Equitable Access in Primary Medical Care Workshop 2 Invitation to Tender ITT

1
Equitable Access in Primary Medical CareWorkshop
2 Invitation to Tender (ITT)

• NHS North East
• Riverside House
• Wednesday 7th May 2008

2
Welcome and Introductions

• Cathy Pickles, Programme Manager Middlesbrough
  PCT

3
Purpose of today

• To provide you with an enhanced understanding of
• Commercial principles that inform the Invitation
  to Tender (ITT) for GP Practices and GP- Led
  Health Centres
• The standard ITT Documentation and how it secures
  services outcomes
• How to adapt template documents to meet PCT needs

4
AGENDA
5
Improving GP AccessMike Warburton National
Programme Director for GP AccessDepartment of
HealthEquitable Access in Primary Medical Care
Workshop 2
Invitation to Tender (ITT)

6
National support for improving GP access

• Local Procurements of GP Practices and Health
  Centres

• Extended Hours DES - 50 of practices providing
  extended hours by Dec 2008

• Wider access issues and responsiveness as
  measured by the new National GP Patient Survey
  e.g. BME, Specific patient groups

7
Improving GP Access
Procurement support
SHAs
National Support Programme
Support Team
Mike Warburton Philip Walker
Commercial Partnership Managers (CPMs)
Commercial James Gold Rupert Dunbar-Rees Jatinder
Garcha
Policy John Taylor
PASA Commercial Development Managers (CDMs)
Primary Care Contracting Advisors (PCCAs)
Mailbox equitableaccess_at_dh.gsi.gov.uk
PCTs
PCT Procurement Framework www.dh.gov.uk/procurem
entatpcts
Regional master-classes
Support to regional bidder days
NHS Peer Support
8
Extended hours support

• Primary Care Contracting (PCC)- regional
  workshops to support implementation (supported by
  DH)
• Do PCTs/SHAs need any further support?

9
National support for wider access issues and
responsiveness

• Three broad areas of support
• Primary Care Commissioning to improve access -
  sharing of best practice
• Developing a central resource of current best
  practice- including capacity planning and
  process, skill mix, practical solutions,
  leadership and practice manager role
• A programme to share and support implementation
  of best practice
• Initial discussions held with Improvement
  foundation, NHS Institute, RCGP, NAPC, NHS
  Alliance - prior to further discussion with SHA
  primary care leads

10
Progress update on local procurements of GP
practices and health centres
11
Progress

• Some excellent work to date but still a big
  challenge ahead to deliver within timescales
  (consultations, ITT etc)
• Procurement Framework launched at national
  conference in December 08 followed by regional
  master-classes and knowledge days (legal and
  commercial issues)
• Majority of SHAs confirmed PCTs have met
  milestone 1 and that specifications meet core
  criteria (with a handful of exceptions)
• SHAs and PCTs currently arranging information
  days for all prospective providers
• Developing several new pieces of guidance
  (including FAQs) and reviewing support
  arrangements anymore FAQs to
  equitableaccess_at_dh.gsi.gov.uk

12
Next steps

• Adverts and MOIs placed by 16 May
• SHAs continue to identify potential
  front-runners i.e. practices and health centres
  open before Dec 2008
• Work with NHS to develop communication and
  engagement strategy and further support
  arrangements
• Innovations in primary care workshop end of
  April to share best practice examples
• Guidance on Health Centre payment mechanism to be
  published shortly
• Guidance being developed on safeguards/protocols
  for contracting with secondary care providers for
  list-based services

13
Setting the Context of Today
James Gold Programme Lead
(Procurement) Commercial Directorate7th May
2008
14
Where we are today

• NHS Interim Report Our Health, Our Future
  October 2007
• Equitable Access website 12 Dec 2007
• National programme launch 13 Dec 2007
• Workshop 1 24 January 2008
• Knowledge workshops Feb 19th and 26th 2008
• Milestone 1 SHA Sign Off 29 Feb 2008

15
Knowledge Sharing Today

• Themes covered in today's workshop are
• Commercial Strategy
• ITT
• Consultation

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PCT Procurement Framework

• Template and Guidance Documentation relevant to
  todays Workshop
• Guidance Papers Template Documentation
• Consultation Guidance
• Project Specification template
• Commercial Strategy Framework and
  Provision Clarification Question form template
• Guidance for GP Practices and Health Centre
• Addendum
• Clarification Question Guidance Clarification
  Question log template
• Conflicts of Interest Guidance ITT Volume 1
  template
• ITT Volume 2 template
• ITT Volume 3 APMS Contract Template
• ITT Evaluation Plan template

