Paying for health gains

Paying for health gains
Centre for Health Economics research paper 183, 7 July 2021

• Payments to healthcare providers are often based on the number of patients they treat according to their particular health condition with well-known limitations. Payment based on health outcomes, a form of pay-for-performance, has long been advocated as a possible solution. 
• This study adopts a contract theory approach and illustrates how it can inform practical implementation of pay-for-performance schemes that reward health outcomes. The study develops a model that rewards providers for improved health using patient reported outcome measures from hip and knee replacement procedures.

Implementation Outcome Repository

Implementation Outcome Repository 

• A free online resource for implementation stakeholders, including researchers and healthcare professionals, wishing to quantitatively measure implementation outcomes. 
• Developed by researchers in the Centre for Implementation Science at King’s College London, King's Improvement Science and the Behavioural and Implementation Science research group at the University of East Anglia.

The effects of structure, process and outcome incentives on primary care referrals to a national prevention programme.

The effects of structure, process and outcome incentives on primary care referrals to a national prevention programme.
Health Econ. 2021 Jun;30(6):1393-1416. doi: 10.1002/hec.4262. Epub 2021 Mar 30. PMID: 33786914.

• A survey of local commissioners about their use of financial incentives linked to numbers of programme referrals and attendances from 5170 general practices in England between April 2016 and March 2018 found that financial incentives were offered by commissioners in the majority of areas (89%), with 38% using structure incentives, 69% using process incentives and 22% using outcome incentives. Outcome incentives were the only form of pay-for-performance to stimulate more participation in this national disease prevention programme.

Commissioning out of hospital care services to reduce delays

Commissioning out of hospital care services to reduce delays
IPC March 2020

• This paper offers a structured approach to understanding demand, supply and impact of our out of hospital care systems through a data collection template and proposition for a ‘model’ for describing the service elements which make up ‘intermediate care services’. It looks in detail at the services that are most likely needed in order to build an effective set of intermediate care services and the quantity of that service that may vary from place to place. It introduces an approach to outcome based commissioning.

A guide to commissioning outcomes for young people

A guide to commissioning outcomes for young people
National Youth Agency October 2019

• This guide provides information for local authority commissioners on how to involve young people throughout the commissioning process, and commission effectively for outcomes. This includes involving young people in analysing what young people need, defining outcomes, delivering and evaluating services. 
• The guide also demonstrates how youth work and youth workers could be commissioned to deliver outcomes. It provides five examples of commissioning challenges that local authorities are working on for young people. Each challenge is accompanied by a corresponding description of how youth work can be used to deliver the intended outcome. 
• The examples cover supporting young people in family breakdown, improve placement stability of looked after young people, preventing child sexual exploitation, improving emotional wellbeing, and improving educational inclusion for young people with Special Educational Needs and Disabilities (SEND). The guide also highlights an outcomes framework for young people to help local authorities looking to commission outcomes through a youth service. (Edited publisher abstract)

Integrated Commissioning for Better Outcomes: a commissioning framework 2018

Integrated Commissioning for Better Outcomes: a commissioning framework 2018
LGA NHS Clinical Commissioners 11 April 2018

• A practical tool for council and NHS commissioners to support improving outcomes through integrated commissioning.
• The framework covers four areas: building the foundations; taking a person-centred, place-based and outcomes-focused approach; shaping provision to support people, places and populations; and continuously raising the ambition; and includes annexes giving further resources plus background on NHS and local authority contexts.
• Annex B: Guidance and tools for market shaping
• Annex D: Person-centred, place-based and outcomes focussed
• Annex E: Health and local government working together: the evolving policy landscape

The following principles for the framework have been agreed: 

• A focus on the benefits for the ‘3 Ps’: people, places, and populations, with the individual person at the heart of the approach. 

• A focus on outcomes over ‘episodes of care’. 

• Recognition that integrated commissioning needs to happen at multiple levels: with individuals and their families and carers; with communities; and across larger populations. 

• Awareness and acknowledgment that commissioning is about more than procuring services, it is about a wide variety of activities which improve the outcomes and the lives for people, places and populations. 

