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Hugh Reeve: How is the NHS in Cumbria adapting to lessons from the Alternative Quality Contract?
How is the NHS in Cumbriadrawing on lessons from theAlternative Quality Contract?Hugh ReeveChair: Cumbria Clinical Commissioning GroupNHS Cumbria
In 2007 we embarked on a journeyIn March 2011 this took us to Boston,Massachusetts
Insurers Tufts Health Plan Blue Cross Blue ShieldProviders Atrius Health (multispecialty IPA) Mount Auburn and Cambridge IPA (multispecialty) and Mount Auburn Hospital Hampden County IPA (primary care only) These 3 providers all had extensive experience with risk based contracts
Key take-aways from BCBS Contracts for the whole continuum of care, over 5 years allowing time for the “tanker to turn” For organisations to hold an AQC a primary care provider with sufficient patient base is essential to participation Risk (gain) share between insurer and provider, determined by quality performance Financial incentives promote affordability and efficiency Performance incentives promote quality, safety and patient centred care (process, outcomes and patient experience measures) Significant investment by insurer in supporting AQC providers (10-12 WTE middle to senior managers)
Key take-aways from Providers New paradigm of global risk based contracts (not just the AQC) – “keeping my population healthy” Investment in areas that previously wouldn’t have generated income Health coaches, case managers, hospitalists Data management systems + data analysis – clinician performance, hospital utilisation rates, prescribing, and imaging and lab rates Electronic Medical Records Strong clinical leadership and a culture of independent physician practices working together Partnership with BCBS Regular performance feedback and support Collaborative, long term commitment in a 5 yr contract
Collaboration with hospitals – formal and informal partnerships, drives value throughout the delivery system Atrius Health: “We want to use hospitals that enable us to integrate our specialty care into the fabric of the hospital to the greatest extent possible” MACIPA and Mount Auburn Hospital: Managed care partners since 1985 with history of investing in systems and programmes to manage costs Strong, long term relationship between the two senior leaders Each are independent entities with no joint legal structure Contracts with insurers signed separately as three-way agreements and all parties at the table in discussions Risk share between IPA and hospital is defined and agreed outside of the contract with insurers
A networked commissioning group in 2011across a 500,000 population Carlisle Allerdale Eden Copeland Cumbria CCG Furness South Lakeland Commissioning Support Services
Immediate actions (0-6 months)2011/12 contract 50/50 split on any underspend on 11/12 PBR element of contract Risk share on elective activity – marginal rates for activity 0.5% or more above plan Risk share on non-elective admissions as nationally This signalled a new style and approachPrimary care One CCG with devolution to six localities
Immediate actions (0-6 months)2011/12 contract 50/50 split on any underspend on 11/12 PBR element of contract Risk share on elective activity – marginal rates for activity 0.5% or more above plan Risk share on non-elective admissions as nationallyPrimary Care One CCG with devolution to six localities Secondment of support staff to localities – data analysis, referral support, medicines mx, project mx Roll out single EHR (Emis Web) across general practice, community services and community hospitals
Medium term (6-18 months) Develop our own narrative – culture, leadership and a new paradigm (“keeping you healthy”) Honest discussions with partners (health, social care and 3rd sector) about new ways of working Develop capacity within primary care Workforce – doctors, nurses, HCA’s, Mx, new roles Industrial scale long term condition management Education and training QOF+ incentives using Local Enhanced Services But long term … the real prize is clinically led, multi-specialty groups taking on accountability for the whole continuum of care.
A central “Payer” with a network of ProviderFederations Carlisle North East Cumbria Allerdale Eden Copeland CCG “Payer” Furness South South Lakeland Cumbria
Provider Federations Consultants, nurses, therapists, etc. Community Existing and GP Specialists new roles Practices Out of Community Hours BedsBack office, SupportEd/Training, Day care & ServicesAudit, etc Day case Multi-specialty groups Stand alone or joint ventures Accountable for whole continuum of care – “make or buy” Contracts that promote efficiency and high quality
Lessons from the AQC? Our current contracts for both general practice, community services and specialist services need a radical overhaul. Make change voluntary not compulsory; but make staying still an increasingly difficult place to be. Perhaps our real challenge is creating a primary care infrastructure fit for the 21st century. This is a 10-15 year programme – will our lords and masters have the courage to let it happen?