1. Developing Accountable Care in Greater Nottingham
Claire White: Deputy Director of Integration

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

3. 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…

4. 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

5. 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)

6. 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

7. 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

8. 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

9. ACS Integration Framework

10. 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

11. 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

12. 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

13. 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

14. Questions?