The Health Systems Support Framework is divided into 10 Lots. Each Lot covers a different range of services. Further detail on the solutions/services available within each of the Lots can be found below.
Provision of advice and support on the development and implementation of a Local Health and Care Record solution infrastructure and surrounding governance including but not limited to:
- Strategy development – working with the STP or ICS to develop their local technology architecture and implementation strategy for interoperability and information exchanges leveraging the national health and care record infrastructure, including but not limited to governance (including IG advice to ensure all data flows have clearly defined purposes and legal bases), user-centric solution design, making the case for change, engaging key stakeholders, identifying and supporting the commissioner to secure funding, identifying key barriers and designing solutions (for example aligning local processes and adhering to national standards), identifying and mitigating key risks and opportunities, supporting data quality improvement (including but not limited to targeted data quality performance reporting, outreach, education, training and other engagement and support to ensure good data quality practice is applied) and providing a detailed plan for transformation and change.
- Implementation support – provision of a project management office and dedicated support to ensure that the new Local Health and Care Record infrastructure is implemented effectively. Support includes but is not limited to supporting and training users, change management (including culture change and business transformation), information governance support (including but not limited to supporting creation and operation of IG policies; capturing and mapping all information assets ensuring GDPR requirements for processing activities are covered; definition of the purposes of data use; Privacy / Data Protection Impact Assessment; creation of data processing agreements, information sharing agreements and Fair-Processing / Privacy Notices; IG governance and compliance advice and assurance; support for the design, implementation and maintenance of organisational, process and technical controls that ensure data security and confidentiality), monitoring utilisation and identifying opportunities for further improvement, benefits management and realisation, call management of services and systems that would have a direct link to the implementation support structure including but not limited to third party suppliers, NHS care providers, private care organisations, local and national infrastructure (N3, CoIN / HSCN), local access services and local care response.
Provision of infrastructure services as an appropriate and secure collection of software, cloud services and / or hardware to enable near real time integration, exchange and storage of patient data as part of a Local Health and Care Record and which provides appropriate read/write access to patient data by actors across a local economy across multiple organisations and EPR solutions in line with overarching architectural standards as defined by NHS England and NHS Digital.
A Local Health and Care Record will consist of a set of technical capabilities with the precise makeup being determined by each ICS / STP in line with national strategy. The precise specification and means of delivery of a Local Health and Care Record that maintains patient security and provides linkages to an individual’s data held in other Local Health Care Records in something that will evolve with our pilot sites, so we are open to propositions that use approaches not fully captured in the characteristics below. The specification will evolve with learning from the pilot sites. The main characteristics of a Local Health and Care Record infrastructure are that they will:
Be designed around user needs;
- Enable the delivery of local, longitudinal care records for the delivery of integrated care;
- Be interoperable so that information can be shared securely (in line with information governance and cyber security requirements) as patients move across boundaries;
- Support directly and / or enable a comprehensive block and incremental feed to dedicated solutions to support multiple individual patient care management, local population health management and de-identified feeds to non-patient care solutions such as business management and clinical research; and
- Provide data for national purposes such as statutory functions and for accessing data held nationally for wider regional use in a standard format agreed across the regions / nationally where appropriate.
The services of a Local Health and Care Record infrastructure must include:
- Shared health and care record – Interface with multiple provider systems across a health and social care economy to receive, link, de-duplicate, normalise and store multiple data sets using NHS Number to form coherent longitudinal patient records. These data sets should consist of structured data with access to other supporting data types as defined by FHIR specifications and support vendor-neutral exchange of other well adopted healthcare industry standards such as CDA and OpenEHR.
- Accommodation to make information available to non-exchange-capable providers – Support a web-based, patient-controlled method to make information securely viewable to providers or other users that do not use an EPR or use an EPR not capable of standards-based data sharing.
- Open APIs – Support for real-time access to data held by a Local Health and Care Record using APIs that support NHS FHIR specifications, RESTful interfaces and OAuth profiles for API security.
- Master citizen index – Support for a citizen index for the local population and for processing leavers and joiners.
- Record location – Support for discovery of what records exist for an individual within a Local Health and Care record and national record locator service using an NHS Number.
- Local event management – Support an event management service and publish/subscribe patterns for sharing event messages, alerts and notifications. Support for a subscription service so an event published by one entity can be sent to other entities based upon a subscription policy.
