Transcript Hazel Stuteley

Notes from NHS Alliance
conference 18-19/11/10
Siân Williams for IMPRESS
Chris Ham, summary of points from day 1 NHS Alliance conference 18/11/10
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Fantastic opportunities in white paper
Feels different from previous white papers. Less prescriptive, so don’t wait, don’t seek permission
How do we combine best of choice and competition with the need for integration
– Includes decisions to buy and make services (new models of care)
– Concerns about conflicts of interest
– How to avoid bureaucracy of tendering
How do we get others involved in something more than GP commissioning, how to involve 2ry care?
Up to healthcare professionals to find a way in this more liberated and permissive model
How do we manage transition to ensure we give best possible start to GPs, including management support (David
Nicholson’s priority)
How to remove perverse incentives - beyond the tariff write to Jim Easton with ideas to align incentives and payment
to quality and productivity
Architecture and mechanics of white paper caused lot of debate but need to move beyond it so asking not how to build
it, but what’s it for - example from Gloucestershire showed the way
Need to pay attention to “followership” not just leadership if we want this to work
There’s a lot of disengagement from the silent majority. Need to improve the incentives.
Earl Howe, Minister for Health NHS Alliance conference 19/11/10
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Evolution - building on Blairite principles, incremental change - want GP practices to test the water (pathfinders by New Year), DH
commissioning research unit will evaluate it - new learning network (£1m); will be no manual - up to you
NHS not a machine - it depends on human relationships
Good healthcare is an exchange - between managers and HCPs, between different HCPs, between HCPs and patients
White paper is to support that system
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No decision about me without me
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Focusing on what matters:outcomes
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New culture of innovation and entrepreneurship and by empowering frontline to do the right thing for your patients - GP
commissioning is unique opportunity for all primary care clinicians
Applauds NHS Alliance GP-led commissioning Academy
GPs will need strong management as will NHS Trusts as open market to any willing provider
Why GP commissioning: 300 million reasons - 300 million consultations a year - know patients best - you have population responsibility
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Eg Northamptonshire Nene - peer review - in 6/12 prevented 900 referrals to orthopaedics saving £600,000
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Eg Croydon - worked with senior clinicians - one stop service for women with menstrual problems - 10 weeks down to 2 weeks wait
and fewer than 10% needing secondary care
Not expecting GPs to stop being doctors - some flexibility about how engaged they are in commissioning
Will coordinate clinical aspects, can employ staff or buy-in support from exernal experts - will lead, but not be alone
NHS Commissioning Board - will support, not DH. Will hold you to account for the money you’ve spent but won’t interfere with how you
run your consortium or what you do
Eg commissioning packs will be provided - care pathways
Operating Framework in Dec will say more about straightening out finances so GPs don’t inherit deficits
Tariff: Monitor will be responsible for setting maximum prices to drive competition - Spring 2011
Want fundamental relationship between doctor and patient to become more of a partnership: so patients decide where, when, by whom especially about after-care
Transparency - people aren’t fools - will be able to see where best care is offered, and will vote with their feet”
Any willing provider - essential clinical standards will underpin this provided by Care Quality Commission - better incentives to provide
better quality care
Patients will be able to access, add to, and share own patient records
Patients will have strong voice via local Healthwatch and local authorities - real powers of scrutiny and over local health services
Can also work closely with local authorities eg pooling budgets eg far more can be done to help older people live independently and reduce
reliance on NHS
Earl Howe
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with local authorities eg pooling budgets eg far more can be done to help older people live independently and reduce reliance on NHS
New white paper on Public Health out shortly. GPs can influence this too - working to make prevention as important as cure
Integration v market: there is a drive towards promoting competition and Monitor as the “vehicle” is shorthand way of saying it will be there
to monitor unfair competition not to drum up competition. Where you have good services, nothing much to fear but where services are
falling down, there ought to be scope to do it differently. Can have integrated care pathways and have an element of competitiveness, as
appropriate, along the pathway. Hope that the DH response to the white paper consultation response will provide a much better sense of how
it will be rolled out.
Will be able to commission from local ex-PCT provider eg community nursing services as long as transparent “Cosy relationships between a
practice and a community service has to go under the spotlight. But there are reasons to go for local service as long as not anti-competitive.”
