A reference guide for organisations making value …...A reference guide for organisations making...

A reference guide for organisations making value-based decisions for healthcare services

futurefocusedfinance.nhs.uk

In healthcare context, value is the outcomes realised by service users per unit of cost. This means maximising the health and wellbeing impact, care experience, and treatment safety that patients and the public are receiving for the money that they put in to the system. We can use this definition of value to work to a single, common goal and to demonstrate that we get the most value for service users from our decisions.

The aim of our programme is for finance and clinical colleagues to be the joint leaders of putting best value for service users at the heart of the way we do business. We’ve collated a variety of healthcare value tools and resources to support individuals, organisations and local health economies in making effective, value-based decisions.

The Decision Framework contains three main elements (which can be applied iteratively or individually as needed) to improve the effectiveness of decision-making:

The framework can be used for intra- and inter-organisational decision-making by all healthcare system players including commissioners, providers, regulators, public health and other arms-length bodies. The framework is particularly suited for use by Sustainability and Transformation Planning (STP) footprints and Accountable Care Organisations (ACOs), and have been designed to support putting value thinking into practice for all individuals holding responsibility for deciding how resources are used.

Stakeholders are invited to participate in a series of facilitated workshop sessions. A series of templates are collectively populated and agreed in order to set up an effective decision-making process. BPV tools are generic and principles-based, so can be locally adapted for incorporation into existing systems and processes.

The Decision Planning tool supports multi-stakeholder groups in designing and planning a structured decision process that clearly defines the value goal and agrees stakeholder responsibilities up-front

The Value Generation tool builds on decision planning to generate a rationale for the impact of a decision on outcomes and value, and details the evidence supporting the decision rationale or assumptions

The Option Priorities tool allows users to demonstrate that decisions have been prioritised based on maximising outcomes and minimising risk, and not solely on the financial or strategic implications

✓ Evaluate decisions using value and the evidenced outcomes for service users

✓ Make and enact value-based decisions with the agreement of all key players

✓ Make decisions transparent and demonstrate good organisational governance

✓ Reduce waste in terms of the time, effort and resource spent making decisions

✓ Adopt a consistent and comparable approach to evaluating success

✓ Support value-based shared decision-making between finance and clinicians

Familiarise yourself with the framework and tools using this guide and its supporting resources. Then identify a decision in your organisation that can benefit from applying BPV, build a decision team and start inviting stakeholders to local workshops.

Check the Future-Focused Finance members map to find a local BPV Specialist.

Decision Framework bpv.futurefocusedfinance.nhs.uk Best Possible Value

bpv.futurefocusedfinance.nhs.uk

http://www.futurefocusedfinance.nhs.uk/map

Decision Handbook - blank electronic templates [link]

How will the decision be made? How will steps in the process be completed?

How will communication take place?

Helps complex, multi-stakeholder groups to define value objectives and design an effective decision process

What is the problem to be solved? What steps will be taken?

What are the value outcome objectives?

When will each step be decided? When will the decision be completed? When will the decision be performed?

Who will make the decision at each step? Who will play the required decision roles? Who will perform or enact the decision?

Builds on decision planning to model value and assess available evidence for the value outcomes generated

What is the main case for change? What value outcomes will be generated?

What assumptions have been made? What evidence supports value delivery?

Which of the available options generates the most value?

Demonstrates that planned decisions are prioritised based on maximising outcomes and minimising risk

How do value and risk compare? Which options should be prioritised?


http://bpv.futurefocusedfinance.nhs.uk/

This guide has been produced by Future-Focused Finance as part of a series of tools and resources to support individuals, organisations and local health economies in making value-based decisions more effectively.

We performed an initial diagnostic survey of finance and non-finance healthcare sector colleagues to determine what our priorities should be. In response, the development of our resources have been supported by research evidence, best practice, and testing and feedback from our demonstration sites.

This is a reference guidebook to support decision teams in applying the Decision Framework and its supporting tools. It contains example templates, instructions for completion, and suggestions for making the change to value-based decisions.

Symbols appear throughout this guide containing links to freely-available supporting or supplementary resources:

This symbols indicates that a supporting electronic resource is available from the BPV companion website

This symbol indicates that an optional background reading recommendation has been made.

This symbol indicates that another optional supporting tool applying value principles has been recommended for use alongside BPV

A collection of supporting and related documents, links and other resources are available from the BPV companion website, including a collection of databases:


Learning Area webinars, e-learning and CPD recommendations

Value Tools other practical value-based tools and techniques

Case Studies casebooks and completed BPV templates

Data Sources sources of outcome metrics data for analytics

BPV Community online community of BPV practice for networking

Value Library reports and journals about value-based healthcare

Value Networks value-based programmes from our peer networks

http://bpv.futurefocusedfinance.nhs.uk/learn

http://bpv.futurefocusedfinance.nhs.uk/tools

http://bpv.futurefocusedfinance.nhs.uk/cases/

http://bpv.futurefocusedfinance.nhs.uk/data

http://www.futurefocusedfinance.nhs.uk/groups/bpv

http://bpv.futurefocusedfinance.nhs.uk/library

http://bpv.futurefocusedfinance.nhs.uk/networks

Best Possible Value (BPV) is one of six action complementary areas within the UK-wide Future-Focused Finance programme (www.futurefocusedfinance.nhs.uk).

BPV aims to support the delivery of the Five Year Forward View by:

• ensuring that all health and social care system organisations embed effective, value-based decision-making practices; and,

• promoting and facilitating the philosophy of ‘I drive value’ for everyone involved in making decisions about how healthcare resources are used.

We offer a future vision for decision-makers working in healthcare to aspire to:

As the stewards of public resources, all health system leaders have a responsibility to deliver better value on behalf of both service users and taxpayers. It ’s everyone’s duty to pursue maximum value and make shared decisions about balancing the use of limited financial resources with improving health and wellbeing outcomes. This guide indicates a framework and associated tools to support colleagues in delivering and demonstrating this core competency in practice.

This aim is supported by the following objectives:

• Ensure that decision-makers are equipped with skills and knowledge to drive value

• Provide colleagues with evidence-based tools to put value thinking into practice

• Facilitate joint working and shared decisions between clinicians and finance

• Populate a library of best practice for users to refer to when considering value

• Promote finance and clinicians as joint leaders in driving value

‘I drive value’ is one of the 4 Strengths; key attributes the NHS Finance Leadership Council advise finance business partners should develop to play their part in working towards a modern, patient-centred NHS1

The Faculty of Medical Leadership and Management recognises that high levels of team working and medical engagement will result in continuous improvement in the value of care for patients2

Leading Change, Adding Value provides a framework for nursing, midwifery and care staff who play a crucial role in delivering safe, high quality and patient-centred care that realises a best value goal3

Future-Focused Finance’s ‘Close Partnering’ action area provides resources to assist finance, clinical and managerial staff, patients and the public to work together to produce high value services [link]

‘A Culture of Stewardship: The Responsibility of NHS Leaders to Deliver Better Value Healthcare’ by Muir Gray via NHS Confederation and Academy of Medical Royal Colleges [link]

‘I drive value’ means understanding the concept of value in healthcare, being able to evidence value for money, assessing ideas using value principles, and working to increase value. It means ‘I think like a patient and act like a taxpayer’ when at work.