17
Whats New?

• New guidance and documentation is now being
  developed for
• Evaluation
• Health Centres
• FAQ Database (to be updated on a regular basis)
• Conflicts of Interest
• Vertical Integration
• And will be made available on the Equitable
  Access web site (www.dh.gov.uk/procurementatpcts)

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The Commercial Strategy Guidance on Health
Centres James Gold Commercial
DirectorateRupert Dunbar Rees Commercial
Directorate
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Equitable Access - Core Criteria

• GP practices
• Core GP services
• List size of at least 6,000 patients
• Extended opening hours (minimum of 5 hours per
  week)
• Plan to be a accredited training practice
• Engaged in practice based commissioning
• With extended (and overlapping) practice
  boundaries

• Health Centres
• Core GP services
• Easily accessible locations (e.g. reflect
  commuter needs)
• Open 8am-8pm, 7 days a week
• Bookable GP appointments and walk in services
• Registered and non-registered patients
• GP-led

Diagnostic services Community pathology Radiology
Audiology
Specialist services Minor surgery Dermatology Chro
nic pain GU medicine
Rehabilitation COPD Chronic pain Orthopaedic Strok
e care
Local flexibilities will enable PCTs to maximise
innovation by integrating and co-locating health
centres with other services
Social care
Pharmacy services
Palliative care/ end of life care
Urgent out-of-hours care Dental services
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Payment Mechanisms

• Health Centres
• PCTs to choose
• Need for flexible payment mechanism to cope with
  registered/unregistered patients
• Steer towards mechanism based on payment for
  Registered List plus Volumes for unregistered
  Walk-in
• Consider before choosing
• Provider Behaviour/Cost- Neutrality
• Volume Estimation issues
• Growth of Registered list base from zero

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Patient Pathway

• Health Centres
• Registered Patient Component very similar to GP
  Practices
• PCTs determine offering to Unregistered Patient
• Need to carefully consider issues arising
• Front-end experience
• Information handover
• Clinical considerations
• Registered List obligations- Day Home Visits,
  QOF, recall

22
ITT DocumentationVolume 1 and 2 Jatinder
Garcha Commercial DirectorateRupert Dunbar-
Rees Commercial Directorate
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PCT Procurement Handbook

• Invitation To Tender (Step 11)

• Resource Guide
• Expertise
• Project Management
• Clinical
• Commercial
• Financial
• Legal
• Workforce/IMT/Estates
• Documents
• ITT Volume 1 2 Templates
• ITT Volume 3 (Contract) Template
• ITT Evaluation Plan Template
• ITT Mid-Tender Meeting Guidance
• CQ Log template
• Completed PQQ Evaluation Report Template
• Time
• 50 MD

Objective To compile ITT

• Tasks to complete
• Develop appropriate local, clinical, workforce,
  estates, IMT, legal, commercial and financial
  specifications and requirements
• Complete Invitation To Tender (ITT) Volumes 1
  (Process Overview and Guidance to Bidders) and
  ITT Volume 2 (Requirements and Bidder Responses)
  Templates with detailed project specifications
  and bidder requirements
• Complete ITT Volume 3 (Contract) Template (see
  Step 12)
• Develop associated ITT Evaluation Plan with
  short-listing methodology using ITT Evaluation
  Plan Template
• Issue ITT to short-listed bidders from
  Evaluation of PQQ (Step 10) using completed PQQ
  Evaluation Report Template
• Hold meeting with bidders after issue of ITT to
  clarify detail ITT specifications and
  requirements using ITT Mid-Tender Meeting
  Guidance
• Log and respond to any bidder clarification
  questions using CQ Log template

Outcomes Finalised ITT sent to short-listed
bidders Completed ITT Evaluation Plan
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PCT Procurement Handbook

• APMS Contract (ITT Volume 3) (Step 12)

Objective To set out the contractual terms for
the procurement

• Tasks to complete
• Reflect the commercial requirements of the
  completed ITT Volume 2 Template in the Contract
  Template
• Review and complete the Front End of the
  Contract Template
• Complete all Schedules in the Contract Template
  with particular reference to
• Schedule 2 (Service Specifications)
• Schedule 3 (Payment Mechanism)
• Schedule 4 and 18 (Workforce and Training
  Specifications)
• Schedule 7 (Performance Management and Key
  Performance Indicator Specifications)

