Learning report: Looking for value in hard times How a new approach to priority setting can help improve patient care while making savings August 2012 Identify Innovate Demonstrate Encourage © 2012 The Health Foundation Learning report: Looking for value in hard times is published by the Health Foundation, 90 Long Acre, London WC2E 9RA ISBN: 978-1-906461-42-3 Contents Commentary 2 1 Introduction 3 Context 4 2 What is Star? 6 A socio-technical approach to resource allocation 6 How Star works 8 3 The Star project in Sheffield 10 Background 10 Introducing Star in Sheffield 11 The Sheffield decision conference 12 What was the impact? 17 Lessons learned 19 4 Next steps 20 LOOKING FOR VALUE IN HARD TIMES 1 Commentary The NHS is under greater pressure than ever It soon became clear that something of real to secure high-quality, value-for-money health practical value was emerging and we are services. At the same time, commissioners therefore delighted that this methodological and providers are expected to involve research has been applied in practice. stakeholders – including patients and the public – in decisions. As this report shows, by using the Star approach, NHS Sheffield were able to agree As clinical commissioning groups in England changes to their eating disorder services begin to take on their new responsibilities, with clinicians, service users and other they will need tools that help them meet stakeholders. The changes they have made are these demands – and which enable them to expected to improve both patient care and demonstrate that they have done so. This value for money, with the project showing will be particularly the case where they have potential for substantial savings. to take difficult decisions that may involve disinvestment. The Health Foundation and LSE are currently working with a commercial provider and This report describes how NHS Sheffield used a group of clinical commissioning groups a new approach, called Star (‘socio-technical to pilot a Star toolkit, comprising a tool allocation of resources’), to re-allocate to aid deliberative decision making and a resources within its eating disorder services. training module. The toolkit will be made publicly available, free of charge, and will The Star approach emerged from a programme enable a step forward in transparent decision of research into value for money in healthcare making and planning resource use. However, carried out by Professor Gwyn Bevan and implementation of changes in service delivery, his team at the London School of Economics to achieve better value healthcare in the long and Political Science (LSE) and funded by the term, will rely upon the negotiation skills, Health Foundation. good management and tenacity of healthcare At the time the programme started in 2005, it providers, planners and commissioners. was not expected to develop tools or products; This report describes a methodology to rather, it was exploratory work to understand inform rational decision making – and its how a health economist’s view could add to application in practice. We hope that it will our knowledge of how to improve the quality both interest readers and encourage them to and value of healthcare. try the approach for themselves, using the As the work progressed, new techniques forthcoming Star toolkit. to look at comparative value of healthcare Helen Crisp options were developed. These were used in Assistant Director – Research and Evaluation conjunction with an innovative decision- The Health Foundation conferencing approach to involving stakeholders in decision making. 2 THE HEALTH FOUNDATION 1 Introduction This report describes a new approach to It works by producing simple visual models, priority setting called Star. The approach developed interactively with stakeholders, combines value for money analysis with so that everyone involved can understand stakeholder engagement. This allows the nature of the choices to be made, and those planning services to determine how the disadvantages of not changing current resources can be most effectively invested, practices. while the engagement of stakeholders means the decisions are understood and supported The Star approach has several unique by those most affected. The report sets out characteristics and considers the scale of how NHS Sheffield used Star to re-allocate impact that interventions have on costs resources within its eating disorder services. and on a population’s health. This enables By early 2012, indications suggested the new commissioners and providers to focus on strategy would reduce spending on inpatient reducing spending where total costs are high services by more than 50%. but total benefits are low, and increasing spending on activities that produces high Setting priorities, allocating resources, value at low cost. commissioning and redesigning services will all take place in a harsh financial climate for The Health Foundation funded the project the foreseeable future. At the same time, the to use the Star approach in practice, which NHS must strive to meet ever-rising demand was carried out by a research team from the and to improve the quality of patient care. London School of Economics and Political It must involve a wide range of partners – Science (LSE) working with NHS Sheffield. including local people and communities – in It builds on and complements the LSE’s earlier work with NHS Isle of Wight (see its decision making and must be able to show 1 that the way it has allocated resources is Commissioning with the Community for more evidence based, transparent and systematic. details). In contrast with the Isle of Wight, where the primary care trust had extra money Change is difficult, especially where to invest, NHS Sheffield wanted to increase disinvestment in services may be an option, health benefit without additional spending. and these challenges may appear all the more testing as responsibility for commissioning The Star approach involves patients, clinicians NHS services in England is passed to new and other stakeholders gauging the relative organisations – clinical commissioning benefits of interventions on a consistent basis. groups (CCGs). It avoids a situation where commissioners have only piecemeal data on the benefits of an This report describes a new approach to intervention and are consequently working priority setting called Star (socio-technical in the dark. This lack of data can make it hard allocation of resources). The approach is to engage people and convince clinicians, designed to help commissioners and others patients, carers and the general population pinpoint where they may be able to get that changes are needed. additional value from their resources by using them more effectively. 1 www.health.org.uk/publications/commissioning-with-the- community/ LOOKING FOR VALUE IN HARD TIMES 3 The approach focuses attention on identifying Engaging stakeholders in decisions key changes that are likely to have the greatest impact on population health. It has been The government argues that ‘commissioning shown to work not only in situations where has been too remote from the patients it is resources are growing but also where they intended to serve’, and says ‘We want local are not. It has also produced results where people to have a greater say in decisions that purchasers and providers form separate affect their health and care and have a clear 3 entities, and where (as in the Isle of Wight) route to influence the services they receive’. they are part of the same organisation. This CCGs must demonstrate ‘meaningful shows that the approach has the potential to engagement with patients, carers and their be useful both in the NHS in England and also communities’ as part of the authorisation more widely. process. They must include ‘mechanisms for The Health Foundation is currently gaining a broad range of views then analysing developing a Star toolkit that will help clinical and acting on these. It should be evident how commissioning groups, health boards and the views of individual patients are translated 4 others to make decisions on setting priorities, into commissioning decisions’. allocating resources and redesigning Every CCG must publish an annual and commissioning services. For more commissioning plan specifying how it information, email [email protected] intends to involve patients and the public in commissioning decisions. CCGs have a duty Context to involve the public in any changes that affect patient services, not just those with a Obtaining value for money has always been ‘significant’ impact. The NHS Commissioning an important aim for the NHS, as has a Board will assess how effectively CCGs do this. commitment to transparent and rational priority setting. The NHS Constitution also establishes as a guiding principle that the NHS should work in partnership with other organisations. The NHS has an explicit duty to ensure that patients and the public have a say in how services are planned. The Constitution also gives them the right ‘to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation 2 of those services’. 3 Department of Health (2010). Liberating the NHS: Local democratic legitimacy in health. London: Department of Health. 4 Department of Health (2011). Developing Clinical 2 Department of Health (2012). The NHS Constitution for Commissioning Groups: Towards authorisation. London: England. London: Department of Health. Department of Health. 4 THE HEALTH FOUNDATION Improving productivity in the NHS The efficiency savings needed are difficult to make and, in practice, will require Chief executive Sir David Nicholson has commissioners to focus their efforts on a committed the NHS to finding £15–20bn in small number of priorities. To do this when efficiency savings by 2015 under the Quality, planning how best to prioritise resources, Innovation, Productivity and Prevention they will need tools to identify which options (QIPP) programme.