Input into decisions

Focus on value

Combine the best in financial informatics and health economics

Focus on cost

Use financial metrics

Analyse challenges

Leadership role as drivers of robust decision-making based on value

Solve biggest challenges

http://www.futurefocusedfinance.nhs.uk/

http://www.futurefocusedfinance.nhs.uk/close-partnering

http://www.nhsconfed.org/resources/2015/09/a-culture-of-stewardship-the-responsibility-of-nhs-leaders-to-deliver-better-value-healthcare


=

Care outcomes e.g. population health, survival rate, extent of

functional recovery

Experience e.g. comfort, treatment by staff, waiting time,

ease of access +

Safety e.g. diagnostic error,

post-operative complications,

infections

+

Finance e.g. income, revenue

and capital spend, sustainability

Activity e.g. demand, improvement,

innovation

Workforce e.g. capacity, systems

and infrastructure, staffing resources

+ +

The value equation is intended to apply a single, common definition of ‘best possible value’ and provide a common goal for all decision-makers; it acts an anchor point to link discussions in multi-disciplinary teams, and to ensure that all parties are able to unite in identifying the right issues from the start. The value equation is used throughout the decision framework as the basis for effective decision-making, and to compare options in a consistent and measurable manner.

Our philosophy, thinking and linked tools are all driven by the ‘POETIC Vision’4 which provides a set of unifying principles that value-based services may aspire to:

The Five Year Forward View identifies three main areas of unwarranted variation affecting our populations and provides us with a ‘triple aim’ for the future:

✓ Better outcomes for people ✓ Better experiences for people ✓ Better use of resources

We can achieve these aims by pursuing the best possible value on behalf of service users and taxpayers as our single, uniting goal.

Value in healthcare is defined as the health outcomes achieved per unit of cost spent. This is often illustrated with the ‘value equation’, which demonstrates the classical value for money relationship between quality and cost. At BPV, we’ve expanded the value equation to include the key components of quality used in healthcare:

‘What is Value in Health Care?’ by Michael Porter via the New England Journal of Medicine [link]

Maximising value means either improving outcomes delivered without raising costs, lowering resources consumed without compromising outcomes, or - ideally - both.

The Value Library is a repository of reports, articles and journals regarding healthcare value and decisions [link]

PATIENT-CENTRED Services are designed around patient and population need

OUTCOMES-DRIVEN Unifying outcome objectives are clearly defined and agreed

EVIDENCE-BASED Services are designed using best practice to reduce variation

TEAM-ORIENTED Multi-disciplinary teams share value-based decisions

INTEGRATED System-wide primary, secondary and social care integration

COST-AWARE Value for money is realised whilst being clinically governed

http://www.nejm.org/doi/full/10.1056/NEJMp1011024#t=article

http://bpv.futurefocusedfinance.nhs.uk/library


To deliver better value we must have effective decision-making processes and be able to reach agreement about the desired outcomes of decisions. International studies of high-performing organisations show that places that are effective at making decisions have a higher return on investment and have staff that are much more likely to recommend their organisation as a place to work.

The key measures of an effective decision are:

According to our diagnostic survey, the health service as a whole scores fairly typically against industry in terms of quality and yield, but we can be slow to make decisions and often put too much effort into reaching agreement.

Explore the full feedback from the initial diagnostic surveys performed by Future-Focused Finance for the Best Possible Value and Close Partnering action areas [link]

‘Decision Insights’ by Bain & Company is a series of short articles about the various elements of effective decision-making [link]

How often do you choose the right course of action?

How quickly do you make decisions

relative to stakeholder expectations?

How often do you execute decisions as

intended?

Do you put the right amount of effort into

making and executing decisions?

Template Description

WHAT

1 Decision Charter Define the main decision and key outcomes required

2 Decision Steps Break the main decision down into sequential steps

3 Value Measures Agree the value criteria and metrics to monitor

WHO 4 RAPID Roles Assign roles and responsibilities for each Decision Step

HOW 5 Key Actions Summary of issues and actions for each Decision Step

6 6Cs Details and relevant forums for each Key Action

WHEN 7 Decision Timeline Decision process calendar with key milestones

VALUE 8 Value Building Establish a case for change and supporting assertions

9 Evidence Log Assess the available evidence and set targets

OPTIONS

10 Scoring Rationale Establish value scoring mechanisms and tolerances

11 Value Comparison Compare and rank the value generated by options

12 Value Priorities Prioritise the available options using value and risk

The BPV framework has been developed to support health and social care system organisations and economies in making effective, participative decisions; there is a single point of accountability for making a decision and input is taken from those with relevant knowledge and expertise. The Value Equation is applied throughout.

An example of each template for a scenario detailing a collaborative decision about maternity services within a local patch of organisations is provided in this document.

Search the Case Studies library for similar decisions and completed templates that may be replicated or adjusted locally [link]

http://bpv.futurefocusedfinance.nhs.uk/survey

http://bpv.futurefocusedfinance.nhs.uk/insights


Engagement from a balanced set of stakeholders is critical when working through the framework; clinicians should be involved as much as possible.

Other desirable participants include finance business partners, project or programme managers, analysts, colleagues from local networks (including arms-length bodies), and patient and public representatives.

Workshop sessions can be set up by the co-ordinator, lead by the facilitator, and promoted by the champion. Stakeholders with relevant input to the decision are invited to the workshops where they collectively complete templates for the decision. The number and content of workshop sessions may be dependent on the size and nature of the decision and local circumstance. Sessions for 3 hours are suggested:

• Workshop 1: Overview of BPV and first WHAT template • Workshop 2: Complete WHAT and WHO templates • Workshop 3: Complete HOW and WHEN templates

Feedback from our demonstration sites suggests that just the WHAT and WHO sections of the framework are beneficial for small- to medium-sized decisions. Additional time to work through the Value Generation and Option Priorities tools may also be required. The decision team will need to be flexible in how they interpret and apply the framework to suit their organisation (or patch) and particular decision.


The Decision Framework can be applied to any decision type, for example:

Allocation - we need to decide where to prioritise resources for best value Dis/investment - we need to decide how to configure infrastructure for best value Service delivery - we need to decide how to structure services for best value Innovation/risk - we need to decide our innovation and risk appetite for best value

The size, nature and timing of the decision will need to be considered, and if BPV is suitable to help make a more effective decision in each case. For example,

• is there a decision coming up that will benefit from good decision planning?

• has a decision in progress become ‘stuck’ that needs some process clarity?

• has a previous decision gone badly that BPV could be retrospectively applied to, to demonstrate how future decisions might run more smoothly using the framework?

It can be helpful to have individuals from within the organisation(s) acting as:

Champion builds stakeholder commitment and engagement; this could be an executive sponsor (‘top down’) or a Value Maker (‘bottom up’), or both.

Facilitator leads and facilitates workshops to support participants in completing templates, and trains others in the theory and application of BPV.

Co-ordinator runs and administrates the process between meetings and writes up workshop output; this could be a project manager, for example.

The Learning Area contains e-learning modules and explanatory videos to support individuals in understanding the frameworks [link]

Identify and priorities relevant decision stakeholders using the ‘9Cs’ and ’Stakeholder Mapping’ as summarised by Rachel Fleming via the Cumbria Learning and Improvement Collaborative (CLIC) [link]


http://www.futurefocusedfinance.nhs.uk/value-makers

http://bpv.futurefocusedfinance.nhs.uk/learn

http://www.theclic.org.uk/component/phocadownload/category/leadership?download=175


• We found that much of the benefit of the framework can be gained from simply inviting a diverse group of stakeholders (e.g. finance and clinical colleagues) to sit together and discuss the concept of value in their services. The conversation that is generated by BPV can offer fresh perspectives and drive innovative thinking.

