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Rules and behaviours to make the new NHS environment work in an age of austerity

Yale leadership courseNovember 19 2015Paul Corrigan

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Rules and behaviours to make the new NHS environment work in an age of austerity

What constitutes the new environment for the NHS 4 big drivers?1 REFORM OF THE NHS The Health and Social Care Act is passed in march 2012 and

has different authors.• From April 2013 the structure is implemented but there is confusion about the

new structure and whether it creates new behaviour2 PUBLIC CONCERNS SAFETY AND REGULATION Feb 2013 the Francis Report

emphasises the importance of developing a much more open culture within the NHS. Then the Keogh review and new CQC inspection regime

• This is having a big impact on change3 THE FIVE YEAR FORWARD VIEW AND THE NEW MODELS OF CARE; The history of fragmented care, the current need for coordination of care 4 THE MONEY The spending review June 2013 establishes a standstill spend for the NHS (much better than others)• Demand for health care will continue to increase• Post Comprehensive spending review, the money and FTs

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The main theme of reform 2000-15

• The NHS is moving for a single organisation to a system of organisations

• The 2012 legislation created a separation at the top between :- DH, NHS England, Monitor, NHS Trust Development Authority, (Now joined together as NHS Improvement) CQC, Public Health England and Health Education England

• In terms of behaviour by 2015 this is only one third of the way through.

• Senior leaders (and politicians) are still trying to run it as a single organisation and therefore no one is really doing the job they were appointed to do

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1 a Reforming the Centre

• Contrary to what Andrew Lansley wanted The Secretary of State retains responsibility for ensuring the provision of a comprehensive NHS. This current SoS takes this very seriously and regularly reaches beyond his powers in the Act.

• NHS England receives resources and mandate from SoS. It commissions GP service and national services and since May is looking to chare this with CCGs.

• It distributes resource, provides contracts/performance management to clinical commissioning groups. Its new CEO will reform it.

• Public Health England has contracts with local public health commissioned through local authorities

• Monitor system regulator as in other quasi markets• Monitor will performance manage FTs in a system under stress It will set prices for

NHS services in consultation with NHS England and will review payment mechanisms• Trust Development Agency performance manages non FTs• These two become NHS Improvement• The Better Care Fund mandates integrative relationships and care.

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1B Reforming Local Commissioning

• CCGs from April 2013• With 211 CCGs there is very considerable variations with some

trying to do very radical new things and others reproducing the past

• New forms of contracting see URLs at end re COBICs. Some CCGs/HWBs starting to commission new integrated care providers.

• From April 2013 Health and well being boards run by the local authority are integrative with Public Health Commissioned through Local Authority

• Locally the Better Care Fund will commission billions for new services which integrate health and social care and will drive integration where it is not happening organically

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1 c Reforming the provision of health services for NHS patients

• NHS Trust Development Agency set up to move providers through FT pipeline and work with those that cannot make it. But the drive to FT status has stalled? But what is policy for those that do not make it

• Most mergers fail• Dalton Review suggests relationships including chains and the

designated right to take over non FTs and form chains GP provision is being sized up through networks and federations and super practices

• New integrative providers are being developed primarily through provider pressure to integrate but also BCF and commissioning. URL for Accountable Lead Provider

• To what extent can FTs move into the primary care space?

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2 Safety the public and CQC ratings

• 2014 Act empowers CQC to rate NHS Trusts, private providers, GPs dentists and social care

• New NHS trust inspection regime which categorises trusts as Outstanding; Good Requires Improvement and Inadequate.

• In education over time for OFSTED these categories have impacted on institutions through the public.

• The issue for the NHS is not inspection but improvement . • NHS Improvement has been created to focus attention on

this

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3 The history of fragmented care, the current need for coordination of care and new models of care

• 60 year history of the NHS and social care is the history of passionate fragmentation at an institutional and professional level.

• This fragmentation at the core of professional and organisational life is now unsustainable because of long term conditions and multi morbidities

• Creating local integrated health and social care is very hard but is the future • NHS England Forward View Oct 2014 It posits 7 new integrative health care

models • Feb 2015 260 expressions of interest in becoming vanguards• 29 selected in March 2015• Supplemented by 7 emergency care vanguards and Acute care vanguards.• If these are seriously the future of the NHS there needs to be very speedy

development over the next five years

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What we are trying to achieve

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There are three key elements to the New Models of Care programme

• A need to manage systems of care not just organisations• Integrated services around the patient giving the patient

greater control• Addressing pre-existing barriers to change

Dissolving traditional barriers

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• Harnessing the ‘renewable energy’ of communities• Targeted prevention initiatives • Investment and flexibilities to support implementation of

new care models• Active patient involvement

Co-designing local services

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• Promote peer learning with similar areas• Fast learning from best practice examples • Applying innovations and learnings across the system

Applying learnings across the health system

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New Models of Care

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Initially the new models of care programme will focus on:

• Multi-agency support for people in care homes and to help people stay at home

• Using new technologies and telemedicine for specialist input • Support for patients to die in their place of choice

Enhanced health in care homes

• Coordinated care for patients with long-term conditions • Targeting specific areas of interest, such as elective surgery • Considering new organisational forms and joint ventures

New approaches to smaller viable hospitals

• Integrated primary, hospital and mental health services working as a single integrated network or organisation

• Sharing the risk for the health of a defined population• Flexible use of workforce and wider community assets

Integrated primary and acute care systems

• Blending primary care and specialist services in one organisation• Multidisciplinary teams providing services in the community • Identifying the patients who will benefit most, across a population of at least

30,000

Multispecialty Community Providers

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4 NHS resources now to 2025

• In 2020 election no major political party will stand on a platform which challenges the current funding principle of the NHS. That’s 10 years with the current method.

• The only financial resources that the NHS have will come from taxation.• GDP in 2020 will not have risen much above 2008• NHS Expenditure as a % of GDP will not go up• Demand for health care will increase by over a third in next 10 years• Most of this will be in long term conditions• Five Year forward view expects a £30 billion gap by 2020. Productivity and health

care model change will make £22 b (heroic) and still need £8 b• Spending Review 25/11 will announce some immediate increase but will it be

tied to specific actions?• The NHS needs to develop significantly better outcomes for the same resource • Most in the NHS do not believe this is possible and will demand more money

spent on similar business model

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What does this all mean for leadership

• System leadership of the NHS is very different from single organisational leadership

• Most managerial experience re resources (when there was a lot of growth) up to 2012 is irrelevant

• Commissioners have changed and they have a remit to create integrated care beyond existing organisations

• The hospital business model of offering to do everything for everybody all the time cannot work

• Every Board needs to develop specific business models• To develop a sustainable future you will need to develop new business

models• To achieve this you will need agility.• The public need to be engaged in this throughout or it will stop you

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References

• Pamphlet by Paul Corrigan and Caroline Mitchell on the need to develop new business models http://www.reform.co.uk/resources/0000/0302/The hospital is dead.pdf

• Accountable lead provider http://www.rightcare.nhs.uk/index.php/tools-resources/casebooks/#alp

• Bedfordshire MSK contact on • https://www.supply2health.nhs.uk/5P2/Lists/Advertis

ements/DispForm.aspx?ID=17 -

• Capitation Outcome Based Integrated Contract.(COBIC) more can be read on http://www.cobic.co.uk