Samantha Jones - Adass...Samantha Jones Director lending on New Models of Care, NHS England Conversations with Health Learning from the Vanguards Chaired by Grainne Siggins

Samantha JonesDirector lending on New Models of Care, NHS England

Conversations with Health

Learning from the VanguardsChaired by Grainne Siggins

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

www.england.nhs.uk/vanguards #futureNHS

New care models

New Care Models: Learning from the

vanguards

Samantha Jones

Director, New Care Models Programme

@SamanthaJNHS

14 April 2016



Clinical engagement

Patient involvement

Local ownership

National support

Our core values

3



Integrated primary and acute care systems

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:

9

14

6

8

13

50 vanguards selected

4


www.england.nhs.uk/vanguards #futureNHS5

While all vanguards are working in response to their different local needs, we are learning that there are common components across each of the first wave of care model types.

Common components of successful new care models are emerging

Core characteristics in the emerging

PACS framework:

A. A population health and

wellbeing care model

B. Accountability for the whole

population

C. Integrated governance and

organisational form to support

population health

D. System leadership to support

population health

E. Contracting and payment

systems that support population

health

Core components to the emerging MCP

framework:

A. A population health and care

model focused on proactive and

preventative care tailored around

the needs of the individual

B. Empowering patients and local

people to support each other and

themselves in their health and

care

C. Multi disciplinary health care

professionals working within an

organisation that has

accountability for the delivery of

health and care services for their

population;

D. Contracting and payment

systems that incentivise and

enable the delivery of services for

population health

Core themes to the framework

emerging from the enhanced health in

care homes vanguard community:

A. Enhanced primary care support

for care home residents

B. Multi-disciplinary team in-reach

support:

C. Re-ablement and rehabilitation to

promote independence and living at

home

D. High quality end of life care and

dementia care

E. Joined up commissioning

between health and social care

F. Workforce training, development

and shared planning.

G. Data, IT and technology – shared

data, records and new technology.



Isle of Wight PACS, My Life a Full Life

• focusing on older people, and those with long-term conditions and mental health

needs

• brings the NHS trust, the local authority, the clinical commissioning group plus

the voluntary and private sector together to deliver for integrated care and

support

• health and adult social care sit side by side

• allows instant access to the patient’s records from all those organisations.

Since April 2015, the crisis team has seen 489 people, and has

spent an estimated £725,000 less than it would have done with a

more traditional approach. Of those 489 people, just 58 were

admitted to hospital, mostly due to complications of existing

long-term conditions.

The vanguard aims to introduce the “Island of Wight pound”,

“a joint, pooled budget”, where money from the trust and the

council gets put in the same pot.

Integrated primary and acute care systems (PACS) vanguards

Nine 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

Social care providers play an important role in keeping people out of

hospital

6

https://nhsengland.sharepoint.com/TeamCentre/VisionandValues/Half page images/NHS_England_GP__038.jpg

https://nhsengland.sharepoint.com/TeamCentre/VisionandValues/Half page images/NHS_England_GP__038.jpg



Multispecialty community providers (MCPs) vanguards (1/2)

Social care providers are an important part of care teams, in primary care

and in the community

7

West Wakefield health and wellbeing (MCP) has introduced an extended primary

care model, including:

• Physiotherapy First

• Pharmacist embedded in General Practice

• Care Navigation

• Social Prescribing

• HealthPod

A cadre of care navigators (over 100 so far) has been trained to

break down the automatic assumption that a GP appointment is

the best first place to go for any problem.

Care navigators are:

• ‘queue busting’ at reception by offering patients who arrive

at the practice advice,

• signposting people to the most appropriate health, social or

voluntary service for their needs.

• backed by a digital platform and care record

• expected to save around 4.65% of GP time.

These 14 vanguards are focussing on taking services traditionally provided in hospitals into the

community, bringing care nearer to patients’ homes

https://nhsengland.sharepoint.com/TeamCentre/VisionandValues/Half page images/NHSEng_LGI_1Aug14_0028.jpg

https://nhsengland.sharepoint.com/TeamCentre/VisionandValues/Half page images/NHSEng_LGI_1Aug14_0028.jpg



Multispecialty community providers (MCPs) vanguards (2/2)

8

In West Wakefield, social prescribing can include: exercise, healthier lifestyles,

carer support, money and benefit advice, and meaningful activities to combat lack of

purpose and social isolation.

West Wakefield’s HealthPod is a pop-up primary care pod, allowing health and care

support, including social prescribing, to be provided in the community.

The pop-up service centre offers all-round health assessments, with a focus on

risk of heart problems and diabetes, and access to a variety of community and

voluntary services.