- National event management – Interfacing with a national event management service where each Local Health and Care Record acts as a publisher and subscriber for an arbitrary set of events defined by a national events authority.
- Access to Local Health and Care Record – Read and write access to patient records held by a Local Health and Care Record by professional and patient facing apps, subject to local access policies with access brokered by the Authorisations service working with key local stakeholders to understand requirements utilising privacy impact assessments and national and local policies.
- Federation broker – Support for a federation broker service for single sign-on so professionals and patients can authenticate to local apps using trusted identity providers. The federation broker to support management of Public Key Infrastructure based trust between entities established by a local trust framework agreement. Support for trust between STP federation brokers to enable cross-STP sign-on to apps and APIs. Support for the OpenID Connect protocol and protocol translation with SAML 2.0 for organisations with existing federated identity services.
- Authorisation service – Support for controlling access to APIs for cross-organisation use cases using an authorisation service that supports the OAuth 2.0 standard and patterns, and by applying data sharing policies and patient information sharing preferences established by local information sharing agreements.
- Information sharing agreement – Support for enabling local provider organisations to maintain control over their data in line with GDPR, how it is shared and used, by supporting machine readable and human readable data sharing agreements and policies. Support for machine readable information sharing policies to be used by the Authorisation service.
- Terminology and code sets – Support for nationally defined SNOMED, LOINC and dm+d code sets by providing a standardised interface for management of terminology used in the data content provided to a Local Health and Care This service will support the interoperability goal for shared semantics.
- Meta data definitions – Support for common meta data specification for patient records to facilitate discovery and matching.
- Directory of services – Support for a directory of services that can be used by providers across a local economy to determine what services exist, to search for relevant services and determine how to access services, via APIs, professional & patient portal access, administrator access.
- Cross STP data distribution – Interface and linking between Local Health and Care Record infrastructures using distributed ledger services for sharing meta data for staff identities, events and patient consent preferences. To ensure that information can be shared in near real time across boundaries between Local Health and Care
- De-id – Support for the policies and process, as per ICO guidelines, to remove potentially patient-identifiable information from a patient’s clinical record so that it can be used for secondary uses by linking with NHS Digital master reference indexes.
- Re-id – Support for re-identification of pseudonymised data in line with NHS policy and guidance.
- Audit – Support for creating entries in an audit log for every access to a patient record within a Local Health and Care
- Data landing – Complementary services for landing data sets into a Local Health and Care Record, such as deduplication, codification from text, data cleansing, conversion of data structure and codes from other standards, e.g. transforming EMIS CRV format to HL7 V3 FHIR, and HL7V3 CDA to HL7 FHIR.
- Personal Health Record (PHR) data exchange – Support for data exchange between EPRs and PHRs (personally held records). To enable patients to provide patient sourced data and for clinicians and providers to share data with PHRs. Data sets should comply with FHIR specifications, ranging from sharing of test results to gathering patient observations and queries.
- Patient accounts – Support for patients to create an online account using a trusted patient identity linked to their NHS Number so they can set consents and other preferences, monitor record access, subscribe to receive alerts and access records and documents.
- Caseload management and workflow – Support for managing cohorts and patients according to pathway workflows so patient care is coordinated between provider organisations.
- Structured medications data – Support sharing structured medications data across all care settings for a variety of uses such as population health management, risk stratification, patient assessment, medications reconciliation, and decision support. Services include support for: Care Connect FHIR standards for sharing structured medications data; read/write access to patient records using FHIR and REST based APIs; dm+d standard; implementation of dose syntax translation as this becomes standardised.
Provision of ICT infrastructure, strategic ICT support services and ICT outsourcing, including in a Primary Care setting, in line with GP IT best practice and market developments and relevant national guidance (such as the latest GP IT Operating Model, Securing Excellence in GP IT Services and associated CCG Practice Agreement requirements) and other best practice including but not limited to:
- ICT Infrastructure – Provision / sourcing of IT infrastructure including but not limited to network services (including Wi-Fi, HSCN, overlay services such as site to site connections, network monitoring and filtration services,), telephony, IT equipment and specialist advice on commissioning / decommissioning IT systems and aligning / sharing infrastructure.
