clinically led commissioning in the english nhs
TRANSCRIPT
@robertvarnam #qfi11 #Quality2015
Session I11Clinicians steering the
design of health services#qfi11 #Quality2015
@robertvarnam #qfi11 #Quality2015
Dr Robert VarnamHead of general practice development, NHS England
@robertvarnam Introduction
Dr Chris JonesWest Wakefield CCG
@DrChrisJones1 Engagement of professionals and practices in shaping future primary care
Dr Caron MortonClinical accountable officer, Shropshire CCG
@DrCaronMorton Creating a distinct approach to rural health
Sir Sam EveringtonChair, Tower Hamlets CCG
Making a reality of outcomes based commissioning
@robertvarnam #qfi11 #Quality2015
Commissioning in the NHS in England
@robertvarnam
#qfi11 #Quality2015
@robertvarnam #qfi11 #Quality2015
Commissioning in the NHS
• Single national health system, funded from taxes, free at the point of care. Planning = hospital committees.
• Growing focus on planning services at meso level.
• Interest in quality, workforce, clinical microsystems.
• Internal market to improve quality, appropriateness & cost.
• Commissioners as place-based system leaders.
@robertvarnam #qfi11 #Quality2015
New Government 2010
• Contain costs, improve quality, widen patient choice of specialist provider.
• Address primary care frustrations.
• Greater clinical power. Greater competition.
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Clinical Commissioning Groups 2013
• 212 groups, 70-80% NHS budget (secondary care).
• Statutory body / membership body … composed of primary care practices.
• Strong clinical leadership, mostly medical, mostly primary care.
@robertvarnam #qfi11 #Quality2015
Dr Chris Jones
@DrChrisJones1
#qfi11 #Quality2015
Engaging primary care practices in
radical service redesign
Dr Chris Jones
Project Director, West Wakefield Health and Wellbeing Ltd
GP, Ossett, West Yorkshire
Chair, Wakefield Commissioning Network 6
@drchrisjones1
@westwakefield
uk.linkedin.com/in/drcjones
Declaration of interests
Organisation Role Interest
Wakefield CCG 111 Clinical Governance Lead Paid role
Church Street Surgery GP Partner
Wakefield Clinical Commissioning Network 6 Chair Time reimbursed
West Wakefield Health and Wellbeing Ltd Chair, Project Director Paid roleShareholderWave 1 PMCF FundingWave 1 MCP Vanguard Site
365 Response Ltd Medical Director Co-ownerSBRI Grant funding
IQUS Limited Executive Chair Owner
Wakefield is at the centre
Wakefield
West Wakefield
• 6 Practices
• 63,910 Patients
The Challenge
Extended Hours
Extended AccessHealthPod Care Navigators
Extended Team
• 7 day service 8am to 8pm• Routine & urgent appointments
• Physiotherapy• Pharmacy• Social Worker• Mental health worker• Health and wellbeing • worker etc
• Extra training• Detailed knowledge of local
services• Able to signpost internally and
externally
The Challenge
New contact types
Digital
AccessPopulation health and Wellbeing
Service Directory
Digital Resources
• Video consultations• Electronic messaging• Telephone consultations• On-line chat
• Care Navigation app• App library• HealthPod app• Unified Communications
• Self-service kiosks• Schools app project• On-line Mental Health therapy
The Challenge
Social Prescribing
IntegrationHospital District Hub
Care Home Project
• Mild cognitive impairment• Mild depression• Link to voluntary/third sector
services
• Record sharing• Virtual ward rounds• Prescribing support
• Consultants• 111• 999• A&E
• Co-location• Admissions avoidance• Early supported discharge• Frailty tool
?
The Challenge:
Quite difficult
The Context: Quite adverse
Progress
The recipe
3 key ingredients
The Challenge:
Quite difficult
The Context: Quite adverse
Progress
The recipe
3 key ingredients
The Challenge:
Quite difficult
The Context: Quite adverse
Progress
The recipe
Clinical Leadership
Full Engagement
Communications
Knowledge & evidence
A good plan
Sufficient resources
Disciplined project management
Clinical Leadership
Who?
• Local
• Respected, with substantial relevant clinical experience
• History of success in other extended roles
• Already a leader in smaller role (practice, CCG)
• Willing, not obliged or persuaded
• Freed up
Clinical Leadership
How?
• Having found them your clinical leaders must be properly supported
– Time to lead
– Funding. ‘Backfill’ pay and recognition of responsibility
– Sustainable: reasonable tenure, planned exit
– Training
• Development
– Invest in your leadership
– Develop skills and experience, training, mentoring, networking
– Find the next generation and plan succession
Clinical Engagement
• Clinically, not managerially led
• Principles of engagement still apply
• Start at the beginning
• Create a compelling vision
– Develop a shared vision of the future
– Grounded in the here and now but with a roadmap to the end goal
– Consult widely, test and refine. Be prepared for disassembly.
– Get a mandate
• Make it happen
– Business case, bidding
Patient & Carer Engagement
• Essential, incorporate from the beginning
• Proper dialogue, not just informing
• HealthWatch Wakefield
• Dedicated project manager
• Liaise with existing PPGs
• Created new Patient Reference Panel
• Involve in major decisions
– (premises, video consultations, apps)
• Regular contact, come to national meetings Engagement Infographic
Patient & Carers
Together
Community Engagement
• Youth Café
• St Georges Community
Centre
• Community Anchor
• Getting involved in what
they are doing
Community Engagement
• Schools App project
– Connecting with kids
– Fun
– Healthy messages
– Not just around illness
– Demystifying health
services
Practice Engagement
• Practice engagement meetings
• Educational sessions
• Extra ad-hoc meetings
• Practice manager meetings
• Project team develop
• relationships at different levels
– Nurse for nurse engagement
– GP for GP engagement
– Network Development manager for Practice Manager engagement
Communications
• Never enough until it’s too much. Hard to get the right balance.
