Commissioning - Health Committee Contents

Memorandum by UnitedHealth UK (COM 92)


  1.1  UnitedHealth UK welcomes this opportunity to submit evidence to the Health Select Committee's inquiry into commissioning within The National Health Service (NHS). The purpose of this note is to comment on the role that effective commissioning should play in ensuring high quality outcomes for patients and efficiencies within the NHS; the role of the private sector in supporting Primary Care Trusts (PCTs) and Practice Based Commissioners enhance their commissioning capabilities; and evidence that demonstrates that UnitedHealth UK is already working in partnership with the NHS to deliver results.


  2.1  For 60 years, the NHS has provided comprehensive access to primary and acute care services to all long-term residents of the United Kingdom (UK). Free at the point of care and financed through a progressive tax code, the NHS is one of the oldest examples of an attempt to reduce individual inequity of access to a desired good-health.

  2.2  However, as with many other health systems throughout the world, it faces significant financial pressure caused by changing demographics, technological advances, and increasing individual patient expectations.

  2.3  While the NHS budget grew on average at 7% per year in the last century, a recent report published by the King's Fund predicts that the NHS would have to increase productivity by 3.4 to 7.4% in order to fill potential funding gaps as a result of the worsening fiscal climate—equaling gains of £3.6-7.8 billion per year.[69] The increasing burden of chronic disease, the tendency for people with chronic illness to have multiple co-morbidities, and the rapidly aging societies of the industrialised world compound the fiscal challenges facing the NHS. For example, in the UK there are more than 15.4 million people living with long-term conditions. This number is expected to increase 23% over the next 25 years. Further, evidence from a number of PCTs shows that a small percentage of patients (from 5 to 10%) drive more than 40% of NHS costs.

  2.4  Improved commissioning, managing clinical-care pathways, and using care-management strategies are among the best options for organising and financing an NHS that can meet today's health care challenges. In the Next Stage Review, Lord Darzi established a 10-year vision for an NHS that is fair, personalised, effective, and safe. World Class Commissioning (WCC) is an essential component in establishing policies that spread this vision across all PCTs and communities.

  2.5  Automated technologies that enable use of patient, provider, and population data regarding quality and cost means that commissioners can make decisions based on real-time evidence. Providing commissioners with support from expert organisations—both public and private—is a key strategy to making evidence-based commissioning a reality.

  2.6  With a wide and ambitious range of high-level policy objectives, public-private partnerships that improve NHS commissioning provide a powerful lever to build consistency among objectives and initiatives; to create innovative solutions within the NHS itself; and to translate policy into meaningful health improvement for patients.

  2.7  The range of Department of Health (DoH) goals and initiatives combined with the current financial outlook necessitate strong organisational capabilities that produce meaningful productivity and quality improvements. Specifically, initiatives advanced by public-private partnerships include: WCC; Practice Based Commissioning; Integrated Care; Expanded Consumer Choice and Provider Competition; Quality, Innovation, Productivity and Prevention (QIPP); The Quality and Outcomes Framework (QOF); and Public Reporting of Quality Data.

  2.8  Through risk-sharing arrangements and other mechanisms, UnitedHealth helps PCTs to implement the strategies that we recommend. While these are still in early stages of development, initial evidence suggests that more time and increased project-scale can produce outcomes consistent with the WCC agenda, and all WCC competencies.

  2.9  Through collaboration with private companies and building on the work already underway in the NHS to commission health services, the NHS has a unique opportunity to harness the capabilities and experiences of the private sector to help it deliver improved outcomes for patients.

  2.10  As such, we believe that external contractors that implement practical solutions should be viewed as an integral part of reform and used to their full capacity to: improve use of data; redesign clinical care pathways; drive evidence-based policymaking and adherence to clinical standards; transfer knowledge and performance management techniques; and empower patients to make informed choices.


  3.1  UnitedHealth UK is the UK company which forms part of UnitedHealth Group—a leading international health and well-being company that commissions care and provides health management services to over 70 million individuals.

