Chris Ash: creating a multi-speciality community provider in Southern Hampshire

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Chris Ash

Chris Ash, Director of Integrated Services at Southern Health NHS Foundation Trust, shares lessons from the vanguard multi-speciality community provider in Southern Hampshire.

Chris Ash: Creating a multi-speciality community provider in Southern Hampshire

This presentation was recorded on 16 September 2015 at our Multi-specialty community providers: implementing new models of care conference.

Transcript

My name is Chris Ash, I’m Director of Integrated Services with Southern Health NHS Foundation Trust and I lead on the Vanguard MCP in southern Hampshire. The vanguard MCP that we’re trying to build covers an absolutely enormous geography.  So potentially over one million lives affected by what we’re trying to build, five maybe six GP federations, three maybe four CCGs, three large acute trusts and numerous natural communities of care and from the outset we are very clear that this had to not be about organisations leading it had to be about people who voluntarily wanted to become part of that movement and wanted to build something different for patients and citizens in southern Hampshire.

So that was very much about coming together in terms of what are we trying to achieve and at the outset there were three overriding aims for the MCP that we were seeking to build in southern Hampshire. One has actually become the tag line of the MCP so that better local care for local people, care that meets their expectations and what they aspire to in their own lives.  Secondly it can be something that preoccupies us all in terms of a financially and operationally sustainable NHS, systems that work, systems that aren’t perpetually in crisis, but thirdly and quite unashamedly our MCP in southern Hampshire was about creating a viable and stable future for general practice in our county.  We’ve heard earlier today about the many stresses and strains our GP colleagues are under and there was a real recognition in our vanguard from the outset that the cornerstone of family medicine is something without which the entire NHS would come crumbling down and that was something that we were actively seeking to promote and protect as part of the vanguard we built in southern Hampshire.

So this may look like three boxes but I’m going to try and convince you it’s two. This is how we’ve conceived of the tasks that we have in the MCP that we’re building and the first box is over on the left broadly what I’m going to talk about today not so much from the detail of the what have we done, but more from the angle of how have we tried to get a consensus behind that new care model.  This is the sort of stuff that we’ve just been hearing about and what physically is going to be different for patients in the new model of care that we build.  The other two boxes are pretty much one side of the same coin and that’s about how do the organisations currently involved in delivering and purchasing that care change what they do and how they operate to make that new care model possible.

So in terms of provider reform it’s probably all the things that large NHS organisations aren’t. It’s how do we become fleet footed and responsive to local need?  How do we make ourselves able to build on the best traditions of family medicine and not purely become about delivering a contact or services?  How do we build the capability to become sophisticated enough to manage health at a whole population level, benefit financially from economies of scale and grow and develop a professional workforce that will be fit for the future five/ten years hence?

Alongside that there are significant implications for our commissioners and in southern Hampshire that is a journey that they are fully committed to going on with us. So our local CCGs will acknowledge that when we have a fully established MCP many of the functions currently undertaken by CCGs will need to be delivered by that MCP.  The MCP will need outcome based contracts.  How are they going to start the movement of that contracting process over the next two to three years to be in a position to help us deliver that?  Then the whole future of commissioning and particularly the links to the devolution agenda is something that they’re going to need to be actively grappling with as we’re building new care models.

This is practically about where did we start in southern Hampshire. As I’ve mentioned, a registered population of just over a million that we’re hoping to be able to target in the fullness of time but in terms of starting we really went where the energy was and the three green circles that you see on the map are the coalition of the willing if you like.  Three very separate and distinct areas in the south west of the New Forest, in the Gosport peninsula and in east Hampshire all of whom had very separate and distinct motivations for wanting to step up and be at the very front of the vanguard queue.

