English physician-led organisations: how are they supporting people with complex needs?

1. English physician-led organisations:
How they are supporting people with
complex needs?
Rebecca Rosen
Stephanie Kumpunen
Judith Smith
The Nuffield Trust
13/11/2013

2. 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)

3. 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

4. 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

5. 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

6. • 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)

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. • 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

14. • 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