Michael Macdonnell The future NHS Director of Strategy, NHS England

2 Radical upgrade in prevention Back national action on major health risks Targeted prevention initiatives Much greater patient control Harnessing the ‘renewable energy’ of communities Health & wellbeing gap 1 1 New models of care Neither ‘one size fits all’, nor ‘thousand flowers’ A menu of five care models for local areas to consider A wave of ‘vanguard’ areas, supported by national bodies, to demonstrate the new care models Care & quality gap 2 2 Efficiency & investment Deliver 2-3% efficiency across the NHS’ total funding base However, there remains an additional funding – which the Government has accepted And the need for upfront, pump-priming investment Funding gap 3 3 Three gaps & three arguments

3 Now a Four Year view…but we’ve made progress An upgrade in prevention A new Diabetes Prevention Programme that will ramp up to ~100,000 people at risk over the next three years A new childhood obesity strategy, and a much higher profile around the issue But lots more to do… New models of care Five different types of vanguard now operational around the country Support programme for each underway Cancer Taskforce published; Mental Health shortly; Maternity next year But lots more to do… Efficiency and investment £8bn by 2020 committed by the Government £200m Transformation Fund and £250m Primary Care Infrastructure Fund Action to deliver the £22bn challenge, e.g. agency; Carter review But lots more to do… And the Spending Review settlement hangs in the balance

Integrated primary and acute care systems (PACS) vanguards 1Wirral Partners 2Mid Nottinghamshire Better Together 3South Somerset Symphony Programme 4Northumberland Accountable Care Organisation 5Salford Together 6Better Care Together (Morecambe Bay Health Community) 7North East Hampshire and Farnham 8Harrogate and Rural District Clinical Commissioning Group 9My Life a Full Life (Isle of Wight) Multispecialty community providers (MCPs) vanguards 10Calderdale Health and Social Care Economy 11Erewash Multispecialty Community Provider 12Fylde Coast Local Health Economy 13Vitality (Birmingham and Sandwell) 14West Wakefield Health and Wellbeing Ltd 15Better Health and Care for Sunderland 16Dudley Multispecialty Community Provider 17Whitstable Medical Practice 18Stockport Together 19Tower Hamlets Integrated Provider Partnership 20Better Local Care (Southern Hampshire) 21West Cheshire Way 22Lakeside Surgeries (Northamptonshire) 23Principia Partners in Health (Southern Nottinghamshire) Enhanced health in care home vanguards 24Connecting Care – Wakefield District 25Gateshead Care Home Project 26East and North Hertfordshire Clinical Commissioning Group 27Nottingham City Clinical Commissioning Group 28Sutton Homes of Care 29 Airedale and partners Urgent and emergency care (UEC) vanguards 30Greater Nottingham Strategic Resilience Group 31Cambridgeshire and Peterborough Clinical Commissioning Group 32North East Urgent Care Network 33Barking & Dagenham, Havering & Redbridge System Resilience Group 34West Yorkshire Urgent and Emergency Care Network 35Leicester, Leicestershire & Rutland System Resilience Group 36Solihull Together for Better Lives 37South Devon and Torbay System Resilience Group 50 vanguards across the country Acute care collaboration (ACC) vanguards 38Salford and Wigan Foundation Chain 39Northumbria Foundation Group 40Royal Free London 41Dartford and Gravesham 42Moorfields 43National Orthopaedic Alliance 44The Neuro Network (The Walton Centre, Liverpool) 45 MERIT (Mental Health Alliance for Excellence, Resilience, Innovation and Training) (West Midlands) 46Cheshire and Merseyside Women’s and Children Services 47Accountable Clinical Network for Cancer (ACNC) 48East Midlands Radiology Consortium (EMRAD) 49Developing One NHS in Dorset 50Working Together Partnership (South Yorkshire, Mid Yorkshire and North Derbyshire

5 Implications: follow the money… DCLG HM TREASURYPARLIAMENT PUBLIC HEALTH ENGLAND DEPT OF HEALTH MENTAL HEALTH 211 CLINICAL COMMISSIONING GROUPS HEALTH & WELLBEING BOARDS (Directors of public health) LOCAL AUTHORITIES NHS ENGLAND £113BN £67BN £64BN £98.3BN£3.6BN £22.1BN £1.8BN£2.8BN £1.1BN COMMUNITY SERVICES SPECIALISED SERVICES PRIMARY CARE HOSPITAL SERVICES Commissioned by CCGsDirect and co-commissioning £16BN£12BN Commissioning—and funding—currently follows organisations rather than people or populations Source: Department of Health, 2014/15 figures

6 …and the way we buy healthcare needs to change From… Single contracts Commissioner-to-provider contracts remain the norm, structured service by service Money that follows organisations Which makes collaboration hard Payment tied to activity A declining proportion of total provider reimbursement is through PbR/tariff But even block contracts are usually based on historic and projected activity Understanding costs at the provider level Including reference costs which, although procedure based, do not capture total costs across the pathway Accountability for organisational performance Towards… Collaborations between providers Integrated provision will require increasingly sophisticated provider-to-provider contracting Money that follows people For which collaboration is usually required Payment tied to patients Payment linked to quality and cost for a specified population (e.g. Liverpool) Or payment linked to quality and cost for a specified patient group (e.g. cancer patients) Understanding costs at person level An understanding of the total costs across sectors and providers at the patient level Which can in turn underpin population costs Accountability for patient and population outcomes

7 Commissioning as midwife to new provision models Multispecialty Community Providers (MCPs) Primary and Acute Care Systems (PACS) Based on GP registered lists May be a single list but more likely to be a combination covering a population >30,000 Provide integrated out-of-hospital care Including community services, community pharmacy, social and consultant generalists working in the community Underpinned by a new voluntary contract That encompasses a wider range of services, integrating primary and community services A single budget based on capitation And a new blended CQUIN/QOF pay for performance scheme Based on GP list(s) but also incorporating a hospital Covering populations of ~250,000 or more Combine core primary medical services with core secondary and mental health services Achieving ‘vertical’ integration for a geographically defined population A single PACS contract Held between GPs a hospital and community services typically through a joint venture model A single budget based on capitation Combining GP-list income with hospital budgets and community services Both combine different funding streams Both enable providers to influence demand and allocate resources more effectively Both depend on much greater interdisciplinary team working Both shift accountability to the population level

8 Five observations about the future NHS Systems and populations not just organisations “Jointly and severally” accountable Place-based budgets Combining CCG allocations with primary care and, in time, much of specialised Commissioning changes but doesn’t wither And changes differently in different places Its purpose to drive better value (outcomes/cost) at the level of the person An empowerment and support model for national bodies Reverse the traditional model of making and (trying to) implement policy Back leadership and ambition wherever we find it Visible backing when the proverbial hits the fan 5