Developing Accountable Care in Greater Nottingham Claire White: Deputy Director of Integration Claire.white2@nuh.nhs.uk 07812 275009

Our Journey The Need for Change Work to date What does different look like? Challenges Questions

The STP: the ‘Goal’ This will only get worse over time… Since 2014, we have confirmed the need to change our current model of health and care services which is reactive, fragmented and acute bed based. This doesn’t provide quality care for patients nor does it provide value based sustainable care for our tax-payers. The current pressures the NHS and Social Care system are facing will get worse if we don’t change but this change isn’t easy esp. in the current context. This will only get worse over time…

Accountability Integration Outcomes Populations Value The Principles Care organised around individuals not institutions Removal of organisational barriers enabling teams to work together Resources shifted to preventative, proactive care closer to home Services based on the real needs of the population “Creating a sustainable, high quality health and social care system for everyone.” Hospital, residential and nursing homes only for people who need care there High quality, accessible, sustainable services Outcomes Integration Accountability Value In 2014 we confirmed our desired future state. This hasn’t changed. Outcomes Populations Value

Work to date Actuarial analysis of the Greater Nottingham Health and Care system compared to internationally renowned health and care systems. One insight suggested that 40-60% of our patients have potentially preventable care and associated cost undertaken within the acute sector compared to integrated, accountable systems Validation of the actuarial analysis leading to detailed design to support delivery of the programme of change and realise the model of care. The design has focussed on service change: pathways of care, population health management and integrating social care. There has also been a focus on some of the enablers of change, namely: IM&T, provider payment mechanisms and governance (contract design)

Example of current contractual relationships CCG: Locality 1 CCG: Locality 2 CCG: Locality 3 CCG: Locality 4 Treatment Centre Services Mental Health Services Primary Care Social Care Community Services Secondary Acute Care CITIZEN No collective accountability for population health outcomes

In an Accountable Care Model Integrated Commissioning CCG: Locality 1 CCG: Locality 2 CCG: Locality 3 CCG: Locality 4 Contract Treatment Centre Services Mental Health Services Primary Care Community Services Secondary Acute Care Social Care Integrated Provision: collective responsibility for population health outcomes

Accountable Care Organisation (ACO) Accountable Care System (ACS) One provider organisation responsible for delivery of population health outcomes Accountable Care System (ACS) A collective arrangement for a number of individual statutory providers to deliver the population health outcomes. Can be an alliance model, a prime or host provider model or a corporate joint venture

ACS Integration Framework

Example: Assessment Scenarios John’s level of care should be medium. He is assessed by two different assessors and gets two different results: The first assessor derives a score that reflects a low level of need. The second assessor derives a score that reflects a medium level of need. Example 3: Sue Example 2: Bob Example 1: John The following slide is intended to highlight the importance of consistency and transparency in the assessment process and decisions regarding care packages and the impacts of unwarranted variation on the health and care system: Bob’s level of care should be low. He is assessed by two different assessors and gets two different results. The second assessor derives a score that reflects a high level of social need. Sue’s level of care should be medium. She is assessed by two different assessors and gets the same result but two different packages of care. Different questions and criteria lead to different conclusions in level of need. System allocation of resources to the patient are then inconsistent which may not result in best care at the best value Same assessment leads to same conclusion in level of need but different packages of care are created. Results in inconsistent services provided which makes it difficult to measure best practice and re-calibrate effective packages of care

1 2 3 £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ Assessment Care Package Home Rehab / Community Acute Care Home Social Cost Health Cost Not enough resources allocated, ends up in hospital Assessor #1 Assessor #2 Actual Cost Social: £ NHS: ----- Actual Cost Social: ---- NHS: £££ Budgeted Social: £ £ score = low £ £ £ John: His actual care need is medium Budgeted Social: ££ Actual Cost Social: ££ NHS: ----- £ £ score = med Assessment Care Package Home Rehab / Community Care Home Social Cost Health Cost Acute Actual Cost Social: £ NHS: ---- Assessor #1 Assessor #2 Budgeted Social: £ £ score = low Bob: His actual care need is low Actual Cost Social: ££ NHS: ---- Actual Cost Social: ---NHS: ££ Actual Cost Social: ££ NHS: £ Budgeted Social: £££ £ £ £ £ £ £ £ score = high Loses Independence, degrades faster, goes to care home earlier Assessment Care Package Home Rehab / Community Acute Care Home Social Cost Health Cost Actual Cost Social: £ NHS: ---- Actual Cost Social: ---- NHS: £ Assessor #1 Assessor #2 Budgeted Social: £ £ £ score = med Sue: Her actual care need is medium Actual Cost Social: ££ NHS: ---- Actual Cost Social: ---- NHS: £££ Budgeted Social: ££ £ £ £ £ £ Not the right care package, ends up in acute score = med 1 2 3 Citizen meets the three national criteria to get an assessment Same citizen assessed by two different people, may result in two different scores Resulting care package varies in cost and services

A New System of Care: Phase 3 The primary objective of the current stage of work is to establish and build the ACS enablers and integration functions We are in unprecedented territory: no-one in England has achieved the level of transformation required We have engaged external expertise in Centene UK to work with us on an interim basis to mobilise this new system of care. Centene is not a provider of care but a Care Integrator with experience of transforming care systems: Across 25 states in America developing integrated and accountable care organisations and systems and in Spain in partnership with Ribera Salud who operate the internationally-renowned Alzira model in Valencia The work we have done to date with Centene has gained us national recognition and inclusion in the ACS Accelerator Programme but there is still much work to do however and challenges to overcome including in our approach to transformational change This work will be carried out by building on current work in the system and using the existing governance structures

Challenges Managing today and delivering the future Overcoming individual organisational challenges and pressures including statutory responsibilities Uncertainty of detail Embedding this into ‘business as usual’ Co-ordination of messaging and engagement in a complex and fast moving environment Political environment – two local authorities have differing majority parties, differing levels of political involvement and views Current system architecture – barriers that are outside of our direct control

Questions?