Commissioning in the Brave New World

Dr Nick Kennedy Taunton & Somerset NHS Trust

NEW Devon and South Gloucs CCG’s

SODIT June 16th 2017

Why am I talking on this subject?

•  Consultant Intensivist

•  Commissioner Secondary Care Clinician on CCG Governing Bodies NEW Devon South Gloucestershire (Bristol, BNSSG)

!  What will structure of healthcare commissioning look like in future?

!  Current structure !  STP’s !  Devon position !  Future structure

!  How could this affect critical care services?

Commissioning in the Brave New World

What is the “Brave New World” of commissioning?

NHS England “5 Year Forward View”

STPs- “Place based care”

Accountable Care Organisations/systems,”

“Strategic commissioners”

Single control totals, Capped Expenditure plans, “Capitated” budgets

Benchmarking/outliers/performance

How could this affect critical care services?

• Critical Care is inherently bound up with acute sector

services. Restructures will affect services using critical care

• Different in the different STP areas

• Some Specialised commissioning services moving to CCG

commissioning

• Focus on outcomes and quality

• Getting it Right First Time/Right Care

• CCGs  created  following  the  Health  and  Social  Care  Act  in  2013  •  207  clinically-­‐led  statutory  NHS  bodies  responsible  for  the  planning  and  commissioning  of  health  care  services  for  their  local  area.    

•  Led  by  an  elected  Governing  Body  made  up  of  GPs,  other  clinicians  including  a  nurse  and  a  secondary  care  consultant,  and  lay  members  

•  Responsible  for:  •  approximately  2/3  of  total  NHS  England  budget;  £73.6  billion  in  2017/18;  •  healthcare  commissioning  such  as  mental  health  services,  urgent  and  emergency  care,  elecNve  hospital  services,  and  community  care;  

•  the  health  of  populaNons  ranging  from  under  100,000  to  900,000,  (average  populaNon  covered  by  a  CCG  is  about  250K)  

(NHSE  Specialised  Commissioning  and  GP  services)  

CCG’s  Current  Structure    

South West CCG’s

Fast Forward

Financial issues

Changes needed

New models of care 5YFV Multispecialty community providers MCPs

Primary and Acute Care Systems (PACS) Urgent and emergency care networks Specialist services reconfiguration Etc

But finances still concentrating minds

Success  Regimen  introduced    (Devon)  2015  •  Success  Regimen  potenNal  benefits  include  the  opportunity  to:  

•   •  avoid  place-­‐based  discussions  descending  into  a  zero-­‐sum  game  that  inhibits  the  development  of  collaboraGve  working  between  local  NHS  leaders  

•   •  develop  new  care  models  that  span  organisaNonal  and  service  boundaries,  supported  by  new  approaches  to  commissioning  and  paying  for  care  

•   •  establish  robust  governance  arrangements  that  balance  organisaNonal  autonomy  and  accountability  with  a  commitment  to  partnership  working  and  shared  responsibility  

•   •  develop  services  that  are  financially  and  clinically  sustainable  through  greater  integraNon  of  care  and  a  focus  on  improving  populaNon  health  and  wellbeing    

•  •  provide  a  foundaGon  for  collaboraGon  with  a  wider  range  of  organisaGons  from  different  sectors    

•  •  work  in  partnership  with  the  public  and  local  communiNes  to  transform  the  way  that  services  are  delivered  •  enable  naNonal  bodies  to  work  differently  and  in  a  joined-­‐up  way  to  support  providers  and  commissioners  in  finding  soluNons  to  their  challenges.  

" They are integral to NHS England’s Five-Year Forward View

" Devon, Cornwall, Somerset, Bristol (3 CCG’s) are developing a Sustainability and Transformation Plans (STPs)

" 44 STPs in England.

" The plans will test current thinking and shape how health and care services need to change to meet future demands

Sustainability and Transformation Plans (STPs) 2016

Dr ick Kennedy, Taunton & Somerset NHS Trust

"  Wider Devon is one of 44 strategic planning footprints in England

"  Involves 10 statutory organisations working collaboratively for benefit of the whole

"  NHS and local authorities focused on a common set of health and care challenges

"  Plan activities to make biggest difference to both population health and financial recovery

"  Plan will be presented to Governing Bodies, Boards and local authorities for endorsement of the framework within which detailed plans will be developed

The STP footprint and ambition

Our unified ambition is to create a clinically, socially and financially sustainable health and care system that will improve the health, wellbeing and care of the populations we serve

Resident population of around 1,160,000 - just over half living in urban communities just under half living in rural communities. Spans 2 CCG and 3 local authority areas

" The STP will test current thinking " It will help us shape how health

and care services need to change to meet the future

" The STP has a clear vision, and three areas of focus

" Work taken forward in seven priority areas

What the STP will do…

Bristol (BNSSG) STP

Devon’s health and wellbeing challenges

The STP is a plan that all organisations across Devon are signed up to and united in delivering…