So in terms of New Forest we have a very demographically skewed population, the highest proportion of 85 year olds and above in western Europe living in that part of the world and a very separate or a very distinct set of health needs that arises from that and some GP leadership locally that could see where things were going in the two to three year time horizon and wanted to be ahead of that curve. If I contrast that for example with the Gosport peninsula this is one of I’m sure numerous areas around the country where general practice is in active crisis right now, struggling to recruit new partners into surgeries, struggling to make the business model stack, struggling to meet the needs of the population and causing considerable stresses on the professionals working in that system.  So a different set of motivations but very much the same sort of galvanising force in general practice locally to become part of the movement.

The orange circles are probably already out of date but our principle has been to say that there will be no limit to the rate at which new localities, new communities occur during the vanguard and start to define what that will mean for them in their local areas.

So in terms of the new care model I’ve alluded to the fact that each community of care is being actively supported to develop their own vanguard and tailoring that to local needs and the needs of their population but we are fundamentally aligning that to quite a simple care model framework. I’m going to go through it, as I said, very briefly because I would like to focus more on the how than the what but I’d be very happy to take questions.

So the first chapter about redesigning access we now really term this, and should have changed it in the presentation, wider primary care at scale. So this is building on the significant work of local federations, I mentioned we have five or six of those in our target area and helping practice take advantage of their collective capacity to deliver clinical services initially those within their contract but potentially to grow and expand the scope at which they do that.  I think this is a recognition that certainly in Hampshire many federations are relatively young organisations and don’t have the benefit of the large infrastructure that goes alongside many more mature NHS providers.  So how do we make sure that the local system can provide that management support and infrastructure to enable federations to realise their potential and start to realise primary care at scale?

The second piece is about the extended primary care team and I’ll come onto this in a bit of detail in a second. This is about undoing the artificial split that’s existed since the inception of the NHS between primary care and other NHS services that exist outside of hospitals.  So standalone community trusts and potentially community mental health trusts will struggle to find a niche in the future NHS if they don’t look actively at the partnerships they need to foster to become viable on their own.  So we believe the most effective way to solve that problem is effectively to merge with general practice and bring that wider primary care workforce back where it is part of a single team outside of hospital and I’ll describe some of that shortly.

Delayering specialist support is actually a term that was coined by Fiona Daulton, one of our key hospital chief executives locally and I think it well describes what the next stage of evolution will be. So once you have the bedrock of primary care, extended primary care operating at scale and a single out of hospital team it’s then about how do you reconceive a specialism.  We heard earlier this morning Neil Language, one of my colleagues in Southern Health, talking about how we’d done that with extended scope physiotherapy looking after target patients with musculoskeletal presentations.  Chris also referred earlier to some of the pilot work we’ve done with our mental health services where those specialists are seeing individuals instead of GPs and having quite a profound effect on onward referral into other services.  I think and I wouldn’t be surprised if one or two questions come this way, there is a question about the diagnostic role of the GP and can that adequately be reflected by other professions, but I think we’re beginning to produce some really early evidence about how that can work.

Then the fourth which I don’t dwell on massively really knits through the previous three which is that we’re trying to increase the focus on prevention, on self management, on social innovation. Many ideas along the lines of what we’ve just heard from West Wakefield colleagues about how do we reconceive of care in all elements of this model.

So I really am going to skip fairly quickly through the next three slides where I’m just beginning to go down into a bit of the detail of those first three. Now in a way it’s helpful to give an example of what we mean by extended primary care of scale but in a way it’s not.  So what we’ve put up here is the primary care access centre that two of our three early implementer sites have decided to pursue as their first active movement towards wider primary care operating at scale.  This isn’t another minor injuries unit or contact centre.  This is about another branch of general practice within that locality that begins to stream on day demand primary care.

