For the Nuffield Trust Health Policy Summit, Stephen Shortt tells the story of a journey from multiple unconnected practices to accountable community based integrated services at scale.

1. Transforming the NHS:
A journey from multiple unconnected practices to
accountable community based integrated services
at scale
Stephen Shortt
GP
Principia MCP
Nuffield Trust Health Summit
Friday 4th March 2016

2. • Integrated health and care system
• Accountability for clinical outcomes
• Align budgetary accountability with clinical decision to
commit resource
• Reduce / eliminate funding gap [£140m] by 18/19
• Vire resource into preventing hospital admissions and
reduce length of stay
• Support personal lifestyle behaviour change - reducing
prevalence/ burden of long term conditions
• Empower patients and carers to self-manage long term
conditions, support independent living
• Redirecting activity from secondary care into capable, at
scale primary care
Focus of Principia New Care Model transformation

3. • A clinician led, patient centred organisation: data driven,
supports management of clinical care, operations,
service and financial performance for local population
• Population health organisation that is fit for the purpose
of bearing risk for triple aims with a capitated budget for
population of Rushcliffe
• Planned and staged transfer of financial and service
responsibility from CCG to accountable risk-bearing
provider organisation for in-scope services
End state

4. “Only physicians and provider organizations can put in place the set of
interdependent steps needed to improve value [the relationship between
outcomes and costs] , because ultimately value is determined by how
medicine is practiced and care is delivered.”

5. Performance and value creation are a product of science
(30%) and sociology (70%); the adaptive challenge
Science
(Identifying “the right thing to do ”)
Sociology
(“Making the right thing happen/easy”)
• Evidence-based guideline development,
goal setting
• Design and development of care
management programs for clinical
priorities; service and operational
improvement s
• Granular, actionable metrics; internal and
external benchmarks
• Measurement, timely reporting and
feedback, unblinded sharing of data,
identification of successful practices
• Shared ownership/responsibility/
• Risk and reward aligned around shared
business objectives
• Stewardship
• Lay- clinical leadership, relentless focus
and communication, champions
• Culture of accountability, commitment,
pride, performance
• Clinical-managerial compact; joint
responsible for programme success
• Performance management, recognition and
celebration of success
• Continuing improvement in the quality of
real time data and metrics
• Leveraging technology to facilitate quality,
service, personalization of care, efficiency

6. [Urgency, capacity and knowing where to start]
• Understanding and managing risk; value based contracting; payment models;
transitioning to capitation
• Advanced data management capabilities ; use of actionable intelligence
• Re-imagining care model; care management processes; risk stratification
• Establishing preferred relationships with motivated and efficient specialists, partners
• Implement standardised care management protocols; tracking and managing
clinician behaviours and performance
• Technology and infrastructure requirements; EHR
• Reward systems , payment mechanisms aligned with organizational and system goals
to reward desired behaviours, cost utilization, quality and patient experience
• Activation of patients and families in managing own health and self determination
• Cross-system engagement, leadership and governance
• Implementing change in complex care organisations and networks
• Capital; financial protection
Technical challenges

7. • Extending the scope and quality of the primary care offer through
collectivised general practices
• Integrated practice delivery to care home residents
• Developing fit for purpose accountable care system
Mobilising the Principia NCM: illustrations

8. • LLP GP provider interface for 118K Rushcliffe patients, established 2015
• New inter-practice governance and accountability for achieving better
outcomes for population
• Professional leadership; continuous quality improvement core values
• New NHS contract with CCG ; practices retain existing contracts with
CCG/NHSE
• Point of difference is strong focus on the future and retention of high
quality general practice locally
• Priority the design and delivery of sustainable high quality solutions and
services for patients, GPs and practices that improve outcomes at pace
• Develop internal effectiveness and efficiency; collective resilience
• Develop new alliances, partnerships as required to resolve performance
and financial pressures in local care system
• Restore general practice as best place in world to work 8
PartnersHealth LLP - a partnership of partnerships

