Chris Ham: Place-based systems of care - the way forward for the NHS in England

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  • Posted:Tuesday 01 March 2016

Chris Ham gives an overview of our report, Place-based systems of care, and discusses the importance of NHS organisations and services moving from a 'fortress mentality' to working collaboratively.

This presentation was recorded at our event Moving towards place-based systems of care on 1 March 2016.


I hope some of you will have seen this and also had a chance to look at it, the paper that Hugh Alderwick and I wrote and we published in November last year. This is part of our work at the Fund, not just to comment on what’s going on but to suggest some practical ways forward, practical ideas which we hope will be useful to colleagues in the NHS and partner organisations as you and they navigate through the very challenging times that we have at the moment.

It’s a short paper, it’s deliberately meant to be a paper that inspires and supports action on the issues we address.

The starting point is a growing sense of crisis both around the money and increasingly in relation to performance and the NHS trying to rise to the challenge of that emerging crisis, with very complex organisational arrangements. This, if you like, is the legacy of the 2012 Health and Social Care Act. I’ve been working with, or alongside, the NHS throughout my career, I really can't think of a time when we’ve had such complex and fragmented organisational arrangements.

The abolition of strategic health authorities has left a vacuum, there’s a sense locally that there is nobody in charge and by the way our paper is not a plea for the reinvention of strategic health authorities, I don’t think that’s what we need at the moment. What we need is to find are sensible creative ways of filling the vacuum at a local level. And in a few places that’s already being done, so in London at UCLP, UCL Partners is helping to bring together expertise across not just North London but into some of the Home Counties too. We know in other parts of England there are ideas about accountable care organisations or accountable care systems, sometimes called accountable care partnerships. Different varieties on the same theme you might say, for organisations that do see the need to work across a place in a much more collaborative way.

So place-based systems of care, the notion of these systems of care, for us an opportunity to you might say make the best of a bad job, try and work with what we’ve go, that complexity and that fragmentation without another major reorganisation by organisations seeing the need within the NHS and across the NHS local government and other sectors to manage the resources that they have available for the greater good of the populations that they’re all serving.

And the alternative would be more of a fortress mentality where organisations look after their own interests, fight for their own survival which in many ways is a rational response to the environment in which we’re operating, because our regulators at a national level are still by and large regulating down organisational silos rather than across places.

There are some emergent initiatives which are trying to overcome that but the context which we’ve come from is one where organisational performance matters more than local system performance. And if that happens exaggerating to make the point, we might end up with a war of all against all, a competition rather than collaboration, the tragedy of the Commons if you want to refer back to that set of ideas where we have a common pool of resources but through competition we don’t achieve an optimal outcome because organisations are working independently of each other.

In another paper we published last year we talked about a shift in focus away from at the bottom of this matrix individual care management to making every contact count but particularly towards the emergence of much more integrated models of care of the kind that many of you will be involved in developing. But then going beyond that, the bigger prize, what we’ve described as population hell from population health systems. So yes we need to bring primary and secondary care, physical and mental health, health and social care together through the growing interest and support for integrated care models but we need to join that with a public health prevention focus where we bring a wider range of public services in local government sector as well as in the NHS together around health and wellbeing, and I’m sure that’s what Simon Stevens will touch on when he talks this morning about the idea of the healthy terms, that’s not just about integrated care, it’s about these broader social and economic determinants of health and wellbeing.

What we do in the paper is very simply set out a number of design principles. There are ten of them which I’m going to list now on the next two slides. This is not meant to be a blueprint, I don’t think there is a blueprint for place based system of care, it’s about finding local solutions that work for different areas because geography, demography, need, demand in the population does vary for many different reasons.

And these design principles may appear quite simple but in our experience of working in a number of places in the last few months they’re actually quite complex. It’s about defining the population group that’s being served and the boundary of the system. I’ll come back to that point about the boundary of the system because increasingly it’s about how we develop systems which are sitting within larger systems.

Who are the right partners who need to be involved both within the NHS family and in other parts of the public and third sectors? And which services, are we talking about place based systems covering all the services that populations need or a sub-set of those services like children’s’ services or those for frail older people? It’s about then working towards a shared common vision and shared objectives which reflect what matters in this county or in this city or in this community and is there agreement on that between the partners, assuming you’ve already defined those partners?

It’s about governance putting in place the right governance structure which is not a question I think of the partnership boards which many of you will have had experience of, it needs to be really quite hard-nosed, hard edged governance because in our view place based systems of are partly about the willingness of organisations to share in decision making rather than to persist with separate decision making based on the common pool of resources, based on a commitment to work together by sharing their governance and giving up some of their own sovereignty, some of their own independence in the process.

And that governance needs to involve patients and the public as well as people in leadership roles in public services. Which leads into the fifth design principle, identifying the right leaders to be involved and thinking much more about system leadership not just organisational leadership which is a challenge I would say for NHS colleagues more so than local government colleagues because there has been a history in local government much more of local authority leaders focusing on the communities and places that they have responsibility for, being used to working across organisational and service boundaries. That is less common in the case of the NHS. So system leadership and other key building block.

And there will be conflicts. It will not be possible to reach agreement on all issues among the partners who are involved. Conflicts are healthy to be expected but they need to be planned for to agree how they will be resolved between organisations and between partners. And particularly where people may fail to play by the agreed rules.