• The framework is best suited to decisions being planned and made from scratch; for those decisions which are in ‘midstream’ it is crucial to determine at the outset how much progress has already been made.

• Specific aspects of the framework may require multiple iterations to lock down the final version (for example, agreeing top value criteria and metrics).

• Workshops should ideally be limited to 10 to 12 people to facilitate engagement.

• Make sure everyone’s expectations and understanding of what the framework is and isn’t intended to achieve are managed:

it isn’t a means of structuring analysis or building a business case, and doesn’t replace existing business case or project management models;

it isn’t a guide to negotiating with stakeholders;

it isn’t a methodology to evaluate results after a decision has been made;

It isn’t a means of generating solutions.

Join the online BPV Community to network with other framework users and share good practice and learning [link]


For the specific decision, BPV will result in a set of completed templates. This means that everyone involved is clear about what the decision process will entail. Stakeholders will have signed up to the contents of the templates; good up-front planning will mean that the decision can be driven forward as agreed.

You can use some of the BPV templates in the business case (for example, the Value Measures, RAPID Roles or Value Comparison) to illustrate how the decision has been planned and the value rationale behind the options considered.

Having demonstrated and proved the concept of BPV with a single decision, your organisation or patch may wish to apply the frameworks on a more regular basis to other decisions. The speed and ease with which the frameworks are applied will increase with each iteration as more colleagues become familiar with the approach.

After the decision is complete, you may wish to run a lessons learned session and discuss a change management plan for rollout and sustained framework use.

The best way to learn how to apply the framework is to actually work through a decision in practice with your group. BPV recommends this as a ‘see one, do one, teach one’ approach to wider rollout. Stakeholders who have attended workshops and witnessed the BPV toolkit in action may then themselves become trainers and change agents.

You may wish to offer training sessions to colleagues about BPV, perhaps alongside existing training for other finance and business processes.

The Finance and Clinical Educator (FACE) network from Future-Focused Finance offers support to individuals to demystify NHS finance within their organisations to improve value [link]

‘Constructive comfort: accelerating change in the NHS’ by Claire Allcock, Felicity Dormon, Richard Taunt, Dr Jennifer Dixon via the Health Foundation [link]

‘The Right Tool’ by Seamus Ward via HFMA’s Healthcare Finance is an article exploring feedback, experience and lessons learned from our original demonstration sites [link]


http://www.futurefocusedfinance.nhs.uk/finance-and-clinical-educators

http://www.health.org.uk/node/634

http://bpv.futurefocusedfinance.nhs.uk/articles/the-right-tool

• Establish and agree the key issues under consideration (the ‘known knowns’)

• Establish and agree the main decision (in the form ‘we need to decide…’)

• Establish and agree the key outcomes required (in terms of maximising value)

• What is the situation? This is a set of non-controversial, factual observations about the context / subject that all those involved in the decision agree with;

• What is the complication to this situation? These are challenges, points of contention, areas of change and the ‘so what’ of the situation;

• Use the situation and complication to generate the key decision that the group is trying to make. The group needs to agree the precise decision subject and scope;

• What are the key objectives? These should be considered in the context of maximising value and focusing on the outcomes and impact for service users;

• What constraints need to be addressed in relation to the decision? These set the broad envelope within which the decision needs to be made.

‘Question Fanning’ by idenk may help groups widen or narrow the scale and agree the scope of their main decision [link]


BPV Decision Handbook (pptx) includes electronic versions of blank templates with instructions for use, which stakeholder groups can collectively complete during workshops [link]

• Break down the main decision into logical, sequential steps

• Establish and agree the key milestones in the process (‘we need to decide…’)

• Aim to have no more than 8 sub-decisions;

• Steps should be written in sequential order;

• Steps may have iterative elements;

• Deciding Value Measures is ideally an early decision step;

• Consider using or applying existing organisational business processes such as those used by the your Project Management Office or steps used by previous BPV cases for similar decisions.

http://www.idenk.com/questionfanning/



• Best possible value for service users goal (considered in terms of outcomes, patient experience, safety and cost)

• Service should strive to reach ‘best in class’

• Offer services in good standard facilities

• Avoid critical shortages of service users and staff

• Must be acceptable to all key stakeholders including patients/public, clinical staff, financial staff

• Public input must be taken into option appraisal and choice of preferred option

• Must align with commissioning strategy and allocation decisions

• Must consider all viable options and must not destabilise providers beyond their ability to cope

The patch needs to decide how to configure maternity care services that offer best possible value to service users and taxpayers, now and for the future

• Maternity services are currently available in five different locations across the area

• The service is commissioned by two CCGs and offered by two provider trusts

• Demand for maternity services across the geography of the patch is changing and forecast to continue to do so, largely due to changes in population demographics and the evolving care expectations of service users

• Some of the sites are financially unsustainable and some are unable to meet changing demand

• An opportunity to make dis/investment in infrastructure is available given recommendations from Better Births

• The decision team now need to agree how to proceed in order to maximise value for service users

• The providing trusts need to decide how to respond to and implement the commissioning changes



Decide governance structure

Decide value objectives and value measures

Decide the case for change and priorities

Decide set of available solution options

Decide preferred option to work into full service specification

Decide service reconfiguration to meet specification

Decide implementation or mobilisation plan

Decide contracts or procurement

• Establish and agree the value metrics that will be used to represent the key outcomes required as set in the Decision Charter

• Establish and agree the priority ‘must have’ outcomes

• Outcomes must always considered from the perspective of the service user;

• Value criteria should align with the key outcomes selected in the Decision Charter;

• When choosing metrics, only choose those where data is relevant and accessible;

• Evidence for the metrics should be relevant and accessible;

• If a long list of metrics are identified, highlight those which you believe are the most important to progress your decision and which you will focus on going forward.

This template links to the Value Generation tool (page 18) which you may wish to incorporate into discussions at this time if adjustments to the base value components are required


The Data Sources library catalogues publicly accessible data repositories which can be used to inform value measures [link]

The RAPID model clarifies the accountability that different stakeholders have in a collaborative decision. Assigning a role - recommend, agree, perform, input or decide - combines the benefits of expert input with a single point of authority for progressing a decision; it ensures that everyone is clear and agreed about their responsibilities.

Stakeholders may be organisations, boards, departments, teams or individuals. Roles can shift throughout the Decision Steps depending on the decision stage or context.

R does 80% of the work to develop a credible recommendation to

make to D

I is consulted by R for expertise; views may or may not be reflected in the recommendation

P actions the decision that is made by D

D is solely accountable for committing to an

action, usually based on recommendation of R

A has the power to veto the recommendation of R on legal or regulatory

grounds

RAPID® is a registered trademark of Bain &

Company, Inc.



