From one year to the next – welcome to our blog

2016 – an exciting year for Conrane IHS.

We supported the business cases for two NHS Vanguard sites, while our work on clinical care coordination for people with complex needs figured at two major international conferences.     Clinical care coordination is a co-production model which builds patient knowledge and self-care skills within individual, patient-centred care programmes.   David Cochrane presented on this at the 2016 Johns Hopkins ACGs International Users Conference in San Diego in April whilst Jayne Molyneux and Jackie Holdich from North Kirklees CCG shared the first year’s outcomes at the International Federation for Integrated Care Conference in Barcelona in May .       We have now begun a new project in Leicester CCG which is linked to the local STP footprint strategy to focus the next stage of integrated care within the local STP footprint strategy.      The project fully integrates the support of the ACG risk adjustment system to identify patients which Conrane helped introduce to the NHS with Johns Hopkins and Imperial College 10 years ago now.

Implementing the Forward View

We have also supported two Vanguard Projects move their thinking from initial strategy to more operational implementation plans at the level of detail required for business cases.  This models the activity, capacity, staffing and estates requirements and includes dynamic, realistic change in these parameters which can be achieved by whole system transformation at local level within a 5-year timeframe.       It is important that this work is based on your local population needs and current data on activity, capacity, workforce, costs and income.   Hence we can develop workable scenarios which   inform the decision-making process, any capital investment and thus a preferred option for the business plan.    This shows how the financial targets can be delivered and sets out a practical implementation timescale and the benefits of changes, separately and cumulatively   for each of the forthcoming 5 years.     This process has enabled us to develop modelling tools for activity, costs,  revenue, and detailed workforce requirements.    We have been able to work with our US partners to explore the opportunities and performance in the more successful accountable care organisations such as Group Health and Kaiser Permanente.    These include new workforce designs to meet the challenge of managing diverse population needs and meeting supply and quality challenges in primary and community care.

2017 – Making Sustainability and Transformation Plans (STPs) happen.

We agree wholeheartedly with the Kings Fund who have recently said:  “STPs offer the best opportunity to transform the delivery of care provided they move from planning to implementation. Kings Fund 2017 Priorities for the NHS and Social Care.     We have therefore produced a set of guidance notes for managers and clinicians who are coordinating the next stages of work on STPs to turn the aims and objectives into implementation plans and achieving early wins.    These guidance notes are designed to reflect the key priorities and enablers identified in the published STP.    Of course we also want to demonstrate how we at Conrane IHS have the skills, experience and not least client recommendations which enable us to support the next stage of work within the tight financial parameters for external support available to the NHS at local level, whilst helping you build your own capacity to deliver this challenging agenda. We focus on :

  • Managing whole population needs including risk adjustment and predictive modelling
  • Sustaining Primary Care ‘of the future’
  • Workable integrated delivery systems which optimise the use of hospital capacity and how concurrent utilisation review can support implementation in both acute and ‘out of hospital’ care.
  • Sustainable workforce development
  • Detailed, costed implementation planning based on local population needs, baseline activity cost and revenue data.   This includes what if models to support business cases
  • Optimising the estate and making it fit for purpose in secondary and primary care
  • Accountable care in practice

The Importance of Care Coordination to Sustainability and Transformation Plans (STPs)

Managing demand for unscheduled hospital care has re-emerged as a major priority in most published STPs.    5 years ago, the annual growth in emergency admissions was controlled by changes to the NHS tariff system.   This trend has reversed in more recent years as the diagram shows.    This rising demand is placing enormous operation and financial pressures on   acute care and the commissioners who fund it.

The first results from North Kirklees not only show qualitative benefits for patients but also savings  from unscheduled hospital utilization and pharmacy.    At £1000 per patient per annum once the costs of the services have been allowed for, the potential savings from delivering at scale are significant.    Indeed a typical CCG will have at least 5% of its total population who should be considered for this service.   The Leicester project is part of a strategy to expand pro-active preventive services.    This reflects the opportunities identified by Prof Martin Roland  to  control acute admissions by addressing the needs of a wider population than the very high -risk patients typically on the caseload of community matrons or virtual wards. (BMJ2012;345:e6017doi:10.1136/bmj.e601718.September.2012).   This approach parallels the more successful accountable care organisations in the US where care coordination is a core service.     One recent example,  highlighted  by the Commonwealth Fund, reports these  outcomes in one of the national demonstration Pioneer ACOs  which is exceeding its  minimum savings target and achieving all its quality goals.  https://www.commonwealthfund.org/publications/case-studies/2016/oct/guided-care

Workforce development

This has been part of our core business for 20 years now, we have been working with a large acute Trust in the north-east to improve the deployment of nursing staff so as to reduce reliance on agency and locums.      This builds on our other recent experience of improving productivity, reducing overall costs and complying with local CQC requirements and prescriptions.       We always love to innovate so we welcomed the challenge to develop a detailed workforce plan for 3 distinct localities – rural and urban –  in a GP Federation in Yorkshire.  This sustains the locally accessible general practice service within a hub and spoke model for advanced primary care and accountable  care.  We were able to facilitate input from Group Health in the US who shared their recent experience in re-energising primary care to address workload pressures for GPs,  falling morale and consequent supply problems.   This included the design and implementation of new support roles such as the medical assistant working  in response to patient’s day-to-day needs and also pro-actively to support  a more pro-active, co-production mode of care for people with long-term conditions.    The new comprehensive primary care has also delivered a 24% reduction in hospital utilisation and shifted  40% of (routine)  GP patient activity to the wider team and virtual care.   Family doctors now have the time to work as clinical team leaders and focus on patients who genuinely need their specialist input.      So we developed a baseline of the current activity, and staffing by practice and locality to show the pressures and opportunities offered through local good practice in skill-mixing, remote working and extended support roles.      This analysis showed that many of the changes which Group Health introduced were already happening in whole or in part at some of the Federation’s constituent practices.     Some of the nursing assistants were already performing extended roles thus facilitating their further development to NVQ 3 and 4 levels.

Pathways for whole population management within accountable care

Working with one of our Vanguard clients, we have also produced a set of pathways for whole population management within an accountable care system based in advanced primary care.   These pathways can be accessed on the website.  They cover:

  • A typical levels of need, whole population analysis
  • Description of the specific requirements of each of levels 1 up to the most complex level 4 patients
  • Service specifications for each of levels 2, 3 and 4 patients
  • Pathways of care for each of these levels showing the relative role of registered practitioners and medical assistants;
  • Outline role descriptions for each of these two staff functions