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Are the latest NHS structures an opportunity for radical change?

Author: Tracey Bleakley
10 May 2018

In the first of a new series of blogs, Hospice UK CEO Tracey Bleakley writes about the latest NHS restructures and the impact they are having on hospices.

It is often hard to keep up with the latest NHS acronyms. The latest concept, the Integrated Care System (ICSs), has evolved from Sustainability and Transformation Plans (STPs) and is the new name for the ten Accountable Care Systems currently operating across the UK. ICSs will take the lead on planning and commissioning care for local populations, provide system leadership, take more control of how they are funded and how performance is measured.  ICSs are partnerships of NHS organisations, but a variant (Integrated Care Partnerships, or ICPs) will also involve the third sector and local authorities.  Accountable Care Organisations (ACOs) will then be formed when commissioners award a long term contract to a single, lead organisation to provide health and care services to a defined population following a tender process. The process is expected to take several years.

So what does this mean for hospices?  Well as a minimum, local hospices need to be working with their local STPs to make sure ICSs become ICPs and involve hospices as well as the wider third sector in co-design.  But moving away from jargon and structures for a second, it is interesting to consider how hospices can use these ideas to radically change the way palliative care is delivered locally.

The challenges faced by the NHS are of course, mirrored by hospices.  We all recognise the challenges of lack of funding, rising demand, an ageing population and multiple complex morbidities alongside an ageing workforce with a high vacancy rate.  Hospices, like acute hospitals cannot simply work harder and smarter under the current model to meet demand. 

The 2014 NHS five year forward view suggested the answer was more care in peoples own homes, breaking down silos between services (increased coordination) and a focus on prevention and tackling risk.   What would this look like for palliative care and how can we balance taking a population health approach with providing individualised person (or family) centred care?

Imagine a social contract with your local population along the lines of the following:

  1. If you have a terminal or life shortening illness, or you are approaching the end of life and need our help, we are here for you.
  2. If you have a friend, family member or colleague with a terminal or life shortening illness, or who is approaching the end of life and you need our help, we are here for you.
  3. If you are bereaved and need our help, we are here for you.

When I have suggested this to hospice leaders, some feel it is a bridge too far, a huge risk in expectation management and could unleash a tidal wave of local demand.  Other hospice leaders feel they are already close to having many of the building blocks.  A hospice could never do this alone.  It would take strong local partnerships and investment to make this happen. 

Examples would include agreeing leadership and governance structures, establishing GP relationships and training, investing in coordinated care helplines and shared IT systems, implementing consistent and shared advance care planning systems, using a shared resourcing system and hub across community providers (such as hospice at home, NHS community teams, Marie Curie nursing, etc).  It would involve anticipating new technologies and taking full advantage of the opportunities they bring by taking more risks.  It would also involve close working with community groups and volunteers (community neighbours), social prescribing and signposting (across a range of partners), family (network) centred care, carer support toolkits, joined up pre and post bereavement services, and population based volunteer planning and coordination.

All of these things are already happening in pockets all across the country.

The biggest change I think we need to make is to extend all this by working in equal partnership with communities, carers, families, workplaces and the entire social network around everyone facing death, dying and bereavement.  We need to re-empower the public.  Done well, this would involve (and deliver) the societal change we need to improve death and dying in this country. 

I often wonder what we could achieve by borrowing the John Lewis partnership model.  Making everyone involved in death and dying (which at some point is everyone) an invested and equal partner in care with no hierarchies.  I will be developing this idea in a future article.

The recent update on the NHS forward view announced that some STPs will evolve into accountable care systems, now rebranded as integrated care systems.  The expectations are that they will:

  • agree a performance contract to deliver faster improvements in care and performance
  • manage funding for a defined population by taking responsibility for a system ‘control total’ 
  • create effective collective decision-making and governance structures locally
  • demonstrate horizontal integration (e.g. hospitals working as a clinical network)
  • demonstrate vertical integration through linking hospitals with GP and community services
  • use population health management to improve prevention, quality of care and manage avoidable demand
  • establish clear patient choice over place of treatment

All of the above would be possible for local palliative care Integrated Care Partnerships (although I would personally make patient choice more sophisticated than place of treatment).  Updated NHS planning guidance published in February 2018 states that other areas will become integrated care systems where they can demonstrate strong leadership, a track record of delivery, strong financial management, a coherent and defined population, and compelling plans to integrate care.  Can hospices drive this locally for palliative care?

If we follow this model, I wonder what funding and commissioning changes we could achieve as a result.  Longer, more reliable contracts based on population need would be interesting.  Over the medium term a move away from percentage of cost (or agreed cost) and grants to a different model all together might be the only way we can sustain the hospice movement and meet rising demand.

The current ICS development programme requires collaborating organisations to agree governance, leadership and staffing models; to propose the financial model needed to support delivery; agree a performance contract and develop population health management capabilities to support the plan.  The changes are expected to take several years.  If we want to play in this space we need to expect continuous change and be flexible.  To borrow a phrase from Birmingham St Mary’s CEO Tina Swani, we need to be comfortable with “adhocracy”.

We also need to ask ourselves how much sovereignty are we willing to concede for the greater good of the populations we serve?  What are we willing to give up or compromise on and how much change and risk are we willing to embrace?

The hospice movement is facing unprecedented financial challenge at a time of increasing demand.  We cannot solve the problem by simply working harder.  New care models and partnerships may take years to develop and may go through several iterations and multiple challenges – but investing the time and space to design creative new models and build new relationships is possibly the best long-term investment a hospice can make.  There is a clear opportunity to take a local leadership approach now – are we willing to take it?

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