- Management of infrastructure – Managed IT estates services (n.b. IT assets purchased with NHS capital (e.g. for GP IT) will be retained by the NHS but may be managed by the supplier) including asset management and software licensing support for systems and associated software (e.g. antivirus, encryption etc.), version control and patch management, provision of desktop support / service desk, managed data hosting (including storage and server management), management of third party providers and integration of third party goods and services, print management and remote access to the clinical record solutions, including mobile device management.
- IT Systems functionality – Sourcing / provision and ongoing support of IT systems on behalf of the commissioner including but not limited to NHS Mail, system integration and interoperability, implementation and support of software solutions, remote access solutions and access control and administration, mobile applications development, electronic messaging for direct patient communication.
- Support services – Provision of Primary Care Enabling Services for General Practice, Registration Authority (RA) administration and management, NHS Mail Administration, Clinical Safety Officer Support and provision of specialist Information Governance advice and support to ensure that commissioners and providers are advised on how data can be compliantly stored, managed and used in line with the IG Toolkit Level 2 (or equivalent) and the General Data Protection Regulations, National Strategic System Implementation Services (including deployment and implementation support, project and change management support, clinical systems training and systems optimisation support), support to improve data quality including delivery of training to improve coding (including in a primary care setting), , management of third party providers and integration of third party goods and services.
- Cyber security support – Provision of support to ensure systems are secure and patient data is protected including but not limited to identification of cyber security threats, regular penetration testing, disaster recovery and business continuity support services, supporting / implementing critical actions related to CareCERT alerts, supporting / acting on recommendations from cyber security assessments, support the checking of supplier certification (in line with the Department of Health’s Data Security and Protection Requirements) and supporting the management and mitigation of cyber security risks.
- IT Optimisation, Strategy and Transformation – Provision of expertise and PMO support to develop and implement local IT Strategies (such as Local Digital Roadmaps), supporting Sustainability and Transformation Partnership (STP) working including but not limited to: providing expert advice on strategy design, development, market development, benefits testing and realisation, national and international best practice, information governance, national policy advice, regulations and standards, infrastructure and system architecture design, barriers and solutions.
Provision of informatics and analytics to support whole system planning, strategy development, management, assurance and evaluation (cost, quality, clinical outcomes) including but not limited to:
- Actuarial analysis and intervention modelling – provision of analytics and statistical modelling to evaluate current and future utilisation, effectiveness and cost of care providing insight and analytics to support care design / redesign / optimisation and modelling the impact of an intervention.
- Supporting system financial management, quality and outcomes measurement (including clinical outcomes) – Provision of capabilities which enables design, production and dissemination of spend, cost (including PLICS and programme budgeting), quality and clinical outcomes information. Integration of financial activity, outcomes and finance data across care settings. Provision of analytics (including actuarial analysis) to enable greater transparency of activity and utilisation, prediction and prioritisation of spend, identification of unwarranted variation and to support management of pooled / shared capitated budgets at both a patient and population level including but not limited to managing quality of health and social care services (including clinical audit); monitoring service utilisation, health and social care pathway mapping and compliance, patient experience and outcomes; supporting budget planning, management and reporting; monitoring the value for money for allocations towards care of patients; monitoring activity and cost compliance against contract and agreed plans; monitoring provider quality, demand, experience and outcomes against contract and plans; comparing provider quality, demand, experience and patient outcomes against contract and agreed plans; supporting the improvement of provider data quality; comparing performance and managing variation across health and social care professionals, services, providers and systems; comparing expected levels of activity against targets and plans; ensuring compliance with evidence and guidance; maximising services and outcomes within financial envelopes; supporting benchmarking, comparisons, regulation and assurance at all levels of the health and social care system; producing regulatory compliance reports.
- Planning and evaluation, needs assessment and opportunity analysis – Advice and descriptive, diagnostic, predictive and prescriptive analysis to develop and support the optimum method for delivering an ICS / STP whole system vision including but not limited to reviewing and transforming current health and social care service provision across and within populations (including needs assessment); workforce modelling support and tools; understanding the impact of wider determinants of health on populations (including but not limited to how health, housing, social and environmental care services impact on the health of a population); defining and identifying relevant segments and cohorts within populations driving cost, utilisation and quality challenges (and the associated opportunities to improve care provision) including: health inequality groups, preventable and existing conditions and gaps in care; comparing population groups, peers, national and international best practice; designing and evaluating risk stratification approaches; identifying future population needs, spend, growth and change drivers using simulation or modelling techniques; data visualisations including but not limited to individual patient timelines (for example and where appropriate “Theographs”) and pathway diagrams (“Bow Tie diagrams”); evaluating the impact and opportunity cost of different preventive interventions using experimental and quasi-experimental approaches (e.g. A/B testing, propensity-score matched cohort studies) and the deployment of other operational research techniques as appropriate to underpin decision support mechanisms.
