The document outlines a journey towards transforming the NHS into a community-based integrated health and care system, focusing on accountability, resource allocation, and patient empowerment. It emphasizes the importance of data-driven approaches and collaboration among healthcare providers to improve clinical outcomes and manage long-term conditions effectively. The strategy includes financial restructuring, the establishment of new governance models, and enhancing general practice contributions to create sustainable solutions for the population's health needs.

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