LINCOLNSHIRE

• Good Idea• Good Data• Budget right in first place• Configuration / Clinicians working together

(unscheduled care example) - framework• Succession planning• Risk – size of budget – what bit of the budget• Control of Contracts• Workload / Time• Understanding what we commission• Legislation - passion / will• Locally Sensitive• Governance Framework• Lean & Agile System

Real Budgets in the East Midlands event 8Jun10

LINCOLNSHIRE (cont)

Glass is half full in NHSL !!!

Team engagement

CBSM

Dashboard

-Up for it

-Started bits of it already ( 2 devolved Budgets)

-We feel we are ahead of the game

-Radical

-Break from tradition sky is the limit THINK BIG!

Solve how the budget works GMS / PMSSuccession Planning

Will / Desire

Buy in from all GP’s

Framework / levers

Budgets right

Scale up

Real Budgets in the East Midlands event 8Jun10

NOTTINGHAMSHIRE COUNTY

What do we need?• Legal entity & form, set up costs• Managing internally – rules of engagement & sanctions for underperformance• Rules for performance management• Data & intelligence – is this good enough to sign the cheque?• Clarity over direction of travel ? No longer clear commissioning / provision split• Incentives for providers• ? Tariffs for whole pathways of care• Less income = less capacity to do anything but the “day job” so incentives to engage essential • Infrastructure

Real Budgets in the East Midlands event 8Jun10

NOTTINGHAMSHIRE CONTY (cont)

• ? Liability for overspend• ? 1 year “break even” no longer 3 years• Shared incentives with providers including secondary care shared targets• Threshold for tendering• Need to move from small scale risk-averse to large scale impact = higher risk, permissive culture• Huge reduction in management capacity• What % of the total PCT budget – including (PCT) management?• How big to influence provider behaviour vs how small to keep everyone engaged & local perspective?

Real Budgets in the East Midlands event 8Jun10

NOTTINGHAM CITY & BASSELAWINFORMATION ORGANISATION

How to make data fit for purpose?What will budget be:HistoricalWhat are the sanctions?What’s wrong with current PBC toolkit?How do we deal with outliers?Who will negotiate prices?

• Dependent on willingness to become engaged (size)• Like minded or Geographical• Economies of scale – size does matter• Consortia SLA to negotiate• Who regulates consortia? • Governance

CLINICAL ENGAGEMENT TRANSACTIONS

What do GPs want to do?How will internal practice opinions be managed?How will we manage secondary care?Leadership vs followshipOwnership vs commitment

• EU Procurement• Managing conflict• Organisation more commercially savvy• Private industry “Boots”• Join commissioning with social care

Real Budgets in the East Midlands event 8Jun10

DERBYSHIRE COUNTY

Answer from task 1:

Tiered approach• levels of risk sharing• choice for clinical consortia• Increasing autonomy & Increasing responsibility • 2 dimensions size “federation”

size “super-federal”

responsibility & autonomy• Decision devolved to lowest possible level & nearest to problem & delegate upwards issues that need to be shared subsidiarity• Networks of shared interest i.e. all consortia coming together to negotiate with acute provider • Consortia contract for commissioning expertise on an ‘agency basis’, ‘chambers’, ‘virgin’ or ‘BUPA’• Would need a governance framework to act as a safety net in case of market failure of commissioner or providers• Would also want to retain some of benefits of larger organisations & joint working

Real Budgets in the East Midlands event 8Jun10

DERBYSHIRE COUNTY (cont)Key Issues - ‘Hard’ budget #1

a. What happens when you overspend?

b. Need to completely disentangle & fully understand budget (how possible?)

how do we disentangle block contracts?

c. Link GMS/PMS prescribing & commissioning as whole – risk assess, due diligence & go

d. Issues of time, capacity & skill to do this

e. How do we manage conflict of interest in whole budget’?

f. Revolution may be unrealistic & undoable – Evolution may be option – currently GPs manage services & risk

g. How do we make the difficult decision to close the local hospital?

h. What are the transaction & management costs of operating this system?

Real Budgets in the East Midlands event 8Jun10

DERBYSHIRE COUNTY (cont)

Key Issues - ‘Hard’ budget #2

i. Solution – give clusters the budget & they will disentangle

j. Benefits in joint working & a federated approach – spread best practice

k. Increased management costs offset by reduced duplications

l. Not a vehicle for equity but a vehicle for innovation – will this be politically acceptable? & to the public?

Real Budgets in the East Midlands event 8Jun10