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Chris Ham: What does the future hold for integrated care systems?
Ben Collins: Montefiore Accountable Care Organisation
Warren Heppolette: Transforming health and care across Greater Manchester
- Chris Ham: What does the future hold for integrated care systems?
CH: Chris Ham
CH: Integrated care systems aren’t provider-based organisations, although providers are key partners. They are planning mechanisms to try and make sense of that complexity and fragmentation within the organisational landscape.
But within them, at least within the larger and more complex ones, there are integrated care partnerships which are very much about how care is provided. So alliances of NHS providers working together, agreeing to collaborate rather than compete and including in their most advanced development, hospitals, community services, mental health, GPs and social care and independent and third sector providers.
80% also will get delivered at a place-based partnership level. In places like Sheffield and Doncaster and Barnsley and Wigan and Bolton and Trafford - to give you those examples - with 20% perhaps being led at a system level. There is no manual. There is no guidebook that says this is what an integrated care system is, this is how it should be organised and this is what it should do.
The colleagues involved in the ten integrated care systems are themselves writing the manual on system working. You have the larger ICSs, Greater Manchester not far short of 3 million, South Yorkshire, Bassett Moor 1.6 million. Large complex and the way I’ve been describing.
At the other extreme we’ve got Blackpool, about 300,000, you’ve got many of the ICSs around about the half, three quarter of a million size. And there is a kind of emerging bubbling debate about, well can it be right that we have so much variation in size and complexity in the cohort in this first wave of ICSs and is there any move at all to begin to bring together the smaller ones to make them more like the bigger ones. I think there’s an obvious rationale for doing that, but there are some big risks potentially as well, given the importance of the relationships within the systems and partnerships and the risk of putting those on one side for the sake of neatness around some kind of organisational map.
What are the emerging functions and roles of integrated care systems? Well the way we’ve seen it, is there’s a planning function, building on what the STPs have set up. It’s about how you then can then align but not do the commissioning behind the plan. It’s about bringing together over time, the functions of NHS E and I alongside the integrated care system. Putting it bluntly, the worst of all outcomes would be to add another layer of complexity called an integrated care system to the already too many layers of complexity we have in the fragmented complex legacy of the 2012 Act. It’s about taking responsibility at a system level, for overseeing performance in the system. Self-evidently it needs to be about the provision of system leadership on the issues that require system leadership and owning and resolving system challenges rather than looking externally for help from the management consultants or from the turnaround specialists or from others. This is all about collective leadership across the organisations and distributed leadership from the top to the bottom and the staffing of integrated care systems is developing through changes to the roles of CCGs, the roles of regulators and through secondments from partner organisations.
Great Manchester has within it ten integrated care partnerships to use my language, they call them local care organisations, based around the boroughs and the City of Manchester, building the links between the hospitals, the community services, GPs and local government and they’re doing fantastic work in some parts of Greater Manchester. I’d highlight particularly the work I had the opportunity to visit with colleagues in Wigan to reach into their community and work with community organisations and the wider range of community assets in looking at the wider determinates and working across different sectors to address them.
So a lot of green shoots appearing, but be under no illusions, all of the ten areas face exactly the same operational pressures and stresses and strains, certainly through the winter as the rest of the NHS and why should we expect it to be any different, when ICSs haven’t even celebrated their first birthday, with the exception of Greater Manchester.
So I hope I’ve been moderately positive in my comments so far, but let’s recognise the reality, the harsh reality of the challenges in doing this work. Regulators have been, in my view, far too slow to align their work in the right way behind integrated care systems and that continues to be a problem. I worry about the demands we’re placing on our leaders who have their organisational roles, their ICS roles, their partnership roles and so much more besides.
Local authority involvement has been really positive in many places but not everywhere and we’ve got work to do to tackle that. The concerns about, is this really to do with privatisation and the two judicial review challenges have raised concerns in some quarters that have not been particularly helpful and integrated care systems have started to deliver but we need to see more of that to reassure those who aren’t naturally supportive of the ICS system-based working.
- Ben Collins: Montefiore Accountable Care Organisation
BC: Ben Collins
BC: Way back in the 1930s the original Jewish and Italian settlers started leaving the Bronx, the were escaping prohibition gangs for calmer suburbs. Into the vacuum came Hispanic and African Americans, fleeing grinding poverty in Costa Rica or discrimination in the deep south. The remaining middle-class families upped sticks in the 70s when heroine, opioids, HIV took possession of the Bronx. People described a synergy of plaques so, you know, destruction of housing, homelessness, economic decline as well as profound health problems. You know, a good 10% of people have diabetes, 15% of people have asthma, 8-10% of people in the south of the Bronx report severe psychological distress. That’s 2-3 times higher than the national average.
