Hugh Reeve draws on the lessons that can be learnt from the Alternative Quality Contract and shares how Cumbria Clinical Commissioning Group have started to put those lessons into practice.
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Hugh Reeve: How is the NHS in Cumbria adapting to lessons from the Alternative Quality Contract?
1. How is the NHS in Cumbria
drawing on lessons from the
Alternative Quality Contract?
Hugh Reeve
Chair: Cumbria Clinical Commissioning Group
NHS Cumbria
2. In 2007 we embarked on a journey
In March 2011 this took us to Boston,
Massachusetts
3. Insurers
Tufts Health Plan
Blue Cross Blue Shield
Providers
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
4. 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)
5. 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
6. 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
7.
8. A networked commissioning group in 2011
across a 500,000 population
Carlisle
Allerdale
Eden
Copeland Cumbria
CCG
Furness South
Lakeland
Commissioning Support Services
9. 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 approach
Primary care
One CCG with devolution to six localities
10. 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
Primary 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
11. 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.
12.
13. A central “Payer” with a network of Provider
Federations
Carlisle
North East
Cumbria
Allerdale
Eden
Copeland CCG
“Payer”
Furness South
South Lakeland
Cumbria
14. Provider Federations
Consultants,
nurses,
therapists, etc.
Community Existing and
GP Specialists new roles
Practices
Out of Community
Hours Beds
Back office, Support
Ed/Training, Day care &
Services
Audit, 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
15. 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?