Samantha Jones, Director, New Care Models Programme, NHS England, discusses progress made in developing and delivering new care models.
This presentation was recorded at our conference on Mainstreaming primary and acute care systems and multispecialty community providers on 21 March 2017.
Hello. My name is Sam Jones, I have the honour of leading the new care models programme but before I start, first of all, it is so intimidating presenting stuff about the vanguards to many of the vanguards in the room. So, could you please forgive me if I get it wrong. If I am not necessarily reflecting what is actually happening in practice and you can just wave your arms in the air a bit if you need me to correct something that I have said.
I stand here, yes, as somebody who leads the new care models programme, but I just want to start by saying, actually, I am also the daughter-in-law of some very elderly parents-in-law who are experiencing the best and the worst of the health care system that we have. My husband and I and our family are navigating it. I sat, on Sunday evening, watching a GP phoning switchboard to get through to the on-call registrar because my father-in-law had a, probably a blocked catheter. I could have told her, we all knew it was a blocked catheter, but she needed to get, rightly get, that clinical advice. So, she went through switchboard. She stood there for seven minutes waiting to get a response from switchboard, to then have advice from the on-call registrar. The whole thing took about twenty minutes for the GP to actually get through. I am sitting there and I am thinking – it is 2017, I am literally rugby tackling this poor GP to make sure he goes nowhere near an A&E department because his catheter was actually blocked and I use that as an example because, like many of you, I am somebody who uses our health care system all the time and we should never be afraid of saying what is good, of which there is a significant amount, but also things that we need to do better. We have got technology. We have got relationships but we have actually got things that we need to improve.
So, I had a really good reminder for me on Sunday about why I personally do this and why many members of the team and what this is really all about. So, when we come to talk about the contracts and the commissioning arrangements and the things that we need to do around regulation, which are all of course extremely important, it is also about remembering that at the heart of this are both individuals and the population that we serve up and down the country that we are trying to improve the care that we give through the care models, irrespective of whether they are multi-speciality community providers or whether they are PACS, the primary and acute care systems or the ACCs (the acute care collaboration) vanguards. Who have I missed? The care home vanguards and also you will hear a bit more about primary care home, a bit later on.
The five year forward view beautifully articulated what we know. Many of us who were working in the service know about the health and wellbeing gap, the care and quality gap and of course the funding gap. I am just going to stop for a second. When we started the programme, I felt very, very strongly that we needed to make sure the values of what we were trying to achieve and how we were trying to achieve them, were kind of, all the way through everything that we did. So it sounds extraordinarily obvious but if we do not have clinicians involved in the shaping, the design, the planning, the thinking around care models, there is just no point in us doing anything. I have scars on my back from when I have tried to change clinical services and I have not either had clinicians involved or indeed the local community because unless we get that right, right at the beginning, we will not be able to make the changes that we all know we are trying to adapt across the country.
If I had my time again, I would change it from being around patient involvement. I would make it about user involvement because it automatically assumes that this is patients when we are talking about care models but actually the care models are around the local community, around local government. They are around people, the voluntary sector, so people carers, families, as well as of course individuals themselves.
So the second value of the programme, and indeed we ask the vanguards to show and consistently show all the way through, is how have patients, users, families, been involved in the shaping of the care models? Not perhaps the more traditional way we like to parody about, we have got a great idea, then we will go in a room together, then come out and consult on it. You will hear some extremely impressive examples around how people who have used the services are actually designing them and fundamentally challenging our existing ways of doing things.
I spent about twenty odd years moaning about the national bodies, if only they got out of our way and let us locally do what we needed to do as their chief executive and the principle behind this value is that the vanguards are local. There are about fifteen, sixteen, seventeen different organisations working together within our existing architecture, which is challenging, but it is about local services, the local population that is being supported by that vanguard. Our job through the national programme, is to work across all of the arms-length bodies, a vanguard challenge in itself, and to support the local vanguards to deliver the changes as needed by moving the blocks out the of way. Our job is not to do. So, I do not do the care models. I have not actually done anything for a couple of years. I am not the one, my team will tell you, that. I am not actually the one that is doing the really hard stuff. So, our job through the national programme is to support, by moving those blocks out of the way. These are the vanguards up and down the country. I have a notoriously bad sense of direction but they cover the whole of the country and just to remind people what these care models actually, are, and what they are in practice.
So, we do like a three letter acronym as we know but PACS, not those of you that perhaps have a radiology background, we are not talking about PACS from that perspective, we are talking about integrated primary and acute care systems working together. This is around based on the registered list of population that is being served by the registered list, primary and acute care systems working together.
