The Pennine MSK Partnership created a new organisational form – the Integrated Pathway Hub – which works like a lead accountable provider and is responsible for all musculoskeletal services in Oldham.
Since 2011, it has held a budget of around £23 million, covering primary, community and acute services.
- Musculoskeletal spend per head decreased by £10 in Oldham compared to an increase of £10 nationally (for the period 2009/10 to 2011/12).
- Oldham’s knee replacement patients received an average health gain of 0.35 in 2011/12, compared to 0.27 in 2009/10, representing a statistically and clinically significant increase in patient health outcomes. (The England average health gain was 0.30 during the period).
- Involving patients in decisions to treat appears to lead to better outcomes.
What the partnership is doing and why
A key driver for developing the partnership was a desire to focus on improving people’s outcomes rather than being micromanaged against detailed, process-driven key performance indicators. There were concerns that care was too fragmented, with no effective performance management of care and outcomes. Payment by results contained perverse incentives to deliver more care in acute settings.
The focus on commissioning this contract is now on health gain, using tools such as patient reported outcomes measures, based on Pennine MSK Partnership’s work to develop a framework that combined programme budgeting and marginal analysis as an alternative to payment by results.
How it works
The partnership is a company which holds a specialist PMS contract with the range of services and terms of operation covered by service level agreement with the commissioner. As lead accountable provider, the Pennine MSK Partnership shares responsibility for care coordination, quality and performance across the entire pathway. This means it is incentivised to performance manage the entire pathway.
For many years, national survey data showed that over 40 per cent of patients wanted more involvement in their care. Given this, and evidence that shared decision-making leads to improved outcomes and greater patient satisfaction, shared decision-making has been central to the approach, with the AQuA shared decision-making model implemented within the past two years.
The service was developed by two GPs and a nurse consultant in rheumatology. This clinical leadership has been key, particularly in overcoming an initial lack of interest among the wider GP community and helping develop a shared vision among clinicians. The first iteration of the service started, in 2002, as a triage system for rheumatology referrals and was able to divert 70 per cent of GP referrals away from hospital.
In 2006, the service was commissioned as an integrated community musculoskeletal service incorporating rheumatology, elective orthopaedic outpatients and persistent pain services through a specialist PMS contract which then incorporated the lead accountable provider responsibility in 2011.
Most areas considering outcomes-based commissioning will not have ten years to develop the approach and contract, but the developed model has been adopted by other commissioners who have either procured, or are procuring, this approach.