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Case study: Derby City Primary Care Trust

Overview

Continuing health care and complex cases are an area of high spend and increasing demand for PCT commissioners. A systematic review of continuing care and complex care commissioning (CHC) processes and commissioning can ensure PCTs are commissioning for population needs, reviewing and reducing costs where appropriate and having a better whole systems understanding and control of current and future needs and costs.

At the end of 2009 Derby City PCT were amongst the highest ranked nationally for CHC spend and activity. In addition there was a high level of referral for CHC from the local acute provider, often before the opportunity for rehabilitation and assessment and patient’s ongoing needs were established. Capita was asked to support the PCT in reviewing the CHC processes and reducing the spend, with an estimated opportunity to reduce costs by £1 million pa. The PCT saw the CHC review as a key enabler within the Transformation plan as it not only required internal efficiency but also joint working across the acute, community mental health and social services within the local health economy.

Our approach

A systemic review and implementation was undertaken to develop the new CHC processes and associated savings:

  • Review of current CHC processes against DH national Guidance with recommendations for compliance
  • Close working with the CHC Clinical assessment team to understand decision making and support them in fulfilling the PCT responsibility for CHC, often under pressure from patients, families, health and social care providers 
  • Activity and finance monitoring dashboard established to ensure up to date snapshot of current position 
  • Weekly monitoring meetings to review activity and address any issues proactively 
  • Established new acute Hospital Assessment process. Pathway co-designed with hospital staff, full awareness training for staff delivered and implementation. 
  • Review of delayed transfers of care to ensure that CHC assessment not delaying a hospital discharge review of Learning Disability Packages of Care ensuring PCT compliant with DH guidance and case law 
  • Reviewed fast track CHC packages for terminal care with reconciliation to community palliative and core community care services. Identified a number of areas for more joined up working and efficiency.

The systematic approach working in an integrated way with the PCT team resulted in a redesign of the CHC processes and re-focus of the team, to provide highest quality patient assessments whilst also recognising the PCT statutory responsibility and financial realities. Spend reduced by £1 million through case by case review and scrutiny and an additional £1.2 million cost reduction identified for 2010/11.

What we delivered

The outcomes included:

  • Reduction in referrals for CHC funding by 40% and reduction on total activity by 23% in year
  • Improved performance in regional and national league tables 
  • Clearer organisational focus and understanding of CHC as a cost driver
  • £1.2 million of savings identified and being released by review of learning disability with challenging behaviour needs
  • Established new acute Hospital Assessment process. 
  • Review of all Out of Area Treatments with repatriation commissioning plans established
  • Introduction of new assessment system into acute hospital and reduction in (appropriate) referrals as ward staff have better understanding of what CHC is
  • Reduced Delayed Transfers of Care from red to green
  • Information led culture with regular monitoring and active problem solving by CHC assessment team
  • Clear understanding for every case the health and social needs and cost of the package of care with clear review dates set
  • Implementation of new information system linking activity and finance 
  • Links to long term care procurement and fair price in anticipation of NHS Community contract
  • Increased confidence in PCT team of the purpose and approach to support patient needs within available resources
  • Closer working with Local Authority recognising differences in interpretation of guidance and increasing pressure on budgets 
  • Development of a CHC needs assessment for adults and children and Predictive Modelling tool.



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