9. • LLP GP provider interface for 118K Rushcliffe patients, established 2015
• Implemented Rushcliffe GP Specification: new investment • extended service
offering to patients aligned to CCG objectives; informed by mass patient
survey on future of local NHS services
• All practice funding allocations levelled up to £88/patient; MPIG / PMS growth
abatement underwritten; financial risk share with CCG
• Domains:
1. Access: Practices open throughout week • Standard offer • Weekend
opening • Data sharing across all providers • Patient access to full on line
services including access to own clinical journal and pathology • e-
Consultation • Video consultation
2. Long Term Conditions: Common templates across all practices •
Standardised data entry • Common recall system • Disease registries •
Introduction of model of shared decision making and patient decision aids
• Motivational interviewing training
9
Enhancing the contribution of general practice

10. • LLP GP provider interface for 118K Rushcliffe patients, established 2015
3. Use of Resources: Individual GP utilisation measurement and reporting •
Practice benchmarking and external peer audit • Continuing Health Care
reviews
4. Integrated Practice: Orthopaedic OPs shifted to community • Integrated
service procured under a new contractual form • Gynaecology OP and
elective DC activity from March • Urology in development • GPs in ED •
Extended service to care homes • GP, community matron in reach to Health
Care of Older People wards • HEEM GP fellows and CEPN
5. Governance: LLP formed • New organisational form and inter-practice
governance • MCP governance developed; interim PartnersHealth lead
integrator role; • External partnership development
10
Enhancing the contribution of general practice

11. • LLP GP provider interface for 118K Rushcliffe patients, established 2015
• Extended scope • Extended value • Pay for performance model
• fixed budget with upside/downside risk share with CCG for
prescribing budget and elective care
• Agreed clinical pathways • Standardised coding of clinical care •
Referral thresholds• FOPA after e-mail Advice and Guidance •
Unblinded individual referral reporting and benchmarks •
Referral management support teams • Prior authorisation
11
2016-18 Rushcliffe GP Specification

12. • CCG commissioned
service (April 2014)
• Specified by CCG
• Supported by patients ,
carers, Age Concern,
general practice
(including practice
managers), community
nurses, community HCOP
consultant, care homes
• Service structured around the needs of the resident
and their medical condition
• Engagement with family and carers
• Dedicated team of clinical and no-clinical personnel
providing for the out of hospital care cycle
• Team works toward s a common goal : maximising the
patient’s overall outcome as effectively as possible
• Team are experts, know and trust one another and co-
ordinate easily to minimise time and resources
• Common care planning templates
installed across all practices
• Systematised data entry , registry and
tracking
• Remote access to GP clinical system
patient record via dedicated laptop;
Wi-Fi for each care home
• Trial of video consultation facilities for
staff, family and residents
• One practice , one care home
• Personalised care plans, advanced
directives, consent for data sharing
• Scheduled GP , community matron
and district nurse visits; dedicated
time
• Dedicated care home pharmacy
advisor / prescriber
• Service review with Age Concern
Rushcliffe extended support to care homes

13. 20-22DAYS
ELSEWHERE IN SOUTH NOTTS
12DAYS
RUSHCLIFFE
INTERMEDIATE CARE
LENGTH OF STAY
QIPP
143%
TRAJECTORY
TARGET
No increase in emergency medical
admissions from Rushcliffe care homes
(compared to between 67-130 %
increase in rest of greater Nottingham)
Number of Rushcliffe care home
residents dying in hospital has fallen
by 3%.
29 PER 100 BEDS (v. 60-67)
CONVEYANCES FROM CARE HOMES
55 PER 100 BEDS (v. 98-117)
RESPONSES TO CARE HOMES
EMAS
Extended support to care homes: impact

14. • Self assessment: insufficient capacity and capability to address systemic
issues of quality and financial sustainability as urgently as required, or
competencies required by a population health risk bearing organisation
• Proposal to recruit transformation partner/system integrator
• Harness efficiencies and expertise in long term relationship to :
• Modernise and create a fit for purpose care infrastructure
• Improve efficiency and quality of delivery
• Secure appropriate risk transfer to stimulate innovation and
performance management
• [Introduce capital] without increasing public sector debt
• Share accountability and risk for cost control and performance
• Actuarial feasibility analysis (14 organisations inc. primary care and LAs)
• Programme design and partnership development
14
Developing a fit for purpose accountable care system