Brian Fisher comment: democratic legitimacy is a good title for the white paper but the proposals don’t really have democracy in them. No
evidence of check or balance if a commissioner wanted to push something through Earl Hower response: will be more flow between local
authorities and GPs. Health and Wellbeing Boards will exist and and voters can vote out local authorities. Plus spotlight from Healthwatch.
Use what we’ve got.
Question: What about financial incentives such as PbR that makes integration very difficult - agree. Encourages fractured episodes of care.
Need to design optimum care pathway and best practice. Lots going on at DH on this.
Waltham Forest GP - what about strategic change - eg hospital configuration. We know difficulties of this. What will be level of support
needed for hospital configuration (we know about 4 tests), and where is the locus of responsibility for these difficult questions? Response:
accept it is a crunch question. Where marked difference of view, and seemingly intractable disagreement, has to be support: Firstly from
NHS Commissioning Board. In the final event if this doesn’t yield a result, the SoS will hold the ring. Advised by the Independent
Reconfiguration Panel. (That will also be available to the NHS Commissioning Board). If it involves loss of essential services (deemed
locally) - Monitor will wish to have a hand in this. Intent that commissioning consortia view should be in pole position - that’s the default.
Question and comment about metrics: if look at what happens in education, how are you going to help those at bottom of the league table bottom quartile to stop local people disowning services. Need a “working towards” metric. Surely need to Bring in patient focused
measures (what’s important to you)? Response: entirely right. Have to remember health need is different. Mustn’t unfairly tar local services
that doesn’t reflect effort and progress to lift quality. Commissioning outcomes framework will contain a mix and balance of metrics. Patient
experience, PROMs and some process (good proxy measures) as well as outcomes. And what about bringing up standards of general medical
practice? Is it right for NHS Commissioning Board and regional offices to be responsible. Isn’t it better for this to be consortia role?
Postcode lottery - how will you avoid? Response: phrase connotes arbitrary and accidental variation in standards and delivery of care. But
there will be variation - want to ensure that it is fully considered and fully worked out and everyone buys into - there for a reason, not
accident.
Highest priority: Pathfinders - enable us to prove GP led commissioning is achievable and can deliver results and will prove to those
not fully on board that it can be done and also learn lessons where not going quite right
Mark Britnall, KPMG Europe (ex Director General of NHS Commissioning): NHS Alliance 19/11/10 - slides will be
available. Final message to GPs: you have power, use it wisely, to meet needs of population. And if you don’t
hospitals will do it for you!
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Essential to focus on the real challenge - to address the challenges of long term conditions as percentage of population over 60 grows
Sustainable change must be from patient’s point of view
GP best placed - registered list is fundamental to success - envied the world over
Don’t leave secondary care on the other side of the fence - integrate - might be with chambers, out of hospital
High performing systems need a desire to be ambitious and to use IT to stratify care, and to blur boundaries
Information Evolution - better title for the white paper rather than Information Revolution: it will be paramount
KPMG client: Northern inner city of 1m plus people - could quickly commission with any willing provider can drive price down - working
groups with secondary and tertiary care working with PEC chairs, to redesign care - time to benefit takes at least 2-3 years. By end of March
2011 money will be short - shows integration essential - can demonstrate better results
Integrated care is way forward
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Examples: Veterans Health Administration in USA. Was an ailing hospital system 15 years ago.for US veterans. New leadership
understood that wouldn’t survive unless connected properly with primary care and created joint incentives and common IT systems,
with robust contracting because otherwise it’s not possible to unpack large hospital systems - the power is unequal. Rapid journey in
mid-late 90s provided higher quality care at cheaper prices (did downsize hospital)
KPMG asked healthcare leaders around the world - which mechanisms will work: 61% thought future would be about integrated care
Report will be produced with Economist Intelligence Unit
Three major reasons: better outcomes, better disease management and reduced cost
Be clear what you mean about integration:
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Functional organisational integration -just a means to an end Suggests need no more than 15-10 industrial powerhouses for
finance, HR, IT, contract negotiation, contract monitoring, quality account. Try not to focus on this
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The end: to help patients through system - clinical integration - focus on this bit - employ people in and out NHS to support you
Accountable Care Organisations (ACOs) - Obama administration talking about this - teaching hospitals, insurers - this is what we are doing.
