english physician-led organisations: how they are supporting people with complex needs? rebecca...

English physician-led organisations: How they are supporting people with

complex needs?

Rebecca Rosen Stephanie Kumpunen

Judith SmithThe 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 navigationProActive 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