• Easy to forget without dedicated resource
• Communications officer
• Weekly activity report
• Branded email updates
• Ad-hoc emails from key personnel
• Dashboard in development
Last word…
“If the person or group you are engaging
with does not feel there has been a transfer
of power to them, they have not been
engaged”.
- Lord Victor Adebowale, 2015
Questions
@robertvarnam #qfi11 #Quality2015
Dr Caron Morton
@DrCaronMorton
#qfi11 #Quality2015
Creating a Distinct Approach to Rural Health
Dr Caron Morton, MBE
Imag
e co
urt
esy
of
Pat
13
82
41
at
Free
Dig
ital
Ph
oto
s.n
et
The Environment
Whitchurch to Ludlow
o 50 miles, 1 hour 20 mins
Bishops Castle to Shrewsbury
o 22 miles, 45 mins
Shrewsbury to Cleobury Mortimer
o 45 miles, 1 hour
Clun to Whitchurch
o 50 miles, 1 hour 25 mins
The Challenge
The Royal Shrewsbury Hospital, Shrewsbury
The Princess Royal Hospital, Telford
The Challenge
The Ask
The Approach
Changing to an asset based approach
A clinical vision for acute services
Community provision centred around GP practices
Building real community resilience with local people
The Offer
The Offer
Partnering with local GPs
Maximising care home impact
Integrating provider teams
Supporting community projects run by volunteers
Working with the voluntary sector
Investing in prevention
“embracing bespoke local solutions within our patch – equal outcomes”
The Impact and Outcomes
Care Homes Scheme reduced A&E attendances and admissions
Care co-ordinators improved outcomes
Compassionate Communities rebuilding local communities
Health Champions 300 young people as champions
Street pastors significant reduction in weekend attendances
Impact of Care Homes Scheme on Acute Sector
% reduction
GP appointments post intervention 66.40%
A&E attendances post intervention 52.20%
Hospital admission post intervention 22.73%
OOH calls/visit post intervention 65.71%
% increase
Voluntary agencies involved post intervention 83.70%
Avoidable hospital admissions reduced in one year by 11.5%
Unplanned hospital attendances from Care Home Sector reduced in 2013/2014 and flat in 2014/2015
AE attendances shown only 3% increase over five years – 2013/2014 dropped by 4.6%
“The Figures”
“Not everything that matters can be measured”
@robertvarnam #qfi11 #Quality2015
Sir Sam Everington
#qfi11 #Quality2015
Dr Sam Everington
Making a reality of outcomes based
commissioning
THPCT legacy: Primary care networks
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Tower Hamlets before networks
• 8 LAPs
• 36 practices
• Total population of ~245,000
• Practice list sizes of 3,000 to 11,000
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Pop: 29,892
Pop: 18,027
Pop: 29,801
Pop: 35,720
Pop: 28,995
Pop: 33,186
Pop: 27,839
Pop: 31,975
8 Networks1 were formed in the borough during 2009
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Why networks?
• Focus on population health across a geography
• Collaborative relationships with wide range of partners (e.g. Borough, schools, charities)
• Sufficient scale for specialisation of staff, ability to access rare skills and ensure access, resources (e.g. equipment)
• Integration with estates plan
Outcome based contract linked to
improving population health
Page 2
Outcome- based
approach
47
MMR Immunisation 2006-10
Improving MMR vaccination rates: herd immunity is a realistic goal. Cockman P, Dawson L, Mathur R, Hull S, BMJ2011;343doi: 10.1136/bmj.d5703
60.0
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90.0
95.0
100.0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2007 2008 2009 2010 2011 2012
Intervention Post-Intervention
% wi
th MM
R by s
econ
d birth
day
Tower Hamlets
London
England
Maintaining MMR improvement
48
Creation of one provider
Roles
• Supports integrated care
• Vehicle to commission from
• Platform for co-commissioning
36 practices
8 networks
1 provider
Page 3
Provider development in WELC – building the alliances Page 8
In te g ra t io n fu n c t io n d e liv e re d c o lle c t iv e ly b y a ll p ro v id e rs in c o lla b o ra t io n
C a re C o -
o rd in a t io nR a p id R e s p o n s e
D is c h a rg e
M a n a g e m e n t
M e n ta l H e a lth
L ia is o n (R A ID )S o c ia l S e rv ic e s
C C G
P r o v id e r S p e c if ic S c h e d u le s
Ge
ne
ric
Sc
he
du
le f
or
All
Creating a specification for integration and adding
as schedule to all NHS contracts
Evaluation process provides focus for
provider collaborative discussion
Evaluation Process
• Stage 1 - Desktop
• Stage 2 – Collaborative panel interview
Domain for assurance
Rating
Initial assessment
Direction of travel
Final assessment
1. Service delivery A → A
2. Corporate governance and operational management A → A
3. Clinical governance, quality and patient engagement A → A
4. Information and performance monitoring R ↑ A
5. Contingency and project planning R → R
6. Commercial framework G → G
• Process led to formation of the THIPP – Tower Hamlets
Integration Provider Partnership
Development of THIPP
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