  3.2  UnitedHealth UK has been working in partnership with the NHS since 2002, drawing on our global expertise and experience to deliver commissioning and health management solutions with all parts of the NHS, including DoH, Strategic Health Authorities (SHAs), Specialised Commissioning Groups (SCGs), PCTs, and Practice Based Commissioners (PBCs). UnitedHealth UK also holds five Alternative Provider Medical Services (APMS) contracts for GP and primary care services.

  3.3  We believe that world class commissioners proactively orchestrate health systems to ensure continuous improvement in health outcomes for their local population. To do this, they need to be underpinned by information technology and tools to drive evidence based practice and to measure, improve, and report health outcomes and patient and public engagement.

  3.4  Our work with the NHS includes the provision of the tools, people, and processes to support four key areas:

    —  Population Health Needs Assessment - understanding the specific needs of a local population, the healthcare community, providers, and individual patient needs

    —  Clinical Services Redesign—reconfiguring the health care delivery system to support the highest quality and most efficient individual clinical needs

    —  Contracting and Performance Management—defining and negotiating contracts, managing relationships with acute and community providers underpinned by robust and evidence based data

    —  Population Health Management—improving the effectiveness of care delivery for individual patients through proactive interventions and empowering patients through the provision of information and decision support programmes

  3.5  There are a number of key principles which underpin the work we do with the NHS to support best practice commissioning that can deliver real value:

    —  A culture of using data to drive decision making (and the skills and tools to identify sources of data, to clean, and to improve this data) and the skills and competencies to systematically use data as part of operating within a PCT/Practice Based Commissioning Group.

    —  Use of evidence based practice to underpin commissioning decisions. Despite high quality tools available to PCTs (eg National Institute for Health and Clinical Excellence (NICE) Commissioning Guidelines and Map of Medicine), these are not systematically used within the NHS to support commissioning.

    —  Technology infrastructure and enablement that supports PCTs/PBCs to bring together disparate sources of information (eg SUS data, GP data, census information) and layers intelligence upon it (eg Evidence Based Medicine rules or population based risk stratification tools) to enhance decision making.

    —  A culture of delivery and execution: identifying outcomes, performance managing implementation, bringing robust and rigorous programme management, and driving rapid change.

  3.6  UnitedHealth UK is an approved supplier under the DoH Framework for Securing External Support for Commissioners (FESC). To date we have worked with up to 60 PCTs. Some of our key FESC work includes partnerships with the following PCTs: Northamptonshire PCT, Northeast Linconshire PCT, Berkshire West PCT, and the South Central Specialised Commisisoning Group. For some of these contracts we have taken risk, meaning we do not get paid our fees unless we drive savings for the PCTs.


  4.1  The following case studies provide examples of partnership working already underway to enhance NHS commissioning.

Case Study: Northamptonshire Primary Care Trust


  UnitedHealth holds a three-year contract with NHS Northamptonshire (NHSN) under FESC. The contract has four major work streams in the initial year, including: (1) health needs assessment; (2) performance management; (3) patient experience; and (4) communications and social marketing. UnitedHealth staff are partnering with NHSN staff on each of the work streams, drawing on support from UnitedHealth Group solutions and data analytic capabilities from the US.

Core Objectives and Outcomes: What is being Done?

  June 2009 marked the end of the first year of the contract. Whilst it would be early to expect substantial quantitative results, there have been achievements that provide insight into the potential impact of the FESC partnership arrangement.

Health Needs Assessment

    —  UnitedHealth is undertaking an in-depth assessment to determine the health needs, disease burden health access inequalities and outcome inequalities of the population. The assessment has started to specify investments necessary to improve health outcomes. Specifically, health needs assessments and equity audits were carried out in five NHSN priority areas: heath failure, stroke, COPD, diabetes, and maternity. The team has deployed actuarial modelling techniques not traditionally been used in this sphere in the NHS.

    —  The team are working together to redesign a care pathway for patients with Cardio Obstructive Pulmonary Disease (COPD). Using international best practice, the pathway is based upon analytical data and will include an accelerated consultation process, which will become a model for other clinical services redesign.

