Hugh Reeve

Chair: Cumbria Clinical Commissioning Group NHS Cumbria

How is the NHS in Cumbria drawing on lessons from the Alternative Quality Contract?

In 2007 we embarked on a journey In March 2011 this took us to Boston, Massachusetts

Insurers Tufts Health Plan Blue Cross Blue Shield

Providers Atrius Health (multispecialty IPA) Mount Auburn and Cambridge IPA

(multispecialty) and Mount Auburn Hospital Hampden County IPA (primary care only)

These 3 providers all had extensive experience with risk based contracts

Key take-aways from BCBS Contracts for the whole continuum of care, over 5 years

allowing time for the “tanker to turn” For organisations to hold an AQC a primary care provider

with sufficient patient base is essential to participation Risk (gain) share between insurer and provider, determined

by quality performance Financial incentives promote affordability and efficiency Performance incentives promote quality, safety and patient

centred care (process, outcomes and patient experience measures)

Significant investment by insurer in supporting AQC providers (10-12 WTE middle to senior managers)

Key take-aways from Providers New paradigm of global risk based contracts (not just the

AQC) – “keeping my population healthy” Investment in areas that previously wouldn’t have

generated income Health coaches, case managers, hospitalists Data management systems + data analysis – clinician

performance, hospital utilisation rates, prescribing, and imaging and lab rates

Electronic Medical Records

Strong clinical leadership and a culture of independent physician practices working together

Partnership with BCBS Regular performance feedback and support Collaborative, long term commitment in a 5 yr contract

Collaboration with hospitals – formal and informal partnerships, drives value throughout the delivery system Atrius Health: “We want to use hospitals that enable us to integrate our specialty

care into the fabric of the hospital to the greatest extent possible”

MACIPA and Mount Auburn Hospital: Managed care partners since 1985 with history of investing in

systems and programmes to manage costs Strong, long term relationship between the two senior leaders Each are independent entities with no joint legal structure Contracts with insurers signed separately as three-way

agreements and all parties at the table in discussions Risk share between IPA and hospital is defined and agreed

outside of the contract with insurers

Cumbria CCG

Carlisle

Eden

Furness South Lakeland

Allerdale

Copeland

Commissioning Support Services

A networked commissioning group in 2011 across a 500,000 population

Immediate actions (0-6 months) 2011/12 contract

50/50 split on any underspend on 11/12 PBR element of contract

Risk share on elective activity – marginal rates for activity 0.5% or more above plan

Risk share on non-elective admissions as nationally This signalled a new style and approach

Primary care One CCG with devolution to six localities

Immediate actions (0-6 months) 2011/12 contract

50/50 split on any underspend on 11/12 PBR element of contract

Risk share on elective activity – marginal rates for activity 0.5% or more above plan

Risk share on non-elective admissions as nationally

Primary Care One CCG with devolution to six localities Secondment of support staff to localities – data

analysis, referral support, medicines mx, project mx Roll out single EHR (Emis Web) across general

practice, community services and community hospitals

Medium term (6-18 months) Develop our own narrative – culture, leadership

and a new paradigm (“keeping you healthy”) Honest discussions with partners (health, social

care and 3rd sector) about new ways of working Develop capacity within primary care

Workforce – doctors, nurses, HCA’s, Mx, new roles Industrial scale long term condition management Education and training QOF+ incentives using Local Enhanced Services

But long term … the real prize is clinically led, multi-specialty groups taking on accountability for the whole continuum of care.

CCG “Payer”

Carlisle

Eden

Furness South Lakeland

Allerdale

Copeland

A central “Payer” with a network of Provider Federations

South Cumbria

North East Cumbria

Provider Federations

GP Practices

Out of Hours

Community Specialists

Support Services

Consultants, nurses, therapists, etc. Existing and new roles

Back office, Ed/Training, Audit, etc

Community Beds

Day care & Day case

Multi-specialty groups

Stand alone or joint ventures

Accountable for whole continuum of care – “make or buy”

Contracts that promote efficiency and high quality

Lessons from the AQC?

Our current contracts for both general practice, community services and specialist services need a radical overhaul.

Make change voluntary not compulsory; but make staying still an increasingly difficult place to be.

Perhaps our real challenge is creating a primary care infrastructure fit for the 21st century.

This is a 10-15 year programme – will our lords and masters have the courage to let it happen?