Geisinger eHealth Integrated System. North West USA. Unpacked hospital system
Integration of providers should be encouraged - clinical commissioners can stand apart from that - eg outcome based clinical specifications
and then leave providers to work out how to do it
Future of specialists? Partner organisations are good - balances right reward and risk (KPMG is a partner organisation and good model)
Would like the information “revolution” to start with primary care and what patients should expect from it
Chaan Napaul comment: politicians don’t understand integration -demonstrated by tariff, adversarial commissioning, separating coprovision, reforms haven’t grasped it - and it’s too much hard work to sidestep it
Michael Rawlins, Chair of NICE NHS Alliance conference 19/11/10
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Broad purpose of NICE unchanged
Clinical programme of appraisals will change a little. Currently NICE appraises pharmaceuticals, diagnostics,
devices etc and looks at benefits and costs. Includes acquisition costs of drugs which is the price given by the
manufacturer under the Prescription Pricing Regulation Scheme. Currently say no about 10% of the time usually
because does not seem to carry benefits in relation to the cost. The new proposal is that pricing should change to
value-based pricing. NICE analysis may trigger a price negotiation.
Agreed that need to improve who chairs the guidelines committees - ideally it should be a generalist not a specialist
Guidelines programme - currently 130, largest producer in the world. Highly regarded. Used in the QOF to define
and propose indicators. This will continue.
Public health programme - will change a little
Quality indicators for QOF and quality standards - new (high level statements about what high level care will look
like)
NHS Evidence - Google-like portal to source evidence. Accreditation system. Unchanged
Health Bill should get Royal Assent July 2011. NICE will be re-established as a non-departmental body from April
2012.
Quality standards 150 over the next 3-4 years - four pilots. Learnt that they must be built on clinical guideline.
Should NICE produce commissioning guides and the Commissioning Outcomes Framework - discussion continues.
New - responsibility for guidance on adult social care. Unclear about including children’s social care as yet.
May produce social care quality standards
May also produce public health quality standards
Reports of demise are premature!
Comment from floor: NICE - worry about issue of expensive treatments devolved down to local level - will lead to
health tourism…. MR agreed - for pharmaceuticals need one standard for all. Maybe some variation in access to
certain services due to density of population and so on
Cynthia Bowers - Chair Care Quality Commission Regulator of health and social care
NHS Alliance conference 19/11/10
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Purpose: police the bottom line - firstly, is provider meeting quality standards, if so, leave it alone. Meanwhile,
constantly look for information from all sources (Monitor, inspectors, local newspapers, blogs, soft data, emails,
letters and so on - not directly from providers or GPs) to see that providers of care are compliant with the CQC
standards and if not, do something about it
Essence of difference from Healthcare Commission - it made an annual statement about secondary care - retrospective
judgement, not an inspection-based system - it was about assurance (“assure us that you are doing….”) Now it is
inspection based, enforcement powers, and within the system trying to leverage improvement,
Interested in hearing voice of service users in establishing what “good enough” and “excellence” looks like
Programme of registration - GPs from April 2012 (as providers); Dentists from April 2011
409 NHS trusts v 12,500 social care businesses so lots of work other than what you expect
Will have capacity to take in service user information - investing in software (hugely powerful, used by military for
detecting terrorist attacks on the internet) for this - will then be able to receive infinite amount of information
Quality and risk profile produced against 16 standards for each organisation in 6 headings - available now as a report
on the web including all the data that led CQC to make that judgment. Will be live from April - as new information is
analysed, so it will be added. Ultimately all 50,000 organisation CQC regulates will have live reports on the website.
Not there to offer rating or targets but to prompt activity by CQC inspectors to talk to providers or commissioners
Enforcement powers - civil and criminal powers
CQC wants to ensure GP commissioners use CQC intelligence and want to see how best to get GP intelligence
Question from the floor: what about rubbish doctors? CB response: professional regulatory bodies’ responsibility but
CQC can use intelligence to identify who they are and help them to get them up to standard and if not, will close them
down.
