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Change management is key to the new models
Good change management is seen as the most important factor in establishing new integrated models of care, a PCC event in Leeds discovered.
A majority (54%) of event delegates to our New models of commissioning for integrated care workshop gave mobile text feedback that change management was the most important element to successful implementation.
This was closely followed (42%) by ‘system facilitation’ as the key factor. Options of ‘contract management’ or ‘procurement’ found relatively little support.
The event explored the evolving approach to commissioning better integrated and patient-centred services with presentations focusing on a range of linked subjects such as alliance contracting, the role of competitive dialogue in procurement and contracting for outcomes.
PCC development manager Peter Bullivant spoke of the potential of accountable care organisations (ACOs) and encouraged delegates to consider the notion of accountability. “When we talk of accountability you have to ask the question ‘to whom and for what?’ Within the NHS we are quite good at being accountable to others, to commissioners, to NHS England, to the secretary of state, but are we very clear about being accountable back to patients because that is what accountability should be, bringing in openness, transparency and clarity?”
He provided a series of case studies of new approaches to integrated working, highlighting the Alzira model based on the integration of primary and secondary care providers. Named after a Spanish town where it was first piloted, under this model a provider receives a fixed fee per local inhabitant (capitation) from the regional government for the duration of the contract, and in return, must offer free, universal access to a range of primary, acute and specialist health services to the local population. Supported by a unified IT system, different providers receive incentives to ensure care is carried out in the most appropriate and efficient setting.
Closer to home, he highlighted two successful integrated models achieved through collaborative approaches. The West Norfolk Alliance, a partnership of organisations involved in providing health and care services in and around the King’s Lynn area, has brought together the NHS, local authorities and voluntary services, and in so doing is removing organisational barriers and achieving efficiencies. The alliance has established a vision and clear set of high-level principles and is seeking to improve co-ordination of services, reduce duplication and simplify the system for patients.
Elsewhere, in south-east London, the Lambeth Living Well Collaborative, is advancing a new mental health care model, which is strong on changing the relationship with patients through co-production and patient empowerment and includes commissioners within a structured alliance.
Bullivant added: “It is important that those involved in establishing new integrated models establish the principles of what they want to achieve. Sometimes we do not always spend enough time trying to work out what the problem is that we are trying to fix.”
Bruno Desormiere, pricing development manager for integrated care with Monitor, provided examples of how new payment approaches, such as capitation, may help to promote innovation.
“One of the key issues of the Five Year Forward View is ‘how will payment manage to make this work in the transition to new models of care?’ A key message from Monitor and NHS England is that there is no single approach and we do not have all the answers – we are keen to see local areas innovate and keen to support them.
“There are various options for payment approaches. With capitation the first thing that providers say is that it is predictable. Predictability helps you plan your care and your investments a bit better. One of the bigger deals is that accountability shifts from the commissioners to people on the frontline who can do something about the patient journey.”
Mike Thorogood, director of economics at Capita, provided delegates with insights from other industries which could be gained in helping establish new integrated care systems.
In considering the outcomes based contracts that have been developed for The Work Programme by the Department for Work and Pensions and in a new alliance contract and case management approach for offenders within Doncaster prison, Thorogood said lessons could be applied. “You have got to incentivise. There are carrot and stick methods but it is often very difficult to work out what will happen and what the consequences will be. Keep the measurements simple – if you have hundreds of measurements in the performance assessment system it will just not work.
“You need to leave opportunities for people to innovate and encourage genuine experimentation. Through innovation, the outcome of saving money is not necessarily an automatic result. You need to treat cost savings as an objective in itself and not see it as the by-product of everything else.”
Simon McCann, a partner with Blake Morgan, discussed how available procurement methods could be best used to meet the complex requirements of procurement while also saving time and cost in the process.
“There are two main concerns in procurement - that you need to comply with the law but even more importantly that you need to choose a procurement method that will deliver the requirements of your project in terms of improvements in patient experience and value for money.
“Often organisations think they have to adopt competitive dialogue but nothing says you have to do it that way. You can use the methodology you wish as long as it fulfills the basic requirements of transparency and equal treatment.
“A dialogue element is often involved where solutions need to be adapted to the requirements, to create something bespoke, and where the nature of complexity or risks justify it. This may take place in the case of an alliance bottoming out the relationships and risks between parties or when there is an inability to establish the technical specifications. The key thing in all this is setting out the ‘known unknowns’ and working out how these can be resolved. Dialogue can be limited to those areas rather than adopting the full competitive dialogue procedure.”
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