Dr Geraint Lewis FRCP FFPH - Chief Data Officer, NHS England

Our values: clinical engagement, patient involvement, local ownership, national support
www.england.nhs.uk/vanguards #futureNHS
New care models
Population Health Data – Learning
from three ACOs in the United States
Dr Geraint Lewis
Chief Data Officer
NHS England

NHS Five Year Forward View
• Published in October 2014
• A shared vision across seven
national bodies
• New care models programme key to
delivery
• Focuses on both NHS and care
services
2

The challenges we face
Radical upgrade
in prevention
Health and
wellbeing
gap
1
New care
models
Care and
quality gap
2
Efficiency and
investment
Funding gap3
www.england.nhs.uk/vanguards #futureNHS 3

Clinical
engagement
Patient
involvement
Local
ownership
National
support
Our core values
4

50 vanguards selected
5
Integrated primary and acute
care systems
14
13
8
9
6
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

Overview
Coverage:
• National coverage of over 5 million people (9% of
population).
• Average PACS/MCP: 200,000 patients and 20 GP
practices.
Diverse demography:
• Least deprived CCGs - e.g. Rushcliffe 56%
deprivation levels lower than national average.
• Most deprived – e.g. Tower Hamlets - 39% of children
live in poverty (the highest in the UK).
6

Through the changes they are making, the vanguards are defining what the new
care models look like in their end-state
Systematic
approach to
population health
management
Engaging the
population in
their own health
and wellbeing
A person-centred
approach to
delivery of care
and support
Shared care
records and
digital technology
A new model of
enhanced primary
care &integrated
community teams
Specialist advice
and treatment in
the community
A whole pathway
approach to long
term care
Integrated
access to acute
and emergency
care
A new model of
inpatient care
A whole-system
approach to
workforce and
leadership
Primary and Acute Care Systems (PACS)
Multi-specialty Community Providers (MCPs)Enhanced health in care homes
The care model frameworks, published
over the summer, will set out for the rest of
the NHS the detail of the care models,
share the vanguard learning and best
practice, and be available for others to use
nationally

Addressing the key enablers of transformation
8
1.
Designing new
care models
2.
Evaluation and
metrics
3.
Integrated
commissioning
and provision
4. Governance,
accountability
and provider
regulation
5. Empowering
patients and
communities
6. Harnessing
technology
7.
Workforce
redesign
8.
Local
leadership and
delivery
9.
Communications
and engagement

Case Study:
Walgreens Accountable Care Organisations (ACOs)
• Medicare Shared Savings Plan
• Walgreens plus 3x physician groups in:
– Florida
– New Jersey
– Texas

Predicted Costs, Quality Hurdle & Shared Savings

Predicted Costs

Crossing the quality hurdle as efficiently as possible
• Gap analysis
• Every contact counts
• Multi-channel
• Annual cycle

Opportunity Analysis
Note: no ‘gatekeeper’ allowed
1. Duplications in care
2. Unwarranted variation
3. Non-evidence based practice
– ‘Croydon List’
4. Preference-sensitive treatments
5. Preventing ‘Triple Fail’ events

Preference-sensitive treatments
• Multiple evidence-based
treatments for a condition
• Similar outcomes
• Different side-effect
profiles
Examples
• Back pain
• Stable angina
• Prostate disease

Patient decision aids
Individual
• All treatment options available
• Greater satisfaction with decision made
Population
• Less invasive options chosen more often
• Lower cost overall
Preference-sensitive treatments

‘Triple Fail’ Approach

A Third Approach to the ‘Triple Aim’
1. Population
approach
Stratify the population according to each individual’s risk of experiencing a
Triple Fail event (i.e., a healthcare event that is simultaneously costly,
represents a suboptimal health outcome, and is a poor patient experience).
Offer different interventions to different strata.
Source of the Figures: Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14(1):32-38.
Examples: programs that encourage self-
management of chronic conditions,
promote e-mail communication between
patients and physicians, and encourage
greater use of primary care.
Examples: interventions aimed at
improving access and care for individual
patients who have low incomes, are
uninsured, or who have complex chronic
conditions.
2. High-risk
approach
3. Stratified
approach

