NHS Five Year Plan: Implementation and Progress

1. NEW MODELS OF
WORKING IN THE
FIVE YEAR
FORWARD VIEW
OPEN FORUM
EVENTS
26 May 2016
Siva Anandaciva
Head of analysis

2. The care and quality gap
Unless we reshape care
delivery, harness
technology, and drive
down variations in quality
and safety of care, then
patients’ changing needs
will go unmet, people will
be harmed who should
have been cured, and
unacceptable variations
in outcomes will persist.
NHS Five Year Forward
View

3. Our current operating model
Fragmentation
• Between primary
and secondary care
• Between physical
and mental health
• Between health
and social care
Medicalisation
• Treating illness as
opposed to
ensuring health
and well being
• The preponderant
role of medical
professionals
Hospitalisation
• Illness -> Hospital -
> Intervention ->
Wellness
• Dominance of
hospital in local
health / care
system
Specialisation
• Hospital care
dominated by
increasingly
specialised
specialists
History
• Historic service
structure and
patterns
• Importance of /
emotional
attachment to
existing buildings &
institutions

4. Achievedgreatthings but now under pressure
A&E performance
Current emphasis of asking individual institutions to improve technical
efficiency and clinical outcomes within their four walls no longer enough
NHS provider aggregate deficit
98% 92% 91% 88% 86% 83% 82% 80% 77% 75% 73% 67%
97% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%
96% 92% 90% 88% 85% 83% 81% 80% 77% 75% 73% 66%
95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%
95% 92% 90% 87% 85% 83% 81% 80% 77% 75% 73% 64%
94% 92% 90% 87% 84% 83% 81% 79% 77% 75% 72% 63%
94% 91% 89% 87% 84% 82% 81% 79% 77% 74% 72%
94% 91% 89% 87% 84% 82% 81% 78% 77% 74% 71%
94% 91% 89% 87% 84% 82% 81% 78% 76% 74% 70%
92% 91% 89% 86% 84% 82% 80% 78% 76% 74% 69%
92% 91% 88% 86% 84% 82% 80% 77% 76% 74% 68%
92% 91% 88% 86% 84% 82% 80% 77% 76% 73% 67%
%
seen
in 4
hours
Type 1
A&Es
Q4
2015/
16

5. 2016/17
Source: Kings Fund QMR April 2016
2016/17 is already falling
apart. We closed 2015/16 with
a £50 million deficit. Our
control total for this year is a
£15-20 million deficit. At the
end of April we are already at -
£10 million.
NHS FT Director

6. What does good look like anymore?
Source:
How are things going? Well
demand is up to our eyeballs,
we are nowhere near our
financial control total, and we
have a Requires Improvement
from the CQC. So we feel we
are upper quartile at the
moment….they call it gallows
humour because it’s life or
death
NHS FT NED

7. Leading to a strategicfermentfor new approaches
Vertical integration
• Bringing together
combinations of
provider, CCG,
primary care, social
care, voluntary
sector
• In a tight locality –
c100k to 500k
population base
• MCPs, PACS and
Enhanced Care
Homes
Horizontal
integration
• Providers working
together with their
neighbours
• Standard operating
procedures
• Wider geographic
footprint
• Acute care
collaboratives,
chains, mergers,
shared back offices
Applying
improvement
methodology
• Deep dive on
pathways
• Improve outcomes
and efficiency
• Patient journey
mapping
• Virginia Mason
Institute
programme with
five NHS trusts

8. And new behaviours
We’re all in this together
• Focus on specified populations
• Use of outcomes that matter to
those populations
• Measuring outcomes
• Performance incentives and risk-
sharing
• Coordination of delivery across
providers
• Maximising value
Source: Noun project, Health Foundation
The zero sum game
• Focus on providers
• Process targets to support day
to day delivery
• Monitoring performance
• Risk transfers and
micromanagement
• Fragmented care with multiple
hand-offs
• Maximising cost reduction

9. New models and behaviours harnessed through 5YFV
Two further new care models proposed
Reinvention of the acute medical model
in small district general hospitals
Differs from Acute Care Collaboration
(ACC) vanguards by specific focus on
small district general hospitals, and
interest in care pathways and clinical
workforce, rather than organisational
forms and operating models
Tertiary mental health services
Secondary MH providers taking on
tertiary MH services such as secure MH
and forensic services, perinatal mental
health, Tier 4 CAMHS, CAMHS eating
disorders, Tier 4 personality disorder
services
x14
x9
x6
x8
x13

10. Mid-term reviewon the programme
• Emerging evidence that we can increase patient
outcomes and value
• But we are starting from a poorer base than we thought
• Sustainability eating transformation funding and resource
• Capacity and capability for transformation?
• Lacking infrastructure of linked data sets
• Regulatory barriers when doing right thing for the system
means wrong thing for your institution – real governance
challenge
• Turbocharging exiting plans for new models, but not
catalysing poor areas or Vatican States into developing
new models?
• Will take longer than we thought, will be harder than we
thought, will not save as much money as we thought

11. And new care models are like marriages
• They look wonderful
from the outside
• You get some
advantages
• But they take a lot of
work
• There are tax
implications
• They cost a lot of
money up front
• And they don’t
magically solve a
dysfunctional
relationship

12. What is the plan for the whole distribution?
Vanguards,
self-starters,
historically
strong, good
relationships
Fast
followers
with a plan
In distress,
within success
regime or
special
measures
Everyone
else???

13. Will we have organisationalinequalities?
Source: Sir Michael Marmot
We are shifting the distribution up,
but not contracting the distribution

14. Some things I hold on to
Primary and acute
care system (PAC)
• It’s the little things that count e.g. meet GPs on their turf, have a
GP clinical director ‘GP proof’ communication, offer help e.g. back
office support, agreeing things with a partner is not the same as
agreeing things with a practice, give GPs an exit strategy
• We may not have outpatients in the future
Integrated care
pioneer
• Start from the Nigel Edwards position that merging a bankrupt
NHS system and bankrupt social care system will not result in one
financially viable system
• Do not go straight for the shared budget. Start with a shared
governance structure with a joint venture to delegate powers,
then will have shared planning, then a shared workforce and
finally a shared budget.
Acute care
collaborative (ACC)
• Really forcing us to work out what makes us good, what is our
standard operating model, what is our ‘way’, how do we do things
around here?
• Clinical governance without line of sight, culture of franchises
Telehealth in care
homes
• ED consultants say we have fewer people come here to die

15. Welcome to Croydon
• ED rebuild with CAMHS
paeds area
• Frailty Unit reducing length
of stay and medical outliers
• Accountable care
partnership
• 10 year capitated
outcomes based
contract
• Under/over 65
incentives
• Age UK a key member
• One member one vote

16. THANK YOU
• Sivakumar Anandaciva
• Head of Analysis | NHS Providers
• One Birdcage Walk | London | SW1H 9JJ
• DDI: 020 7304 6819
• siva.anandaciva@nhsproviders.org
Q&A
Images from Googleimages & HSJ