"  Devon 2017/18 opening deficit position against control total is £229m – 15% of turnover o  £163m NEW Devon CCG, plus £66m South Devon & Torbay

CCG "  Our three-year STP plan, submitted in Dec 2016, moves Devon

system to financial balance over a 3 year period: o  Year 1 (2017/18): Planned deficit of £78m o  Year 2 (2018/19): Planned deficit of £36m o  Year 3 (2019/20): Breakeven

" We may be asked to accelerate these plans "  Delivery requires large scale service redesign and change

STP addresses need for Devon to live within its means

Seven priority areas

(health and social care, includes CCG’s recent consultations on community services)

Priority 5: Review of acute hospital and specialist services

Increased need for treatment and care, longer waiting times

Hospital services designed to meet

different needs many years ago

Ability to comply with rising standards, new drugs and

treatments

Failing to meet key NHS targets and quality standards

Not enough staff, with impact on 7-day services

Services under review: "  Hospital urgent and emergency care "  Stroke services " Maternity, children’s health and services for premature babies

Strong progress in working as a system "  First year as STP has seen great progress and achievement "  Significant progress in collaborative working in Devon "  System working has led to: o  Real progress in tackling the money, with in-year savings of £66

million. Year-end system deficit was £80 million o  Improvements to service performance, notably urgent referrals for

cancer treatment within two-weeks, psychological therapies for mental health, and improvements to A&E despite huge pressures

o  Reduction in elective activity, with routine referrals down by 3.4% o  Two major public consultations on new models of care

"  More change to come, such as focus on accountable care systems and working in more integrated ways

"  Recognise change is unsettling

The  ASR  Case  for  Change  Devon  wide  ‘case  for  change’  underpinning  STP  –  specifically  highlights  concerns  with  regard  to  acute  services:  

Some  services  are  fragile  currently,  increasing  the  risk  of  providers  being  required  to  implement  short  term,  unplanned  change.    There  is  therefore  a  risk  to  ‘doing  nothing’  

Increased demand for treatment and

care - longer waiting times

Current configuration of services designed for historical demand

model

Ability to comply with rising standards,

increasing need, new drugs, diagnostics,

interventions

Fragility of current services – failure to

delivery on key access and quality

standards

Resilience and retention of work

force, particularly at sub specialty level

Acute system in Devon costing more than funded levels

Priority  Review  areas  

Stroke  &  cardiovascular  

•  The  objecNve  of  this  review  will  be  to  recommend  opNons  for  service  models  within  which  hyperacute  stroke  and  stroke  rehabilitaNon  services  are  commissioned  

Maternity,  Paediatrics  and  Neonatology  

•  Acute  maternity,  paediatric  and  neonatal  services  will  be  reviewed  together  given  the  interdependencies  between  them  

•  Clinical  assessment  is  that  gynaecological  services  can  be  out  of  scope  for  this  review  though  that  view  will  be  tested  with  the  specialist  contributors  

Urgent  &  Emergency  Care    

•  The  objecNve  of  this  review  will  be  to  recommend  opNons  for  service  models  within  which  acute  emergency  services  are  commissioned  

•  Services  included  in  this  review  will  be:  •  Emergency  department  •  Acute  medical  take  •  Acute  surgical  take  (emergency  surgery)  •  Interdependent  areas  

Scope  

Each  review  will  define  a  set  of  standards  defining  ‘best  care  in  Devon’  which  is  supported  by  key  stakeholders    

Stroke services Led by George Thomson, Medical Director, Northern Devon Healthcare

"  Not enough consultants or nursing staff

"  An increasing number of older stroke patients

"  Different hospitals have different approaches, leading to variation in treatment, outcomes and costs

"  People don’t come to hospital quickly enough following a stroke – more education and awareness needed

"  Access to the right speciality and treatments at the right time quickly improves outcomes

Hospital urgent and emergency care Led by Adrian Harris, Medical Director, RD&E

"  National requirement to meet new standards for 7-day services and critical review by consultant within one hour.

"  Staffing shortages becoming critical

"  Inability to ‘flex’ to meet peaks in attendance

"  Not meeting national targets, eg four-hour wait

"  High numbers of very sick people with complex needs

"  Inappropriate transfers of care

Next Steps on the NHS Five Year Forward

View

32

#FutureNHS

Next  steps  on  the    Five  Year  Forward  View  

•  Deliver improvements in the priority areas: –  cancer –  mental health –  primary care –  urgent and emergency care.

•  A national move towards integrated care. •  Learning from the vanguards is integral to Sustainability and Transformation Plans

It also includes:

•  Movement towards Accountable Care Systems in certain areas •  Articulation of how the NHS is becoming more efficient and carefully spending

patients’ money. •  33  

34

#FutureNHS

Sustainability & efficiency

35

The NHS’ 10 Point Efficiency Plan

•  Free-up 2,000 – 3,000 beds by reducing delayed transfers

•  Further clamp down on temporary staffing costs

•  Standardise and improve trust procurement to release £350m

savings in 2017/18

•  Get best value out of medicines and pharmacy – eg

–  Publishing and tracking a list of the top medications savings

opportunities

Sustainability & efficiency

36

The NHS’ 10 Point Efficiency Plan (continued) •  Reduce avoidable demand and meet demand more

appropriately: –  reduce unwarranted variation in care –  programmes to prevent illness and support health –  reduce demand for emergency care and meet demand more

appropriately – NHS 111 –  reduce avoidable demand for elective care.