• Resource Guide
• Expertise
• Legal
• Commercial
• Clinical
• Financial
• Workforce/IMT/Estates
• Documents
• Contract Template
• Completed ITT Volumes 1 2 Templates
• Time
• 40 MD

Outcome Issue ITT Volume 3 (Contract) with ITT
Volumes 1 2 to bidders (see Step 11)
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ITT Documentation

• Volume 1 Process Overview Guidance to Bidders
• Introduction and Overview
• Purpose, Structure Next Steps for Bidders
• ITT to Contract Signature
• Procurement Rules
• Instructions on completing the ITT
• Administration
• Glossary

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ITT Documentation (contd)

• Volume 2 Requirements Bidder Responses
• Structure Organisation
• PCT Scheme Overview
• Clinical Quality Requirements
• Workforce
• IMT
• Premises
• Facilities Management
• Equipment
• Commercial Financial
• Contract Management
• Compliant Bid
• Glossary
• Annexes

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Key Elements of ITT Evaluation

• Evaluating the bidders proposals to meet PCT
  service requirements
• There are four key elements to the ITT
  Evaluation
• The ITT evaluation process should be documented
  in the ITT Evaluation Plan

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ITT Evaluation Performance Element Example
Weightings
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PCT Scheme Overview - Local IntegrationVolume 2,
Section 2

• Covers the PCT Scheme Requirements
• Description of the Services to be procured
• Patient Volumes, Contract Length and General
  Requirements
• Allows the PCT to ask specific questions on the
  proposed model of service delivery
• How they will integrate with local services
• How they will participate in PBC
• Heavily weighted for Fairness in Primary Care
  will have a great influence on evaluation outcome

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Clinical Quality Requirements Volume 2, Section
3

• Patient Centred Care
• Access and Convenient Services
• Appropriate/Responsive Care
• Clean and Pleasant Environment
• Safe Delivery/Learning Environment Leadership- 3
  roles
• Effective Delivery

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WorkforceVolume 2, Section 4

• Organisation- Management Structure Chart,
  Staffing, Policies, HSE
• Recruitment Policy, Competency Assessment,
  ScreeningBBV
• Leadership and Governance Structure
• Registration- GMC, NMC, HPC
• Qualifications- (MRCGP)
• Induction, Resuscitation, (Training),
  Supervision, Appraisal

32
Building clinical quality requirements into the
contract Rupert Dunbar- Rees, Clinical Lead-
Commercial Directorate
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Purpose of this session

• To help you put the clinical requirements at the
  heart of this procurement, we plan to provide
• A high level clinical perspective
• Guidance on preparing a robust clinical
  specification for the Invitation to Tender and
  Contract
• Aim to tie together needs assessment, clinical
  innovation, and outcomes for whole LHE

34
A clinicians perspective

• Were not talking about buying more of the same
• Its vital to set up requirements to suit our
  populations needs
• The core criteria are designed to encourage
  innovation
• Onus on the commissioner to ensure service meets
  needs
• We have a duty of care to ensure safe delivery of
  clinical services
• Needs to be a flow of Clinical Quality
  Requirements and Governance through each stage of
  tendering process to ensure meaningful patient
  benefit and a safe provider

35
Complete Clinical Specification

• High quality clinical services
• Patient centred and value for money, primary
  medical care services, delivered in a safe and
  effective manner, through a learning environment
• Clinical specifications submitted under
  affordability model define
• what services
• Patient Volumes
• Service Requirements (e.g. Additional Services)
• DES / LES / NES
• amount of services
• Affordability Model
• but little detail on quality/governance
• See Section 3 Clinical Quality Requirements ITT

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Clinical Quality Requirements

• Patient Centred
• Access and Convenient Services minimum access
  requirements- appointments, equity (Hard to
  Reach), translation, convenience
• Appropriate/Responsive Care ID key patient
  groups/needs, continuity of care issues, children
• Clean and Pleasant Environment dignity, respect,
  gender, confidentiality, infection control
• Safe Delivery/Learning Environment Governance,
  clinical safety, SEA/informatics, incident
  reporting
• Effective Delivery SBH, QOF plus, training
  accreditation, health promotion, prescribing and
  referral monitoring, Urgent Care/OOH integration