Examples of ‘Triple Fail’ Events
Source: Lewis G, Kirkham H, Duncan I, Vaithianathan R. How Health Systems Could Avert ‘Triple Fail’ Events That Are Harmful, Are Costly, And Result In Poor Patient
Satisfaction. Health Affairs 2013;32(4)

Three Phases of the Stratified Approach
to the Triple Aim
Phase Components
Planning Identify Triple Fail events in historic routine data
Conduct a literature review to identify evidence-based
preventive interventions that mitigate the risk
Develop predictive risk models stratify the population according
to risk of experiencing the Triple Fail event
Develop impactibility models to stratify the population
according to likely to response to preventive interventions
Conduct an ethical review
Operational Apply predictive models and impactibility models to current
data in order to stratify the population according to
opportunity
Offer different interventions to different strata of opportunity
Feedback Continuously adapt the predictive models and impactibility
models according to the responses of different patients to
the interventions
The aim is to
identify high-
opportunity patients
(i.e., those who are
both at risk and are
amenable to a
preventive
intervention)

Ethical Considerations
• Stratification is a form of
population screening
• Any screening test has the
potential to cause more harm
than good
• Certain types of impactibility
model may worsen healthcare
disparities
Prerequisites for the Stratified Approach to the Triple Aim
1. The Triple Fail event should be an important health problem.
2. There should be an intervention that can mitigate the risk of the Triple Fail event.
3. There should be resources and systems available for timely risk stratification and
preventive interventions .
4. There should sufficient time for intervention between stratification and the
occurrence of the Triple Fail event.
5. There should be a sufficiently accurate predictive risk model for the Triple Fail
event.
6. The predictive risk model and impactibility model should be acceptable to the
population.
7. The natural history of the Triple Fail event (i.e., the practices and processes that
typically lead to the event) should be adequately understood by the
organization offering the preventive intervention.
8. There should be an accepted policy about who should be offered the preventive
intervention.
9. The of cost stratification should be “economically balanced” (i.e., it should not
be excessive in relation to the cost of the program as a whole).
10. Stratification should be a continuous process, not just a "once and for all"
occurrence.
Adapted by the authors from: Wilson J, Jungner G. Principles and
practice of screening. Geneva: World Health Organization; 1968.

Multi-year MCP
contract
Multi-year
whole
population
budgets
Effective
gain/risk share
approach and
P4P
Codifying local
solutions to
implement a
shared care
record
MCP, PACS and
care homes
framework
documents
Standard
models for one
of a set number
of
organisational
forms
National and
local metrics
measuring
progress and
evaluating
success
A set of
solutions to
key workforce
challenges
Developing an
approach to
place-based
regulation
Population
health
approaches
The national health bodies will continue to support the vanguards across
a number of deliverables in 16/17
22

Success of the new care models programme will see
improved health and care for people in the vanguards…
…and widespread adoption of the new care models for the
benefit of populations across England.
23

Early signs of progress – Principia MCP
24

Early signs of progress – North & East Herts CCG Care Home
25
HomeFirst rapid response service has:
• reduced hospital admissions by 7.2% in Lower
Lea Valley.
• reduced A&E attendance in North Hertfordshire
by 14%.

Early signs of progress – Southern Hampshire Better
Local Care (MCP)
Same Day Access Service (SDAS) has pooled primary care workforce of four
practices into a single service operating from a central location.
It has achieved:
 5500 patients referred to the service in its first 6 weeks.
 3350 (61%) able to have needs met on the telephone.
 greater GP availability.
 better working conditions for practice staff.
 longer appointments available for patients with complex needs.
 reduced waiting time for routine appointments (down from 3-4 weeks to
10-14 days).

Early signs of progress - Wakefield District Care Home
Connecting Care Wakefield’s work includes a multi-disciplinary team
identifying care needs which, if not met, may lead to residents needing hospital
care.
They have seen:
• admissions reduced by 27%.
• reduction in A&E attendance by 16%.
• ambulance call outs reduced by 16%.

