NHS Confederation Visit Dr Amanda Sullivan Chief Officer

NHS Confederation Visit Dr Amanda Sullivan Chief Officer

NHS Confederation Visit Dr Amanda Sullivan Chief Officer Helping to shape future health and social care in Mid Nottinghamshire Better Together is part of the STP Partnership in Nottingham and Nottinghamshire PACS (Primary and Acute Care Systems) Vanguard Better Together Patient population: 330,000 41 GP Practices

Helping to shape future health COMMERCIAL and social care in Mid Nottinghamshire IN CONFIDENCE Care Model Service developments in Further developments in Developments in 2016/172014/15 2015/16 2017/18 Roll out of integrated health

Design and implementation of Further development of and social care community specialist intermediate care specialist intermediate care teams (PRISM) in Mansfield and services to join up expanded facilities to required capacity Ashfield and extension of community services with hospital NCC have created a Short Term Independence Service (community existing services to 7-day services and general practice & beds) aligning to this working in Newark and 7 day integrated community team Sherwood

working in Mansfield and Ashfield Implementation of the cancer and end of life strategies, in includes social workers, line with integrated community voluntary sector, link into health teams and social care services Development of joint working arrangements across hospital and community clinical teams LGA evaluation on impact on preventing or delaying need for social care to complete Sept 2017 Service developments in 2014/15 Further developments in 2015/16

Developments in 2016/17-2017/18 Introduction of new hospital discharge processes and community services to prevent medically fit people being detained in hospital for assessments regarding their long-term care requirements (transfer to assess) Redesign of continuing healthcare assessment

process to reduce complexity and hospital length of stay National requirements Expansion of crisis response teams in peoples homes, introduction of care navigator for professionals (Call to Care), so that they can guide people to the services they need first time Pathways are being linked with the NCC Customer

Services Centre Expansion of transfer to assess to wider patient groups Development of a self-care Development of Health and Integration of advice and strategy (including how we will Wellbeing Hub at Ashfield Health information with provide additional information Centre and Self-Care information and integrated community and support for people to advice centres in other locations teams

promote health and wellbeing and across Mid-Nottinghamshire, Introduction of systematic independence, advice and targeted communication shared decision making support for carers) for elective procedures Joint clinical protocols between Building extensions and adaptations Development of primary out-of-hours GPs and emergency at both sites and integration of care hubs, full care at Kings Mill A&E and hospital and GP urgent care implementation of single Newark MIU, pilots of ways to services, roll out of successful GP

front door, centralised change GP appointment systems extended access pilots, includes acute home visiting and improve access to urgent social workers 7/7 care Reduction in mortality Reduction in length of stay 10000 9500 9000 8500 8000

7500 7000 6500 6000 5500 5000 4500 SFH Trust Total 15/16 OBD LOS 10 days plus Linear (15/16 OBD LOS 10 days plus) 16/17 OBD LOS

10 days plus Linear (16/17 OBD LOS 10 days plus) The Alliance Contract Making the most of whole-system leadership: Alliance Contracting A co-operative relationship between a client and key Suppliers to deliver significant project performance improvements AND enhanced business results for all involved What is Alliance Contracting:

When to use Alliance Contracting Complex risks and interfaces Difficult stakeholder issues Likelihood of scope changes e.g. technological change or political influence A need for customer involvement Threats or opportunities that can best be managed collectively

The Mid-Nottinghamshire Alliance Overarching Alliance contract between Commissioners and Providers includes governance, risk/reward mechanism and performance regime Subcontractors Individual bi-lateral service contracts with Provider Participants incorporating, for example, mandatory NHS Standard Contract terms

12 The Alliance is a group of partners who collectively determine how services will be delivered and are collectively responsible for improving health outcomes. The Alliance covers the following areas: Development of whole-system plans for sustainable services until 2020/21 Development and shadow testing of new payment mechanisms (capitation, based on outcomes) Working together to achieve some defined service changes under an Alliance contract Individual contracts with providers also exist alongside this Why change our approach to contracting and payments?