37
A Patients Perspective

• GMS vs APMS
• Vastly improved access- Practices open longer (at
  least 5 hours/week) and gt35 hours each GP
  consulting per 2000 patients, HC open 8-8 7/7
• KPI Eg. Any GP in less than 48 hours- guaranteed
  or provider loses 75 on KPI
• gt95 chance of waiting less than 30 minutes, or
  provider loses on KPI
• Specified GP in less than seven working days
• Able to book more than four weeks in advance
• Right skill-mix/Continuity of Care Strategies
• Patient Designed Services
• Patient central to whole process, tailored health
  promotion to locality
• Increased choice of appropriate services (and
  provider cant opt-out)

38
Quality Control for the patient

• All referrals audited and learning needs
  addressed
• Prescribing monitored and learning needs
  addressed
• All significant events risk stratified, actioned,
  reported
• Collection of patient safety data- infection
  rates etc.
• Any actions identified above implemented
• GP Practices deemed sufficiently high quality to
  train new GPs
• Using APMS model this all happens because the
  contracting and payment mechanism enforces it
• Nothing is optional for the provider
• Translates all of what you hear about today into
  meaningful patient benefits- gold standard
  practice
• Quality Control - Safe Commissioning/Governance/Pr
  ovider

39
Outcomes Options

• Opportunity for PCTs to consider whole LHE
• Prescribing ensure appropriate prescribing
• Referrals continuous improvement
• Admission reducing unplanned admissions
• Out-of-Hours Integrated approach
• KPI/data recording supports measuring outcomes
  against previously identified needs
• Ultimate outcome improvements -
  morbidity/mortality
• Opportunity to engage with existing providers

40
Aim and Objectives for the Equitable Access
procurement

• Our aim is to
• Improve quality and safety
• Extend access
• Tackle inequalities
• Objectives
• Build on the best local pathways from
  across the Region.
• Innovate to match patient and
  population needs
• Reduce Variability
• Improve our responsiveness to patients
• (Damian Riley Slide Yorks and Humber Bidder Day
  10/04/08)

41
Outcomes and Innovation

• Improvement in QOF overall and in former practice
  in particular
• Improvement in patient satisfaction overall
• Improved early identification and management of
  long term conditions
• Community development approach
• Creativity in using opportunities of walk-in
  unregistered patients to improve the overall
  satisfaction and outcome for patients across the
  district
• (Helen Hirst Slide, Bradford and Airdale PCT
  Yorks and Humber 10/04/08)

42
ITT DocumentationVolume 3 APMS ContractJames
Gold Commercial DirectorateRupert Dunbar
Rees Commercial Directorate
43
Volume 3 APMS Contract

• Structured as follows

• Schedule 10 Complaints Procedure
• Schedule 11 Administration
• Schedule 12 Particulars Leaflet
• Schedule 13 Exit Plan
• Schedule 14 Operational Management Plan
• Schedule 15 Termination
• Schedule 16 Approved Subcontractors
• Schedule 17 Training
• Schedule 18 Staff Transfer

• Main Body - Contract
• Schedule 1 Definitions
• Schedule 2 Services
• Schedule 3 Payment Mechanism
• Schedule 4 Workforce
• Schedule 5 IMT
• Schedule 6 Premises
• Schedule 7 Performance Management
• Schedule 8 Change
• Schedule 9 Insurance
• If you want it, it has to be in the contract

44
APMS Contract Main Body

• APMS Directions 2008
• Planned APEX Contract
• Variation to Provider Arm Requirements

45
Invitation to Tender and APMS Contract

• Clinical Sections of ITT/Contract
• Volume 2- Workstream Requirements
• (Section 3) Clinical Quality Requirements
• Volume 3- The APMS Contract
• Schedule 2
• Part 1-Service Requirements (CQRs in contract
  form)
• Part 2- GP Practice Service- Hours, Boundary
• Part 3- Essential, Additional and Enhanced in
  contract form
• Part 4- QOF
• Schedule 7- Performance Management/KPIs

46
Schedule 2, Part 1 General Service Delivery
Requirements

• Equity of Access
• Patient Dignity and Respect
• Obtaining Informed Consent
• Obligations relating to Children
• Prescribing Obligations
• Clinical Safety and Medical Emergencies
• Good Clinical Practice
• Medical Equipment
• Obligations relating to Infection Control
• Referral Process
• Health Promotion and Disease Prevention
• Adverse Incidents