• Quality of pre, during and post child delivery care • Outcome of interventions • Recovery

• Volume of at risk births (e.g. premature, low weight, medical condition) • Perinatal mortality and still birth rate • Volume of births by birth type (e.g. natural, c-section, episiotomy, induced) • Medical complication rate (e.g. postpartum haemorrhage) • % of complications successfully treated • Days to discharge post-c-section / premature birth

• Accessibility to care facility • Accessibility to people within care facility • Comfort of environment • Quality of interactions • Patient choice

• Average and maximum travel time to maternity ward within catchment area • Ratio of midwives and obstetricians to patients • Availability of alternative birthing facilities e.g. home birth support • % of patients able to choose where to have their baby • % of patients provided with advice on post-birth baby care

• Avoidance of harm to patient • Safe environment that supports delivery of care • Adequate resourcing

• Rate of avoidable mortality • Rate of avoidable harm done to patient e.g. infection rate • % adherence to best practice estate maintenance protocols • % of time staffed according to best practice minimum staffing levels • Staff experience (measured as number of patients per staff per year)

• Clinician salary • Admin staff salary • System running costs

• ‘Stranded costs’ i.e. costs of unmet overhead as result of disinvestment • Staff relocation and training costs • Co-dependency expansion costs (e.g. gynaecology consultant salaries) • Operating cost per birth

• Investment in facilities / equipment • Upfront investment for facility expansion • Co-dependency expansion costs (e.g. additional facilities)


‘Who Has the D? How Clear Decision Roles Enhance Organizational Performance’ by Paul Rogers and Marcia W Blenko (Bain & Company) via the Harvard Business Review [link]

• Agree RAPID roles for stakeholders for each Decision Step

• List stakeholders that hold power to influence the decision across the columns (e.g. individual roles, committees, boards or representative groups);

• List the Decision Steps as rows;

• Only one Decide for each decision step;

• Only one Recommend for each decision step;

• Few Agree, if any at all;

• Only Inputs that have something valuable to add;

• If roles are held by groups, clarify how sign-off will be reached.


• Establish and agree the activities needed to complete each Decision Step

• The activities could be such things as data gathering, analysis, meetings etc.;

• Order the Key Actions sequentially, noting any feedback loops required.

The BPV companion website features a short instructional video for completing the HOW section of the framework [link]

Example WHO and WHEN templates are provided in the Decision Handbook example at the end of this document from page 25

https://hbr.org/2006/01/who-has-the-d-how-clear-decision-roles-enhance-organizational-performance

http://youtu.be/dlc1OA6HPfE



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• Establish and agree the details and relevant forums for each Key Action

• Criteria: What are the criteria to evaluate the options/make a decision?

• Critical Steps: What Key Actions are needed?

• Choices Considered: What are the choices that need to be made?

• Committees: Which groups need to be engaged?

• Communication: How will this decision be communicated to the relevant parties?

• Closure: How will we know that closure has taken place? How will we practically mobilise to implement this decision?

Some of the supporting tools listed in the Value Tools library may feature here as a means to achieving Key Action closure [link]



• Establish and agree a decision timeline with Decision Steps as key milestones

• Consider how long it will take to complete each of the Decision Steps;

• Refer back to the Key Actions identified for each Decision Step to inform the estimation of the amount of time required;

• Work can take place in parallel and may be iterative;

• Strike a balance between pace and realism, informed by past experience.

The Quality Improvement Hub by NHS Scotland offers a short introduction to project planning and a Gantt chart template [link]



http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-tools/project-plan.aspx


The Value Generation tool may be used in conjunction with logic modelling, value chains and process mapping where appropriate. Find links and more information in the Value Tools library [link]

• Establish and agree a main hypothesis or case for change

• Establish and agree sets of assertions for each component of the main hypothesis

• Outcomes must always be considered from the perspective of the service user;

• Lay out the main hypothesis or case for change, e.g. ‘we should perform action X because of Y’;

• For each value component, generate a set of assertions that you believe are necessary to support the case, e.g. ‘action X will benefit value component Z by…’;

• Refer to the Value Measures and outcome objectives previously decided.

‘NEW CARE MODELS: Vanguards - Developing a Blueprint for the Future of NHS and Care Services’ via NHS England [link]

• Establish the availability of evidence for each assertion

• Set targets for improvements to each value measure

• Carry forward the assertions from the Value Building template;

• Briefly describe the evidence that supports each assertion;

• Indicate the next steps to gather any further evidence that is needed for greater confidence (and who will provide it and when);

• Set targets for each value measure – targets should be SMART:

✓ S – specific (relating to value criteria), ✓ M – measurable (relating to value metrics), ✓ A – attainable (relating to evidence base), ✓ R – relevant (relating to value components), ✓ T – time-based (how often metrics will be measured).

Example templates are available on pages 41 to 43

‘Using Evidence in Identifying and Assessing New Ideas’ via the NHS Innovation Agency [link] and ‘Research, Evaluation and Evidence: a Guide for Commissioners’ via Bath Research & Development [link]


https://www.england.nhs.uk/wp-content/uploads/2015/11/new_care_models.pdf

http://www.innovationagencynwc.nhs.uk/evidence

http://www.rdforum.nhs.uk/content/wp-content/uploads/2014/05/NHSEng_V13-FINAL.pdf


Case for change: The option to invest in maternity services is worthwhile because it will generate a long-term positive impact on value for service users and taxpayers. Implementing models of care in line with Better Births recommendations will deliver safer, more personalised, kinder, professional and more family-

friendly care to service users. This will result in improved care outcomes, better service user experience and choice, and efficient and sustainable services.

Care outcomes will be improved by designing and operating services across organisational boundaries and a culture of learning and continuous improvement

Investing in this option will be an effective use of resources that will result

in a sustainable service that delivers best possible value to service users

User experience and choice will be improved by designing local services the operate continuity of carer models that

reflect the choices women want

Implementing the Better Births recommendations re: choice, technology

and safety will reduce harm to service users and improve service efficiency

• Moving to outcomes-based commissioning will drive a greater focus on quality and therefore improved care outcomes

• Shared clinical governance will facilitate the efficient transfer of women and babies across organisational boundaries, ensuring the right care in the right place at the right time, thereby improving care outcomes

• Joining up hospital and community services, in particular through community hubs, will improve access to services and enable greater personalisation of care, ensuring that complications are detected earlier and therefore improving care outcomes

• Improving postnatal care will help parents to care for their baby and give children the best start in life

• Collaboration in the design and operation of local maternity systems with improve the variety and availability of choices offered to service users

• Introducing personalised care plans will ensure that service user choices are better reflected in the care they receive

• Introducing continuity of carer models will enable service users to develop a relationship with a single professional and improve their experience of care

• Ensuring the provision of access to all three types of birthplace will result in more women with a lower risk profile choosing to give birth at home and in midwifery units, where care costs are lower than in obstetric units

• Electronic care records will make recording and sharing information with service users and care professionals easier and more efficient, reducing the amount of time and effort needed for data processing

• Supporting a learning culture will enable care staff to learn with and from each other and lead to continuous service improvement, reduced harm, reduced waste and also reduced litigation

• Investment of £Xm will enable the patch to rollout the recommended actions to deliver to the Better Births vision and implement and manage the change

• Improvements to care outcomes for services users will offer efficiency and productivity cost saving to the area; the project will breakeven within X years and offer annual recurrent financial savings of £Xm

• Local areas will reinvest any resources at their disposal to deliver the change

• Changes will make effective and appropriate use of non-financial resources in line with local system strategy, and staff and public and patient requirements


• Establish the scoring mechanisms and tolerances that will be applied to the available options

• Refer to example scoring mechanisms and tolerances (page 21) or case studies;

• Apply a mechanism for scoring each value component against:

value outcomes and confidence; risk; and, strategic considerations.

