Transformational System Change Dr David Paynton National Clinical Lead RCGP Centre for Commissioning Holly opens the day

System Transformation The shift into the community 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 Hospital Care Community services Prescribing costs Mental health costs Re-ablement (social element with LA) 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

While the majority are frail elderly by no means all 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 Holly

The rise in numbers and complexity

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

Integrated care that keeps her in the community What does this mean for Mrs/Mr Smith with his/her multiple morbidities/frailty/End of Life 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 David takes over and describes role of Coalition and next slide

What does this mean for the system 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 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 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 Commissioners decide when, where, how & if to use competition, based on: Needs & priorities Scope for improving quality & patient feedback Sustainability and impact on other services Suitability, clinical risk and continuity 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

But that will have a domino effect! 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

Getting local ownership is as important as market management 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?