Comment from floor by GP: general practice scrutinised already - QOF, revalidation etc why do we need CQC? CB
response: should ensure practices fit to provide care
“Must have public health connected (GPC Negotiator, Chaand
Nagpaul), not remote
in local authorities, otherwise commissioning is just a [unconnected] process”
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Hazel Stuteley OBE gave great illustration of transformational community
development in Cornwall, very deprived area
www.healthempowermentgroup.co.uk
Located energy for change
Gained agencies commitment to share power eg police
Connected at every level
– Eg to reduce 999 calls, on site paramedic and beat officer
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“we’ve done it for ourselves” - dance workshops kids stopped smoking, eating
fruit donated by Aldi, people start looking after their gardens, disaffected
young people given free driving lessons in return for improving estate gardens
and meanwhile learning horticulture
Operation Goodnight - self-imposed curfew during school holidays; self
policing - reduced anti-social behaviour
Need to ensure this is initiated and commissioned - Secretary of State is very
interested in their achievements.
Personal health budgets Dr Alison Austin, DH Project Lead, NHS Alliance conference 19/11/10 from DH
www.personalhealthbudgets.org.uk or email [email protected]
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One element of personalising care agenda and here to stay
Gives the individual what they need - eg chance for carer respite by paying for arrangements to enable it to happen
Satisfying for HCPs - can offer help
Helps the system - generates some efficiency savings
Way of giving someone choice and control
Four stages:
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Identification and allocation of money spent on their care now
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Used to develop and agree a care plan by the individual alone or with HCP
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Buy it - like now with contracts traditional service,s or passed to independent third party, or direct payment to the individual eg
responsible for employment if pay for personal assistant
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Process of review and monitoring. 3/12 review and then check that money spent as agreed if a direct payment
Pilot programme at the moment - half of PCTs in country involved - looking at long term conditions, continuing health care (likely to be early
win - who already have personal budget for social care but once eligible for continuing care then lose all that control), mental health, end of
life, learning disability and other (maternity)
3000 patients to be recruited to pilot: 20 in depth sites, and then wider cohort going at own pace (small numbers)
Mirroring rules of social care direct payments wherever possible - support planning, and the infrastructure - will make it easier to integrate
with social care later
Some differences: driven by policies eg professional registration,
Who can have one? Anyone with a care need that you can reasonably set a budget for. Even if fluctuating health need. Need to be in pilot
area at the moment and meet local criteria.
Few rules - not for emergency care or core GP services, must be legal, and appropriate for state to fund - not for alcohol, gambling, debt
repayment, tobacco; anything else is OK
Egs Adult with Huntingdon’s disease had social care budget used to employ Personal Assistant. Then as condition deteriorated, added
personal health budget - kept same Personal Assistant and then bought additional top-up. Avoided agency fees, and personalised service
Eg Ventilator dependent adolescent. If has chest infection he can quickly get physio bought by mum. Saves hospital admission.
Eg someone with major head injury following RTA. Rehab is a slow process. Used to fund this - swimming, dancing and singing.
Future - here to stay. In white paper Equity and Excellence - it will be rolled out further Spending Review includes it too - not just health
but in other service areas eg education, children with disabilities…
Need to think how it will fit with GP consortia, Health and Wellbeing Boards, any willing provider, NICE optimal care pathways
Still looking for pilots - contact the team
Question: What is the return on investment? DH is looking at this. Anticipate at no extra cost. Some set-up costs - cultural change but in
longer term - ROI of savings in care packages and prevention - reduced admissions eg for chest problems eg from 7 - to none in year
Comment: Opportunities: pool administration costs eg social work teams could float into independents. Some are testing this pooling of back
office.
What if care plan not agreed (eg mental health - alternative therapies that aren’t evidence based). Who decides? DH: up to local governance
structure. Allowing everything - may test it and review. Eg overweight man with COPD, diabetes, high BP, reclusive, wanted a dog. Had to
feed dog and learn about nutrition, take dog for a walk (whippet) - social with other dog walker. Nottingham - hypnotherapy deemed OK for
an individual.