- Research tools – provision of tools to support the use of de-identified data to drive research and innovation across health and social care. These tools will enable the use of the unique data assets within the NHS to benefit service users through resultant improvements in care provision facilitated by research findings. Research tools must have the capability to link and process data across health and social care and information exchanges. These tools, including software, will: enable researchers and modellers to construct theories and system models to interpret data for research purposes (supporting data driven study planning); span data collection, processing, modelling and analysis of both quantitative and qualitative data; identify and manage cohorts of patients for research purposes (such as defined demographic groups or target sites); support digitally enhanced clinical trials.
Provision of informatics, analytics and digital tools to support care co-ordination services including but not limited to:
- Risk stratification and impactability modelling for early intervention and preventive care – development of predictive risk models tools, algorithms and analytics capability that can be used to identify the most impactable patients taking into account the wider determinants of health including but not limited to risk modelling of triple fail events over different time periods (e.g. for prediction of unplanned hospital admission over the next 12 months); risk of developing a bed sore in the next 6 weeks); stratifying populations by allocating risk scores to individuals; impactability modelling to determine the likelihood that a particular patient will benefit from different preventive care interventions (approaches to impactability modelling might include prioritising high-risk patients with a high weighted gap score, one or more ambulatory care sensitive conditions, a high ratio of illness vs complexity and/or data-driven approaches (e.g. using machine learning to predict which patients will benefit most from different preventive interventions); provision of a rules engine to determine eligibility for different preventive interventions based on predicted risk, predicted impactability, undertaking an impact assessment to determine the risk of false positive and false negative results, financial impact assessment (to calculate the return on investment) and equality impact assessment (to ensure that the preventive approach will not inadvertently exacerbate health inequalities).
- Supporting systems for the development of individual care co-ordination and management – Provision of insight to support how care is managed in near real time. Services include but are not limited to systems and applications which utilise, or extensions to, electronic patient record systems / health information exchanges to flag potential interventions (including through the use of risk algorithms and predictive modelling) and to trigger alerts, analytics to identify optimal patient pathways and flag them to providers of care, analysis and continuous improvement of support tools to evaluate their utilisation, efficacy and impact, flagging of packages of care where the outcomes appear to be suboptimal, capacity management and predictive modelling to plan for and manage surges in demand, robust use of economic models to optimise decision making.
- Services to support clinicians to make faster and better interventions at the point of care with a patient – Development and deployment of services that utilise patient data to support clinical decision making in real time, embedded in clinician workflows. Services include but are not limited to systems and applications which utilise, or are extensions to, electronic patient record systems / health information exchanges to flag potential interventions (including through the use of risk algorithms and predictive modelling) and to trigger alerts when a patient’s condition worsens / is about to worsen, analytics to identify optimal patient pathways and flag them to providers of care and analysis and continuous improvement of support tools to evaluate their utilisation, efficacy, value and impact.
Provision of a range of expert advice, analysis, transformational and change management capability to design and build the necessary infrastructure for an ICS / STP function effectively. Services include but are not limited to:
- Patient pathway optimisation and care model design – Provision of services to implement best practice and innovation in patient pathways focused on continuous improvement and evidence based change utilising nationally and internationally recognised best practice. Services include but are not limited to assistance with identification of opportunities associated with unwarranted variation in patient outcomes, performance and/or cost; prioritisation of areas for improvement; guidance on identification of best practice nationally and internationally; advice on clinical policy development and decommissioning; assistance with initial viability assessments for proposed changes; engagement and consultation (as required) with key stakeholders including but not limited to patients, the public, clinicians and health service managers; research and reform idea generation; developing detailed reform proposals, case outlines and full business cases; provision of a project management office to oversee, manage and implement the change with the right project managers and clinical expertise; support commissioning and/or decommissioning of services and pathways; development of capability to deliver change at pace, development of continuous feedback loops so that improvements can quickly be fed back and acted upon, making quality improvement an iterative process.