28
www.england.nhs.uk/vanguards #futureNHS 28
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
Or contact me at:
england.cdo@nhs.net
Further information…

29
ANNEX
Vanguard examples

30
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
• Mid-Nottinghamshire Better Together has teams of healthcare staff, social workers and
volunteers now working together to provide prevention services to patients deemed to be at
high risk of future admission. Also established a citizens’ board, made up of patient
representatives, who support the development of communications and engagement activity
• Better Care Together is developing multidisciplinary teams based within communities
across Morecambe Bay. There will be increased general practice capacity and capability,
with an expansion of community based specialist services
Vanguards making it happen
30
• Isle of Wight’s integrated ‘My Life a Full Life’ model is
prevention based, promotes health and wellbeing and is built
on experience-based co-design. It is also founded on the
principles of self-care and empowered communities

31
Multispecialty community providers (MCPs) vanguards
These 14 vanguards are focussing on taking services traditionally provided in hospitals into the
community, bringing care nearer to patients’ homes
• Better Local Care (Southern Hampshire) is piloting a new hub based same-day access
service scheme is which is helping to make it easier for people to receive same-day
consultations with a GP, nurse or relevant healthcare professional on the day they make
contact. The pilot has freed up GP sessions back in practices, enabled longer appointments
slots for patients with complex needs and reduced waiting time for routine appointments in
practice from 3-4 weeks to 10-14 days
31
• Fylde Coast Local Health Economy has launched two new services in the community,
providing high-needs patients with proactive and coordinated care with a single point of
access. These services help build patients’ confidence and give them the knowledge to
manage their own
conditions better; five more similar services are planned to start in the next
18 months
• Stockport is developing a facility to allow GPs to call consultants
directly for advice initially across up to eight specialties. The
vanguard will also utilise the skills of social care and voluntary sector
partners to build community capacity in each neighbourhood

32
Enhanced health in care homes vanguards
Six vanguards are working to improve the quality of life, healthcare and planning for people with
long term conditions living in care homes
• Gateshead Care Home Project sees individual GP practices each allocated to a
specific care home, making it possible to offer greater continuity of care and more
effective prevention of illness through regular home visits
• Airedale and partners is using technology to improve care locally: supporting residents
who are sick by providing a secure video link to senior nurses, so they can remain in the
care home. Have already seen a large reduction in hospital as place of death for
palliative patients and reductions in A&E admissions/non-elective hospital admissions
32
• Connecting Care in Wakefield has introduced E-learning for
care home staff and carers to support well-being and
resilience of people with dementia. This programme has had
positive outcomes with improved engagement, reduced
behaviours and more meaningful care planning

33
Urgent and emergency care (UEC) vanguards
Eight vanguards are redesigning the experience for patients needing urgent or emergency
treatment. The aim is to help people get the right advice in the right place, first time
• Greater Nottingham System Resilience Group has a new navigation programme supported
by a web-based application. This helps refer patients to the most suitable health and care
service location, offering an alternative to an urgent hospital admission. The preliminary
programme has delivered some promising results; reducing acute and emergency admissions
33
• Solihull Together for Better Lives is about improving urgent and
emergency care for the whole population, with an initial focus on
transforming the way they provide care for older people. They are
supporting patients/carers in their homes and the ‘Health and Wellbeing
Campus’ (on the hospital site) through open and accessible information and
services using various portals, building on the local “Solihull Connect”
service
• Leicester, Leicestershire and Rutland System Resilience Group
will create a new alliance-based urgent and emergency care system
where all providers work as one network. This will bring together
ambulance, NHS 111, out-of-hours and single point of access
services to ensure that patients get the right care, first time

34
This group of 13 vanguards is developing new ways to improve the quality and efficiency of
hospital services. They include some of the best-known hospitals in England who are extending
their geographical reach, stepping up to the challenge of driving efficiency and improvement
across the country. The aim is to spread excellence in hospital services and management across
multiple geographies
Acute care collaboration (ACC) vanguards
• The Neuro Network will see the Walton Centre collaborating with local commissioners and
providers to maintain local access to neuro and spinal services in both community and smaller
District General Hospital settings
• Moorfields already provides ophthalmology services across 22 sites in and around London.
The vanguard will extend this work, and make it readily available for other providers to
replicate, by developing standardised clinical, financial and operating models for
ophthalmology services
34
• The National Orthopaedic Alliance will be leading on the
development of quality-based membership clubs that will allow
providers to kite mark their services for specific specialties as best
practice, with support from national bodies to ensure that this is
underpinned by a strong supporting evidence base

Dr Geraint Lewis FRCP FFPH - Chief Data Officer, NHS England

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