NEW MODELS OF WORKING IN THE FIVE YEAR FORWARD VIEW

OPEN FORUM EVENTS

26 May 2016

Siva AnandacivaHead of analysis

The care and quality gap

Unless we reshape care delivery, harness

technology, and drive down variations in quality

and safety of care, then patients’ changing needs will go unmet, people will

be harmed who should have been cured, and

unacceptable variations in outcomes will persist.

NHS Five Year Forward View

Our current operating model

Fragmentation

• Between primary and secondary care

• Between physical and mental health

• Between health and social care

Medicalisation

• Treating illness as opposed to ensuring health and well being

• The preponderant role of medical professionals

Hospitalisation

• Illness -> Hospital -> Intervention -> Wellness

• Dominance of hospital in local health / care system

Specialisation

• Hospital care dominated by increasingly specialised specialists

History

• Historic service structure and patterns

• Importance of / emotional attachment to existing buildings & institutions

Achieved great things but now under pressure

A&E performance

Current emphasis of asking individual institutions to improve technical efficiency and clinical outcomes within their four walls no longer enough

NHS provider aggregate deficit

98% 92% 91% 88% 86% 83% 82% 80% 77% 75% 73% 67%

97% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%

96% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%

95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%

95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%

94% 92% 90% 87% 84% 83% 81% 79% 77% 75% 72% 63%

94% 91% 89% 87% 84% 82% 81% 79% 77% 74% 72%

94% 91% 89% 87% 84% 82% 81% 78% 77% 74% 71%

94% 91% 89% 87% 84% 82% 81% 78% 76% 74% 70%

92% 91% 89% 86% 84% 82% 80% 78% 76% 74% 69%

92% 91% 88% 86% 84% 82% 80% 77% 76% 74% 68%

92% 91% 88% 86% 84% 82% 80% 77% 76% 73% 67%

%

seen

in 4

hours

Type 1

A&Es

Q4

2015/

16

2016/17

Source: Kings Fund QMR April 2016

2016/17 is already falling apart. We closed 2015/16 with a £50 million deficit. Our control total for this year is a £15-20 million deficit. At the end of April we are already at -£10 million.

NHS FT Director

What does good look like anymore?

Source:

How are things going? Well demand is up to our eyeballs,

we are nowhere near our financial control total, and we have a Requires Improvement from the CQC. So we feel we

are upper quartile at the moment….they call it gallows

humour because it’s life or death

NHS FT NED

Leading to a strategic ferment for new approaches

Vertical integration

• Bringing together combinations of provider, CCG, primary care, social care, voluntary sector

• In a tight locality –c100k to 500k population base

• MCPs, PACS and Enhanced Care Homes

Horizontal integration

• Providers working together with their neighbours

• Standard operating procedures

• Wider geographic footprint

• Acute care collaboratives, chains, mergers, shared back offices

Applying improvement methodology

• Deep dive on pathways

• Improve outcomes and efficiency

• Patient journey mapping

• Virginia Mason Institute programme with five NHS trusts

And new behaviours

We’re all in this together• Focus on specified populations• Use of outcomes that matter to

those populations• Measuring outcomes• Performance incentives and risk-

sharing• Coordination of delivery across

providers• Maximising value

Source: Noun project, Health Foundation

The zero sum game• Focus on providers• Process targets to support day

to day delivery• Monitoring performance• Risk transfers and

micromanagement• Fragmented care with multiple

hand-offs• Maximising cost reduction

New models and behaviours harnessed through 5YFV

Two further new care models proposed

Reinvention of the acute medical model in small district general hospitals

Differs from Acute Care Collaboration (ACC) vanguards by specific focus on small district general hospitals, and

interest in care pathways and clinical workforce, rather than organisational

forms and operating models

Tertiary mental health services

Secondary MH providers taking on tertiary MH services such as secure MH and forensic services, perinatal mental health, Tier 4 CAMHS, CAMHS eating disorders, Tier 4 personality disorder

services

x14

x9

x6

x8

x13

Mid-term review on the programme

• Emerging evidence that we can increase patient outcomes and value

• But we are starting from a poorer base than we thought • Sustainability eating transformation funding and resource • Capacity and capability for transformation?• Lacking infrastructure of linked data sets

• Regulatory barriers when doing right thing for the system means wrong thing for your institution – real governance challenge

• Turbocharging exiting plans for new models, but not catalysing poor areas or Vatican States into developing new models?

• Will take longer than we thought, will be harder than we thought, will not save as much money as we thought

And new care models are like marriages

• They look wonderful from the outside

• You get some advantages

• But they take a lot of work

• There are tax implications

• They cost a lot of money up front

• And they don’t magically solve a dysfunctional relationship

What is the plan for the whole distribution?

Vanguards, self-starters, historically

strong, good relationships

Fast followers

with a plan

In distress, within success

regime or special

measures

Everyone else???

Will we have organisational inequalities?

Source: Sir Michael Marmot

We are shifting the distribution up, but not contracting the distribution

Some things I hold on to

Primary and acute care system (PAC)

• It’s the little things that count e.g. meet GPs on their turf, have a GP clinical director ‘GP proof’ communication, offer help e.g. back office support, agreeing things with a partner is not the same as agreeing things with a practice, give GPs an exit strategy

• We may not have outpatients in the future

Integrated care pioneer

• Start from the Nigel Edwards position that merging a bankrupt NHS system and bankrupt social care system will not result in one financially viable system

• Do not go straight for the shared budget. Start with a shared governance structure with a joint venture to delegate powers, then will have shared planning, then a shared workforce and finally a shared budget.

Acute care collaborative (ACC)

• Really forcing us to work out what makes us good, what is our standard operating model, what is our ‘way’, how do we do things around here?

• Clinical governance without line of sight, culture of franchises

Telehealth in care homes

• ED consultants say we have fewer people come here to die

Welcome to Croydon

• ED rebuild with CAMHS paeds area

• Frailty Unit reducing length of stay and medical outliers

• Accountable care partnership• 10 year capitated

outcomes based contract

• Under/over 65 incentives

• Age UK a key member• One member one vote

THANK YOU• Sivakumar Anandaciva • Head of Analysis | NHS Providers• One Birdcage Walk | London | SW1H 9JJ

• DDI: 020 7304 6819• siva.anandaciva@nhsproviders.org

Q&A

Images from Googleimages & HSJ