    —  UnitedHealth prepared a Programme Budgeting Marginal Analysis report, which builds a systematic approach to identify areas for the PCT to drive efficiency and improve health outcomes.

Performance Management

    —  UnitedHealth has implemented sophisticated acute invoice validation (AIV) tools to increase programme efficiency. AIV confirms that payments are consistent, not only with the services provided, but with care according to evidence-based standards. AIV and clinical audits have already contributed to £144,000 of savings within the first few months. Manual audits of coding and clinical practice already completed or scheduled are expected to produce £1.07 million between July and December 2009.

    —  The team has developed a savings work plan that has identified savings of £6.9 million—with an additional £15.9 million projected savings through initiatives under development.

    —  A monthly validation tool (MVT) that can be use as an early warning system to identify data quality and coding issues for the Trusts was developed and implemented—and is projected to return £1.3 million in savings each year.

    —  Data system enhancements were implemented, allowing an automated transition from quarterly to monthly health care utilisation data. This change has not only enabled more timely use of data for intervention, but has assisted the PCT in meeting the national reporting target.

Communications and Social Marketing

    —  UnitedHealth developed the thrive worksite wellness programme; a targeted, data-driven employee wellness strategy designed to improve and maintain employee health. Phase 1 of thrive was launched in May 2009 and specifically targeted at NHS Northamptonshire employees.

    —  Phase 1 of thrive was launched in May 2009 and specifically targeted at NHS Northamptonshire employees. Staff were invited to undergo an individual health needs assessment and respond to a cultural health audit. Based on employee feedback, Phase 2 of the programme will provide each participant with a "Personalised Wellness Programme", enabling staff to track their own health statistics over a period of time. The Wellness Programme will include weight and hypertension management, as well as opportunities to participate in physical activity and wellbeing programmes.

    —  Nearly 75% of staff participated in the thrive health needs assessment and approximately half completed the cultural health audit. The programme aims to sign up 100 employees to the personalised wellness programme by September 2009. The success of thrive will be measured on a regular basis by using different comparisons against the baseline data compiled at programme commencement.

    —  UnitedHealth will work with the organisation to target a broader range of stakeholders within the local health economy and NHS Northamptonshire priority groups.

Case Study: Northeast Lincolnshire Care Trust Plus (CTP) and Community Engagement


  North East Lincolnshire Care Trust Plus (NEL CTP) commissioned United Health UK to support the development of a community engagement model. The CTP is comprised of 177,000 residents served by 33 General Practitioner (GP) practices. The initiative uses a community-membership model to involve stakeholders, including patients, in decision-making and learn about the preferences of the population of North East Lincolnshire. The stakeholder engagement initiatives established make a special effort to include "hard-to-reach" and vulnerable groups.

Core Objectives and Outcomes: What is being done?

  To implement the model, UnitedHealth supported the CTP in the election of 18 public representatives to the emerging `Commissioning Group Boards'. The representatives are elected from a community membership group of 2,200. Seven of the elected representatives sit on Commissioning Group Boards where they will have a majority vote in the commissioning decisions of the CTP. Any member of the community is eligible to join the larger community-membership group.

  UnitedHealth have worked alongside Membership Engagement Services (MES) to implement this Model within NEL CTP.

  To roll-out the community engagement strategy, UnitedHealth staff:

    —  Developed a Community Engagement and Accountability Framework;

    —  Recruited Community Engagement Workers;

    —  Developed draft volunteering and reimbursement policies; and

    —  Launched a of mass community membership outreach plan, including mailing letters to all households and hosting `roadshows.'

Next Steps

  Next steps include setting up a NEL CTP community engagement resource bank; developing a comprehensive Communications Plan; agreeing on performance metrics; and developing a process for gathering continual evidence on the effectiveness of community engagement initiatives and how these initiatives can feed into the commissioning of the most appropriate health care.

Case Study: South Central Specialised Commissioning Group


  UHUK works with South Central Specialised Commissioning Group (SCSCG) under a FESC contract to improve commissioning for specialised and acute-care services with 17 London hospitals. Representing 3.9 million patients in the geographical areas of Buckinghamshire, Hampshire, Berkshire, Isle of Wight, and Oxfordshire, SCSCG commissions care for the population and meets regularly with providers and stakeholders to strategically address and measure quality improvement.