• Indicate tolerances for each scoring component;

• Clearly indicate and agree tolerances, i.e. unacceptable scores;

• Clearly indicate how scoring logic can be consistently applied across options.

An example template is available on page 44

You may wish to include the agreement of value and risk tolerances as part of the Decision Steps within the Decision Planning process

• Assign scores to each of the value components

• Compare and rank the value generated by available options side by side

• Refer to the Scoring Rationale guidance or rank options and assign a quintile;

• Briefly indicate the factors that have led to this score being assigned;

• Ensure scores for all options for value, risk and strategic considerations are populated and correctly assigned;

• Populate the financial implications (e.g. investment amount or savings expected);

• The BPV Option Priorities spreadsheet ranks each available option.

BPV Option Priorities (xlsx) includes electronic versions of blank templates with instructions for use, recommended for use by Recommend or Agree decision stakeholders to compare options [link]


Value measures, risk tolerance levels and strategic considerations will need to be agreed in advance for each scoring category. This may need to be included as a Decision Step or Key Action during Decision Planning.

It is ultimately up to the framework user to define their own scoring means relating to the decision or options under consideration. This section provides some examples.

Scoring may be performed by:

• relative quintiles (rank options and assign 1 to 5 scale)

• RAG statues (1 to 3 scale for red, amber and green)

• Yes / No binary

Decision: Linked to the Value Tree and based on the metrics and targets set

Question: If the options realise the outcomes identified, how much value (relative to other options) will be generated for service users and taxpayers?

Consideration may also be given to the contents of the Evidence Log:

Example: (1-2) Low Option is unlikely to fulfil the value target (3) Medium Option likely to partially fulfil the value target (4-5) High Option highly likely to completely fulfil the value target

Also consider that, based on the quality of the available evidence, how confident are we that the options will realise the outcomes identified?

Decision: Linked to strategy and based on acceptable or managed risk

Question: What is the level of risk that the options expose us to?

Examples:

• Will the quality of care delivered potentially be negatively affected by the option?

• Is there a risk that the option will not generate the value outcomes identified?

• Can the option be implemented without disruption from internal/external factors?

• Does the option risk returning low (or negative) financial savings versus plan?

• Is the available evidence satisfactorily robust?

• For each risk, what are the unacceptable or non-negotiable risk scores?

Decision: Linked to Decision Charter and based on agreed strategy needs

Question: To what extent do option s meet the strategic factors being considered?

Examples:

• Does the option align with organisation or patch strategic priorities?

• Will the options take to implement or realise in time?

• Could the model be replicated or adopted by others?

• Is there an unfavourable opportunity cost against other options?

‘Strategy Development Toolkit’ [link] and ‘In it Together: Developing Local Strategy’ [link] via NHS Improvement



‘Transformation fund call to bid’ documents by NHS England aimed at STPs for mental health, cancer, diabetes and learning disabilities services [link]

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/365697/Strategy_development_toolkit_MAIN_22102014.pdf

https://improvement.nhs.uk/resources/it-together-developing-local-system-strategy/


https://www.england.nhs.uk/stps/tf-call-to-bid/


• Prioritise the available options by value, risk and strategic considerations

• Produce a rationalised recommendation based on option rankings and priorities

• The BPV Option Priorities spreadsheet calculates and maps the relative score for each available option:

value (y axis); risk (x axis); strategic factors (RAG status); and, financial implications (bubble size).

• Summarise the findings including a short rationale statement, for example: Invest / do not invest in options based on rankings; Combine and accept / reject clusters of options; Develop risk mitigation or value improvement plan; Seek resolution to unfavourable strategic consideration scores etc.

• Clearly indicate the basis on which the recommendation has been made;

• Clearly articulate the decision to be made, action requested or response required.

The value generated and recommendation made on this basis may be used to frame a business case. You can include BPV templates and outputs as part of the NHS National Innovation Centre template [link]

1 Future-Focused Finance (2016). The Four Strengths of NHS Finance Professionals. Available from www.futurefocusedfinance.nhs.uk

2 Faculty of Medical Leadership and Management (2016). Leadership and Management Standards for Medical Professionals (2nd Edition). Available from www.fmlm.ac.uk

3 Royal College of Nursing (2014). The Nursing Role in Integrated Care Models: Reflecting on the United States’ Experience. Available from www.rcn.org.uk

4 Lee, J. D., Saravanan, P., Varadhan, L., Morrissey, J. R. and Patel, V. (2014). Quality of Diabetes Care Worldwide and Feasibility of Implementation of the Alphabet Strategy: GAIA project (Global Alphabet Strategy Implementation Audit). BMC Health Services Research, 14(1), 467. Available from wrap.warwick.ac.uk

This guide was written by Jo Parris on behalf of Future-Focused Finance.

The Decision Framework was developed with the support of Bain & Company, Inc. and with special thanks to colleagues from NHS England and Liverpool CCG.

To find out more about the programme and its action areas and networks, please visit www.futurefocusedfinance.nhs.uk

If you have any queries, comments, feedback or technical difficulties then please contact [email protected] or join us on Twitter @nhsFFF

Join the BPV Community online to network with other framework users and share good practice and learning [link]

http://knowledge.nic.nhs.uk/documentDetails.aspx?docId=40

http://www.futurefocusedfinance.nhs.uk/

mailto:[email protected]?subject=BPV%20query

https://twitter.com/nhsfff



OPTION 1 OPTION 2 OPTION 3 OPTION 4 OPTION 5

OUTCOMES

Fall in stillborn rate 25% 4 4 2 2 2

Fall in brain injuries rate 25% 4 5 2 3 3

Increase in breastfeeding 10% 3 3 1 2 1

EXPERIENCE Improved service access 5% 4 4 3 3 2

Improved care experience 5% 4 4 2 3 3

SAFETY Reduced harm 10% 3 5 3 2 1

RESOURCES Cost reasonability 10% 4 3 3 5 2

Sustainability 10% 3 3 2 3 1

VALUE 100% 3.7 4.1 2.2 2.8 2.0

RISK Quality of evidence 50% 4 5 3 2 1

Capacity to deliver change 50% 3 4 4 3 2

RISK 100% 3.5 4.5 3.5 2.5 1.5

STRATEGIC FACTORS

System strategy alignment 50% 3 4 3 1 1

Time to savings realisation 50% 2 3 3 1 3

100% 2.5 3.5 3.0 1.0 2.0 STRATEGIC FACTORS


Strategic factors

High

Medium

Low

HIGH VALUE

LOW VALUE

HIGH RISK LOW RISK

REJECT

ACCEPT

IMPROVE

MITIGATE

Option 5

Option 1

Option 3

Option 4

Option 2

A worked example of a dis/investment decision for improving the value of local maternity services

futurefocusedfinance.nhs.uk


• Best possible value for service users goal (considered in terms of outcomes, patient experience, safety and cost)

• Service should strive to reach ‘best in class’

• Offer services in good standard facilities

• Avoid critical shortages of service users and staff

• Must be acceptable to all key stakeholders including patients/public, clinical staff, financial staff

• Public input must be taken into option appraisal and choice of preferred option

• Must align with commissioning strategy and allocation decisions

• Must consider all viable options and must not destabilise providers beyond their ability to cope


• Maternity services are currently available in five different locations across the area