- Specialist advice on organisational redesign, governance and payment and contract reform – Provision of advice on organisational structures including their design, barriers to implementation, potential implementation paths, enablers / key requirements for success, benefits and disbenefits of different models and supporting the development of the case for change (this should include advice on redesigning existing organisations such as GP practices to improve resilience and sustainability); the identification and quantification of prioritised early interventions to alleviate pressure on finances, patient access and safety, this advice would be underpinned by expert analytics based on population health forecasts and actuarial analysis; provision of change management expertise and, where appropriate, leadership; Advice on business continuity planning, testing and resilience; advising on asset usage, management and rationalisation (including estates, infrastructure and staffing resources); design of payment mechanisms and incentives across organisations within a local health economy for example allocation of a shared capitated ICS budget / pooled STP budget, or development of risk share methodologies and incentive programmes; utilisation of value and outcome based contracting, where appropriate, to drive and change culture across the ICS / STP; supporting the application and use of national and international best practice including template contracts, system models and guidance; supporting the development and procurement of outcome based contracts including the development of measurable and robust outcomes, development of models to assess improvements in the value of the service delivered, outcome based payment mechanisms and models for assessing causality and attribution.
- Communications and engagement – Supporting the identification and engagement of key stakeholders including clinicians, CCGs and Local Authorities; advising on and, where required, undertaking compliant consultation on proposed structure changes for example undertaking public consultation and patient engagement, consulting affected staff etc.; strategic communications advice and support including proactive and reactive media management across media platforms, advising on media lines and dealing with press enquiries.
Workforce and leadership development support including but not limited to:
- Transformational workforce planning – Support development of a vision for the systems workforce that is able to deliver new models of care, including out of hospital models; tools dynamic modelling and support, to understand the implications to the workforce of the new vision; system wide strategic resource planning across organisational boundaries; redefinition of existing staff roles (clinical and non-clinical) and development of appropriate training and support to implement changes; support for the system with workforce HR analysis and planning, including developing the new models of care and a focus on primary care where necessary.
- Workforce development – Support to provide clinical supervision across providers e.g. re-registration; support to ensure the systems workforce is adequately trained and developed to fulfil their roles including statutory and mandatory training; provision of specialist advice and support to manage changes to the workforce (including transition to/from other organisations and appropriate application of TUPE, etc.).
- System leadership development – Providing support, training, development and advice that offers executive, senior team and board capability building to aid strategic decision making and problem-solving. Support should consider and balance the needs of the cross-system leadership and individual organisations, so that the system is balanced and robust.
- System leadership support – Support to the system leadership to create a membership organisation with the processes and structures that allow the system to function, manage itself and make cross-organisational decisions; supporting the leadership and main components of the system governance including administrative support to the ICS / STP board and other formal meetings.
- Scaling innovation – Provision of support and advice to tailor, implement and scale population health management innovations and best practice from elsewhere including but not limited to those identified through NHS England’s Test Beds programme, Vanguard sites and Exemplars.
- Primary Care at scale support – Provision of services to support transformation in a primary care setting. These services are similar to other services within the framework however they must be tailored to a primary care setting / primary care specific delivery models. Services will comprise bespoke offers from the market that can support the development of Primary Care Networks and Primary Care operating at scale including but not limited to change management and workforce redesign, primary care demand management and capacity planning solutions, PMO support, system design / redesign, provider development, support to implement local / national initiatives (e.g. reformed NHS 111 services), corporate services design, build and sourcing and governance and financial advisory support.
Provision of services to support the implementation of shared decision making, self-care programmes (including social prescribing and innovative technologies and associated wrap around support), and personal health budgets & integrated personal commissioning through sharing information with care providers remotely to enable the activation and empowerment of individuals to more effectively manage their own health, care and wellbeing. These products and services will enable people to live with greater independence, confidence and safety, and in many cases reduce the need for unplanned care.
- Support for implementing shared decision making: advisory support to implement tools and training to facilitate shared decision making and support clinical culture change.
- Support for implementing self-care programmes (including social prescribing and innovative digital and remote technologies and e-consultations): linked to new or existing platforms that have the capability to collate data across the system and analyse it to inform care provision and improve patient outcomes across a population.