Multi-speciality community providers – they are what they say on the tin, based on the registered list. There is a clue here – of a population that is served, multi-speciality, multi-agency providers working together and not just the NHS. There is some extraordinarily impressive examples with the voluntary sector leading the way. The voluntary sector actually in the vanguards, being the ones that are designing and implementing the care models. They are enhanced health in care homes, I still cannot say it, serving the most vulnerable of our population in the care home but also again, the support used in the communities in a different way for those residents outside of the care homes also.
Urgent and emergency care – it is what it says on the tin and acute care collaboration is around standardising of care, reducing variations across the country. I think it is something that we all know, those of us that have worked in the service, we know the difference in care that is provided in one part of the country to the other. This is around reducing the variation both in terms of clinical care and also in terms of back office.
We do like a template and we did ask the vanguards what they needed to deliver the care models. For those of you that have not had a chance to watch the compulsive viewing of the vanguards presenting, we filmed it all, it is all on You tube and we then asked the vanguards to vote, so that they could help us decide who are the people moving forward. We then said, tell us what gets in the way of those care models being delivered. We could probably ask many of you the same question and indeed many people outside of the vanguard programme itself and we put it together in, what I like to call, the flower of Scotland, which is just a way of remembering what it is. It is also based on the work from the Health Foundation who helpfully published a document in 2015 and said why haven’t the changes that we have been trying to deliver had traction and sustainability. I have heard all the jokes about pilots and BAs, all of those things, I have heard all of that over the last couple of years and indeed I have been involved in many of those pilots. The Health Foundation, of which we have tried to base our support package, talks about the type one, as you are looking at it, on the right, which are the policy changes that the policy leavers, that need to be adapted. So, commissioning, we know the commissioning contract at the moment. We know the tariff. We know the payment systems do not support and best incentivise the right approaches to care models, as we talk about them. So, NHS England and NHS I, working together to support the delivery of those new commissioning arrangements. Governance, accountability and provider regulation. I was trained to be a provider chief executive for my institution. Population health systems are very different. What does that actually mean for a board’s perspective? What does that mean? You cannot lose your accountability in the governance responsibility for your organisation, but of course it is also about the system. So, working with NHS improvement, NHS England and also the CQC are designing with vanguards, real time, what the new governance, accountability and provider regulation looks like in practice. We have vanguards involved all the way through and indeed holding the national bodies to account on things that are working or do not work, as they design new policies. So this is not just about what is happening in the vanguards. This is also about making sure that policy changes are adapted as real time as is humanly possible for the wider NHS, because for those of you that will have read the mandate, I am sure many of you will have done so. It talks about the spread of care models affecting over fifty per cent of the country by 2021. This is real time changing. You will hear a lot more from Charles around evaluation and metrics and making sure we understand and measure what is happening in real time. We are also, of course, with an independent evaluation.
In preparing patients in communities, the bubble on the bottom. There is just no point. I will keep saying this and there is no point in us trying to do things the way that we have always done them. So, we had patients, carers, voluntary sector involved in choosing the vanguards, identifying the vanguards. We had a beautiful moment, but I do not know if there are any of the acute care collaboration vanguards here, when somebody got to the end of their presentation and this chap said that was very interesting thank you but I have absolutely no idea what you were talking about. Because of the language that we use. And I am still explaining to my 82 year old godmother, what a vanguard is and using the words that people, of course, understand and in making sure that they are involved because this is not about being done to, it is about me and understanding me as a user and as somebody from the community and what I need for the future.
Technology, it is obvious of course. I was very excited in my old organisation that we were getting WIFI. It was 2015 when WIFI was coming and the technology that is available for us. We will hear this morning about an App. I am not even going to try and pretend that I am anywhere near technology literate but there is a huge amount of work going on to support the care models first and foremost, the care models with the technology around it.
So, on the left-hand side, we have the type two, we have the softer but yet arguably harder behavioural changes that are also needed to change behaviours and understand why things have not happened. So, there is leadership that is required all the way through to have those difficult discussions, I need to understand what this means, putting our organisational sovereignty second and putting the population health first. That requires support for leaders all the way through, whether it is in primary care, whether it is in community providers, whether it is in local government. So, we have been supporting through the communities of practice of which the King’s Fund support, as well as mentoring and coaching for those individual clinicians or those clinical teams who are involved in these changes. Because it is those things that make a difference in the glue to support the changes that we are talking about. Unashamedly, we are all over social media using every single form of communication and engagement at all possible. We have an online collaboration tool, Cahoots, which you are very welcome to join. You just need to let us know. We know that sharing is at the heart of everything around the care models and spread, so if you are interested please do let us know. If you want to know about population health analytics, we have a chat room or a webinar thing, if you want to know what an extensivist service is. We have that as well. So, the online platform is there as something from the legacy for the future. Also, the use of social media because there is a fact that I heard the other day, which is not actually a made up fact, that more people have access to social media than are registered to vote. If that is the case, many of us will know that is, then how we communicate and how we involve people in the design and the delivery of our services moving forward is crucial that we do so.