• The service is commissioned by two CCGs and offered by two provider trusts

• Demand for maternity services across the geography of the patch is changing and forecast to continue to do so, largely due to changes in population demographics and the evolving care expectations of service users

• Some of the sites are financially unsustainable and some are unable to meet changing demand

• An opportunity to make dis/investment in infrastructure is available given recommendations from Better Births

• The decision team now need to agree how to proceed in order to maximise value for service users

• The providing trusts need to decide how to respond to and implement the commissioning changes









Decide implementation or mobilisation plan



• Quality of pre, during and post child delivery care • Outcome of interventions • Recovery

• Volume of at risk births (e.g. premature, low weight, medical condition) • Perinatal mortality and still birth rate • Volume of births by birth type (e.g. natural, c-section, episiotomy, induced) • Medical complication rate (e.g. postpartum haemorrhage) • % of complications successfully treated • Days to discharge post-c-section / premature birth

• Accessibility to care facility • Accessibility to people within care facility • Comfort of environment • Quality of interactions • Patient choice

• Average and maximum travel time to maternity ward within catchment area • Ratio of midwives and obstetricians to patients • Availability of alternative birthing facilities e.g. home birth support • % of patients able to choose where to have their baby • % of patients provided with advice on post-birth baby care

• Avoidance of harm to patient • Safe environment that supports delivery of care • Adequate resourcing

• Rate of avoidable mortality • Rate of avoidable harm done to patient e.g. infection rate • % adherence to best practice estate maintenance protocols • % of time staffed according to best practice minimum staffing levels • Staff experience (measured as number of patients per staff per year)

• Clinician salary • Admin staff salary • System running costs

• ‘Stranded costs’ i.e. costs of unmet overhead as result of disinvestment • Staff relocation and training costs • Co-dependency expansion costs (e.g. gynaecology consultant salaries) • Operating cost per birth

• Investment in facilities / equipment • Upfront investment for facility expansion • Co-dependency expansion costs (e.g. additional facilities)




R Recommend A Agree P Perform I Input D Decide









Stakeholders

I

NH

S En

glan

d

A

I

Regu

lato

rs (e

.g.

CQC,

NH

I Im

prov

emen

t)

I

Loca

l Aut

horit

y / P

ublic

Hea

lth

A

O

verv

iew

and

Sc

rutin

y Bo

ards

D

A

A

D

D

D

D

D

CCG

Boa

rd

A

A

A

A

A

A

Prog

ram

me

Boar

d

R

P

R

R

R

R

R

Prog

ram

me

Boar

d Ch

air /

Le

ad C

CG re

p

I

CCG

Hea

d of

Fi

nanc

e

A

R

Trus

t Chi

ef

Exec

utiv

e or

Eq

uiva

lent

D

D

A

A

A

Trus

t Boa

rd

P

R

I

I

Trus

t Hea

d of

Fin

ance

A

I

I

Trus

t Hea

d of

Med

ical

A

I

I

Trus

t Hea

d of

Nur

sing

P

P

A

I

I

I

Trus

t Se

rvic

e Le

ad

I

I

I

Serv

ice

user

re

ps (e

.g. P

PI)

I

Oth

ers

(e.g

. po

litic

ians

)






Decide preferred option to work into full service

specification



Map out potential scope of key

players

Map out decision and governance pathway

Agree other roles and responsibilities

Communicate roles and responsibilities


Decide service reconfiguration to meet

specification

Describe objectives, define value and

constraints

Gather expert input and engage relevant

stakeholders

Review evidence and produce summary

document

Define value measures in line

with strategy

Review recommend-ations in line

with local strategy

Review Right Care, Carter, etc. priority recommendations

Document long list of options

Seek best practice, evidence or ideas for

option set

Review and sense check assumptions

Create and communicate

options shortlist

Collect and assess data and evidence

Gather expert input and engage relevant

stakeholders

Agree decision pass/fail value criteria

Generate and communicate

recommendation

Assess priorities in terms of value

and risk

Draft strategy and outline business

case

Perform service review to identify case for change

Produce and submit final business case

Communicate response to

commissioners

Options negotiation between trusts

Gain necessary regulatory approval

Create benefits realisation plan

Formulate terms of contract

Review guidance Allocate owners

and workstreams Develop risk and

issues log

Negotiate contracts or agree

procurement model

Identify function leads (clinical, finance etc.)

Draft strategic outline case in line

with value objectives

Analyse risk and investigate funding

options/impact

Align with suppliers and workforce

Develop and communicate

mobilisation plan

Programme Board Chair / Lead CCG representative

CCG Board D



R N/A N/A A I

• Map out decision and governance pathway for entire decision process

• Identify function leads (e.g. clinical, finance etc.)

• Map out potential scope of key players

• Agree other roles and responsibilities

• Communicate roles and responsibilities

• Chair to inform CCG Boards

• Engage with Competition and Markets Authority (CMA), Overview and Scrutiny Committee and Health and Wellbeing Boards

• There should be a clearly defined governance structure based on:

Geographic dominance Expertise Capacity

• The should be adequate clinical input to the decision

• Programme Board: commissioning-led Board made up of cross stakeholder representatives

• Programme Board Chair is a designated lead from one of the CCGs (ideally lead CCG)

• Create a new committee?

• Designate a lead organisation?

• Work as separate organisations?

• Borrow/procure project staff?

• Evidence of Project Initiation Document (PID) and Terms of Reference

• Develop stakeholder map including ‘keep informed’ and set up communication team

Examples of value tools are offered here; others are available, listed in the Value Tools library at the BPV companion website [link]

• BPV WHAT and WHO templates

• Stakeholder mapping [link]

• Public engagement [link]

• PID and project templates [link]


http://www.theclic.org.uk/component/phocadownload/category/leadership?download=175

http://www.wales.nhs.uk/sitesplus/documents/888/Public_Health_Practitioner%27s_Public_Engagement_Toolkit.pdf

http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-tools/project-initiation-document.aspx


CCG Board D



R Trust Service Lead Service user reps (e.g. PPI)

Programme Board A I

• Gather expert input and engage relevant stakeholders

• Describe objectives, define value and constraints

• Define value measures in line with strategy

• Review evidence and produce summary document

• Chair to inform CCG Boards

• Keep provider trusts informed of rationale behind intention to reconfigure services

• The objective of the decision should be to maximise value for service users (in terms of clinical outcomes, patient experience and safety)

• There should be access to sufficient evidence and data to assess metrics

• It should be straightforward / practical to collect evidence and data

• Value criteria and metrics should be sufficient to enable robust evaluation



• What value components, criteria and metrics reflect the objectives set out in the Decision Charter?

• Evidence of decision via final summary paper, signed off by CCG

• Engage / inform stakeholders as per communication strategy


• BPV Value Generation tool and BPV Data Sources library [link]

• International Consortium for Health Outcome Measures (ICHOM) [link], Patient Reported Outcome Measures (PROMs) [link]



http://www.ichom.org/

http://healthcareimprovementscotland.org/his/idoc.ashx?docid=595f3ffe-c11d-4023-b253-7ae90d629f3b&version=-1


CCG Board D



R NHS England Regulators Public Health

CCG Head of Finance Politicians

Programme Board Overview and Scrutiny Board Trust Board

A I

• Review Right Care, Carter etc. priority recommendations

• Review recommendations in line with local strategy

• Draft strategic outline case in line with value objectives

• Consultation document to stakeholders (audience-specific)

• Keep provider trusts informed of rationale behind intention to reconfigure services

• The objective of the decision should be to maximise value for service users

• Timing (sequence and pacing) needs to ensure smooth transition

• Providers experiencing changes to commissioned services must remain sustainable

• Co-dependency impact is acceptable (e.g. clinical, asset, access)



• What national recommendations have been made?

