Alistair Blair: Building a caring future

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Dr Alistair Blair

Dr Alistair Blair describes integrated care in Northumberland at The King's Fund's implementing primary and acute care systems conference.

Alistair Blair - building a caring future

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The first slide – and we’ve not done this presentation before but we have done several on PACS – the first slide that often comes up is normally a quick video clip of Gallipoli, people going over the top, which is often people’s understanding of vanguards: you jump over, you get shot and there are bits flying all over the place. I think vanguards are both a massive opportunity and significant risk as well. People are watching you; people are expecting you to deliver, which is good because you do need people to be that ‘monkey on your back’, making you deliver; but there is also quite a lot of shrapnel potentially flying around as well.  It’s not all a bed of roses.

Really a quick reminder about what has been happening in Northumberland. As Nicola says, I think we have been on this journey for about 20 years in terms of looking at integrated services, of which really the primary and acute care systems are just another step along. I think, do we need the PACS to achieve that?  You can easily say that you don’t but I would challenge that.  One of the things we are very keen on is actually taking PACS and going through and becoming an accountable care organisation.  We are using the stages within our PACS submission and provided we achieve all the stages within our PACS submission that would ultimately lead us to becoming an accountable care organisation.  Even then, accountable care organisations can be good or bad.  They can either succeed or not.  Structure is only one part of how this whole thing will come together.  Even creating an accountable care organisation is just the next step on creating more and more clinical integration around that population.

Roughly, just to give you an idea of the scale, Northumberland CCG covers about 330,000. You can see our allocation. The turnover of the Foundation Trust which is an Acute provider with Community Services and an element of Social Services covers two CCGs, so that is why their turnover is greater than ours.  It is not just that we run a massive deficit.  They have got a variety of community hospitals as you would expect, certainly in a geographically rural part of England.  We have got integrated hospitals and Community Social Care provision.  We have got some new models of primary care.  We have emerging federations; emerging super practices and we have also got the hospital looking at either supporting back office functions or indeed creating a much more advanced model with certain primary care practices in Northumberland as well.  There is quite a mixed model of primary care provision and quite a good standard of primary care provision across the county and really a history – and this goes back to some of the earlier speakers - of I think strong relationships.  Much as we all fall out during contracting and money is tight, the relationships are actually quite genuine and generally survive beyond that.

We have had integrated leadership across the system which started off probably less structural, more in terms of direction of travel than with any formal partnerships with the County Council and with the Care Trust, which preceded the PCT, and then the CCG. We had Transforming Community Services which ended up with the Foundation Trust hosting in effect the Care Trust so that they host both Community and Social Services, and really we have had a very, very strong focus on commissioning right from the start, certainly even before we were in shadow formation Chris came and did a series of seminars in Northumberland, really looking at how we could set things over the next 5-10 years, bearing in mind this was five years ago, around getting better integration going.

Things that we are trying to do – these are the building blocks around what we want to do within PACS, certainly a new model of emergency care. We have created a brand new hospital site which is basically only focused on Acute Care. The aim is that will deal with people really with a three-day length of stay or less, to a coalition of lots of the other peripheral hospitals all coming together, consultant rotas; we are getting 24-hour A&E consultants and actually seven-day working in sub-specialties as well which we hope will really improve quality.  We also hope we will improve length of stay.  We have a lot of plans around enhanced primary care, both in localities and integrated hubs looking at those as you would expect with Community Social Services and elements of primary care as well.

Just a couple of things of interest – in our PACS bid we started creating a set of hypotheses by which we would both be externally judged and judge ourselves. We created a whole set of null hypotheses so the first is that a consultant-delivered speciality-based emergency care hospital does not provide more efficient and safe service when compared to general hospital administration. The second is increasing primary care access does not reduce A&E attendances and admissions to hospital.  We obviously hope these null hypotheses are proved wrong.  Throughout our bid we have created a whole set of these null hypotheses.  As Sam was saying, this has really been attempt almost to define the way by which we will measure ourselves and also by which I think we hope to be measured as well.

Fundamentally going forward, there needs to be a much greater grip on population health. We say, particularly the accountable care organisation, as probably the first time genuinely that the Acute Trust and all providers will have a massive financial incentive as well as the good will incentive of population health and some of the upstream issues around public health. You can see that quite clearly with the models in The States and other areas where they have a really fundamental grip on what those who are insured with them do about their own health care, and we would hope absolutely in designing a lot of this with our communities that really buys them into how they can actually help improve their own health.