In terms of work force re-design supported by Health Education England, yes it is about the type, whether it is about more generalist, more specialist professionals, but it is also about supporting people through the changes that are required. If it takes fifteen years to train a doctor, we have got fifteen years of this work force who actually need support. I trained as a paediatric nurse, kind of not right now for the future, you will be gasping, I don’t practice. But I would need support to be working in the community in a different way and vice versa, we are asking people to work in a very, very different way and we are investing time, effort and support through the support package to make sure we understand what that is in practice and you will hear a bit more from Nav a bit later, who also is a part of the workforce group, holding us to account on what is actually happening on re-designing the workforce.
The last year, I think a year in the new care models team is probably like a dog year for people, it has been going for about seven years, has actually been around developing and delivering the new care models and as Chris said, early signs of impact are emerging and we have had some badges made up in the team, depending on how we are feeling and Charles will talk a bit more about it later. We are mildly optimistic, cautiously optimistic. It is not statistically relevant. There are some signs of impact emerging because we are walking a line here. Everybody wants to know what the results are. Everybody wants to know and people understand from an evaluation perspective, it is stuff that takes time but we are seeing some signs of impact and I am not going to steal Charles’s thunder later on but we have had some very encouraging indicators of progress and positive impact around emergency admissions, attendances, elective activity and also within the over 75s and we are working with the individual vanguards to test and evaluate the local findings. This is all aggregated up and it is around making sure, because this is the vanguards data, that it is accurate, that we understand it and that it is something that we can share. Understanding and being able to confidently say, this is the impact that the vanguards are having.
But of course, I could not get through a session without talking about some of the impact that we are seeing from some of the vanguards. Do we have anyone from Fylde coast and Sunderland? Hello, sorry, I did see you earlier on. Hello. I am just showing you back your data. That is okay.
If you have not seen the work that is going on in any of these areas and somebody said I have to go from being a mother of the vanguards to being a midwife, because I have to now let go of - the work is extraordinary that is going on, the extent of this service, you will hear a bit more about it later on. Really supporting individuals. I was lucky enough and privileged enough to sit through one of the consultations that one of the well beings, they call themselves the `well beings` had with an individual. His name was John. The support that he is having, using local community assets in the way that we describe it and you can see the impact on A & E attendances, out-patient attendances and non-elective admissions and there are a number of other examples. We understand, because we understand the population health.
Morecambe Bay, I always feel like we need a whoop when we come to talk the Bay way. Some really impressive work going on across the whole of the community and what is impressive about Morecambe Bay, is that it is all part of the system working together on the Bay way. Some examples here from the health community and I suspect we will hear a bit more about it later on. Sunderland – the impact it has had on staff. The bit that has given me the most joy is seeing and talking and listening to the vanguards, when they talk about the impact this has had on people who are working day in and day out. Some of the pressures that Chris talked about at the beginning and the joy that it has given them to make the differences that they are making. A GP in the South said to me this has reinvigorated why I came into medicine, because I can do the things that I set out to do.
We are seeing the impact and we are measuring impact from the staff perspective. You will hear a bit more about primary care home later on. The new care models programme has also been supporting primary care home, which is being delivered through the national association of primary care. Around 30 – 50,000 population size. It really is delivering population health with professionals, community services, pharmacists, working together, putting their professional rivalries aside and actually focusing on what is best for the population and you will hear a bit more about that from Nav a bit later on.
We currently have 92 sites working on this across the country and again, led by the people who are actually delivering the services, which is an absolute pleasure to see. So, the golden thread is around sustainable population health. The dimension is around population health and making sure that it is around the registered list of population, population budget and eventually may take on the contractual responsibility and accountability for population health. So, we are also working to what this means from a contractual perspective and if you are interested in hearing more and there is quite a significant amount of work going on, around what does the contract mean in practice and what does this mean from a payment. How do you measure risk? How do you share risk? What is the impact? etc. I am very happy to talk about that a bit later.
We set out at the beginning of the programme, to identify big building blocks that need to be in place. If anybody is thinking about delivering the population health or the care models. Now we could have taken this from the myriad of examples from both internationally and also more locally in Europe, but what we wanted to do was make sure that it is context specific and that it is relevant to our health and care system for our population. So, we have published these at the end of December last year. Basically, these are the building blocks that need to be in place. You need to understand your population needs. You need to be able to understand what is really going on in that population and then target the resources appropriately. I am not just talking about the top one per cent or two per cent of people on the frailty register. This is about really understanding the population and the care that is required and without that and without a combined understanding, not perhaps in the most traditional way of what we all understand, because we have all got the same data but actually secretly we have all got our own list. This is around having one combined set of data supported by technological platform and then targeting the resources around it and you can see the gradients of care that is then provided. For those of you that are more observant, you will see that the PACS model looks very similar to the multi-speciality community provider model because they are both population health models. Similar. This building business intelligent system, shared care records and then tailoring the services based on the population need both now and also in the future. Truly getting ahead from a prevention perspective. It is not just about those individuals that are using our services now, but it is also about preventing and supporting individuals in the future.