Why do contracting and payment design matter, and why do we need a new approach? Current contracting and payment systems do some things very well they support the constitution, by enabling patient choice and keeping waiting times down Current arrangements reward acute providers for treating sick patients, but leave many out of hospital providers unrewarded for doing more They do not create incentives for population level outcomes, support overall cost containment or the integration of services for the benefit of patients all of which are becoming increasingly important Therefore a new approach is needed to create the right behaviours to promote effective, coordinated, person-centred care including prevention, support for self-management, addressing mental health and social needs, as well as physical

ones New mechanisms can support sustainable services, with a clear service vision and shared goals they will not achieve this on their own 16 Approach to Risk Management needs to change Alliance Approach Current System Leadership conversations focused on transactional arrangements Focus on Organisational boundaries and requirements

Moving the deficit around the system The financial gap is increasing Leadership conversations focused on transformation and system strategy Focus on what is best for service for the Mid Nottinghamshire population Working to reduce the deficit of the Mid Nottinghamshire System Risk and Reward in place to manage transition risk

Outcome Based Commissioning Patient and public engagement Plans systematically informed by public views. 700 champions. 450 people contributed to outcomes framework. E-newsletter to 40,000 people Regular public events. Benefits of OBC

1 2 3 Increased focus on whole-person care Enabling collaboration and integration Realising efficiencies in the system

OBC aligns incentives across the care economy todeliver the outcomes that matter to patients and the public. Rewards outcomes and not just activity OBC puts resources in the right place in the system to maximise value Improved patient experience through reduced fragmentation Providers are supported, and incentivised, to collaborate in order to deliver whole person care Delivery of improved models of care Promotes investment in prevention, quality improvements and working practices Can reduce duplication across the system

Opportunities to deliver care in lower cost settings Capitated Payment Models and Risk & Reward Capitated Payment Approach: Key Mid-Notts Principles Incentivise clinical models that better anticipate and more completely meet the needs of patients

Incentivise greater opportunity to co-ordinate and integrate services across settings and providers Be an enabler for change, supporting the delivery of efficiencies across the system Build on the positive elements of the current payment systems Recognise risk and include a fair and transparent system-wide risk and reward share

Need to ensure that perverse incentives are not built in, including but not limited to: Avoid the pitfalls / perverse incentives in the current payment systems Avoid unintended impacts on access to services e.g. cherry picking Avoid unintended impacts on patient choice need to include contractual terms for patient choice and out of area care

Includes fixed, variable and outcomes based payments 23 Example: MSK Pathway MSK Previous Care Model MSK New Care Model MSK: Allocating Risk & Reward Influence Driver

Decision making Referral pathway compliance Delivery of service Total CCG SFH NUH 25% 25%

70% 30% 23.5% 65% 50.5% NHC 25% Split between categories

25% 0.1 0.3 5% 5.5% 30% 20.5% 0.6 1.0 Decision making is equally split all organisations have one vote at ALB. Referral pathway relates to the ability to communicate and influence GPs in following the pathway.

Allocated to CCG as GP performance managers and SFH as coordinating provider of the service. Delivery of service split 70/30 acute/community based on an understanding of contact time with patients. Weightings between categories based on impact on model delivery financial and operational. Service delivery seen as main driver. 27 MSK Initial Reflections Things that went well: Building relationships and networks across the system Providers starting to work together to deliver the best solution - using the right skills and expertise in the right place - collaboration not competition Clinically led discussions on the care model

Opened conversations to different approaches to paying for services and risk sharing Whole system came together at critical points to work at accelerated pace e.g. March to complete the model Valuable learning experience, lessons learned will be reflected in future payment mechanisms work MSK Initial Reflections Challenges: Deficit financial system Detailed costing data was not available from all providers, this resulted in the development of a hybrid capitation model Stranded costs presented a number of challenges: - availability of detailed breakdown - working at pace to remove costs from the system (and wider STP)

- how system stranded costs are funded Governance role of Alliance, statutory bodies and commissioner Capacity / Capability - challenge delivering day job and new model, constrained timeline for final stages, getting the right people involved at the right time, provider and commissioner input required. Clarity of aims and outputs from the beginning Observations and some shared thoughts. Reflections: hidden bends / hazards Provider and commissioner roles some unhelpful perceptions / traditional behaviours

Managing system dynamics moving from polite / apparent agreement (but no real intention or action) to joint effort, commitment and problem solving. Cultural issues old and new behaviours (interpretations of new ways of working, what does best for system mean?) Understanding each other across the system. People arent all excited by transformation and dont necessarily welcome change even on a burning platform. Alignment across the system regulators, all providers, local government , commissioners. No rule book, but it takes more time than you expect. Reflections for future policy Whole system approach impacted more than expected on ED and RTT access standards (productivity good for managing population

demand, not good for managing the money) Fewer beds does not mean fewer admissions and less cost for commissioners (107 beds released) The Alliance could achieve a great deal, but only with regulatory alignment (relates to STP development) Different parts of the system are not aligned and this confuses evaluation of the new care model (eg. Conveyances, price and cost) . Contact details: [email protected]@ne warkandsherwoodccg.nhs

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