1. New care models programme
Charlotte Williams
Adoption Lead
New Care Models Programme
@CEmWilliams
13 December 2016

2. We are realising the NHS Five Year Forward View through the new care models programme
Improve prevention and public health
Give people greater control over their care
Break down barriers in how care is provided
Build a sustainable NHS
Test the models and develop blueprints for widespread adoption
The aim of new care models
Greater focus on care out-of-hospital care and prevention
NHS trusts, GPs, Local Authorities, the voluntary sector and other providers will all work together for the benefit of their population
A long term focus
A focus on supporting vanguard sites to embody nationally replicable models of care
How this is different
How will it address the gaps
The programme will bring investment, both locally and in national support
Dedicated national expertise to work with local systems to unblock barriers
The programme will aim to play “matchmaker” in bringing together parts of the system

3. Four core principles underpin the new care models programme
A national programme supports local development and delivery.
The programme is hosted by NHS England and is accountable to and led by all six arm’s length bodies:
NHS England (NHSE)
NHS Improvement (NHSI)
Care Quality Commission (CQC)
Health Education England (HEE)
Public Health England (PHE)
National Institute for Health and Care Excellence (NICE)
Clinical engagement
Patient involvement
Local ownership
National support

4. The new care models programme is being implemented in three broad phases
Phase 1: Set up
Establishment, principles, and history of the programme
Phase 2: Delivery
Vanguard delivery and early results
Phase 3: Spread
Sharing success and wider roll-out

5. Phase 1: Set up
Establishment, principles, and history of the programme
Phase 2: Delivery
Vanguard delivery and early results
Phase 3: Spread
Sharing success and wider roll-out

6. 50 vanguards are developing new care models, and acting as blueprints and inspiration for the rest of the health and care system. 9
Integrated primary and acute care systems 14
Multispecialty community providers 6
Enhanced health in care homes 13
Acute care collaboration 8
Urgent and emergency care

7. The national programme is supporting the vanguards through the key enablers of their new care models1.
Designing new care models 2.
Evaluation and metrics 3.
Integrated commissioning and provision 4.
Governance, accountability and provider regulation 5.
Empowering patients and communities 6.
Harnessing technology 7.
Workforce redesign 8.
Local leadership and delivery 9.
Communications and engagement

8. Phase 1: Set up
Establishment, principles, and history of the programme
Phase 2: Delivery
Vanguard delivery and early results
Phase 3: Spread
Sharing success and wider roll-out

9. With the vanguards, we have identified the key elements of the care models: MCPs

10. With the vanguards, we have identified the key elements of the care models: PACS

11. With the vanguards, we have identified the key elements of the care models: Enhanced Health in Care Homes
Care element
Sub-element
1. Enhanced primary care support
Access to consistent, named GP and wider primary care service
Medicine reviews
Hydration and nutrition support
Out of hours/access to urgent care when needed
2. Multi-disciplinary team (MDT) support including coordinated health and social care
Expert advice  and care for those with the most complex needs
Helping professionals, carers and individuals with needs navigate the health and care system
3. Reablement and rehabilitation
Rehabilitation  / reablement services
Developing community assets to support resilience and independence
4. High quality end of life care and dementia care
End -of -life care
Dementia care
5. Joined up commissioning and collaboration between health and social care
Co-production with providers and networked care homes
Shared contractual mechanisms to promote integration (including Continuing Healthcare)
Access to appropriate housing options
6. Workforce development
Training and development for social care provider staff
Joint workforce planning across all sectors
7. Data, IT and technology
Linked health and social care data sets
Access to the care record and secure
Better use of technology in care homes

12. In the vanguards, the key elements of ACCs are emerging
There are two types of an ACC model emerging:
Foundation Groups
Clinical networks
Supported by two fundamental emerging characteristics:
Standardisation and evidence-based best practice
Consolidated decision-making mechanism
Trying to find solutions to the same challenges :
Financial pressures
Variation in clinical quality
Workforce recruitment and retention
Viability of specialised services

13. Early results show the vanguards are helping reduce admissions…13

14. Mid Nottinghamshire Better Together PACS – Local Integrated Care Teams
… and are reshaping roles so that they are more rewarding, sustainable and efficient
Mid Nottinghamshire Better Together PACS – Local Integrated Care Teams
Eight care teams provide proactive and co-ordinated treatment to high-risk patients, and are reducing pressure on local hospitals
Teams typically include:
two community matrons;
a district nurse;
occupational therapist;
physiotherapist;
mental health worker;
social worker;
healthcare assistants;
voluntary/third sector workers;
a ward coordinator/Manager.
“Integration is about working together to achieve better outcomes for our patients. As a team, we are committed to delivering quality care around the needs of the patient.” 14

15. … and making diagnosis and treatment more proactive and convenient.
Tower Hamlets Together (MCP) – a new community clinic for chronic kidney disease is removing the need for unnecessary hospital visits.
Three elements to the programme:
A consultant led weekly e-Clinic.
IT tools to identify at risk patients and report practice CKD prevalence and management.
An education plan for patients and primary care staff
In 2015 the average wait for a renal clinic appointment was 64 days, using the new e-Clinic, the average wait has dropped to 5 days.
GPs now have immediate access to a specialist in a ‘virtual’ online clinic who can provide instant feedback on the best way to manage the patient either in the community or with more specialist care where needed.
50% of referrals are now managed without the need for a hospital appointment.

16. Phase 1: Set up
Establishment, principles, and history of the programme
Phase 2: Delivery
Vanguard delivery and early results
Phase 3: Spread
Sharing success and wider roll-out

17. New care models spread
More than 5 million patients will benefit from the work already being taken forward by the first 29 vanguards
By 2020, half of the population of England will be covered by new care models.
Sustainability and transformation plans (STPs) will be an important mechanism for spread; almost all STPs are thinking of developing a population health model.
Spread will be assisted by the care models frameworks, which will enable existing vanguards to learn and borrow from each other, and enable new sites to understand and work towards the implementation of the fully mature models through the STP process.

18. How might we help wider implementation of new models happen?
Encourage public, patients and communities to know more and get involved in local transformation plans – create demand for new models
New care models will be key aspect of place-based planning for sustainable services - Ensure enabling support for new care models aligned to STP process
Creating the enabling environment for delivery – by creating and fostering the right leadership, behaviours and culture, and investing to help adopters succeed
Facilitating learning and communication between communities – vanguard sites, other new care models, wider STPs 18
#futureNHS

19. How might Voluntary Sector partners help?
We need and welcome your thoughts:
What do we need to consider?
How can we help you?
What role might you have?
Who else might like to get involved?

20. For further information…
More details can be found on the NHS England website:
You can the programme at:
Or join the conversation on Twitter using the hashtag:
#futureNHS