1. 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 (
Karmini McCann

2. 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

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

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

5. 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 – 50,000
Economies of localism – avoiding ‘failure demand’

6. 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’

7. 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

8. 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

9. 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

10. 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

11. 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.

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

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

14. 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

15. 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