

    TA132: Hyper Nov 07 Feb 08 Implemented



    TA133: Asthma - Nov 07 Feb 08 Implemented


    TA134: Psoriasis - Jan 08 Apr 08 Implemented


    Feb 08 May 08 Implemented stTA135: Mesothelioma Jan 08 Apr 08 Implemented onset) Pemetrexed Disodium neuro-imaging

    TA136: Atypical TA137: Lymphoma Feb 08 May 08 Implemented psychosis (1(follicular non-Hodgkins)


    TA138: Asthma (in Mar 08 Jun 08 Implemented adults) - Corticosteroids

    TA139: Sleep apnoea Mar 08 Jun 08 Implemented CPAP

    TA140: Infliximab for Apr 08 Jul 08 Implemented subacute manifestations

    of ulcerated colitis

    TA141: Abatacept for Apr 08 Jul 08 Implemented treatment of rheumatoid


    TA142: Anaemia (cancer May 08 Aug 08 treatment-induced)

    Erythropoietin (alpha and

    beta) and Darbopoietin

    TA143: Ankylosing May 08 Aug 08 spondylitis

    Adalimumab, Etanercept

    and Infliximab

    5.2 NICE Clinical Guidelines

    Clinical guidelines are recommendations by NICE on the appropriate treatment

    and care of people with specific diseases and conditions. They are based on the

    best available evidence and aim to improve the quality of healthcare. The NHS is

    expected to follow NICE Clinical Guidelines but there are times when the

    recommendations are not suitable for someone because of their specific medical

    condition, general health, wishes or a combination of these. Providers are

    expected to show progress towards implementing these guidelines if they are not

    immediately able to adopt them due to availability of resources or skills. The PCT

    Board Paper Page 10 of 12


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