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

2. 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

3. 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

4. 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)

5. 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

6. 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

7. The rise in numbers and complexity

8. 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? how_cold_will_it_be_html 2009).

9. So is our current system sustainable or does it require radical change if the NHS is going to survive ?

10. 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

11. Domain two will make or break the NHS Without successful implementation our current system will simply will grind to a halt

12. 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

13. Supporting systems to build their House of Care
David takes over and describes role of Coalition and next slide

14. 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

15. 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

16. But what does this mean for my clinical practice?

17. 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

18. 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

19. 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

20. The Organisational Model Current Workforce

21. 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!

22. 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

23. 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

24. Will our culture allow this to happen?