Asked Alison Austin to send to Siân Williams any contacts where COPD is being tested, and any illustrations of what it is used for
Nottingham City Gemma Newbery NHS Personal Health Budget Project Manager
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People with neurological conditions, memory problems, continuing care, and carers
Need to recruit 75 to test group and 75 to comparison group and if it works the comparison group will be first to be offered chance to hold
personal budget
PCT being encouraged to be flexible - any goods and services agreed in the care plan. Looking at support plan approval policies and
compiling directory of services eg one for neurological conditions and one for memory problems - on the PCT website
Staff training in support plans, change management - huge cultural shift
Logistics and flowchart
Lessons: essential that health and social care work together - need to be able to pool social and health budget
People need support - bring in external brokers - people feel daunted
It’s time consuming if done properly
Culture change to facilitate it is huge
Must recognise and record risks although not all materialise, partly because have identified them and then monitor them
Market needs to develop so that people can have choice - not enough options at the moment
Challenging when someone has fluctuating needs
Eg Lady 29. Has MS lives at home with two children. Used to get home care plus offered 6-weeks of physio and continence support. Got
depressed seeing people with worse condition at hospital appointments and hard to get to the physio, and finding it hard to get round house.
With personal health budget got bladder management with MS nurse at home, joined local gym instead of physio. Can now get up and down
stairs on own.
85 year old lady with dementia. Fiercely independent. Then had stroke. Reliant on neighbours who were also quite old and found it difficult
to cope. Had spell in intermediate care. Unable to get to appointments. Forgetting medication. Not coping on own. Bought Personal
Assistant (PA) from agency - chose the person herself. PA trained to better understand memory problems and to identify issues early to
prevent crisis. Still at home.
Man with complex conditions. Deteriorating assessed for continuing care.
Had 2 PAs and overnight waking carer £7.94 an hour (social care). Same package with NHS would have cost over £11 per hour. Now
transferred to NHS, but same care.
Need to look at ways to combine people’s personal health budget - eg use £ to transport to get to exercise class (could do this with pulmonary
rehab)
Questions: How do you identify patients? Three community teams eg intermediate care staff - randomising all those they see, but use
judgment
Question: how to assist culture change: bespoke training course 2 half days - understanding risks, and benefits and how to shift to see
benefits.. Is that enough? Supervision and mentoring costs too? Some clinicians championing it
Someone had heard that people being excluded due to perceived health and capacity. DH not heard that people excluded. Nottingham working with people with dementia -eg person with fluctuating capacity and no family. Recruited patient and clinician now involved. How
do we realistically get message to individuals that it’s possible - it’s piloting so not a “right” at the moment.
Community Integrated healthcare in Whitstable, John Ribchester - GP. Community integrated care NHS Alliance
conference 19/11/10 (this is Hilary Pinnock’s practice
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19 GPs, 100 staff, 33,000 patients. Single practice GP commissioning consortium. 4th largest in UK. John Ribchester is Shadow
Commissioning Accountable Officer
Advanced training practice. Accredited for research by RCGP. Invest income in own developments.
Great patient engagement - run a café, fundraised for equipment eg digital X-ray
Own day surgery suite
Largest elderly population in East Kent. List size is rising and getting older and more long term conditions. 10 miles from nearest DGH
Some redesign - better patient experience (measured by questionnaire). closer to home, less than tariff, shorter waits by being commissioner
and provider
Choose and Book outpatient outreach clinics - redesign pathways with them, often using a GPwSI to triage referrals so see right person first
time and using in-house diagnostics making it one-stop wherever possible
In house clinics, long term condition integrated care pilot
Long term conditions - bring teams into the community and deliver it faster, and more cheaply with high patient satisfaction
Four workstreams Integrated chronic disease management, urgent care (pharmacy and colocated ambulance service - want to extend to
include OOH and social care based there) , electives and diagnostics, and enhanced rehab at community hospital (under threat -who will own
it in white paper, but interested in using it to reduce los and delayed discharges)
Commissioning consortia - federated model most likely as combined PBC consortia just like a PCT and going it alone not big enough
Preferred model 9 consortia coordinated by one Board, one support organisation for all the federated consortium - 600,000 patients
Question: who is using risk stratification? Whitstable: working with PH department at PCT - compared population to similar populations SMR better than expected and age of death later. Would seem better control leads to better outcomes. 11% fewer referrals to hospital than in
2008. But still overspend.
How might Whitstable plug in personal budget to its services? Response: not yet committed because what happens if money runs out at 10
months…. Have identified those who are most dependent are not necessarily those with most long term conditions - it’s about poor control
What if money runs out - no-one will be denied healthcare. Process of review at 3/12 and monitoring. Where are contingencies then?
Unclear.