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
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 climateequaling
gains of £3.6-7.8 billion per year.
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
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 organisationsboth
public and privateis 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
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 Groupa 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 Redesignreconfiguring
the health care delivery system to support the highest quality
and most efficient individual clinical needs
Contracting and Performance Managementdefining
and negotiating contracts, managing relationships with acute and
community providers underpinned by robust and evidence based data
Population Health Managementimproving
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
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.
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 millionwith
an additional £15.9 million projected savings through initiatives
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 implementedand
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
UnitedHealth have worked alongside Membership
Engagement Services (MES) to implement this Model within NEL CTP.
To roll-out the community engagement strategy,
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
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
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
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
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
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
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
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."
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 functionsbuilding an evidence base and using
that evidence to redesign and integrate care pathways and programme
managementwill 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.
69 Appleby et al. (2009) How cold will it
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