Number seven is about money, so what will be the funding model? If there is an interest in pooling of resources both within the NHS and between health and local government and we have much experience of that, how will that happen, how will resources flow down to those providing care? And what if there is over-performance in one part of a place which then affects the resources going to other parts of a place? Why if, to use a non-random example, demand for and use of acute services continues to rise, acute hospital providers expect to be reimbursed for the work they’re doing, but if there’s only one pound that we can spend on the population in that particular place that means it’s not possible to give priority to primary care, mental health, community and other services that are seen to be needy of additional investment.

So discussion, agreement about pooling of resources but anticipating that there will be these pressures through the funding flows and we might up with David Mates when he joins us, the experience in Canterbury as to how they’ve managed those financial pressures, how they’ve used thigs like alliance contracts between their providers to put a degree of formality around the financing model and what we might be able to learn from that.

Number eight having a dedicated team of people with the right skills to manage the work within the system and then back to this point about there being systems within system. Very simply from our work there will be an identity around for example a city or a county but within that city or county there will be localities, communities, where it’s also important to collaborate and pool expertise.

And the cities and counties will sit within bigger geographies, bigger places where it makes sense say for specialised services to plan and commission and provide care across a much bigger footprint. This is part of the debate that’s currently going on around STPs isn’t it? Have we defined or have others defined for us the footprints of STPs in a way that will be helpful or unhelpful? They’re very big footprints by comparison with most of place based approaches that we are aware of and the challenge will be to make STPs work alongside the other places that matter.

And then last but not least having a set of measures, a single set of measures to understand progress and to use the metrics for improvement. They could be about population health and wellbeing, they could be about the use of health and care services, they could be about patient experience, there are many metrics that lend themselves to place based approaches.

In our report Hugh and I borrowed this from the North West. We’ve been doing a little bit of work with colleagues in Wigan, if you like the yellow blob on this diagram, this map, because within the North West you have the Devo plans across Greater Manchester at the biggest level, you have ambitions within Wigan itself which are being taken forward through collaboration between the council, the CCG, and acute and other providers. Then you have Wigan collaborating with Salford and maybe, I think I read in the Health Service Journal, with Bolton too around a more locally based acute care collaboration. And this is a simple representation of the complexity of systems within systems. If this looks complex then there are far more complex examples out there as well.

One of the obvious points is this will be very demanding around the management capacity and the leadership capacity to work in systems within systems within systems, not least because organisations are also expected to work on and develop their organisational plans while collaborating in the way that I’ve been describing.

Do we have enough capacity, do we have enough of the right capabilities for working in the way that the NHS is now being required to do given the planning guidance before Christmas and further guidance on STPs and what no doubt many of you will be currently involved in?

Let me come back briefly to say a word about governance. You’ll find this in our report as well. A simple visual to represent some of the choices for how organisations might collaborate. So we are not talking about informal collaboration nor are we talking in our report about mergers and acquisitions. The space we’re talking about lies between the two. And there are some options here for local systems of care. They might involve networks or federations and they probably will if you think about what’s happening in primary care. But there may be a need for greater formality and this, of course, is where the lawyers will come in around joint ventures which could be contractual, they could be corporate, there are other contracting approaches. Canterbury has experience of some of these approaches that might be relevant to us as we think about what we’re trying to do in relation to governance.

And there’s a complex figure in our report drawn from the Canterbury experience around their model which includes alliance contracting that might be worth referring to as you think about your own approaches.

So my last two slides. One is what does this mean for commissioning? Well it means we still need commission but not as we know it. We need to move towards a much more strategic approach to commissioning in our view rather than a tactical approach which is focused on the micro-aspects of contract negotiation and contract management.

Commissioners need to work across much bigger footprints as is beginning to happen. Health and social care commissioners need to pool budgets and work together. We need to make much more rapid progress with different ways of paying for care, capitated budgets would be one example of that. We’ve been talking about capitated budgets for quite a long time in my experience and it would be good to see more living examples in practice for how they could be used.

Commissioners have an important role in defining the outcomes expected of providers who are working in this way. We would argue for longer term contracts to remove some of the unnecessary and unhelpful transaction costs involved in the current arrangements. And commissioners doing less detailed contract negotiation and management and being literally more strategic.

The last point picks up what has been said by Simon Stevens and others, this may involve shifting the boundary between commissioners and providers. In the recent past there’s been a view that there should be a neat division between CCGs and others doing commissioning and providers providing care, that is likely to become increasingly blurred if ideas around accountable care organisations, and accountable care systems and partnerships get more traction. Because you will end up with innovative provider partnerships being both providers and commissioners, they will be sub-contracting with other providers where they can't directly deliver all the care and all the services that they’ve been commissioned to provide under this more strategic approach to commissioning, so complexity.

And then there are implications obviously that we might want to discuss with Simon and Jim Mackey and others during the course of today. Because the fortress mentality that you see in many places now is a rational response as I’ve said to how the national bodies and the regulators in particular interact with and oversee the performance of both commissioners and providers. We need to migrate away from that towards more of a whole system performance framework. Much more coordination between NHS England, NHS Improvement and of course CQC. They also need to support new kinds of payment and new commissioning and contracting models with greater flexibility for providers to establish new corporate vehicles which don’t fall foul again of the 2012 Act and the regulation of competition which is embedded within the current legal framework.

So procurement and competition rules need to support place based systems of care rather than work against them. And final observation, much of this is already beginning to happen, partly around STPs but pre-dating STPs, quite a bit of wheel reinvention going on around the country, we’ll play our part in helping to share innovations in care but there needs to be a concerted effort to do that to avoid wasteful duplication of effort.

So that’s setting the scene from the Fund’s point of view, that’s a very brief and rapid run-through what our report said. I hope that’s helpful.


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