Massive lots of opportunity around better use of collective resource; part of this we see as a retraction model of commissioning; we also look at where commissioning support will lie; where a lot of different functions can overlap and we can reduce transaction costs; eliminate quite a lot of the barriers, and some of these are structural, some are cultural between primary and secondary care, Community and Social Care; also, you know, bits around the community and voluntary sectors want absolutely to be driven by outcomes and satisfaction. We need a different approach to the workforce. I think the different approach to workforce is the short-term solution because we do need to look at other models; we do need to look at how we get pharmacists, nurses, lots of people working absolutely in different roles.  We also need to look at the 5-10 years which is about fundamentally looking at GP recruitment, models around GP recruitment and how we look at specialties.  We have been talking locally - everybody is familiar with the training that a community paediatrician goes through.  Geriatricians do not get community geriatrics as a specialty or any specific training around community geriatricians.  We have the same with palliative care.  Do we start integrating all the sub-specialties within those, of people who have got the skill set where most of their work from the start will be considered to be community rather than hospital based?

Is this the next step or the final destination? I think before we can do that, we need to look at some of the building blocks that we have. Just to echo some of the things that have been talked around, the first thing is culture, which has been around regarding clinical leadership; we have had a lot of leadership development programmes run throughout Northumberland, open to primary care practice managers, GPs, secondary care, secondary care managers which I think has really helped in terms of the leadership culture.  We have built trust and trust I think is one of the things that is actually an iterative process.  I think the CCG has helped create that trust and accelerate that process. I think if Jim was here he would say that was the case.

One of the first things - you cannot create, I think, a fundamental change that is needed within PACS if you do not actually have created the trust and are building on that. A lot of what we have been doing has been around aligning, both in aligning the incentives within the system and in aligning the approach. We have been committed to integration as a commissioning organisation; the Trust has been committed to integration around what they want to do and our local GPs, if we speak to them as providers and speak to the LMC as their voice, are also around integration.  We have also tested the model quite a lot along the way.  We have created a prime provider model, around end of life care, which - Northumbria FT hold that model.  It means that certainly for the last 2-3 years we have already been experimenting with actually how that can work.  Continuing health care is a massive pressure on the NHS at the moment.  We went with the partnership agreement with the local authority right from the inception of the CCG so that whole budget has been delegated to them; they manage it.  What we have seen has been the result of a lot of trust and discussions to reach that partnership agreement, but the conversations and what that has created in terms of the trust, the change in the ways of working with the local authority has been fundamental; really, really impressive what they have achieved.  So whilst we have still got high CHC costs, they have not increased and what we have seen is across the rest of the North East CHC costs have significantly risen.  Ours have been static.

We have also really explored issues around gainshare and this is how we align incentives. We have had non-elective gainshare, so if the Trust creates reductions in its non-elective admissions, we do not just scoop back all those non-elective savings. There is a gainshare with that.  We have gainshares with primary care around A&E avoidance.  We have tried to put these into as many contracts as possible.  It has become a really popular tool.  We have done that with some really successful areas around mental health, area placement, and it has been the right thing for patients, and it has helped the finances and I think aligning both of those things, but driven by the needs of the population, has worked really well.

These are just some quotes around continuing health care. These are some of the things that people have commented. It shows that whilst we have been talking about numbers and figures, this idea of the service user with a previous CHC experience who said they were surprised and relieved how effective and stress-free the process was.  If we do not get the patients giving us quotes that what we are doing works for them, it is all a little bit immaterial.  As it is, we know that some of this is working really well from a patient point of view and is also delivering for the finances – so it is not one or other, it is both.  I think that this whole agenda, this idea around personal health budgets which we are leading on as well, has made a massive difference.

One of the things about a day like today is that you are all really interested in hearing what is going on and it is very easy to start talking theoretically that actually in the future it will be rosier if, once these vanguards are doing it, they will be showing results. One of the things that we need to do as we go is start capturing data because we will not know the change we are going to make in the future. As Sam said, we have been working around a series of matrices that we think really represent what integrated care will be.  We did a series of workshops with the King’s Fund creating these and we have created them jointly with two CCGs and the Trust.  This is one and I cannot tell you what it means, but we have been tracing it now for just over a year.  This is emergency admissions by number of days from death.  We have not used palliative care; we have used this as from death because it has been quite obvious that some patients nobody in the health sector recognises are actually dying.  We also believe that if you have a really integrated system you are not going to get loads of spikes of admissions on the run up to that person dying because that is surely a breakdown of integrated care.  So we have captured this; we have been monitoring it and what we hope is that we will get year on year improvement on that matrix because surely we are failing our population if they have loads of emergency admissions in that 100 days particularly before death.  So the graph on the left-hand side shows 100 days to death and then right through to one day from death.  You can see that there is always going to be an increase but it should be fairly flat.  This means that we are not identifying those patients and people getting episodic care as they are dying is not what they want.

