Transcript Slide 1

Transformational System
Change
Dr David Paynton
National Clinical Lead
RCGP
Centre for Commissioning
System Transformation
The shift into the community
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The clinical model
The payment model
The commissioning model
The organisational model
Required if we are to deliver the quality
commissioning outcomes
Health Reform Bill 2012
Underpinning Drivers
• Shift direct management control away from central government to
more local control and democratic legitimacy
• Potential for more market intervention
• Change in a climate of financial austerity
• Clinical not managerial leadership
• Continues a process of local decision making starting in 1990
• Integration with local government
A shift to local determination within a strategic framework
New NHS Architecture
• Parliament sets the mandate for NHS England
• NHS England sets objectives for CCG
• CCG manages funds for
a)Hospital Care
b)Community services
c) Prescribing costs
d)Mental health costs
e)Re-ablement (social element with LA)
f) Co-commissioning of primary care (for some)
NHS England directly commissions
via Local Area Teams
• Primary care services (medical, pharmacy,
dental and optical)
• But CCG expected to take responsibility for
primary (GP) care quality and development and
now “jointly co-commission”
• Specialised services
CCG’s and NHS England must be better
aligned
Long Term Conditions
• 15.4m people in England have one or more long term
conditions (LTCs)
• Utilisation of health services is high amongst the LTC group –
they account for 30% of the population, but 70% of NHS
spending (c. £70bn)
• The number of people with multiple conditions is projected
to increase and this will put pressure on NHS budgets
• LTCs are strongly linked to health and economic inequalities
While the majority are frail elderly by no means all
The rise in numbers and complexity
600
Annual admission rate per 1000 patients
500
479
Potentially preventable admission
Other emergency admissions
400
342
318
300
242
200
200
151
151
115
100
100
85
74
64
51
31
0
20
3
0
5
1
9
14
21
2
3
4
34
47
5
6
No of conditions
7
8
9
10+
And the money
Traditional NHS inflation 5%
arctic’ scenario: real funding cuts (-2 per cent for first three years, -1 per cent for second three years)
‘cold’ scenario: 0 per cent real growth in six years
‘tepid’ scenario: real increase (+2 per cent for first 3 years, then +3 per cent for the next three years).
Appleby J, Crawford R, Emmerson C. (2009) How cold will it be?
http://www.kingsfund.org.uk/research/publications/ how_cold_will_it_be_html 2009).
So is our current system sustainable
or does it require radical change if
the NHS is going to survive ?
Changing the Clinical Model
Proactive Care Planning-Domain Two
• Risk profiling and stratification of risk in primary care
• Single point of contact for patient supported by Care
Planning with lead professional and accountable GP
• Transferring knowledge and control back to the patient
Enabled by
• Change in payment systems (capitation such as year of
care and commissioning incentives)
Moving away from
• Single disease specific pathways
Currently 2% of population
A core role for the community
Domain two will make or break the
NHS
Without successful implementation
our current system will simply will
grind to a halt
What does this mean for Mrs/Mr Smith with
his/her multiple morbidities/frailty/End of Life
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a)
b)
c)
d)
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Control and understanding of his/her care plan
Focus on her outcomes not biomedical outcomes
A structured approach to developing her care plan
Preparation and information sharing
Consultation
Agreement and sign off
Review
An understanding of what to do in an emergency
An accountable named GP
A lead professional/advocate who supports her various needs
Integrated response if situation deteriorates
Integrated care that keeps her in the community
Supporting
systems to
build their
House of Care
What does this mean for the system
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A five year journey
The right components in place
The right information systems
A coordinated implementation strategy
Workforce changes with a shift back towards generalism
A change in clinical practice with a focus on psychosocial not
biomedical
• Systems rooted in primary/community care
• Working with the voluntary sector
• Shift away from the paternalistic medical dependency model
A move away for single disease specific solutions
But we cannot throw the baby out with the bath
water!
Specialist care
Single disease
focussed
pathway
Care plans
Coordinating
Complex
Care
Reducing
use of acute
services
Care Planning
Support and
coaching
Reducing
complications
and
exacerbations
Generalist
care
Co-morbidity
and
complexity
Adapted from Year of Care
But what does this mean for my
clinical practice?
The Payment Model to support
domain two
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Payment by Results
Activity contracting
A&E, out-pts, surgical
procedures, emergency
admission, bed stays
“bums on seats”
Silo organisations and income
driven
Weakened primary care
Inflexible community services
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Outcome Commissioning
Capitation contracts
Activity less important
Lead provider or Alliance
Contracting
Different incentives
Opportunities (and risks) for
primary/community care
Who holds the risk
Requires very sophisticated commissioning
A managed system - Local Determination
Competition & Cooperation
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Commissioners decide when,
where, how & if to use
competition, based on:
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Needs & priorities
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Scope for improving quality &
patient feedback
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Sustainability and impact on other
services
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Suitability, clinical risk and
continuity
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Scope for patient choice and
control
The commissioning Model
• Intelligent strategic commissioning required to get the right system
incentives
• Clinical ownership as important as the market
• Joint commissioning with pooled budgets
• Alliance contracting or prime provider
• Our current approach to commissioning is transactional, reactive
with poor links to the clinical “real world” of delivery leading to
perverse incentives
Contracts should be an enablers not a stick
The Organisational Model
Current Workforce
43000
41000
39000
37000
35000
33000
31000
29000
27000
25000
GPs
Consultants
General Practice
• Current business/organisational model
struggling – isolated small businesses
• Increased workload
• Reduced income (capitation not activity based)
• Workforce crisis
• Inward looking “How do we survive?”
Across the country practices seriously looking
at handing back the contract
But that will have a domino effect!
Primary and Community Care
Key foundation to system change
• Operate at scale
• Federations/networks based around registered
list
• Integrate with community services and some
acute services in new structures/incentives
• Take the existing workforce with us
• Strategic recruitment and retention strategy
It will be locally (CCG/Health & Wellbeing
Boards) where key decisions will be made
Summary
• Delivery of Outcome framework requires transformational change
with the emphasis on domain two as we shift care into the
community
• Clinical care with proactive care planning for those at risk is key
• Commissioning will need to refocus
• Payment and commissioning incentive will need to change
• New organisational frameworks will need to be created
Getting local ownership is as important as
market management
Will our culture allow this to
happen?