Dr John Howarth MBBS DTM&H FRCGP FFPH The challenges and opportunities for Mental Health in the new care models Dr John Howarth MBBS DTM&H FRCGP FFPH Director of Service Improvement and Interim Deputy CEO, Cumbria Partnership Foundation Trust Clinical Lead for Cumbria Learning and Improvement Collaborative (www.theclic.org) Karmini McCann 12.2.15

What are the ‘New Care Models’ The new models: 29 original ‘Vanguard’ sites created but the ambition is to spread new care models across England “Over the next five years the NHS must drive towards an equal response to mental and physical health” A Mental Health Taskforce is developing the Five Year Forward View for MH Multispecialty community providers (MCPs) Primary and acute care systems (PACS) Urgent and emergency care networks Viable smaller hospitals/acute care collaboration Specialised care Modern maternity services Enhanced health in care homes + Hospital chains – Dalton Review

Cumbria has 2 ‘place based’ approaches Success Regime in North Cumbria Vanguard PACS in South Cumbria/N Lancs

The IHI Triple Aim – our overall objective Safe, Effective, Timely, Patient Centred, Equitable The IHI Triple Aim – our overall objective

The 3 tiers of our emerging model – more developed in the Morecambe Bay vanguard Bay wide services and ACS Integrated clinical Networks 12 Integrated Care Communities across the Bay 365,000 population Capitated budget Simplified and longer contracts Some servcies organised at this level Integrated networks – e.g. North Lancs, Furness and South Lakes Each has a hospital Creating ‘teams without walls’ Economies of scale for some services Other overlapping clinical networks e.g. for MH Built from GP practice lists and around natural communities as much as possible Populations mobilised for health and wellbeing Population 13000 – 50,000 Economies of localism – avoiding ‘failure demand’

Current financial ‘drivers’ in the system Acute – payment by volume Community providers and MH Payment by block remember - the system delivers what it is designed to deliver! Multiple general practices –payment by ‘block’

Accountable Care System – ‘System Architecture’ Commissioning Macro - Strategic and high level Defining the outcomes Setting the budget Monitoring performance Regulation Care Quality Commission Monitor Providers Population Health Capitated Budget Changed drivers Meso & Micro commissioning Acute Services Community Services General Practice Mental Health Social Care (Independent Sector) (Third Sector) Contracts Longer contract Outcome based Health outcomes Patient experience Value for money Accountability to Commissioners and Regulators

The purpose of an Accountable Care System – what problems we are aiming to solve? Coherent system approach to delivering the triple aim A move away from PBR to capitated budgets Creating the right rules, behaviours, incentives and payments to shift care out of hospital and deliver more prevention and upstream care Radical reduction in transactional costs – longer contracts, moving away from annual contracting round Increasing accountability to the people we serve and simplifying the overall governance of the system ‘Tactical’ commissioning to become part of this ACS

The purpose of our clinical networks– what problems we are aiming to solve? Dismantling the ‘walls’ (both physical and organisational) Primary and secondary care working together Clinical leadership Practising population medicine Creating ‘real’ teams across pathways A sense of ownership -hospitals ‘owned’ locally by both their communities and local clinicians Hospitals providing support to local integrated care communities Integrated care communities supporting their local hospital ‘Face fit’ – knowing your colleagues

care planning and support for self care The purpose of our Integrated Care Communities - what problems we are aiming to solve? Closing the inequality gaps – mortality/morbidity, access and wellness Practicing ‘population medicine’ Local use of data for improvement (most information currently flows upwards for assurance) More prevention, care planning and support for self care Local communities integrated into leadership team – rebalancing our accountability back to the public Much more care delivered outside hospital through multidisciplinary and multi-speciality teams Working with communities mobilised for health and wellbeing including work on the ‘demand side’ Sustaining general practice and enabling it to respond to these challenges Sorting things out locally – avoiding ‘failure demand’ More efficient, less waste

The challenges for MH We are at the table but most of the emergent models focus mainly on physical health, MH strategy is discussed separately We deliver MH on a Cumbria footprint not North and South (many MH providers will cross multiple ‘systems’) The concept of ‘overlapping systems’ (ref. Kings Fund) is helpful in one sense but problematic in another ‘Tactical’ commissioning will transfer to the Accountable Care System/Organisation, PbR will disappear, the system drivers will change. Danger is that MH will sit outside this.

Opportunities for MH at system level System metrics Improving population mental health as a system goal Building skills – Improvement Collaboratives www.theclic.org Co-opting partners as ‘assets’ Influencing the system drivers

Opportunities for MH at clinical network level Better interfaces e.g. Liaison or with general practice Building skills Better realtionships Physical health for MH

Opportunities within Integrated Care Communities Social isolation Schools Building primary mental health Carers Building skills Wider determinants of health e.g. employment Public integrated into leadership team Access Multimorbidity Health Literacy

In summary - we are attempting to build a population health system in 3 layers ACS Clinical Networks 12 Integrated Care Communities across the Bay Changed drivers in the health system (Accountable Care) (system leadership, system architecture, system culture, changed drivers, impacting on commissioning and provision) Teams without walls Placed based Integrated health and social care teams (building real teams around place and pathways) A population mobilised at scale for health and well being (the community as part of the local leadership and delivery team) There are opportunities at each level of this system approach to improve population MH even if as a provider we cover a wider footprint