Services include but are not limited to:
- Identification of patients for intervention – developing and utilising best in class technologies, data analysis/risk stratification, patient activation data & interpretation combined with local knowledge to identify where the most impact can be made on patient outcomes (including proactive identification of patients for intervention).
- Advisory services participation – expertise and advice on local strategies on supporting the activation of patients that helps identify and suggest best practice to an ICS / STP including but not limited to:
- Support to deliver tailored interventions including:
- Patient activation measurement;
- Personalised care and support planning;
- Health coaching, structured self-management education programmes and peer support;
- Advising on specialist technologies, e.g. apps and wearables;
- Social prescribing and community capacity building.
- Training and culture change support for front-line staff and care professionals so they understand the principles of self-care including: care and support planning and health coaching skills;
- Regular review of people’s needs, outcomes assessed & reporting on cost/benefits;
- Matching individual care and support needs to access appropriate technology and monitoring devices including the setting of parameters and alert thresholds.
- Implementation services – solution sourcing, design, deployment, management and ongoing review (including procurement of a solution where appropriate) including but not limited to: solution design (including specification and, where appropriate, build to local requirements); procurement / build of the solution; solution deployment (including mobilisation, launch, support for training of care providers and monitoring of utilisation); evaluation of the impact of deployed solutions and ongoing review of efficacy, outcomes and cost/benefit; Identification of good practice from elsewhere including identification of technologies which enable / empower patients to manage their own care and improve access (including but not limited to Telehealth- remote monitoring of patients in their own homes to anticipate exacerbations early and build their self-care competencies; Telecare- technologies in the citizen’s home and communities to minimise risk and provide urgent notification of adverse events; Telemedicine / Teleconsultations- remote peer-to-peer support between clinicians and/or consultations between patients and clinicians; Telecoaching- telephone advice from a coach to support people by building knowledge, skills and confidence to change behaviours; community capacity building to develop resilience in key areas such as healthy eating, exercise and social isolation; Self-care apps- applications that raise awareness and help people self-manage; identification of effective Social Prescribing Interventions.
- Patient portals – enabling patients to access their care record and care plans, update data and send secure messages to care providers.
Support for implementing Personal Health Budgets and Integrated Personalised Commissioning support as a means of specialist support for those with complex needs, providing people with more choice and control of their own care, whilst transforming the relationship between people and professionals into a true partnership to determine how to achieve the best outcomes. Services include but are not limited to:
- IT solutions to support integrated personal commissioning and Personal Health Budgets including: proactive case finding in which people are identified (using appropriate risk stratification and impactability methodologies) and offered information and advice about self-care support or Integrated Personal Commissioning and Personal Health Budgets; finance platforms to enable effective management of Personal Health Budgets and facilitate required transactions; marketplace platforms that enable individuals to identify and purchase care and support in line with their care plans.
- Care planning including: Personalised care and support planning through multi-disciplinary teams, which ensure people have a person-centred conversation about support to help them manage their health and wellbeing; implementation of a single, summary, care and support plan; supporting shared decision-making, particularly for preference-sensitive conditions such as back pain, prostate cancer and breast cancer.
- System redesign to enable an ICS / STP to effectively design its services to enable the use of Personal Health Budgets and Integrated Personal Budgets including but not limited to: advice on how to combine resources from across the health and care system to empower people to achieve their health and wellbeing outcomes; support with stakeholder mapping and communications and engagement strategies so that all people who could benefit from IPC or personal health budgets know what it is, who it is for and the difference it will make; implementation of a common planning framework using six stages (1. Context 2. Preparation 3. Conversation 4. Record and Agree 5. Make it happen 6. Review); integrated, proportionate processes for personalised care and support planning (incorporating Patient Activation Measure (PAM) embedded to tailor the planning approach to applicable individuals); support programmes for the development of personalised care and support planning to all relevant frontline staff and managers ensuring the training is co-delivered with people with lived experience of care and support; implementation of Integrated Personal Commissioning (IPC) hub / multidisciplinary teams (MDT’s) including a single, named care coordinator.
- Implementation support and management for Personal Health Budgets to put in place all three options for managing the money (with access to direct payment support services and third party budgets); a joined-up process for IPC personal budget implementation and review and an individual statement of resources for the people who can have an IPC personal budget which provides an indicative budget; managing risk in relation to personal budgets and integrated personal budgets i.e. Clinical, Financial, Reputational using risk enablement panels where appropriate to support difficult decision-making; governance framework; checking at appropriate intervals whether the personalised care and support plan is achieving the agreed outcomes for both the person and their carers; use of evaluation, activity metrics and any local measures to count and measure the difference that personalised care approaches are making to people locally; support to undertake specific evidence and benefit work to understand financial impact of personalised care.