Montefiore is fundamentally, it’s a hospital-based system, at its heart it’s an academic medical centre, a training college for doctors and a teaching hospital. But from the very start it committed itself to serving this deeply deprived population. Its purpose was to use medicine and the resources of healthcare to fight the battle and tackle social injustice.
Montefiore, I think, did something remarkable from the 1980s onwards. They built primary care brick by brick from the bottom up. From the 80s they started hiring primary care doctors and training primary care doctors. By the end of the 1980s they had established three clinics in the poorest neighbourhoods in the Bronx. By the end of the 1990s they’d developed pretty much the biggest primary care network in the US at the time. You know, 200 doctors, 21 sites, carrying out almost a million appointments every year. And this really was a start of a tradition of a hospital reaching beyond the hospital’s boundaries. So Montefiore set up children’s mobile clinics to go into the poorest neighbourhoods where they could get directly to children, homeless children.
They set up clinics at homeless shelters, they started building rehabilitation facilities, homecare facilities, residential care facilities. Wherever there was a need, Montefiore attempted to find the solution, even though for the most part, it wasn’t the hospital’s responsibility and there was indeed somebody else to blame.
Montefiore was one of the first hospital systems in the US to start considering the social and environmental conditions that were driving the epidemic in chronic conditions in their populations. Montefiore’s current chief operating officer focusses on the relationship between housing and asthma. What is the point in handing out inhalers if we’re going to send these children back to the damp and rat infested conditions that are fundamentally the cause of their conditions.
Montefiore had an answer to that question. In the 80s they’d established a not for profit subsidiary and over a course of two decades, it pretty much renovated all of the derelict blocks in a large neighbourhood around the medical centre. By now you’re probably wondering what enormous resources Montefiore had to be able to do all of this stuff in the local community, and the honest truth is that by the late 1990s, Montefiore was almost bankrupt. You know, this is a safety net system. It deals with largely Medicare and Medicaid patients who we don’t pay very well in the US. Almost all hospitals in the US rely on their commercial customers to subsidise the costs of their Medicare and Medicaid customers. Way, way ahead of anybody else, before any of us had heard about the joys of value-based purchasing and risk-based contracts, it was working with its insurers to move to capitated arrangements.
Took on its first early risk contracts for a few tens of thousands of people in the mid-1990s, now in 2018, it holds risk-based contracts for around 400,000 patients. That’s still a tiny proportion of the people it serves, maybe 10 or 11%. Their plan is to grow fast; they want to get to a good million and a half.
This really is the jewel in the crown of Montefiore’s system. It doesn’t look like much, it’s a you know, it’s a single storey building on a trading estate in the outskirts of the Bronx but this is the place that crunches the numbers, works out which of the patient groups are, that Montefiore is dealing with have the greatest opportunities for improvements in care and reductions in cost, improvements in coordination and this is the place that takes charge of those high-risk patients and really improves how their care is being delivered.
Every week the analytics team is crunching the numbers, looking through Montefiore’s claims data and utilisation data for how services identify the next group of patients to bring into case management. There’s a team of experienced nurses who run 90-minute telephone interviews to get to the bottom of people’s problems, identify you know, the fundamental drivers causing them to turn up at A&E regularly, causing their high utilisation and then there’s a good team of 200 nurse case managers and social workers who are developing care plans. And I think underpinning all of this is, you know a real commitment to understanding what works. You know, they don’t just put in place an intervention, they know how many people who received peer to peer support for their diabetes management, saw improvement in their diabetes A1C haemoglobin A1C levels. It’s hardnosed and absolutely focussed on results.
Montefiore became the poster child for Obama Care in around 2014 when it was clear that it was by far the strongest performer of the 32 accountable care pioneers in their first two years. Five years into that programme, it was delivering a 96% performance score on 30 metrics, ranging from access to population health to patient satisfaction. Delivered that pretty dramatic improvement in performance in comparison to other US health systems while cutting the costs of care for this group by a good $75 million. $75 million dollars for a small group, 23,000 Medicare patients in the beginning.
- Warren Heppolette: Transforming health and care across Greater Manchester
WH: Warren Heppolette
WH: If you want to maximise the health potential of the population, an awful lot of what you’re going to touch is non-medical. Making sure that people can find and keep good work, making sure that children start school ready to learn and ready to thrive, a shift from a reactive crisis-driven health system to something that’s defined by it’s ability to kind of provide and coordinate reliable, early help. It will be lovely just to drive transformation but the bottom line is, I’m afraid we’re doing this in an incredible headwind, both in terms of finance, in terms of you know, the performance of the system.
In Greater Manchester, we’re doing it across you know ten localities serving nearly 3 million people, 33 health and care organisations playing a part in this. We realise that actually the start line for transformation, for some organisations, some localities, some individual service areas actually is a distance away. There will be events as well.
