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