•  Reduce variation in clinical quality and efficiency.

Sustainability & efficiency

37

The NHS’ 10 Point Efficiency Plan continued •  Better value from estates, infrastructure, capital and

clinical support services •  Reduced costs of corporate services and

administration •  Improved collection of income the NHS is owed •  Improved financial accountability and discipline for all

Trusts.

Accountable Care What do we mean?

Why?

Accountable Care models take many different forms ranging from fully integrated commissioner and provider Accountable Care Systems to looser alliances - Accountable Care Communities - and networks of hospitals, medical groups, community health and social care teams/systems of care and other providers that come together to form Accountable Care Organisations.

•  Overcomes fragmented responsibility for commissioning and

provision of care

•  Not a new organisation but a new set of accountability

arrangements to ensure all partners act as a single system

What do we mean by the term ACDS – how does it differ from a grouping of partners working

collaboratively? Accountable Care models have the following features:

•  Working within an agreed (fixed) resource envelope

•  Working as a system in the interests of population health

•  A system leader with management resource

•  To an agreed set of measurable outcomes, deliverables, priorities

•  Greater freedom to design models of care

•  They are held to account by commissioners

And why are we doing this for our population? Delivering benefits for people who need health and care

We need to put in place new ways of commissioning and paying for care. This includes longer term, outcomes-based contracts and the use of budgets that cover the care needs of a defined population (‘capitated budgets’) rather than payment according to the number of people seen or treated (‘payment by results’).

Ref: The Kings Fund

Accountable Care System, Strategic Commissioner, and Accountable Care

•  A single organisation responsible for resource distribution •  Responsible for setting strategic direction and planning •  Accountable upwards – should seek to take some functions from

regulators (NHSE, I) and holds ability to intervene •  Improves focused and prioritised clinical outcomes and other

constitutional objectives •  Addresses health inequalities •  Facilitates and accelerates the development of ACOs/ACSs

•  ACO is a single organisation that takes capitation and accountability for delivery while a ACS is an alliance model with shared incentive (e.g., alliance) for aligned set of goals

•  Big enough to take on responsibility and accountability for whole populations; small enough to reflect differences in place/geography

•  Positive and full engagement with front-line in design – therefore ensuring appropriate change in behaviours

•  Voices of care professionals and patients central to decisions •  Responsible for the delivery of local care in a way which meets local

needs •  Embedded in local communities, working with local stakeholders

Strategic commissioner

Accountable Care

Organisations/ Delivery Systems

•  New term used for “an Evolved STP” •  Single control total including delivery of 1718 •  In reality more akin to a SHA with LA participation than an ACO

Accountable Care System

(per 5yfv)

The  Brave  New  World  ??  

• Depends  on  poliNcal  landscape  • Other  poliNcal  prioriNes  at  present  

•  Finances  not  likely  to  improve  

• Current  change  model  will  most  likely  conNnue:  –  QuesNons  over:  

•  Timescale  • Affordability  • Public  consultaNon  • Acceptability  

• But  change  is  inevitable  

What  does  this  really  mean  for  us?  

The  Brave  New  World  and  CriGcal  Care  

•  Some  form  of  accountable  care  type  system,  “place  based”  

•  Shared  budgets,  whole  system  budget  

•  Change  in  mindset  for  organisaNons  

–  System  not  individual  organisaNons  or  departments  –  Significant  change  in  approach  needed  by  everyone  

•  CriNcal  Care  services  will  end  up  being  reconfigured  according  to  Acute  Services  Review  etc  •  How  this  pans  out  re  individual  organisaNons,  units,  services  etc  remains  to  be  seen  

•  Expect  scruNny  of  outcomes,  spending,  variaNon,  acNvity  

•  Expect  more  naNonal  benchmarking  and  requirement  to  jusNfy  costs  

Structural  change  in  organisaNons  

Carnall  Farrar  |  43  

Specialised  services  

Carnall  Farrar  |  44  

•     Move  commissioning  of  some  services  to  CCG’s  (e.g    complex  obesity)  

• Commission/co  commission  within  STP  framework  (or  several  STP’s)  • Specialist  service  reviews    

• Paediatric  ICU,  paediatric  burns  • Looking  for  groups  of  providers  in  region  produce  plans  to  improve  quality/sustainability  of  services  

• Reducing  unnecessary  variaNon  Right  Care  GIRFT  • Reducing  delays  in  ICU  transfers  

• Benchmarking  

QUESTIONS?