• Awareness that language matters and that words and concepts can have multiple meanings. 

• A belief that understanding and respecting our differences (of history, culture, legal responsibilities, and ways of working) enables us to work better together.

Delivering an Outcomes-based NHS: Creating the Right Conditions

Delivering an Outcomes-based NHS: Creating the Right Conditions
OHE Seminar Briefing, 2 March 2017

• Summary of a seminar given by Dr Nicholas Hicks, COBIC (Capitated Outcomes-Based Incentivised Care).
• The COBIC approach involves six elements: (1) defined population and scope, (2) desired outcomes associated with indicators, (3) service model redesign, (4) financial analysis and defined budget, (5) agreed contract form and duration, describing incentives and risks, and (6) readied and prepared service providers.
• Includes discussion of the Bedfordshire Musculoskeletal (MSK) project, where COBIC worked with Bedfordshire CCG to improve MSK care and outcomes, and to decrease per capita costs.

Outcomes-focused integrated care

Outcomes-focused integrated care: lessons from experience 

Institute of Public Care January 2017

• An update to work looking at the structural and process requirements for delivering good integrated care. It explores ‘what works’ and what managers embarking on a significant period of change and integration need to consider.

Faulty by design. The state of public-service commissioning

Faulty by design. The state of public-service commissioning
Reform January 2017

• The purpose of this paper is to evaluate the success of current approaches to commissioning by central government, local authorities and commissioning bodies. It uses interviews, a literature review and evaluation of the publicly available data.
• This paper looks at three critical and interdependent areas of commissioning - outcomes based commissioning, fragmentation of commissioning within and across policy areas and the localisation agenda.

Alliance contracting, prime contracting and outcome based contracting. A literature review

Alliance contracting, prime contracting and outcome based contracting: What can the NHS learn from elsewhere? A literature review
PRUComm 25 October 2016

• A summary of the findings of a literature review of the available evidence concerning the characteristics of these new models of contracting, such as alliance contracting, prime provider contracting and outcome based contracting, and their implementation in other sectors. 
• The report outlines the characteristics of each model, discusses contract negotiation and specification using the models and potential governance issues in relation to their implementation in the NHS.

Embedding PROMs and PREMs into Dudley’s MCP contract

Embedding PROMs and PREMs into Dudley’s MCP contract: Findings of a rapid review
ICF International, Midlands & Lancs CSU Strategy Unit, for Dudley CCG, 20 September 2016

• The brief was to:

1. Gather learning from analogous examples of outcomes-based commissioning about how to define and measure person-centred outcomes and experiences, and any issues and challenges associated with this.
2. Define the ‘outcomes’ and ‘experiences’ that are most relevant to the MCP and most valued by service users and the public.
3. Review tools and approaches for capturing person-centred outcomes and experiences, mapping these against the findings from 2. above, to produce recommendations for the MCP contract. 

Review of Cambridgeshire and Peterborough CCG contract with Uniting Care

NHS England Review of Uniting Care Contract: 

NHS England April 2016

• The overall objective of this work is to establish, from a commissioner perspective, the key facts and root causes behind the collapse of the Cambridgeshire and Peterborough CCG contract with Uniting Care Partnership in December 2015 and to advise on next steps.

Outcomes based contracts - implications for primary care

Debate & Analysis: Outcome-based commissioning: has its time come?
British Journal of General Practice, March 2016, e219

• Discussion of the implications for delivery of general practice if some or all primary care budgets were included in new outcome-based contracts.

Outcomes based commissioning of children's early intervention and prevention services

Commissioning for outcomes across children’s services and health and social care 

Social Finance, October 2015

• A summary of discussions with children s and health care commissioners about the challenges they face and the value of outcomes based commissioning, in particular in the context of early intervention and preventative services, and the use of Social Impact Bonds. 

