Dr Geraint Lewis FRCP FFPH - Chief Data Officer, NHS England

Our values: clinical engagement, patient involvement, local ownership, national support

www.england.nhs.uk/vanguards #futureNHS

New care models



Population Health Data – Learning from three ACOs in the United States

Dr Geraint LewisChief Data Officer

NHS England



NHS Five Year Forward View

• Published in October 2014

• A shared vision across seven national bodies

• New care models programme key to delivery

• Focuses on both NHS and care services


www.england.nhs.uk/vanguards #futureNHS 2



The challenges we face

Radical upgrade in prevention

Health and wellbeing

gap1

New care models

Care and quality gap

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Efficiency and investmentFunding gap 3





Clinical engagemen

t

Patient involvemen

t

Local ownership

National support

Our core values

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50 vanguards selected

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Integrated primary and acute care systems

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13

8

9

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Multispecialty community providers

Enhanced health in care homes

Urgent and emergency care

Acute care collaboration

5 new models of care with a total of 50 vanguards



OverviewCoverage: • National coverage of over 5 million people (9% of

population).

• Average PACS/MCP: 200,000 patients and 20 GP practices.

Diverse demography: • Least deprived CCGs - e.g. Rushcliffe 56%

deprivation levels lower than national average.

• Most deprived – e.g. Tower Hamlets - 39% of children live in poverty (the highest in the UK).

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Through the changes they are making, the vanguards are defining what the new care models look like in their end-state

Systematic approach to

population health management

Engaging the population in

their own health and wellbeing

A person-centred approach to

delivery of care and support

Shared care records and

digital technology

A new model of enhanced primary care &integrated community teams

Specialist advice and treatment in the community

A whole pathway approach to long

term care

Integrated access to acute and

emergency care

A new model of inpatient care

A whole-system approach to

workforce and leadership

Primary and Acute Care Systems (PACS)

Multi-specialty Community Providers (MCPs)Enhanced health in care homes

The care model frameworks, published over the summer, will set out for the rest of the NHS the detail of the care models, share the vanguard learning and best practice, and be available for others to use nationally



Addressing the key enablers of transformation



1. Designing new care models

2. Evaluation and

metrics

3. Integrated

commissioning and provision

4. Governance, accountability and provider

regulation

5. Empowering patients and communities

6. Harnessing technology

7. Workforce redesign

8. Local

leadership and delivery

9. Communications and engagement



Case Study: Walgreens Accountable Care Organisations (ACOs)

• Medicare Shared Savings Plan• Walgreens plus 3x physician groups in:

– Florida– New Jersey– Texas



Predicted Costs, Quality Hurdle & Shared Savings



Predicted Costs





Crossing the quality hurdle as efficiently as possible

• Gap analysis• Every contact counts• Multi-channel• Annual cycle



Opportunity Analysis

Note: no ‘gatekeeper’ allowed

1. Duplications in care2. Unwarranted variation3. Non-evidence based practice

– ‘Croydon List’4. Preference-sensitive treatments5. Preventing ‘Triple Fail’ events



Preference-sensitive treatments

• Multiple evidence-based treatments for a condition

• Similar outcomes• Different side-effect

profiles

Examples

• Back pain• Stable angina• Prostate disease



Patient decision aids

Individual• All treatment options available• Greater satisfaction with decision made

Population• Less invasive options chosen more often• Lower cost overall

Preference-sensitive treatments



‘Triple Fail’ Approach



A Third Approach to the ‘Triple Aim’

1. Population approach

Stratify the population according to each individual’s risk of experiencing a Triple Fail event (i.e., a healthcare event that is simultaneously costly, represents a suboptimal health outcome, and is a poor patient experience). Offer different interventions to different strata.

Source of the Figures: Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14(1):32-38.

Examples: programs that encourage self-management of chronic conditions, promote e-mail communication between patients and physicians, and encourage greater use of primary care.

Examples: interventions aimed at improving access and care for individual patients who have low incomes, are uninsured, or who have complex chronic conditions.

