Patient Pathways

and

New Approaches to Care

Facing the healthcare challenges of 2018

in England

The NHS in England

• The NHS (National Health Service)

Beveridge model set up in 1948 : 70 years

• One system (now the largest public health

system in the world, 1.3M employees)

• Universal system, all the population "from

cradle to grave“

• No criteria for patient selection or rationing,

same service for all

• Free at the point of delivery, the patient

contribution remains very limited

• No contribution criteria - System financed

mainly by the general state budget

• A whole system that can not run at a loss

• Serving a population of 50M people in

England in 2018 (66M people in the UK)

The NHS funding in England

3

£12.8bn £15.4bn

£76.6bn

£3,4bn

+£15bn

Social

care

Essential role of the CCGs -

Clinical Commissioning Groups

4

• Around 200 CCGs

• Most CCGs : population 300-500 000 people

• Managed by local GPs who are supposed to be the

most aware of local population needs

• They commission care from acute and community

providers

• Agree both strategy and related funding with providers

through contracts

• Develop local tariffs to meet local needs

• Link to Local Authorities > Better Care Fund

• Drive Pathway integration

System already « lean »

5

• Fewer doctors

• Role of GP

No diagnostic nor specialist appointment without GP referal

• Non medical clinical staff responsibility

• Fewer beds (1/2 compared to France) and hospitals

• Day case surgery and enhanced recovery well developed

• National targets :

18 weeks for treatment, 2 weeks cancer 1st appointment,

4h wait A&E

• « Low priority procedures », payment subject to special local

agreement

• New treatment must provide value for money (NICE appraisal)

• Population educated to health costs

On going challenges • Growing and aging population, increase

of chronic diseases

• New treatments

• Rising pressures on the service yet treatment outcomes are better and public satisfaction higher

• Waiting times still controlled but on the rise

• Pressure on budget in spite of all safeguards already in place

• Priorities

• Urgent and emergency care

• Primary care and general practice

• Cancer

• Mental health

• Frail and older people

7 years of moving away from “PbR”

Introduction

of the

quasi-market

Purchaser/Provider

1990’s

1990

2000

2010

2020

Payment

by Results

2004

Payment

for

Pathways

From 2011

Pathways

and

Value Based

Commissioning

Integrated care

“pioneers”

2013-15

New Models

of care : 50

Vanguards

2015

10

Integrated

Care

Systems

2017

Example of Payments for Pathways

Maternity Under the new system, a commissioner will pay a single lead provider for all the pregnancy related care a woman may need. There are three payments in total,

I. one for antenatal care,

II. one for the birth,

III. one for postnatal care.

One of the first pathway pricing projects

National tariff

The Maternity pathway payment approach was introduced to address two main issues:

Problems with the way different organisations described and recorded antenatal and postnatal non delivery activity

Under the old system, organisations were paid for each inpatient spell, scan or hospital visit, so the more clinical interventions, the more a hospital received.

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Further Payments for Pathways

Further Pathways payments being developed at

CGGs local level through the Vanguards in :

Urgent and emergency care

Mental Health

Long Term Conditions (Diabetes, respiratory etc.)

Complex elective care

Frail elderly

Other examples of development of national tariffs :

HIV outpatients 1 year

Sickle cell (trépanocytose) Transplantations …

More recently Bariatrics

2015 - New Care Models, 50 “vanguards” 5 vanguard types:

Vertical integration

• Integrated primary and acute care systems PACS–

joining up GP, hospital, community and mental

health services

• Enhanced health in care homes EHCH – offering

older people better, joined up health, care and

rehabilitation services

Horizontal integration

• Multispecialty community providers MCPs– moving

specialist care out of hospitals into the community

• Acute care collaborations ACCs– linking local

hospitals together to improve their clinical and

financial viability, reducing variation in care and

efficiency.

• Urgent and emergency care UEC– new approaches

to improve the coordination of services and reduce

pressure on A&E departments

Integration of acute and community

providers - Whittington Health

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• Large Hospital serving inner

north central London

• Approx’ 500,000 population

• Need to reduce

• Demand on urgent and

emergency care

• Incidence of long term

disease

• Unnecessary admission to

hospital for the elderly

• Severe and enduring

mental health conditions

• One decision making body

• Emphasis on prevention : keeping people well

• Easier access to the right diagnostic

• Nurses and physio led services in the community

• Reorganising integrated acute care et community services by pathways

• Integrated team training

• Shared IT System connexion acute / community

• Increases loyalty from local population

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Integration acute and community

providers - Whittington Health

13

Value Based Commissioning VBC - North

London

• Payment for outcomes

• Cohort population based

• Shared financial risk and shared commitment to patient services

• Pathways across the local health economy, acute, community

services, primary care, social care. Implication for all providers.

• Experiment in North London since 2014 :

• Diabetes across Haringey and Islington

• Older People with Frailty across Enfield and Haringey

• Mental Health across Camden and Islington

• Other considered cohorts in VBC : MSK patients, Respiratory,

Chronic kidney disease CKD, Paediatrics

2017 - 10 Integrated Care Systems ICSs

Building on this experience, Commissioners and

Regulators are driving to whole system funding across

multiple pathways

Integrated Care Systems

Greater Manchester

• February 2015,

• Integration of NHS organisations

and local authorities

• Agreement to take charge of

health and social care spending

and decisions in the city region.

• £6 billion health and social care

budget

• 10 Boroughs .

• Population of 2.8 million

• 36% of the population live in the

most deprived areas of England.

• A high prevalence of long-term

conditions

• shorter life expectancy and

• poor health at a younger age.

Integrated Care Systems

Greater Manchester

The partners hope that by 2021 there

will be:

• 1,300 fewer people dying from

cancer, 600 fewer dying from

cardiovascular disease and 580

fewer dying from respiratory

disease;

• 270 more babies born weighing

over 2,500g, making a significant

difference to their long term

health;

• More children reaching a good level of social and emotional

development;

• 2,750 fewer people suffering serious falls, remaining independent at

home for longer.

Merci!

Martin Machray

Director of Nursing North West London

martin.machray@nhs.net

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https://www.england.nhs.uk/new-care-models/

https://www.england.nhs.uk/integratedcare/integrated-care-systems/

https://improvement.nhs.uk/documents/2360/maternity_payment_pathway_system_supplementary

_guidance.pdf

Further information