Provision of services to support smooth transition into, through, out of and between organisations (including by provision of command centres) in a local health system ensuring patients are treated in the most appropriate setting and minimising the amount of time patients wait before transitioning between care settings. Whilst analytical services are an important enabler, these services are intended to provide practical day-to-day support to ICS / STP in mapping, forecasting, managing and ultimately shaping and redirecting patient flows, necessitating different infrastructure, organisational collaboration, skills and tools.
Services include but are not limited to:
- Alignment and co-ordination of transfer of care between health and social care settings including but not limited to by standardising referral processes across a care system, implementing trusted assessment schemes and providing a centralised referral management hub that processes all referrals into, through, out of and between care settings. All referrals will be assessed against a standardised set of clinical guidelines and triaged to the most appropriate care provider / pathway. Educational feedback to referrers on the quality and appropriateness of referrals will support a reduction in referral variations and improved patient flows between services.
- Integrated discharge planning to ensure patients are discharged to the most appropriate place at the most appropriate time and consistently across the system for example through advising on alignment of discharge policies (including identifying and enabling good practice and opportunities, addressing barriers and supporting change management); care package sourcing and management (including but not limited to CHC care packages); providing / supporting the establishment of a central hub that includes community and social care service support to streamline and plan discharge and enables discharge planning to start from patient admission, working across providers to find appropriate discharge arrangements at the most appropriate time.
- Forecasting demand and patient flows in the short to medium term across different care settings for example ensuring that waiting lists, outpatient appointments and elective care are planned effectively to minimise waste as a result of cancellations.
- Forecasting underlying demand in the medium to long term across different care settings that reflect international best practice, demographic trends and new technology solutions for example forecasting the number of beds required in different care settings, the workforce required, utilising data from referral management systems to identify gaps in care pathway and service provision and the potential for technology to deliver better outcomes for patients.
- Advice on / provision of a patient level care co-ordination function to inform multi-disciplinary teams of individual patients’ short and long term care requirements and preferences based on their care plan / EPR and ensure that they are receiving the most appropriate care that delivers the best outcomes at the best value (including tailored personal care approaches based on genetic, environmental and lifestyle factors).
- Coordination of care provision within and between organisations in a local health system to improve day-to-day management of resources including but not limited to bed management solutions (with forecast discharge dates) to enable more efficient discharge; urgent and emergency care access management (such as a triage service to direct patients to A&E / out of hours GP services as appropriate); design, build, deployment and implementation of command centres which bring together staff from across an organisation or health system with supporting tools and information flows (including predictive and performance analytics) to enable real time decision making about capacity (planned and unplanned), forecast surges and optimise discharge routes; capacity improvement of key processes in the patient pathway utilising best-practice and/or re-designing services; development of leadership and management behaviours to support efficient use of resources; use of tracking technologies such as real time locating systems to optimise scheduling, patient flows and resource utilisation (such as outpatients, theatres or staff).
Provision of services to measure, benchmark, model against and support the system to manage quality, cost and clinical outcomes (both analytics and other multidisciplinary skills to provide additional necessary capacity), including but not limited to:
- Provider relationship management and supply chain support including but not limited to: supporting commercial and contractual relationships with members of the system helping determine and co-define (into supply side sub-contracts or partnering arrangements) the allocation of risk, continuous improvement obligations and performance incentives to align organisational behaviour system-wide goals; sourcing participants of the system and agreeing associated commercial and contract terms; provider management and benchmarking and system wide supply chain optimisation; 3rd party supply chain optimisation (outside the local system); administering and managing contracts amongst organisations comprising the system, as well as other relevant contractors (including but not limited to provision of business intelligence solutions and analytics to monitor current activity, finance and performance reporting and recommendations for action); receiving periodic activity and quality reports; participating in relevant contract management meetings, providing support into contract variations and the rectification of poor performance by members of the system; enabling, promoting and incentivising collaboration, innovation and proactive service development between members of the system; proactive management of contract performance ensuring that performance measures are met, delivery is on target and to identify and address potential contract performance issues.