Providers involved offer advice and support about:

• housing

• social prescribing

• mental health

• eating and lifestyle

• legal and financial help

• smoking cessation

• sexual health and contraception;

• care services access and advocacy

Social care providers are an important part of care teams, in primary care

and in the community



Enhanced health in care homes vanguards (1/2)

Six vanguards are working to improve the quality of life, healthcare and planning for people with

long term conditions living in care homes

9

East And North Hertfordshire CCG

HomeFirst is a rapid response service which helps older people and others with long

term or complex conditions to stay well and independent and which now operates in

the Lower Lea Valley and North Hertfordshire areas.

HomeFirst brings together health and social care services to deliver:

• Improved access to rapid support with care from the right

professional

• Better communication between people using services and health and social

care professionals working as part of the same team

• Reduced accident and emergency attendance and unplanned

hospital admission or residential care

• Rapid discharge from acute hospital

Homefirst is one element of a programme of work aimed at keeping

patients well in their place of choice. Elements of the care model

cover MDTs, rapid response to crises, confident staff in care

homes, all supported by technology and data.

Social care services are key to helping people remain, supported, at home

Confident staff in Care Homes

Multi-disciplinary

Team

Rapid Response

Technology and Data



Enhanced health in care homes vanguards (2/2)

10

Other key elements of East And North Hertfordshire CCG’s care model include:

Medicines optimisation:

Multi-disciplinary teams consult in the care homes; 8 visits completed to date,

resulting in: stopping 208 medicines, including 22 linked to increase in falls, and a

direct reduction in drug costs of £18,295.

A complex care framework:

Supporting care home staff to be confident in their care for their patients, and

including the training of advanced care champions in each care home.

Champions are improving services for dementia, falls, wound care,

nutrition, engagement, and health.

GPs aligned to specific care homes

Giving improved access, planning, and continuity of care. 100% of

homes surveyed responded that this arrangement has improved

resident care

Social care services are key to helping people remain, supported, at home

https://nhsengland.sharepoint.com/TeamCentre/VisionandValues/Half page images/NHSEng_14Aug14_0103.jpg

https://nhsengland.sharepoint.com/TeamCentre/VisionandValues/Half page images/NHSEng_14Aug14_0103.jpg



Vanguards are developing new and exciting ways of partnering with local authorities

Northumberland PACS is

forming an Accountable Care

Organisation – a new

organisation that would bring

together all providers in

Northumberland, with a focus on

health outcomes; being

mutually responsible and

working together, removing

perverse incentives in the current

system.

A partnership between the CCG

and Local Authority will take the

role of Strategic Commissioner.

This would use a single contract;

set strategy and health outcomes;

and allocate a capitated budget to

the ACO.

Stockport MCP is establishing a

placed-based joint

commissioning unit.

The unit is built from the CCG

and Local Authority, along with

a provider board made-up of

local trusts, social care, and

independent providers.

The commissioning unit is

envisaged to cover services

including all non-core general

practice, all community services,

community mental health

services, and adult social care in-

house services

It will operating as an alliance with

an open book approach, under a

memorandum of understanding.

Nottingham City Clinical

Commissioning Group and the

Nottingham City Council contract

jointly for all care homes in their

area.

The Council is the lead

commissioner for the NHS

contract, sharing responsibility

with the CCG.

The Council takes the lead on

monitoring residential homes,

while the CCG leads on nursing

homes.

Care homes are better

supported, and care quality

improved, by this joint contracting.



Addressing the key enablers of transformation

1.

Designing new care models 2.

Evaluation and metrics

3.

Integrated commissioning and provision

4.

New operating models

5. Governance, accountability and provider

regulation6.

Empowering patients and communities

7. Harnessing technology

8.

Workforce redesign

9.

Local leadership

and delivery

10. Communications and engagement

12

13



We will track progress in the

vanguards using clear national and local measures.

We will support the design and delivery

of the sustainability and

transformation planning process

to enable the spread of new care

models.

We will have developed and

published common

frameworks for MCPs, PACS and

enhanced health in care homes.

We will start testing new payment approaches,

including whole population

budgets, as well as approaches to

gain and risk share that align financial incentives across

local health systems.

We will work with the vanguards to

co-produce frameworks for the

new organisational

forms that will help other areas to

deliver new care models.

We will be testing a new contract for MCPs and PACS, for use in 2017/18.

We will enable and support MCPs and PACS, as well as

Greater Manchester and

the North East, to contribute to system-wide

changes in 15 to 20 percent of the

country.

We will be codifying local

solutions to implement a shared care

record, with IT systems that work

together.

We will develop a place-based

regulatory and assurance

framework, co-produced with

vanguards.

We will share a set of solutions to key

workforcechallenges around recruitment, MDT working and skills

development.

How the national health bodies will continue to support the

vanguards in 2016/17

14



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

Further information…

Samantha Jones - Adass...Samantha Jones Director lending on New Models of Care, NHS England Conversations with Health Learning from the Vanguards Chaired by Grainne Siggins

Documents