Post on 13-Aug-2015
English physician-led organisations: How they are supporting people with
complex needs?
Rebecca Rosen
Stephanie Kumpunen Judith Smith
The Nuffield Trust
13/11/2013
Overview
• Two case studies of physician led organisations working in collaboration with general practice to transform services
• Key drivers of success for physician groups • Physician leadership and ownership supports engagement
• Entrepreneurial energy has helped realise organisational growth • Range of external factors constraining progress:
» Piecemeal funding arrangements,
» Complexity of data linkage to monitor impact and progress
» Slow pace and complexity of commissioning decision making
• Un-answered question: » Target patients on GP lists or segment patients to new services?
• Lessons from these organisation for the Five Year Forward View (5YFV)
Five Year Forward View: A vision for transformation
• New models of care linking different groups of providers as a route to transformation
• Multi-speciality community provider models could be led by large scale primary care groups
• Five FYFV vanguard sites are led by large GP groups or other primary care providers
A transformational role for ‘scaled up general practice’?
• Individual GP practices grouping into larger organisations
• Several models emerging most of which conserve individual practices
• Many new services remain rooted in established registered lists
• Potential new and extended roles:
– Multi-disciplinary work with community and social care for complex patients
– Primary care elements of integrated pathways at scale (eg MSK)
– Enhanced/extended hours access
– Proactive population health management and building resilience in communities
Super-partnerships
Networks
Federations
Multi-site practices
Out of hours co-ops
Case studies: Selection and methods
Selection
Two contrasting case studies of established primary care organisations working in collaboration with local GP practices
• Different populations and service offers
• Contrasting approaches to services for people with complex needs
• One in a 5YFV Vanguard health economy
Methods
• Structured interviews (face-to-face and telephone) with executives, board members and other staff, plus CCG interviews in each site
• Thematic analysis of interview data, web sites, and background documents
• Founded in 1994 as NFP company limited by guarantee. Every local GP is an individual member
• Initially provided only out-of-hours (OOH) GP services on behalf of all local practices
• Covers two contrasting CCGs: Population 325000. Mix of deprived, younger city population and ageing rural communities
• Early initiative to develop individual OOH care plans for end of life patients evolved into a GP care planning & running a 24/7 contact centre to access care plans for high risk patients
Case study: Fylde Coast Medical Services (FCMS)
FCMS: Evolution of services for patients with complex needs
Collaboration with CCG to develop a Fylde Coast unscheduled care strategy
• 2011: began care planning service for ‘top 2%’ at risk: 10,000 care plans now completed • Support GP to prepare high quality care plans
• 24 hour hub for all health professionals to access plans
• Help line for patients
• Comfort calls after hospital discharge
• Acute home visiting service launched in 2012 with pilot telemedicine link to ambulances (2014)
Additional local and national services • Urgent care centre in local hospital; A&E reception and
neighbourhood walk in clinics
• Building on call centre capacity: NW region provider for NHS 111 National provider of ‘SilverLine’
Graphic of Fylde Coast Unscheduled care Strategy (2012)
Case study: Brighton and Hove Integrated Care (BICS)
• Formed in 2008 as a NFP community interest
company owned by GPs, other practice staff and BICS employees
• Founding vision: use data and leadership to support collaboration between GP practices to improve care. Initially,referral management
• Extended into planned care through competitive tendering in collaboration with willing GP practices
– Community eye services &anti-coagulation; contracts for community gynae/derm/MSK; wellbeing, mental health & memory clinics
• Partnered with a failing local GP practice in 2013 – developed peer role in GP provision
Extended primary integrated care (EPIC)
• Funded nationally through PMCF
– 16 participating GP practices
– 5 work streams to improve access /care coordination, including care navigation
ProActive Care Programme
– Funded by CCG for the whole population
– Targeting 5-8% of registered patients at risk of losing independence
– 2-stage care planning: first by a nurse/soc worker then by a care navigator
– Working with new GP practice clusters
BICS: Evolution of services for patients with complex needs
1. Physician leadership and links with GP members important in engaging practice staff in change Multi-method support to all participating practices to develop and implement new ways of working with high risk patients
» Educational events and visits to practices
» Data dissemination and benchmarking
» Organisational development support for practices
» Action learning sets and involvement in service design/refinement (BICS)
2. Entrepreneurial energy » Rapid implementation of new contracts to high standards
» Diversification of services into new markets
3. Adaptability and collaboration – Ability to adjust organisational offer in line with CCG priorities – Collaboration with CCG on strategic plans
Internal influences on success: Leadership, energy and adaptability
Contrasting relationships with local payers and other stakeholders
External influences on success: Relationships with commissioners & other stakeholders
- Stability of local leadership and enduring collaborative relationship with CCG around unscheduled care.
- Common purpose with all key stakeholders re avoidable admissions
- History of aligned interests and high trust with GP practices
- Receptive context for change despite destabilising factors
- Engaged with CCG on a diverse range of services (referral management, planned care, proactive care)
- Changes in CCG (Ex PCT) leadership and stakeholders – time needed to ‘take stock’ of priorities and local needs
- Heterogeneous relationships with local GP practices – now strengthening through PMCF and ProActive care
- More complex context for change than FCMS
FCMS
BICS
Opportunity or Challenge? Targeting patients on GP lists
• Both organisations rooted in local GP practices • Founding rationale to support collaboration between practices • Established track record in leading change and improvement
BUT: • Working at arms length • Can’t direct clinicians to work differently – support/motivate/
incentivise • Harder to introduce standardised systems and processes for
efficiency and safety than in a single partnership • Little precedent for transferring patients to new providers (care
homes are an exception) although pilots are in progress
• Short term and piecemeal funding from CCG for new services
• Complexity of CCG decision making
– Re-grouping after organisational change
– Taking stock of changing policy priorities
– Consultation with multiple stakeholders
• Difficulty of data synthesis and standardised measurement across whole systems of care
• Both organisations see future sustainability linked to:
– Diversifying their payers
– Broadening their service offer and
– Broadening their geographic spread
Challenges to growth and sustainability
• Could emerging primary care groups develop the strategic and operational management capacity to lead multi-speciality community providers?
• Will we achieve more, faster through vertically integrated new care models employing GPs?
• How can we develop light touch governance and accountability to minimise constraints on provider innovation?
• What role should existing payers play in emerging new models of care?
• advantages and disadvantages of targeting high risk groups on a GPs registered list vs segmenting them out into different services?
Concluding thoughts and implications for FYFV