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Lay of land Integration arguments are coming to fruition. Recent election messages: people want hope not fear – they’re concerned about hard Brexit - don’t want more austerity - have reduced respect for authority. 150,000 EU nationals work in health and social care combined. Unlikely that we will see any controversial legislation, leaving us to work within ‘the Lansley Legacy’. Will be less STP bravery. Social Care green paper will be less radical – less chance now to use public spending differently.
Organisations never in my 42 years of involvement have things ever been so diffused/confused, but there’s no appetite to streamline. STPs are seen as a workaround to make the best of a bad job… shift towards place based working makes sense. All requires collaboration in opposition to aims of Lansley. Regulatory systems have been slow to adapt – still based on organisations, not place / system. Most STPs are combinations of small systems – STPs ‘aren’t it’.
Charlotte Moar (Programme Director – Transformation and Efficiency, NHS England) and Zephyn Trent (Assistant Director, Strategic Finance, NHS Improvement) and Matthew Style (Director of Strategic Finance, NHS England).
STPs are seen as the vehicle to address these issues. This year NHS England will:
The eight initial accountable care systems announced in June 2017 are:
There is also a new devolution agreement in Surrey Heartlands, similar to the existing one in Greater Manchester. This agreement will bring together the NHS locally with Surrey County Council to integrate health and social care services and give local leaders and clinicians more control over services and funding.
Accountable care systems are STPs, or groups of STPs which can demonstrate the following (detail taken from NHS England website)
In exchange, ACSs will be offered by regulators:
Commenced with a summary of the 2016/17 position for NHS provider organisations.
Finance has an important role to play in successful partnerships.
Returned to work with the health sector after a career in central government at HM Treasury and most recently Department of Communities and Local Government. Emphasised the importance of understanding each other’s world and finding ways of working together – LG and NHS finance teams need to reach out to each other.
Don’t ask for permission. Legal framework is already in place so local systems are encouraged to look at what they can already do.
Blurring the boundaries – the future role of commissioning
Ben Collins, Project Director, King’s Fund.
NHS Internal market (tariff and purchase/provider split) had been effective in a particular set of circumstances but that time is close to ending. Drivers for this change include austerity, growing population, plus high profile problems caused by market failures eg Uniting Health.
Case study on Canterbury in New Zealand where co-operative working has led to a range of improvements.
Transaction costs of market now massively outweigh the benefits so we need to rethink.
Mark Britnall – KMPG (former NHS CEO).
Focus on Israel which has a very cost effective health system (Clalit) mainly due to aligned digital systems creating good knowledge on the proportion of population likely to have problems.
His key points for achievement of accountable care:
Nigel Foster (DOF East Berkshire CCGs), Sam Burrows (Director of Strategy Berkshire West ACS).
Helpful and clear explanation of what’s going on in this area. Two different, but neighbouring ACS: West Berkshire and Frimley Health.
Both areas explained that this development is very much part of an ongoing journey, with no major organisational change anticipated in the short term. However, there are many more subtle changes which will lead to closer working, for example Nigel Foster about to become joint DOF of acute trust and CCGs. Stressed importance of strong relationships and sensible geography in order to take things forward.
As ACS exemplars, they had received a small amount of additional funding to help establish the organisations. However, they hadn’t yet agreed whether ACS would receive additional ‘people’ resources from NHSE/I or how new arrangements for joint regulation would work.
The NHS is good at identifying the opportunity for savings through initiatives such as Carter, but this opportunity needs to turn into plans and most importantly to delivery. Initiatives such as GIRFT look promising but we need the right numbers in order to track it. This might involve further central performance management.
The NHS is currently using short term solutions to underpin the fire break – even I think it is old school! This may have reinforced the dependency culture, which we need to guard against and causes problems with perceptions of regulatory style. Longer term we have to find a way of making sure accountabilities at system level work appropriately. Will need some help from the frontline with ideas for how this might work and feel.