- Financial and quality measurement and assurance including but not limited to:
- Financial planning, management accounting, budget setting and control, financial reporting and analysis, financial accounting, finance operations, financial modelling, accounting service support, general accounting services, systems accounting, systems management, cash management and forecasting, working capital and fixed asset management, VAT advisory and management services, expert financial support to transformation and change services, invoice payment, invoice query management, supplies management (including transactional procurement services) and resource allocation;
- Clinical benchmarking and clinician performance management; development of system wide outcome and performance standards and utilisation to inform service strategy and capacity planning; monitoring, collation, synthesis and dissemination across the system of performance against national or local quality performance standards; service user satisfaction goals; activity and outcome requirements and relevant performance KPIs; reporting and escalation of risks and incidents within the system to commissioners and/or relevant regulators or other statutory authorities, contributing to or participating in regional or national risk or incident protocols.
- Provider modernisation and transformation to deliver significant transformation, minimise waste, errors and rework including but not limited to: advising on, leading and supporting the implementation of improvement projects using improvement methodologies (e.g. “Lean” or equivalent) to deliver efficiencies including but not limited to identifying priorities for improvement (recognising the opportunity cost), supporting the local implementation of national improvement methodologies and programme (e.g. Carter, RightCare, GIRFT), designing and implementing the improvement initiative, embedding a culture of improvement through training, mentoring, role-modelling, and systems design, identifying and recommending best practice, evaluating the impact of the improvement, advising on the barriers to improvement and identifying solutions (for example identifying how resources can be redeployed to unlock savings), identifying and implementing sustaining practices (such as standardisation and technological change) that allow organisations to make a permanent step-change in performance; Identification, design and implementation of innovations (both incremental and disruptive) that enable a provider to deliver care more effectively (i.e. delivering better outcomes and / or delivering a more efficient service) for example technologies that reduce surgery time, reduce waiting times for patients (without increasing cost) or frugal innovations that reduce cost (without reducing quality).
Provision of expert medicines management and optimisation support to develop, implement and deliver a strategy to deliver improved outcomes from medicines. The services encompass:
- Engagement with patients and the public to better understand how local services can support patients to get more from their medicines.
- Improving commissioner understanding of the systems around medication use and procurement as well as the value from the investment in medicines through communications and education.
- Working with patients to improve adherence: an improved experience of medicine taking for patients, securing greater value for money from medicines expenditure. This includes disease and therapeutic management programmes that involve outreach and education to high risk or high cost patients.
- Improving medication safety including a demonstrable reduction in harm from medication errors.
- Engagement across the system to improve governance and utilisation of medicines and reduce medication waste and variation in practice (including community pharmacy, care homes, hospital trusts, the Pharmaceutical Industry and others).
- More effective use of non-GP personnel e.g. pharmacists. Particularly enhancing the multi-disciplinary team by commissioning and utilising the best skill mix including community pharmacists.
- Clinical programmes including: prescribing efficiently through switching to biosimilar alternatives; reduction in inappropriate polypharmacy; improving safety, e.g. flagging of potential adverse effects from prescribed combinations of pharmaceuticals; improve Formulary Management: standardised formulary and dosing, tiered formularies; medicines reconciliation and transfer of care.
- Work with physicians to improve drug therapy: relationship building, prescriber enablement and education programmes to initiate behaviour change e.g. the prescribing of drugs with low clinical value, prescribing to counter antimicrobial resistance.
- Integrate and analyse data in new ways: utilisation of data at population and patient level to identify the risk of incorrect / incomplete medication use and undertake a targeted intervention/ enablement programme.
- Effective use and integration of a range of data sources to identify real world efficiencies, quality improvements and outcomes in the way medicines are used locally and nationally to identify value and best practice.
- Supporting prescribers at point of care through tools, technology, data and information e.g. decision support and population health analytics.
- Reporting and analytics on outcomes delivered through the use of medicines.
- Support alignment of incentives and contracts to drive the optimal use of medicines both in primary and secondary care e.g. prescribing incentive schemes including risk and gain share.
- Integration of medicines management and optimisation into the wider system for clinical support and managing total cost of care.
- Business intelligence and data visualisation to identify trends and variance as well as to identify opportunities for medicines optimisation and to track provider performance.
- Working with the pharmaceutical industry including primary and secondary care rebate schemes.