Transforming the NHS - Stephen Shortt

Transforming the NHS:

A journey from multiple unconnected practices to

accountable community based integrated services at scale

Stephen Shortt GP

Principia MCP

Nuffield Trust Health Summit

Friday 4th March 2016

• Integrated health and care system • Accountability for clinical outcomes • Align budgetary accountability with clinical decision to

commit resource • Reduce / eliminate funding gap [£140m] by 18/19 • Vire resource into preventing hospital admissions and

reduce length of stay • Support personal lifestyle behaviour change - reducing

prevalence/ burden of long term conditions • Empower patients and carers to self-manage long term

conditions, support independent living • Redirecting activity from secondary care into capable, at

scale primary care

Focus of Principia New Care Model transformation

• A clinician led, patient centred organisation: data driven, supports management of clinical care, operations, service and financial performance for local population

• Population health organisation that is fit for the purpose of bearing risk for triple aims with a capitated budget for population of Rushcliffe

• Planned and staged transfer of financial and service responsibility from CCG to accountable risk-bearing provider organisation for in-scope services

End state

“Only physicians and provider organizations can put in place the set of interdependent steps needed to improve value [the relationship between outcomes and costs] , because ultimately value is determined by how medicine is practiced and care is delivered.”

Performance and value creation are a product of science (30%) and sociology (70%); the adaptive challenge

Science (Identifying “the right thing to do ”)

Sociology (“Making the right thing happen/easy”)

• Evidence-based guideline development, goal setting

• Design and development of care management programs for clinical priorities; service and operational improvement s

• Granular, actionable metrics; internal and external benchmarks

• Measurement, timely reporting and feedback, unblinded sharing of data, identification of successful practices

• Shared ownership/responsibility/ • Risk and reward aligned around shared

business objectives • Stewardship • Lay- clinical leadership, relentless focus

and communication, champions • Culture of accountability, commitment,

pride, performance • Clinical-managerial compact; joint

responsible for programme success • Performance management, recognition and

celebration of success • Continuing improvement in the quality of

real time data and metrics • Leveraging technology to facilitate quality,

service, personalization of care, efficiency

[Urgency, capacity and knowing where to start]

• Understanding and managing risk; value based contracting; payment models; transitioning to capitation

• Advanced data management capabilities ; use of actionable intelligence

• Re-imagining care model; care management processes; risk stratification

• Establishing preferred relationships with motivated and efficient specialists, partners

• Implement standardised care management protocols; tracking and managing clinician behaviours and performance

• Technology and infrastructure requirements; EHR

• Reward systems , payment mechanisms aligned with organizational and system goals to reward desired behaviours, cost utilization, quality and patient experience

• Activation of patients and families in managing own health and self determination

• Cross-system engagement, leadership and governance

• Implementing change in complex care organisations and networks

• Capital; financial protection

Technical challenges

• Extending the scope and quality of the primary care offer through collectivised general practices

• Integrated practice delivery to care home residents

• Developing fit for purpose accountable care system

Mobilising the Principia NCM: illustrations

• LLP GP provider interface for 118K Rushcliffe patients, established 2015

• New inter-practice governance and accountability for achieving better outcomes for population

• Professional leadership; continuous quality improvement core values

• New NHS contract with CCG ; practices retain existing contracts with CCG/NHSE

• Point of difference is strong focus on the future and retention of high quality general practice locally

• Priority the design and delivery of sustainable high quality solutions and services for patients, GPs and practices that improve outcomes at pace

• Develop internal effectiveness and efficiency; collective resilience

• Develop new alliances, partnerships as required to resolve performance and financial pressures in local care system

• Restore general practice as best place in world to work 8

PartnersHealth LLP - a partnership of partnerships


• Implemented Rushcliffe GP Specification: new investment • extended service offering to patients aligned to CCG objectives; informed by mass patient survey on future of local NHS services

