Eleanor Pearce-Willis sheds light on how lessons learned from vanguard programmes across Nottinghamshire are being applied to the development of the area’s accountable care system.
People are living longer, but they are not living healthier for longer, and many spend their latter years with complex and long-term conditions. Accessing the support and treatment they need to live well and independently is a key component to staying healthier for longer.
In Nottingham and Nottinghamshire, this is a central aim of the work being carried out by partners across the area’s sustainability and transformation partnership (STP).
The developing STP and accountable care system (ACS) in Greater Nottingham bring together eight local authorities, six clinical commissioning groups (CCGs) and a large number of NHS and other providers. The STP aims to add three years to the healthy life expectancy of the population, address variations in quality, change organisational cultures and bridge the financial gaps of £473m in the NHS and £155m in local government.
Transformation has been underway in the region for many years, predating the vanguard and STP initiatives. As part of this process, work was undertaken with Centene, a US-based system integrator, to quantify the gap between current provision in the area and a ‘well-managed system’.
This analysis identified significant savings that could be unlocked with a move towards population-centred care. The system has now been named an ACS accelerator site and has signed a memorandum of understanding with regulators to allow it the freedom to pursue this agenda.
As part of a recent visit to share learning from successful vanguards
, health and care leaders explored three vanguard programmes across Nottingham and how the lessons learned are being applied to the development of the area’s ACS. These were:
1. The Better Together integrated primary and acute care systems (PACS) vanguard in Mid Nottinghamshire, which covers a 330,000 population, with 41 GP practices. Since 2014, the vanguard has been working to roll out integrated health and social care community teams, develop intermediate care facilities, introduce new discharge processes, implement a self-care strategy and develop primary care hubs.
The programme is beginning to show reductions in mortality and length of hospital stay, long-term admissions to nursing and residential homes, secondary care elective referrals, non-elective acute admissions and A&E attendances.
The vanguard is using an alliance contract between commissioners and providers, with a number of other bilateral service contracts with other provider participants. This system has allowed more strategic and less transactional leadership conversations, with more of a population focus and an emphasis on reducing deficits across the whole system rather than just moving them around from provider to provider.
2. The Principia multispecialty community provider (MCP) in Rushcliffe covers a coterminous borough and CCG, with a population of around 126,000 and 12 GP practices. The MCP targets interventions according to peoples’ levels of need. Specific programmes have focused on the diagnosis and management of Atrial Fibrillation and introducing a new frail elderly care model.
Principia has also focused on mental health initiatives, with a commitment to achieving parity of esteem between services for physical and mental health needs. This has included piloting a liaison psychiatry service in primary care for those with medically unexplained physical symptoms – improvements have been shown in both clinician reported and patient reported outcome measures.
3. The Nottingham City CCG care home vanguard covers an area with 28 residential homes and 24 nursing homes, a total of 2,050 beds. The vanguard has focused on improving primary care support and data, IT and technology. Initiatives include the recruitment of pharmacists to work on medicines optimisation in care homes and use of an admissions avoidance tool.
The care homes have also implemented telemedicine services, with reductions in 999 calls and trips to hospital noted over this period. A pilot programme focused on urinalysis did not show promising results, with no impact on admissions related to urinary tract infections – this has not been rolled out to further care homes. Telehealth is also being piloted in ten nursing homes, with outcomes data not yet available.
The second visit in this series offered a comprehensive overview of the wide-ranging transformation initiatives taking place across Nottingham and Nottinghamshire. The area is unique in its scale and breadth of initiatives, and is already identifying the ways in which it can harness learning from the vanguard programme as it develops its accountable care system.
Eleanor Pearce-Willis is a senior policy and membership officer at the NHS Confederation.
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