2. High-risk approach

3. Stratified approach



Examples of ‘Triple Fail’ Events

Source: Lewis G, Kirkham H, Duncan I, Vaithianathan R. How Health Systems Could Avert ‘Triple Fail’ Events That Are Harmful, Are Costly, And Result In Poor Patient Satisfaction. Health Affairs 2013;32(4)



Three Phases of the Stratified Approach to the Triple Aim

Phase ComponentsPlanning Identify Triple Fail events in historic routine data

Conduct a literature review to identify evidence-based preventive interventions that mitigate the risk

Develop predictive risk models stratify the population according to risk of experiencing the Triple Fail event

Develop impactibility models to stratify the population according to likely to response to preventive interventions

Conduct an ethical review

Operational Apply predictive models and impactibility models to current data in order to stratify the population according to opportunity

Offer different interventions to different strata of opportunity

Feedback Continuously adapt the predictive models and impactibility models according to the responses of different patients to the interventions

The aim is to identify high-opportunity patients (i.e., those who are both at risk and are amenable to a preventive intervention)



Ethical Considerations

• Stratification is a form of population screening

• Any screening test has the potential to cause more harm than good

• Certain types of impactibility model may worsen healthcare disparities

Prerequisites for the Stratified Approach to the Triple Aim1. The Triple Fail event should be an important health problem.

2. There should be an intervention that can mitigate the risk of the Triple Fail event.

3. There should be resources and systems available for timely risk stratification and preventive interventions .

4. There should sufficient time for intervention between stratification and the occurrence of the Triple Fail event.

5. There should be a sufficiently accurate predictive risk model for the Triple Fail event.

6. The predictive risk model and impactibility model should be acceptable to the population.

7. The natural history of the Triple Fail event (i.e., the practices and processes that typically lead to the event) should be adequately understood by the organization offering the preventive intervention.

8. There should be an accepted policy about who should be offered the preventive intervention.

9. The of cost stratification should be “economically balanced” (i.e., it should not be excessive in relation to the cost of the program as a whole).

10. Stratification should be a continuous process, not just a "once and for all" occurrence.

Adapted by the authors from: Wilson J, Jungner G. Principles and practice of screening. Geneva: World Health Organization; 1968.



Multi-year MCP contract

Multi-year whole

population budgets

Effective gain/risk share approach and

P4P

Codifying local solutions to implement a shared care

record

MCP, PACS and care homes framework documents

Standard models for one of a set number

of organisational

forms

National and local metrics measuring

progress and evaluating success

A set of solutions to key

workforce challenges

Developing an approach to place-based regulation

Population health

approaches

The national health bodies will continue to support the vanguards across a number of deliverables in 16/17

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Success of the new care models programme will see improved health and care for people in the vanguards…

…and widespread adoption of the new care models for the benefit of populations across England.

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Early signs of progress – Principia MCP

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Early signs of progress – North & East Herts CCG Care Home

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HomeFirst rapid response service has:

• reduced hospital admissions by 7.2% in Lower Lea Valley.

• reduced A&E attendance in North Hertfordshire by 14%.



Early signs of progress – Southern Hampshire Better Local Care (MCP)

Same Day Access Service (SDAS) has pooled primary care workforce of four practices into a single service operating from a central location.

It has achieved: 5500 patients referred to the service in its first 6 weeks. 3350 (61%) able to have needs met on the telephone. greater GP availability. better working conditions for practice staff. longer appointments available for patients with complex needs. reduced waiting time for routine appointments (down from 3-4 weeks to

10-14 days).



Early signs of progress - Wakefield District Care Home

Connecting Care Wakefield’s work includes a multi-disciplinary team identifying care needs which, if not met, may lead to residents needing hospital care.

They have seen:

• admissions reduced by 27%. • reduction in A&E attendance by 16%. • ambulance call outs reduced by 16%.

28Our values: clinical engagement, patient involvement, local ownership, national support



www.england.nhs.uk/vanguards #futureNHS28

More details can be found on the NHS England website:

www.england.nhs.uk/vanguards

Or join the conversation on Twitter using the hashtag: #futureNHS

Or contact me at: [email protected]

Further information…



ANNEXVanguard examples



Integrated primary and acute care systems (PACS) vanguardsNine areas are changing the ways health care has traditionally been provided, bringing much closer together family doctor, hospital, community, mental health and social care services in one single organisation or partnership. By coming together, one organisation will be responsible for people’s care whatever they need, whatever service