  Historically, PCTs determined their contract budgets largely based upon prior experience, rather than through an analysis of population health risks and appropriate case-related hospital payments. Currently and in line with WCC, UHUK is working with SCSCG and London hospitals to move toward a system that pays for and measures quality and efficiency.

Core Objectives and Outcomes: What is being done?

    —  Programme Management. UHUK staff manage contract negotiation and other aspects for provider relationships with the London hospitals.

    —  Reporting. UHUK works with hospitals to improve monthly submission of consistent and high quality cost and utilisation data. UHUK is also developing a provider handbook comparing prices and bundles of services at the Health Resource Group (HRG) level. Monthly reporting has been achieved and based on the data, performance reports have been developed for each individual PCT and individual action plans have been created for each provider.

    —  Knowledge Transfer. UHUK staff, who physically work within the SCSCG offices, share business practice and arrange staff training sessions on a range of commissioning-related issues.

  Currently, UHUK is actively pursing quality and price data that will be used to compile standard cost and outcomes data and specify components of episode-based payment across hospitals. This capability will enable UHUK together with the SCSCG to advance a strategic quality improvement plan for the patients in the partner PCTs.


  5.1  To achieve the goals of improved quality and access while meeting important productivity and efficiency targets, successful commissioning with tested external organisations should be continued and expanded.

  5.2  The current fiscal climate and quality improvement agenda suggest an increasingly important role for good health care commissioning. Public-private partnerships can provide an essential component of improved commissioning, providing strategic needs assessments, improving data capabilities and usage, redesigning care pathways and measurement, and improving provider contracting and performance management.

  5.3  The fundamental success of WCC depends upon a number of key themes, including:

    —  Creating a culture of using data to drive decision making (with skills and tools to identify sources for, to clean, and to improve data) and the skills and competencies to systematically use data as part of PCT and Practice Based Commissioner operations.

    —  Using evidence based practice to underpin commissioning decisions.

    —  Bringing technology infrastructure and enablement that supports PCTs and Practice Based Commissioning Groups to bring together disparate sources of information and layers intelligence upon it to enhance decision making.

    —  Creating a culture of delivery and execution.

    —  Bringing willingness to take risk and to be paid on the basis of results.

  5.4  A new Cabinet Office review of DoH activity praised improvements made, but suggested that it also improve the coherence of its vision. Areas for improvement cited in the review included to the need to: "select direction; build capability; focus on outcomes; base choices on evidence; develop clear roles, responsibilities and delivery models; and ignite pace, passion and drive."[70]

  5.5  Based upon the evidence provided, these "areas of needed improvement" overlap with the value that private sector support can bring to enhance commissioning in the NHS. Therefore, focusing private-sector involvement on these core functions—building an evidence base and using that evidence to redesign and integrate care pathways and programme management—will provide the greatest gain from a public-private sector strategy, pulling the themes of reform together within an action plan.

  5.6  Allowing private companies more autonomy with commensurate increases liability for savings and quality improvements will bring increased value within limited budgets. FESC is unique in setting out a framework that allows for true partnership, for private companies to share risk and not simply to take fee for service payments for traditional consulting. There is significantly more value for the NHS in adopting this model for its relationship with private partners going forwards.

  5.7  PCTs are not always able to build critical mass to be world class commissioners and to invest in the enablement infrastructure required to support this on an individual basis. Private companies can strengthen commissioning by providing enablement across multiple PCTs. This infrastructure needs to include enhanced informatics and other automated technologies that enable improved data collection and analytics; improved actuarial capabilities; population management techniques and robust evidence base. If this can be coupled with rigorous programme management, then the partnership between private organisations and the NHS will ensure that commissioning becomes truly world class.

September 2009

69   Appleby et al. (2009) How cold will it be? Prospects for NHS funding: 2011-17. The King's Fund. Back

70   Civil Service Capability Reviews. (2009) Department of Health: Progress and Next Steps. Back

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