47
Schedule 2, Part 3 Clinical Service
Specifications

• Essential required for Registered Patients who
  are ill but likely to recover, terminally ill or
  suffering from long term conditions
• Additional contraceptive services, maternity
  medical, cervical screening, minor surgery,
  vaccinations and immunisations
• Enhanced examples include weight management,
  smoking cessation, Care of the Homeless, Body
  Mass Index Register, Drug Misuse, Alcohol Misuse
• Directed Enhanced childhood immunisations,
  Access, IMT Adoption, Practice Based
  Commissioning, Choice and Booking
• Critical Issue Relationship with Commissioner /
  Contract Management

48
Payment Mechanism (ITT Volume 3 Schedule 3)

• Payment Overview 000
• 1. SERVICES PAYMENT
• Essential Additional Services Registered
  Patients X Price Per Patient x
• Enhanced Services Relevant quantities X
  National tariffs x
• Locally Enhanced Services Separate Pricing x
• 2. QOF PAYMENT
• As per nGMS Contract x
• 3. PASS THROUGH PAYMENT
• E.g. Premises rent and rates x
• Gross cost to PCT x
• Example
• See Annex 1 in Schedule 3

49
Payment Mechanism (ITT Volume 3 Schedule 3)
(contd)

• Invoicing and settlement
• Provider invoices within 10 working days or less
  of month end (one invoice)
• PCT pays invoice within 20 working days or less
  of receipt or disputes with Provider
• PCT pays undisputed amount within 20 working days
  or less of receipt of invoice
• Parties will work in good faith to resolve
  disputes
• PCT has right of setoff

50
Contract Performance Management (ITT Volume 3
Schedule 7)

• Desired Outcomes
• To drive service quality to the highest standards
  (upper quartile) Band A
• To focus services to address areas of greatest
  need
• To put the PCT firmly in control of the contract
• To minimise the contract management workload for
  the PCT
• Simplicity

51
Payment Mechanism (ITT Volume 3 Schedule 3)

• 1. CASH FLOW
• Core Service Payment 75 x Total Services
  Payment x 1/12
• Performance Services Payment 25 x Total
  Services Payment x 1/12
• QOF Budgeted Qof x 60 x 1/12
• Pass Through Costs Budgeted PTC x 1/12

52
Payment Mechanism (ITT Volume 3 Schedule 3)

• Payments made evenly to assist provider cash
  flow.
• Annual Reconciliation
• Inflation Doctors and Dentists Review Body
  (DDRB)
• Annex 1 Payment and Inflation example

53
Performance Management - Illustration

• Assume a service payment of 100
• 75 is paid to the Provider
• 25 is subject to performance management
• KPIs are split into 5 focus areas
• KPIs are banded

54
Key Performance Indicators

• KPI focus areas
• Access 5 weighting
• Quality 5 weighting
• Service Delivery 5 weighting
• Value for Money 5 weighting
• Patient Experience 5 weighting
• Individual KPIs
• KPI individual weighting within focus area
• Banded performance A, B or C
• Payment Percentage 100, 75 or 25

55
Performance Banding

• Upper Quartile Performance
• 100 Payment Rating
• No Action Required
• Minimum Acceptable Performance
• 75 Payment Rating
• Corrective Action Required
• Unacceptable Performance
• 25 Payment Rating
• Rectification Plan Required
• Sanctions can be applied

Band A
Band B
Band C
56
Performance Management Process

• Month 1 Exception Report
• PCT Review Exception Report
• Month 2 Exception Report
• PCT Review Exception Report
• Quarter 1 Performance Report
• Quarter 1 Performance Percentage
• Quarter 1 Joint Service Review
• Zero list size and transition period
• Annual Reconciliation

57
Performance Incentives

• Quarterly KPI Performance Percentage
• Corrective Actions
• Rectification Plans (at QSR)
• Sanctions (Para 8)
• Reduce individual KPI Performance Band to C
• Reduce Quality KPI Band to C (5 contract value)
• Terminate the Contract
• Self audit
• PCT right to audit

58
Affordability Financial Model TemplateSohin
Shah Commercial Directorate
7th May 2008
59
Contents

• Affordability model
• Financial model template
• Analysis of affordability models

60
Affordability Model

• Purpose
• Staffing costs
• Non-staff costs
• Profit margins
• Risk transfer
• Example

61
Financial Model

• Purpose
• PCT inputs
• Bidder inputs
• Example

62
Comparison of Affordability models and FPC Trend
63
Comparison of Affordability models and FPC Trend
64
Comparison MatrixAffordability Models
65
Question and Answer Session