The morning of the 23rd of May last year, and I was given the task of saying, of coordinating the mental response for the victims of the attack at Manchester Arena. And actually, within about eight hours, I had practitioners from every mental health trust in Greater Manchester, I had representatives from every children’s service department in every Council and we set up the organisation Manchester Resilience Hub within six weeks of the attack and we’re doing proactive screening and proactive support to all of the victims, regardless of where they live. I’m not sure we would have reacted that quickly, with that my clarity, if we hadn’t been on this journey together around integration.
I would see part of Greater Manchester’s kind of stratigraphy as an impulse to collaborate. One of the things that we’d confronted over the last year or 18 months from the election of the mayor in particular, was a specific focus on Greater Manchester’s rough sleeping and homelessness problem. And one of the things that we were able to do quite quickly, was kind of convene a conversation so we find out from representatives of the housing providers, what they’re going to bring to the table, what can they offer. We find out from even fire and rescue service about how they can make use of some of their capacity, assets and resources, and from our part, we were looking to connect our discharge protocols from every hospital into something that didn’t discharge people onto the street, looking to make sure that homeless people could register with GPs, looking to coordinate our work around outreach support for mental health and substance misuse services. So that default and collaboration is something you can move quite quickly once it becomes practiced. You can’t integrate health and social care from Greater Manchester, this has got to be a kind of boots on the ground activity and the task, as much as anything is to ignite the participation of every part and every practitioner and every resident in Greater Manchester.
We can also collaborate and drive out some of the variation if we take a step in terms of commissioning according to the same set of standards. So we did this last year on ADHD services, so recognising where actually the points of connection ought to be made. Certain institutions generate their own rules, their own norms and if we don’t recognise this, collaboration is going to be really, really hard. There is an opportunity, like an airport, to almost operate ourselves as if we were a single entity. If you think about the ownership of airports, that’s got that bizarre mix of you know, public, private, government but actually the experience of us passing through, and having an experience which is partly that of a traveller and partly that of a shopper, gives us a bit of a lesson about the extent to which you can generate something that feels coherent and whole without necessarily having to grab the ownership at anyone level.
It’s definitely essential for us to integrate health and social care, but it won’t answer the big question of how we maximise the health of a defined population and if we get people more comfortable by saying, actually you can join this, just plug yourselves in, come on the journey with us, you’ve got a contribution to make and you’ve got some benefits to take back, we can truly kind of extend where we start to make a difference. So we started a conversation a couple of years ago with the schools across Greater Manchester, booked a big room, said do you want to come and see how we can connect in terms of improving the health and emotional wellbeing of schoolchildren in Greater Manchester. And 250 representatives of 250 schools came at a moment’s notice and we started then to think about, what can we do in terms of mental health, emotional support provision in schools and we got 31 schools signed up within a fortnight.
So suddenly you find that you’re not wrestling just with the financial difficulties in the health and care system, because there are new assets and resources to be able to plug in. I love the idea of the disruption of saying, we all work for the population, the place, leave your baggage at the door and I’ve realised over the last couple of years, it’s not possible. You can’t disconnect people from the baggage and there’s a real risk that it mobilises resistance if people think that you are doing.
So there is still a real feeling for the providers to meet as providers and the CCGs to meet as CCGs and the Councils to meet as Councils, as groups, and we let all of that happen because actually, they like getting stuff off their chest with each other, and then we’ve got more of a chance of saying, so what is it that we can agree on.
There is something about the discipline that we need to bring to the programme management and coordination of 320 things across 33 organisations with hundreds and hundreds of leaders playing across it, but at the same time, not losing that sense of where the creativity comes from and our biggest lesson I think, over the course of the last year, if you think of the, all of that conversation about integrated care organisations, and the extent to which it was utterly flattened by discussions about complex contracts and organisational form and PACS and MCP and all that kind of stuff. I think where we’ve seen real action and we’ve seen most of the faster moving benefits to services for residents is where we’ve said no, the key bit here is however we integrate, the most meaningful level will be in those neighbourhoods, 30-50,000 neighbourhoods. It feels like a good point for primary care to connect. It feels like a good point for wider public services to connect. It feels like a good point to be relevant and recognisable to populations across Greater Manchester and what we found is that those people that were struggling with, we’re not really sure what organisational form we’re going to go for and we’ve just said don’t worry about that, get the stuff happening in the neighbourhoods is where we’ve seen pure gold.
So not worrying too much about letting the kind of creativity run slightly ahead of the organisational form and contract form because I think that stuff catches up.
I think, I’m certain I’m out of time. So, hope that was helpful. Thank you very much.