So in the case of the west New Forest which is the example we’ve got up on the screen, that will involve a practice based within Lymington New Forest Hospital that operates seven days a week eight till eight. The vanguard has supported monies that were secured through Prime Minister’s challenge fund two to support our Local Federation New Forest Health Care Limited to get this up and running and the premise is that we will not only level demand for primary care out over the course of the week we’ve been running that I think seven days today actually that practice has now been operating, and local demand and utilisation of the services in the early instance seems to be quite strong, but importantly we want to test the idea that by having a stronger multidisciplinary team providing that care we are able to release some free medical time so that back in the base surgeries in the locality we can begin to move away from what was referred to as the ten minute treadmill and start to focus on longer appointments for GPs with people who have more complex needs.

The extended primary care team and anybody who has read the recent NHS confederation paper on transformation of community services this graphic appeared in there as well. Very easy to draw on paper very difficult to make happen in practice.  If you ask GPs locally I think they would say that Southern Health has put an enormous amount of effort into the box on the left and has done a very good job of horizontally integrating some of our community services with mental health services that sat as part of the former Hampshire Hospitals Foundation Trust.  That’s brought some benefits, but I think GPs would also say over the last few years we’ve probably neglected the really important transformation which was making sure those community services were lined up with what GPs were doing in the communities and with the registered list.  We believe that the only way that we’re going to move that forward as a vanguard as Southern Hampshire MCP partnership is to formally bring those teams together and to conceive of the way care is provided out of hospital in a very different manner and that’s what we’re describing as the new extended primary care team.

Then finally delayering specialist support I really will skip quickly over this. We used an example of respiratory clinics at the time the new care models team met with us primarily because we were looking for an easily transposable example.  I think there are numerous ways in which specialist support can be brought closer to primary care.  I think the overriding principle that we wanted to get across is this is not having clinics, outpatient clinics based in GP practices this is about embedding more specialist support around the GP and around the primary care.

Then, as I said, unapologetically to come back to primary care sustainability. So as colleagues have previously said, for us the individual identity of the registered list is a strength.  Whenever we speak to international exemplars, and one of our GP leads Nigel Watson has been over in the States this week with the Veterans Association, we hear it from Optum when we speak to them, they marvel at how we have our hands on so much integrated data potential in the NHS but spectacularly fail to use it.  So we see the individual identity of the registered list and that family medicine principle as a founding component of the vanguard.  I won’t go through all of the bullets but I think it is worth coming to the final one which is around our approach to then delivering scale and I think it’s not only possible but it’s actually important that we don’t go down the line of saying, “Actually we need everybody under one organisational model to make this work.”  So actually for us the blend that we’re developing of a strong and thriving partnership model but with targeted support to areas of general practice that are in trouble or in distress is really critical and that way I think the vanguard in its development builds on what is good about general practice in this country and doesn’t dilute that through organisational take over or dilution in that respect.

So we are supporting one practice potentially a second to come on in an extremely distressed area to get more support formally from Southern Health to sustain them in the short to medium term. Do I anticipate that to be a major feature of the vanguard in the next two to three years?  I think there will be more of a trickle than a stream.

So in terms of provider reform this is a diagram that we’ve used a lot and I think beneath this diagram sits a lot of pain because many systems just aren’t used to operating this way and when people begin to understand what we mean by the inverted triangle, so the 80% of the decisions about how our iterative model within the vanguard is going to look, how an MCP is going to be structured, actually sits out there with local clinical delivery groups. Natural communities of care working with their local populations and then the job of some very senior people by the time you get to the MCP sponsor board is to take obstacles out of the way to help people break rules and to make sure that coalesces into something that can be commissioned, that’s quite a flip from the central planning and then we’ll tell you how your services are going to evolve.

In fairness to the NHS England New Care Models team that’s the language that they’ve talked consistently throughout and all the action that we see in support of us reinforces that principle that it’s about local design and about them helping us to remove blocks.