Then you can see the multi-agency, multi-disciplinary teams working together, whether they are locality hubs, whether they are integrated teams, whether they are prison teams. Fundamentally, across the majority of the vanguards, we have multi-agency, multi-disciplinary teams working together in the same place, building those relationships because without the relationships it does not work. Building those relationships and then targeting the resources appropriately and coordinating care from the most complex and also the wider population.
This is the enhanced health in care homes care model. Again, we published this at the end of last year. So, this pulls out all the commonalities between all of the different types of vanguards. It is not just about what is going on in Morecambe Bay or in Yeovil or in Northumbria. These are the common elements. If you are interested in designing and want to know how to support the implementation of the care models, these are the things.
Now, care homes are very interesting, because what this is, is actually a bringing together. None of this is new. None of this is new in terms of what it is that should be happening around care homes. But what the care home vanguards have seen in practice, is that when you do these interventions together, they have the impact that they would desire. So you do need enhanced primary care support. You absolutely do need that multi-disciplinary team support working together and it is these things working together at the same, so it is not just taking one of them and picking them off, it is all of them. And the care home six vanguards have done a superb job of sharing what is happening within the care home, in their individual care homes and also across the other six.
So, as Chris said, cementing the improvements, holding our nerve, supporting the vanguards, supporting the new care models and then spreading the success of the new care models moving forward. Over the course of this year, we do not want people to be talking about vanguards for vanguards sake. Vanguards are there to prototype and design and test the new care models, to support and underpin the sustainability in transformation plans moving forward. We know now, more than we have probably seen before, because we can see the early impact the vanguards have had, that you have to have that collaborative leadership vision in the way that we have talked about before. That is what you see through the emerging STPs. The relationships and the shared vision, I cannot overplay how important these are and you will hear more from the vanguards later on. The vanguards have said that the things that have made the difference are the relationships and building those relationships to be able to do this. Absolutely, then supported by a system wide governance. It is not just about relationships. It is not just about having those conversations. It is also about changing and working through the governance associated with it. Good old fashioned programme governance structure. You do need a PMO, you do need to know where you are against the plans that you set out to achieve. You will hear more about the logic models and the counterfactuals from an evaluation perspective and measuring against those.
You have a care model, but a care model in isolation, that is not supported by a detailed financial model and business model, is not going to go anywhere, but it starts from the care model and then works back and then of course the team design and job roles. We have scenario plans for what type of roles are needed in the future, based on the work that the vanguards themselves have been needing locally. Then making sure that we adapt, as fast as we can, and scale as much as we can, the learning and the impact from the new care models and the vanguards and then of course the appropriate commissioning and contracting changes that are needed. We asked the vanguards what they said they needed at the beginning. We asked them at the back end of last year, what were the things that they found most useful? Charles will be glad to know evaluation and metrics was there. Leadership assisting delivery actually. Actually, what does this mean in practice? It is all very well, these lovely fluffy words, but what does this mean and actually having some time spent working that through to the communities, the practice workforce and then support communications and engagement. They have said they need moving forward, are similar and then the commissioning payments and provision work and the contract development work, which is the right order, because if you do not start with the care model, the commissioning, the contracting, the governance model, does not work behind it. So, starting there and that is the ongoing support that the vanguards will be receiving.
Most of the STPs talk about a version of the care model, whether it is population health model, whether it is a care home or a locality hub or a primary care home or MCPs or PACS, our job is to support the care models and the vanguards themselves, to spread and share the learning and there are some superb events happening up and down the country in the North-East, they had a dedicated event on how do we take what has happened in the vanguards in the North-East and shared that across the STP and make sure we do not reinvent the wheel. Nottingham they have four or five vanguards working together that crossed all of the STP. So, basically metamorphizing from being vanguards to support the new care models and that is the right thing to do and making sure that we have learnt and we have implemented the stuff from the vanguards, and wider, because it is not just the vanguards delivering new care models, so that we support the STPs.
If you want to know more, we do have, obviously, our website and if you want to join the online collaboration tool, please do let us know. The platform you can find everything to do with anything, to do with the care models. We have a lot of conversation on social media. The academy of fab NHS stuff, host stuff around the vanguards. The more we share, the more we spread and that actually has been one of the hardest things, over the last year, is enticing the vanguards to share as much as possible, because we do have quite a British approach of not wanting to say what we have done because somebody is going to have a go about it and also really it cannot be that good, because other people must be doing it. But the more that we share, through webinars, vlogs, blogs, online collaboration tools, that is our approach to make sure that we are sharing the learning from the care models and you can also join the conversation.
Thank you very much for your time.