Outcomes-based commissioning in the NHS

Need to nurture: outcomes-based commissioning in the NHS 
Health Foundation, September 2015

• An examination of outcomes-based commissioning - what it means, the evidence to support it, progress to date on introducing the approach in England, and the optimum role of national policy in response to it. 
• Key points
• Policy makers need a long-term plan to nurture outcomes-based commissioning to enable it to support the transformation of health care.
• Outcomes-based commissioning seeks to solve the issue of how financial flows and the commissioning process can best support quality and efficiency improves across the health care system.
• Outcomes-based commissioning shows promise as a means to help transform health care, but evidence to support it is limited and it is proving harder to implement than foreseen. Careful learning and significant support is needed to help it live up to its potential.
• Outcomes-based commissioning needs long-term support from policy makers, including NHS England to support the capability of commissioners, and the future NHS Improvement to help develop providers’ ability to respond, particularly in primary care.
• There needs to be far greater peer-to-peer learning between areas experimenting with the approach. This should include the development of a ‘learning network’ to connect and share knowledge not only from the NHS, but also from areas internationally and other parts of the public sector.
• The experience of commissioners to date has highlighted that an outcomes-based approach requires a different skill set to traditional commissioning. This involves a stronger focus on the strategic elements of commissioning, rather than the tactical, as can be seen in how the ‘commissioning cycle’ changes under outcomes-based commissioning, as shown below.
• 1: Work with population to determine outcomes, and develop data to track outcomes
• 2: Create and develop markets
• 3: Develop a payment approach
• 4: Lead system-wide working to enable procurement

• Includes a table and map showing details of outcomes-based commissioning contracts in England that have already been awarded, or are being planned. 

Different payment approaches to support new care models

Different payment approaches to support new care models
Monitor, NHS England, 16 July 2015

• New payment approaches will be needed to support local health and care economies to make the rapid shift to payment approaches that will underpin new care models. 
• This page brings together documents around
• the background to reforming the NHS payment system, 
• capitation as an example of a potential new payment model to enable integrated care 
• mulilateral gain/loss sharing, a local payment example which enables finances to be reallocated across a local care economy when delivering new care models.
• Improving Access to Psychological Therapies payment
• Outcomes-based payment for mental healthcare
• 3-part payment for urgent and emergency care
• New documents will be added as they become available.

Outcome based commissioning for social care

Emerging practice in outcome-based commissioning for social care: discussion paper
Institute of Public Care, April 2015

• An exploration of lessons learnt from a variety of approaches taken by councils to “outcome-based commissioning” in adult social care and how councils might incentivise the behaviours for providers so that the services that are offered do more to help people maximise their opportunities for more independent living. 
• The paper has drawn on the experience of the author and discussions with providers, commissioners and customers receiving services.

Myths around outcomes in health

Tackling the myths about outcomes in health

Outcomes Based Healthcare, 2014

• A series of essays to ‘bust’ some of the common myths about outcomes in health
• Outcomes are too difficult to define
• Outcomes are too difficult to measure
• Outcomes are too difficult to contract for
• There are too many cultural barriers
• Includes an Outcomes Measurement Process Map and bibliography.

Outcomes-based Commissioning - NHS Right Care reading list

Outcomes-based commissioning - A Reading List
NHS Right Care, December 2014

• This essential reading list includes 34 documents published 2000-2014, and highlights how people are facing up to the challenge of commissioning for outcomes.

What is good commissioning? a route map for LAs

Commissioning for better outcomes: a route map
Health Services Management Centre for the LGA, 3 November 2014

• A series of standards which describe commissioning, designed to be used by Local Authorities to engage with their commissioning partners in a dialogue about the quality of local commissioning.
• The standards will be used to critically examine the quality of their commissioning practice and then as a framework for the peer challenge process. 
• A peer review methodology will be published in 2015 - see http://www.local.gov.uk/peer-challenge 
• The twelve standards set out ambitions for what good commissioning is:

1. Person-centred and focuses on outcomes 
2. Promotes health and wellbeing for all
3. Delivers social value 
4. Coproduced with people, their carers and their communities 
5. Promotes positive engagement with providers -
6. Promotes equality 
7. Well led by Local Authorities 
8. Demonstrates a whole system approach
9. Uses evidence about what works
10. Ensures diversity, sustainability and quality of the market -
11. Provides value for money 
12. Develops the commissioning and provider workforce