Going forward to things that we are delivering on, I think we have seen a lot of work both within primary care, within the commissioning group but also within the Trust around how we get better value; how we reduce referrals, and this is not being done with any particular scheme of referral management or anything else. This is being done about encouraging peer discussions; encouraging people to pick up phones; encouraging people to email; encouraging people to go through as many non-referral ways as is right for the patient. We have seen pretty much a levelling off of our referrals, which we think, given the fact that we have seen quite a dropping off of first outpatient referrals discharged, which is normally the mark of quality, what we are actually seeing is that the referrals are of higher quality.  We are seeing that very few of them now have first outpatient and discharged.  There are still some because clinicians need that.  You often need that bit to unblock people’s care, but what we have seen is the whole racking up of quality.  Patients love this because if they can get the answer remotely, they can get the consultant opinion without necessarily going to Outpatients, it suits them.  There is no reduction in the quality of care they are receiving; there is a massive increase in the convenience.

This is the other one we have been doing a lot of work on which is admissions to hospital. This is basically showing – the red is the trajectory up to March 12 when the CCG was created; the dotted top line shows where that trajectory would have been going. I think in discussions really we have had a massive emphasis on ambulatory care and a real emphasis on alternatives to admission as well, with increased support.  We have got community nurses whose sole job is to go into nursing homes, for example, which is quite an odd model because nursing homes are not meant to have community nurses going into them.  What we have seen is that we have had a decrease in emergency admissions, a massive increase in ambulatory care, which is great because patients love that.  Patients do not want to be in a hospital bed if they can possibly avoid it.  We have seen a change in the trend and for the cynics out there who think, “That sounds great but the costs just go up,” the green line shows that actually our full costs – and this is through to February 15 – have been decreasing.  You can see the spike there, which we experienced in the winter, which we all did.  Still that trend is decreasing, so doing the right thing for patients, increasing things like ambulatory care, increasing our options out of hospital, delivers both for them and is really working for the money.  I think, if we are going to achieve things, it has got to be about tying those two together each time.

We have suggested that we have three or four building blocks in our primary acute care system bid, creating the new specialist emergency care hospital; creating primary care at scale; looking at hubs so that we have an element of late evening provision and weekend provision where it is needed; looking at how we integrate Social Care and Community Services further. If we do all that coming together, the end result will have ticked those stages and we will be ready to create the accountable care organisation. So it is a step-wise process. We deliver on each step as we go and then the accountable care organisation will be done very much on a joint venture basis.  There was absolutely no appetite from anybody to try and create one single organisation.  Whilst you can create an organisation that is singularly responsible for health care, that is very different from creating one single organisation.

I think we are going to increasingly move away from the terms primary, secondary and tertiary care to in and out of hospital care. That is not getting rid of the fundamentally good bits around primary care but we may well end up with people who are consultants but whose job is actually rarely to be in a hospital building. We will also have GPs, who will for some of their life be out of hospital doing primary care.  We will also have some of them delivering in A&E Departments, doing ward rounds I suspect in terms of some of the community hospitals and that blends what the roles will be.  We are defining it rather by skill set than the very arbitrary sort of way of creating silos.  We also know that a lot of people are still attending A&E for primary care activity.  Rather than counting that as A&E, going forward – particularly in an acute care organisation – what you would be looking at is, they are going to receive primary care in an A&E setting; that surely should count as primary care access, provided it has got access to the notes and we particularly focus on continuity of care where that is needed.

There needs to be a lot done around Social Care so that we can really make the most of Social Care. One of the biggest challenges we have is the budgets that are really fundamentally slashed within Social Care and how you actually balance that. We are in a fortunate position with health care.  There are significant financial pressures but nothing like the financial pressures our local authority colleagues have; making sure that the budgets are not robbed; making sure that we get the best out of that.

Going forward, there have been announcements about the PACS system. There is a little bit of a pregnant pause at the moment. I don’t think any of us know the degree of funding that will come with the PACS vanguard status.  That makes a difference.  I absolutely agree that we need to be a real part of how the NHS can deliver its £22 billion efficiencies.  There is also a bit that if you are going to get the hearts and minds, particularly of primary care and the people who are on the coal face, they need to know there is some pump priming, that there is some investment, that there is something coming that will make their lives easier in the short term, as well as this nirvana in the future.

So I think that pump priming money is both symbolically really important and practically really important. It goes back to the idea about doing the day job twice. You cannot physically run any faster and it also comes down to that hearts and minds.  I think there will be freedoms.  We are going to have to look at contracting freedoms; a whole set of freedoms, but I think one of the things we have got to be really careful of is that if this is a five-year plan, and we do not have the workforce there to pick up the pieces in five years’ time because we have seen a decimation of either specific consultants, specialties or primary care, it is going to be short-term.  So we have to have the right freedoms around Health Education England; around creating the workforce, not just for the next three, four, five years but we need to be looking 10-15 years forwards because this is about people worth going into medical school; people coming out of nurse training; pharmacy training – the whole set.  You cannot build an organisation on a five-year model.  You need to look much more to the future.  I think some of those freedoms are immediate and some of those freedoms are much more to the future.

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