Finance Directors often have a key role in ensuring the delivery of quality – would be good to see a director of finance and quality role.
Distributed leadership - we need to feel accountable for partners. Will need to blur the commissioner/provider split. What is important is getting autonomy back for system – early FTs had autonomy which has largely disappeared recently. Need some thinking of what earned autonomy means when there are few £s around. Regulation of such a closed market could and should be different – the current setup is too complicated.
Bob’s comment on ACO – we don't fully know what it is yet. Might look like a successful foundation trust with ‘bolt on’?
Devolution provides the impetus to move forward, even though 95% of what is needed could be delivered without it. It’s about using the totality of public services to drive economic development and (mutually reinforcing) improvements in health and well-being. Core principles remain the same. About right level of decision making, will still be national/regional/local bits.
Mayor has no formal power, but Andy Burnham’s previous experience and democratic mandate should have an impact. Easy to focus too much, though, on £6bn health as opposed to whole £22bn public spend.
There is strategic commissioning plus tactical elements by subsidiary bodies. As an Accountable Care System (ACS) we will have ten forms of ACO, responsible for ‘from the place’ health services. There will be capitated outcomes based contracts between strategic body and place-based contacts (alliance/single provider).
Recent tendering process led to ‘preferred provider’ for Manchester Health and Care which commissions. Salford, for example, is different…
Transformation fund of £450m makes a big difference, allowing for a signed investment agreement in each locality.
Capital: talking to LAs about how to use their PWLB access to get capital cheaper than is possible through the NHS.
My job is to tell you that you are all on the right track. District Health Boards broke funder-provider split in 2001-02 in New Zealand, but we forgot to change any behaviours. Pre-2007 Canterbury was probably worst deliverer in the country, 30% off targets. Now bed days have declined despite population growth.
‘What’s best for Agnes?’ (a typical user) is our motto, which we’d use for example to look at our falls prevention… key target is to reduce >75 long stays in hospital
Lots of data suggesting shifts to community, preventative etc. has made financial sense. Have cracked ensuring information is available to all across the system.
How do you go on this journey? We don’t do pilots, we just do. Built ‘coalition for change’, consultatively. We have an Alliance model – good faith contracting – everyone loses or everyone gains. The approach works ‘irrespective of structures’.
Block contracts are wrongly called ‘capitation’ in NHS. ACS suggests risk-based cover for whole population. Saying ‘you should made decisions sub-optimal for organisation if it is to benefit of whole population’ won’t be sufficient.
Need to understand the financial risks, define the population, define the services, and set the baseline.
Understanding risks: need to address in contract terms – may impact CCGs, councils, both… Be explicit in contract. NHS and council have different sets of risks, indicating one problem. Economic and political risks. Even if you can’t quantify them, can you know them?
Defining the population: in eg USA models, I can count the population to be dealt with by how many are enrolled, not so simple here... One example had three different counts in same tender document.
Defining the services: from population health perspective rarely defined correctly – tends to just set out what is provided now. We don’t have benefits process… narrow definition is OK, but say capitating >65 pop won’t work. And we often lack data on services, we need it at code level.
Risk adjustment: underlying health need of population affects propensity to require health services – not the same as supply side ‘what is offered?’ Unit costs risk/volatility risk/utilisation risk/population mix change risk... comes to lot of risk. A proper risk adjustment would take that and pass to CCG – eg increase in percent over 65. Then can’t afford the same things to be offered/so pick up points in population… same thing as ‘predictive modelling’.
We don’t have integrated care records (even within NHS, let alone social care though that would be nice) and consequently don’t have population risk adjustor, then means can’t calculate savings as can’t distinguish risk adjustment pop forecast need for actual costs.
Set the baseline: to calculate savings you must have numbers, riskiness of population plus record of how money spent. In absence of that, savings are made up. You may not be able to get more money (if government hasn’t given) but may need to adjust service offer… Savings need to be calculated over a long timeframe.
True capitation contracts will have ‘risk corridors’