• All practice funding allocations levelled up to £88/patient; MPIG / PMS growth abatement underwritten; financial risk share with CCG

• Domains:

1. Access: Practices open throughout week • Standard offer • Weekend opening • Data sharing across all providers • Patient access to full on line services including access to own clinical journal and pathology • e-Consultation • Video consultation

2. Long Term Conditions: Common templates across all practices • Standardised data entry • Common recall system • Disease registries • Introduction of model of shared decision making and patient decision aids • Motivational interviewing training

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Enhancing the contribution of general practice


3. Use of Resources: Individual GP utilisation measurement and reporting • Practice benchmarking and external peer audit • Continuing Health Care reviews

4. Integrated Practice: Orthopaedic OPs shifted to community • Integrated service procured under a new contractual form • Gynaecology OP and elective DC activity from March • Urology in development • GPs in ED • Extended service to care homes • GP, community matron in reach to Health Care of Older People wards • HEEM GP fellows and CEPN

5. Governance: LLP formed • New organisational form and inter-practice governance • MCP governance developed; interim PartnersHealth lead integrator role; • External partnership development

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Enhancing the contribution of general practice


• Extended scope • Extended value • Pay for performance model • fixed budget with upside/downside risk share with CCG for prescribing budget and elective care

• Agreed clinical pathways • Standardised coding of clinical care • Referral thresholds• FOPA after e-mail Advice and Guidance • Unblinded individual referral reporting and benchmarks • Referral management support teams • Prior authorisation

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2016-18 Rushcliffe GP Specification

• CCG commissioned service (April 2014)

• Specified by CCG • Supported by patients ,

carers, Age Concern, general practice (including practice managers), community nurses, community HCOP consultant, care homes

• Service structured around the needs of the resident and their medical condition

• Engagement with family and carers • Dedicated team of clinical and no-clinical personnel

providing for the out of hospital care cycle • Team works toward s a common goal : maximising the

patient’s overall outcome as effectively as possible • Team are experts, know and trust one another and co-

ordinate easily to minimise time and resources

• Common care planning templates installed across all practices

• Systematised data entry , registry and tracking

• Remote access to GP clinical system patient record via dedicated laptop; Wi-Fi for each care home

• Trial of video consultation facilities for staff, family and residents

• One practice , one care home • Personalised care plans, advanced

directives, consent for data sharing • Scheduled GP , community matron

and district nurse visits; dedicated time

• Dedicated care home pharmacy advisor / prescriber

• Service review with Age Concern

Rushcliffe extended support to care homes

20-22DAYS ELSEWHERE IN SOUTH NOTTS

12DAYS RUSHCLIFFE

INTERMEDIATE CARE LENGTH OF STAY

QIPP

143% TRAJECTORY TARGET

No increase in emergency medical admissions from Rushcliffe care homes (compared to between 67-130 % increase in rest of greater Nottingham)

Number of Rushcliffe care home residents dying in hospital has fallen by 3%.

29 PER 100 BEDS (v. 60-67)

CONVEYANCES FROM CARE HOMES

55 PER 100 BEDS (v. 98-117)

RESPONSES TO CARE HOMES

EMAS

Extended support to care homes: impact

• Self assessment: insufficient capacity and capability to address systemic issues of quality and financial sustainability as urgently as required, or competencies required by a population health risk bearing organisation

• Proposal to recruit transformation partner/system integrator

• Harness efficiencies and expertise in long term relationship to :

• Modernise and create a fit for purpose care infrastructure

• Improve efficiency and quality of delivery

• Secure appropriate risk transfer to stimulate innovation and performance management

• [Introduce capital] without increasing public sector debt

• Share accountability and risk for cost control and performance

• Actuarial feasibility analysis (14 organisations inc. primary care and LAs)

• Programme design and partnership development

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Developing a fit for purpose accountable care system

Healthcare

Transforming the NHS - Stephen Shortt