• Mid-Nottinghamshire Better Together has teams of healthcare staff, social workers and volunteers now working together to provide prevention services to patients deemed to be at high risk of future admission. Also established a citizens’ board, made up of patient representatives, who support the development of communications and engagement activity

• Better Care Together is developing multidisciplinary teams based within communities across Morecambe Bay. There will be increased general practice capacity and capability, with an expansion of community based specialist services

Vanguards making it happen

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• Isle of Wight’s integrated ‘My Life a Full Life’ model is prevention based, promotes health and wellbeing and is built on experience-based co-design. It is also founded on the principles of self-care and empowered communities



Multispecialty community providers (MCPs) vanguardsThese 14 vanguards are focussing on taking services traditionally provided in hospitals into the community, bringing care nearer to patients’ homes

• Better Local Care (Southern Hampshire) is piloting a new hub based same-day access service scheme is which is helping to make it easier for people to receive same-day consultations with a GP, nurse or relevant healthcare professional on the day they make contact. The pilot has freed up GP sessions back in practices, enabled longer appointments slots for patients with complex needs and reduced waiting time for routine appointments in practice from 3-4 weeks to 10-14 days


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• Fylde Coast Local Health Economy has launched two new services in the community, providing high-needs patients with proactive and coordinated care with a single point of access. These services help build patients’ confidence and give them the knowledge to manage their own

conditions better; five more similar services are planned to start in the next 18 months• Stockport is developing a facility to allow GPs to call consultants

directly for advice initially across up to eight specialties. The vanguard will also utilise the skills of social care and voluntary sector partners to build community capacity in each neighbourhood



Enhanced health in care homes vanguardsSix vanguards are working to improve the quality of life, healthcare and planning for people with long term conditions living in care homes

• Gateshead Care Home Project sees individual GP practices each allocated to a specific care home, making it possible to offer greater continuity of care and more effective prevention of illness through regular home visits

• Airedale and partners is using technology to improve care locally: supporting residents who are sick by providing a secure video link to senior nurses, so they can remain in the care home. Have already seen a large reduction in hospital as place of death for palliative patients and reductions in A&E admissions/non-elective hospital admissions


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• Connecting Care in Wakefield has introduced E-learning for care home staff and carers to support well-being and resilience of people with dementia. This programme has had positive outcomes with improved engagement, reduced behaviours and more meaningful care planning



Urgent and emergency care (UEC) vanguardsEight vanguards are redesigning the experience for patients needing urgent or emergency treatment. The aim is to help people get the right advice in the right place, first time

• Greater Nottingham System Resilience Group has a new navigation programme supported by a web-based application. This helps refer patients to the most suitable health and care service location, offering an alternative to an urgent hospital admission. The preliminary programme has delivered some promising results; reducing acute and emergency admissions


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• Solihull Together for Better Lives is about improving urgent and emergency care for the whole population, with an initial focus on transforming the way they provide care for older people. They are supporting patients/carers in their homes and the ‘Health and Wellbeing Campus’ (on the hospital site) through open and accessible information and services using various portals, building on the local “Solihull Connect” service

• Leicester, Leicestershire and Rutland System Resilience Group will create a new alliance-based urgent and emergency care system where all providers work as one network. This will bring together ambulance, NHS 111, out-of-hours and single point of access services to ensure that patients get the right care, first time



This group of 13 vanguards is developing new ways to improve the quality and efficiency of hospital services. They include some of the best-known hospitals in England who are extending their geographical reach, stepping up to the challenge of driving efficiency and improvement across the country. The aim is to spread excellence in hospital services and management across multiple geographies

Acute care collaboration (ACC) vanguards

• The Neuro Network will see the Walton Centre collaborating with local commissioners and providers to maintain local access to neuro and spinal services in both community and smaller District General Hospital settings

• Moorfields already provides ophthalmology services across 22 sites in and around London. The vanguard will extend this work, and make it readily available for other providers to replicate, by developing standardised clinical, financial and operating models for ophthalmology services


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• The National Orthopaedic Alliance will be leading on the development of quality-based membership clubs that will allow providers to kite mark their services for specific specialties as best practice, with support from national bodies to ensure that this is underpinned by a strong supporting evidence base

Health & Medicine

Dr Geraint Lewis FRCP FFPH - Chief Data Officer, NHS England