• Which recommendations apply to us in line with our local strategy?

• Which recommendations to prioritise?

• Evidence of decision via minutes issued, agreement in principle

• High level business case produced



• Commissioning for Value data packs via Right Care [link]

• Strategy Development Toolkit via NHS Improvement [link]

• NHS Business Case template via NHS National Innovation Centre [link]


https://www.england.nhs.uk/rightcare/intel/cfv/data-packs/

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/365697/Strategy_development_toolkit_MAIN_22102014.pdf

http://knowledge.nic.nhs.uk/documentDetails.aspx?docId=40


CCG Board D


Decide set of available options

R Trust Head of Nursing / Medical Trust Head of Finance / Service Service user representatives

Programme Board Trust Board A I

• Seek best practice, evidence or ideas for option set

• Document long list of options

• Collect and assess data and evidence

• Review and sense check assumptions

• Create and communicate options shortlist

• ‘Keep informed’ stakeholders kept appraised of options considered

• Options considered must be realistically and appropriately available

• Options must be comparable according to agreed Value Measures

• Options must consider risk to stakeholders impacted by the change

• Outcome of public consultation must be acceptable



• Where to look for best practice and replicability?

• What change targets to set and measure?

• Where to find evidence? How to classify evidence?

• CCGs send draft of new contract proposition and high level business case to providers



• ‘Better Births’ [link], maternity transformation [link] and new care models [link] via NHS England

• ‘Using Evidence in Identifying and Assessing New Ideas’ via the NHS Innovation Agency [link]


https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiKqfXyiPnSAhWkI8AKHT92BegQFggaMAA&url=https%3A%2F%2Fwww.england.nhs.uk%2Fwp-content%2Fuploads%2F2016%2F02%2Fnational-maternity-review-report.pdf&usg=AFQjCNGWxwnMlkx

https://www.england.nhs.uk/mat-transformation/

https://www.england.nhs.uk/wp-content/uploads/2015/11/new_care_models.pdf



CCG Board D



R Trust Service Lead Service user representatives

Programme Board Trust Board A I

• Agree decision pass/fail value criteria

• Gather expert input and engage relevant stakeholders - public consultation

• Assess priorities in terms of value and risk

• Generate and communicate recommendation

• Consultation document to all stakeholders - focus on stakeholder engagement opportunity

• Recommended option should be that which maximises agreed outcome objectives compared to alternatives

• Preferred option(s) must be deliverable within required time horizon and available resources

• Preferred option(s) must include recommendation for mitigating or managing risk to impacted stakeholders



• Dis/invest in sites or capital?

• Pace and sequence of change?

• Co-dependency of services?

• Workforce flexibility?

• Pricing and tariff options/implications?

• Based on best practice or recommendations?

• Evidence of decision via minutes of CCG Board



• BPV Option Priorities tool

• Using Evidence in Identifying and Assessing New Ideas’ via the NHS Innovation Agency [link]

• Logic Modelling [link]



http://info.wirral.nhs.uk/document_uploads/evidence-factsheets/12%20Logic%20Modelling%20factsheet%20Feb%202014.pdf

Trust Chief Executive or Equivalent

Trust Board D



R Trust Head of Medical Trust Head of Nursing Trust Head of Finance

CCG Board Trust Service Lead A I

• Perform service review to identify case for change

• Draft strategy and outline business case

• Analyse risk and investigation funding options/impact

• Options negotiation between trusts

• Produce and submit final business case

• Communicate response to commissioners

• Consultation document to all stakeholders - focus on service user impact

• Engage regulators if financial impact is over threshold

• Reconfiguration must aim to maximise value as per objectives

• Financing available to providers

• Financial impact of transition is acceptable

• Timing (sequence/pacing) needs to ensure smooth transition


• Trust Board

• Investment Committee

• Procurement Committee

• Capital Board

• Service reconfiguration options?

• Risk share between trusts?

• Transitional funding agreements between trusts and commissioners?

• Evidence of decision via business case for sign off



• Service reviews [link]

• Capital regime, investment and property business case approval guidance via NHS Improvement [link]


http://commissioning.libraryservices.nhs.uk/commissioning-cycle/reviewing-services-and-gap-analysis

https://improvement.nhs.uk/uploads/documents/NHSI_Capital_Regime_Investment_Property_Business_Case_Main_Comms_V9.0_final_v2.pdf

Trust Head of Finance Trust Board D



R Programme Board Chair Trust Service Lead

Regulators CCG Board Prog. Board

Trust Head of Medical / Nursing

A P

• Create benefits realisation plan

• Gain necessary regulatory approval

• Align with suppliers and workforce

• Develop and communicate mobilisation plan

• Consultation document to all stakeholders - focus on staff and trade unions

• Reconfiguration must aim to maximise value as per objectives




• Timescale to maintain stability including cost/speed trade-offs?

• Workforce migration?

• Risk share of residual/stranded costs, repurpose vacated locations?

• Integration options?

• Delivery line/provider partner options (e.g. joint venture, contract with GPs)?

• Evidence of decision via minutes of Programme Board



• Quality and Equality Integrated Impact Assessment tool [link]

• Capital regime, investment and property business case approval guidance for NHS providers via NHS Improvement [link]


http://www.miltonkeynesccg.nhs.uk/modules/downloads/download.php?file_name=311

https://improvement.nhs.uk/resources/capital-regime-investment-and-property-business-case-approval-guidance-nhs-trusts-and-foundation-trusts/


CCG Board D



R Trust Head of Finance Trust Service Lead

Programme Board Trust Chief Executive or Equivalent A P

• Review guidance

• Formulate terms of contract (align with strategy):

Service specifications Outcomes, experience and safety Tariffs Cost or risk sharing

• Commissioners/providers to negotiate contract(s) / procurement model

• Allocate owners and workstreams

• Develop risk and issues log

• Consultation document to all stakeholders indicating final decision - focus on media

• Reasonability of cost and other strategic considerations



• Programme Board - acts as facilitator between commissioner(s) and provider(s) and will need to Agree the final contract

• Investment Committee

• Procurement Committee

• Capital Board

• Sign contract?

• Evidence of decision via signed contract



• NHS Standard Contract via NHS England [link]

• Value-based procurement via North West Procurement Development [link]

• Value-based contracting via Capsticks [link]


https://www.england.nhs.uk/nhs-standard-contract/

https://www.nwprocurement.co.uk/eis2015supplierandbuyer.php

http://outcomesbasedhealthcare.com/Contracting_for_Outcomes.pdf











2017 2018

Sep Oct Nov Dec Jan Feb Mar Apr May Jun


Case for change: The option to invest in maternity services is worthwhile because it will generate a long-term positive impact on value for service users and taxpayers. Implementing models of care in line with Better Births recommendations will deliver safer, more personalised, kinder, professional and more family-

friendly care to service users. This will result in improved care outcomes, better service user experience and choice, and efficient and sustainable services.