So again a quick slide and we’ve just listed here some of the enabling work streams that then sit alongside the work of our local clinical delivery groups where we’re trying to organise them more at the level of the whole MCP whole vanguard. I think some of these asks are tricky enough when you’re trying to do them in one organisation I know how difficult it’s been within Southern Health to have a conversation about how to rationalise our estate and drive services out of fewer buildings.  When you then try and do that across numerous organisations of differing sizes, each with their own incentives, each operationally and financially distressed some of that becomes tricky and complex in the extreme.

So all of these work streams have had to be quite flexible and also accept that some of them will move at different paces according to where the opportunities arise and exist. I think to take the creation of the single health record and shared information we struggle to get out of the blocks on that one but actually beginning to work with some of our early implements or localities and hearing what an important enabler that is going to be for some of our clinical teams coming together and culturally working in a different way that’s begun to focus mind and galvanise effort to find solutions to some of those previously intractable problems.

So this is probably the slide that I would seek to dwell on and given Sam’s piece earlier about Katrina leading nationally on the leadership stream I guess that’s probably what you’d expect, but for us this is really important and I’ve mentioned the theme of trust throughout the presentation. I’ll be absolutely candid we’re not building this partnership in southern Hampshire from a set of relationships that have always functioned perfectly and I’m looking at one of my GP colleagues from the patch, probably a wry smile at that point, and I guess the only solace that I take in that is the speaking to other community organisations and GPs around the country we’re probably in good company on that score and why would those relationships function perfectly because we know we have differential incentives, we have different levels of personal risk, massive disinvestment from the out of hospital sector in comparison to maybe the investment that we’ve seen go into hospitals over recent years, geographical dispersion?  None of which promotes trust all of which makes leadership more important in the task of transformation and of course many clinical colleagues will not have had the benefit of structured leadership development as part of their clinical training but the hunger we find is absolutely out there and particularly amongst a group of GPs earlier on in their careers who see this as an opportunity to create a sustainable future for themselves in family medicine.

So the top level of our diagram about senior leadership development this is about senior clinical leaders, this is about supporting people on their own journey of leadership development and helping them play a full and active part in defining what the vanguard of the MCP in southern Hampshire will become.

The middle layer is also about clinical leaders but again laying cards on the table, for somebody like me it’s about unwiring years of accumulated this is how we do things around here within my own organisation. So a whole tier of junior and middle management that have been used to the organisational model are very good at saying, “No can do,” and being quite intransigent on that at times and there is a task for senior leaders within the new care models to make the mantra of ask for forgiveness not permission real for those people because when I put myself in their shoes I can often understand why no can do is the answer that comes out.

Then the bottom layer probably the most important. So the founding strand certainly of our value proposition early on is a program where we pump significant backfill time and leadership development support into the new extended primary care teams that are emerging and for our clinical staff this is about overcoming the baggage of history, it’s about overcoming culture and it’s about tackling an understandable human aversion to change particularly when some of that change may threaten your understanding of your own professional identity and the way that you’ve been used to working.

So I guess no presentation on the issues we’ve focused on early would be complete without a nod to our regulators up the line. There is an acknowledgement that in time the MCP will need to emerge from the various vanguard localities not least because some of what we want to achieve in the very immediate term will require us to break rules and overcome existing organisational, procedural or regulatory hurdles.  Already two GP alliances within Hampshire are talking actively to Southern Health about how we create some sort of shared vehicle that would enable us to overcome some of the pressing issues and Sam put up some earlier, but particularly live for us is the issue at the moment of clinical indemnity as we develop new services and how we overcome some of the financial implications of that and ultimately the MCP will need a new organisational form and that may be none of the above in terms of what currently exists in our health and care economy.

Now that poses a massive issue for people who are accountable presently for running organisations and I wouldn’t be exaggerating if I said that was absolutely true of the Southern Health Board as much as other organisations involved in Hampshire, and that’s about negotiating at pace the management of risk to create a future of which their current organisations may not necessarily be a part. So the work that we need to do with our regulators and with NHS England throughout that journey to make sure the way they adapt, the way they do business map to the journey that those organisations are on is critical.

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