Care outcomes will be improved by designing and operating services across organisational boundaries and a culture of learning and continuous improvement

Investing in this option will be an effective use of resources that will result

in a sustainable service that delivers best possible value to service users

User experience and choice will be improved by designing local services the operate continuity of carer models that

reflect the choices women want

Implementing the Better Births recommendations re: choice, technology

and safety will reduce harm to service users and improve service efficiency




• Improving postnatal care will help parents to care for their baby and give children the best start in life







• Investment of £Xm will enable the patch to rollout the recommended actions to deliver to the Better Births vision and implement and manage the change

• Improvements to care outcomes for services users will offer efficiency and productivity cost saving to the area; the project will breakeven within X years and offer annual recurrent financial savings of £Xm

• Local areas will reinvest any resources at their disposal to deliver the change

• Changes will make effective and appropriate use of non-financial resources in line with local system strategy, and staff and public and patient requirements


Main assertion Sub-assertion Evidence available Further evidence Value metrics Target

• Care outcomes will be improved by designing and operating services across organisational boundaries and a culture of learning and continuous improvement




• There is strong international evidence that an outcomes-based approach to commissioning can deliver high quality care and value for money

• There is evidence that the components of clinical governance contribute to improving the quality of care for service users

• Evidence from Saving Babies’ Lives (NHS England) shows that early intervention in some key areas can reduce stillbirths and neonatal deaths

• Statistical evidence via Right Care

• Mental health evidence

• Public health evidence

• Stillbirth and neonatal mortality rate [data source]

• Number of brain injuries occurring during or soon after birth [data source]

• Breastfeeding at 12 weeks (proxy for improved postnatal care because improved child health indicators will take years to feed through) [data source]

• Fall in stillbirth rate of 50% by 2030 (trajectory to get there)

• Fall in rate of brain injured babies by 50% by 2030 (trajectory to get there)

• Increase in breastfeeding at 12 weeks by 20% by 2020

CAR

E O

UTC

OM

ES


Main assertion Sub-assertion Evidence available Further evidence Value metrics Target

• Service user experience and choice will be improved by designing local services the operate continuity of carer models that reflect the choices women want




• Providing access to services in a larger footprint will increase choice and improve access to services

• Evidence of improved experience (and improved clinical outcomes) summarised in report the contribution of continuity of midwifery care to high quality maternity care (Royal College of Midwives)

• Teams to map services to assess current choice and access to services

• Personalised care plans data

• Cost benefit analysis to be informed by experience of early adopters and lessons learned feedback

• Access to all three types of birthplace [data source]

• Experience of choice [data source]

• Percentage service users experiencing continuity of carer [data source]

• Care experience [data source]

• All sites to provide access to all three types of birthplace to all service users within 2 years

• Percentage of service users reporting the ability to choose to improve by 20% by 2020

• Percentage of service users reporting continuity of carer to improve by 20% by 2020

• Friends and family net promoter score to improve by 20% to 2020

EXPE

RIE

NCE


Main assertion Sub-assertion Evidence available Further evidence

to be gathered Value metrics Target

• Implementing the Better Births recommendations re: choice, technology and safety will reduce harm to service users and improve service efficiency




• In 2012 87% of births took place in Obstetric Units, whereas a survey by NCT &NFWI showed that only 25% of women would choose one

• Better Births highlighted that data collection is an efficiency issue for NHS maternity services

• Evidence from Sweden and from North Bristol shows that a good culture in the context of a no blame culture can reduce poor outcomes and lead to a reduction on litigation costs of 50%

• What actual level of community births is safe and achievable bearing in mind complications will have a significant influence on choices made

• The extent to which this is replicable locally

• Missing data / mitigate for survivorship bias

• Numbers of births taking place in each setting [data source]

• Number of women with an electronic care record [data source]

• Number of brain injuries occurring during or soon after birth [data source]

• Increase births at home and in midwifery units on a trajectory to double in four years

• E-records rolled out to 100% of service users by end of programme

• On a trajectory to reduce harm by 50% over four years

SAFE

TY


Criteria Importance

(%) Rationale Scoring

Fall in stillborn rate 25% Is the option likely to achieve the target fall in stillborn rate? 5 largest reduction offered 1 smallest reduction offered All options scored on sliding scale between 1 and 5 proportionate to distance between them and highest/lowest scoring options

Fall in brain injuries rate 25% Is the option likely to achieve the target fall in brain injuries rate?

Increase in breastfeeding 10% Is the option likely to achieve the target rise in breastfeeding rate?

Improved service access 5% Is the option likely to achieve the target improvements to access? 5 plans to achieve targets are clear, impressive, and demonstrate the means to measure improvements 3 plans to achieve targets are described and promising but require more detail and clarification 1 no improvements are described with no measurement plans

Improved care experience 5% Is the option like to achieve the target improvements to experience?

Reduced harm 10% Is the option like to achieve the target reductions to harm?

Cost reasonability 10% Are the costs per head of population clearly indicated? Is the option financially viable to all stake-holding parties?

5 there is a clear, specific answer to all questions 3 there is an answer to all questions but more detail is needed 1 none of the questions are answered satisfactorily

Sustainability 10% How much money will be saved? How will the saving be reinvested?

Quality of evidence 50% Is the evidence used to generate the option robust? 5 quantitative evidence from this site 4 quantitative evidence from national study 3 quantitative evidence from international study 2 anecdotal evidence or robust logic model 1 no evidence

Capacity to deliver change 50% Can the change be delivered without service disruption? Does the option have senior level buy-in and strong leadership to deliver the change?

5 strong case for change, delivery plan, leadership and risk assessment 3 partially defined plan with milestones but some elements lacking 1 weak case for change, delivery plan, leadership and risk assessment

System strategy alignment 50% Is the option aligned with local system strategic plans and intent? 5 strong strategic alignment and planning between players is clear 3 plans adequately aligned between players but further clarity required 1 the option does not align with local strategic intent or planning is poor

Time to savings realisation 50% When will breakeven be achieved? 5 breakeven by 2020/1 1 breakeven by 2024/5

STR

ATEG

Y R

ISK

RES

OU

RCE

S O

UTC

OM

ES


OPTION 1 OPTION 2 OPTION 3 OPTION 4 OPTION 5

OUTCOMES

Fall in stillborn rate 25% 4 4 2 2 2

Fall in brain injuries rate 25% 4 5 2 3 3

Increase in breastfeeding 10% 3 3 1 2 1

EXPERIENCE Improved service access 5% 4 4 3 3 2

Improved care experience 5% 4 4 2 3 3

SAFETY Reduced harm 10% 3 5 3 2 1

RESOURCES Cost reasonability 10% 4 3 3 5 2

Sustainability 10% 3 3 2 3 1

VALUE 100% 3.7 4.1 2.2 2.8 2.0

RISK Quality of evidence 50% 4 5 3 2 1

Capacity to deliver change 50% 3 4 4 3 2

RISK 100% 3.5 4.5 3.5 2.5 1.5

STRATEGIC FACTORS

System strategy alignment 50% 3 4 3 1 1

Time to savings realisation 50% 2 3 3 1 3

100% 2.5 3.5 3.0 1.0 2.0 STRATEGIC FACTORS


Strategic factors

High

Medium

Low

HIGH VALUE

LOW VALUE

HIGH RISK LOW RISK

REJECT

ACCEPT

IMPROVE

MITIGATE

Option 5

Option 1

Option 3

Option 4

Option 2

Version 2.1 June 2017

A reference guide for organisations making value …...A reference guide for organisations making...

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