Value Proposition
Version 1
June 2015
Contents
Vision
3
Value proposition in summary
3
Introduction and context
5
Population based approaches and logic model
10
Providing for the future and care model
16
Commissioning for the future
32
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MCP delivery and spread
35
Ask and offer
35
Appendix A – High level programme & milestones
Appendix B – High level risk register
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1
Vision
Our collective vision for the MCP is to improve the health, well-being and independence of people
living in our natural communities of care, making Hampshire an even greater place for all our
residents to live. We want people to take greater control of their own health and happiness and to
feel confident about the support they receive when they need it. We aim to do this by delivering a
step-change towards more accessible and higher capability out-of-hospital care, designed with and
by the people living in our communities, and founded on the things that are important to them.
We often refer to our vision for Better Local Care as ‘Your health, In your hands, With our help’.
2
Value proposition in summary
This document describes in some detail the value that we will bring to our local communities
through our delivery of an MCP across Southern Hampshire. The paper describes the outcomes and
benefits we intend to yield through the delivery of our transformational care model and associated
commissioner and provider reform. A high level summary can be shown as:
Healthier
communities
Improved life
expectancy
Decreased
inequalities
Value of South
Hampshire MCP
Increased
engagement
Improved
experience
Increased
activation
Improved
access
Safer services
More care closer
to home
Decrease in
hospitalisation
Increased
independence /
interdependence
=
DELIVERED
Strong local
clinical
leadership
Time
Trust
Shared vision
Effective
engagement
Commitment to
cultural change
Improved clinical
outcomes
Better value for
money
More sustainable
system
Better experience
for staff
THROUGH
Effective
population
health approach
Provider reform
Commissioner
reform
Coproduction
Evidence base
Contractual re alignment
Support from
NHSE team
Support from
peer Vanguards
Transformation
Fund
We feel that it is most important to consider this value through the eyes and experience of the
people who pay for and make use of our services – our citizens and their communities. On this basis
we have deliberately chosen to illustrate our value through adopting the “Think Local Act Personal:
Making it Real’ approach which highlights the issues most important to the quality of people's lives
and what they want experience from personalised care services. Our engagement with patients and
citizens to date and our review of wider evidence suggests the value that matters to them includes:
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Easily available information and advice to remain as independent as possible;
Access to a range of support that helps me live the life I want, take control of my health and
remain a contributing member of the community;
Flexible, responsive integrated care and support that is directed by me and my carer;
Considerate, consistently high quality care delivered by competent people;
Support systems in place so that I can get help at an early stage to avoid a crisis;
Accessible, high quality services should I need urgent or emergency care.
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The following comparative case study in intended to illustrate the shift in value between current
experience of our services and a future position with MCP:
In 2014 Mrs A was seen by the Out of Hours GP, who performed an assessment and prescribed
antibiotic therapy for a respiratory infection. Later that night Mrs A was feeling increasingly unwell
so called an ambulance. Mrs A is keen to stay at home and did not want to go to hospital but her
assessment showed that she was increasingly short of breath when talking. The paramedics were
unable to speak to Mrs A’s GP or the local community team so decided to take her to hospital. Mrs
A spent a few days in hospital recovering and was discharged home. Initially she is visited by a
community nurse and then by adult social services, but Mrs A finds these visits confusing and is
not sure what support she needs. After several weeks she starts to feel unwell again…
In 2019 Mrs A will be identified by the local MCP Extended Primary Care Service as in need of
support using purpose-designed software. Dr B is assigned as Mrs A’s GP - lead professional and
they will work with the local integrated Extended Primary Care Team (made up of her community
nurses, adult social care and therapists) and Mrs A to develop a care plan for her, which will have
been shared with local OOHs doctors and the ambulance service.
As a result of the care planning Mrs A is given a telehealth device to allow her to monitor her
respiratory condition; the results are monitored remotely in a telehealth centre. The telehealth
centre notice that Mrs A results are deteriorating and contact the local Integrated Care Team so
they can visit her to assess her breathing, look at how she is managing to eat, drink and use the
bathroom; and understand what family help she has.
Mrs A is keen to stay at home and does not want to go to hospital but her assessment showed
that she was increasingly short of breath when talking, didn’t have her normal appetite and
needed help with washing, dressing, getting food and preparing it. The team help Mrs A with the
care she needs until a personal care package is arranged by the Community Response Team.
Mrs A’s medication is reviewed as despite being on the antibiotics for two days she is still short of
breath. The team speak to a respiratory nurse specialist who then visits with the team. She and
Mrs A discuss the benefits of changing the type of antibiotic therapy and starting steroids. Mrs A is
taught how to use a nebuliser machine which makes drugs turn into a vapour which helps open up
Mrs A's breathing passages.
A special mattress to avoid skin damage and bed sores is put in to Mrs A's home with a hospital
bed to help her to sit up and change position. Her GP is told about what has been put in place to
help Mrs A and the respiratory nurse specialist, Integrated Care Team, GP and Community
Response Team continue to work together to care for her in her own home. This new way of
working means that Mrs A is able to stay at home as she wants and doesn’t need to go to hospital.
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3
Introduction & context
3.1
Purpose of document
This live document is the Value Proposition for ‘Better Local Care’ - the Southern Hampshire
Multispecialty Community Provider Vanguard (‘the MCP’). Our MCP has a clear and consistent view
of how we want to change delivery of health and care in our county, a detailed plan that we are
enacting now, and strong, productive relationships – within our system, between the MCP and
neighbouring systems and among a growing community of Vanguard sites. Our aim is to deliver
sustainable change through:
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Pooling management capacity between our organisations and reducing processes that do not
add direct value to patient care
Collaboration and sharing of replicable best practice between our natural communities of care,
and between ourselves and other geographies – specifically with integrated care programmes in
the cities of Southampton and Portsmouth, North East Hampshire & Farnham PACS Vanguard,
and our growing network of other Vanguard sites nationally
An environment of permission and autonomy for clinicians in our localities, doing what makes
sense and creating immediate efficiencies in the way skilled time is used
The pace at which we can deliver beneficial change depends on the specificity, clarity and shared
ownership of our Value Proposition. The Value Proposition is therefore an iterative document via
which the MCP will seek to:
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3.2
Document our model of care and the planned benefits for local people
Set out our roadmap for achieving change at scale and pace, including how existing organisations
will evolve to create and sustain momentum
Define the support and resource which we require from the New Care Models team and
Investment Committee (‘The Ask’) to secure delivery at pace, including clear SMART outcomes
which this support will unlock
Outline areas where our MCP can provide significant learning or support in kind back to the
national Vanguard programme (‘The Offer’)
Anticipate and continuously update / refine our projected future ‘Ask and Offer’ over the
lifetime of the MCP transformation cycle
Document and track delivery of the intended outcomes against the Value Proposition
Key dependencies for understanding value within the MCP
The MCP seeks to radically transform the clinical outcomes and experience of people supported by
our health and care system, by building a system of integrated and extended scope primary care, in
and between communities clinically focused local service redesign, in line with an evidence-based
assessment of population health need.
We have recent strong experience of service redesign - in integration of existing services e.g.:
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Integrated Community Teams (supporting both physical & mental health needs)
Commissioning of new pathways to support a recovery approach, including Enhanced Recovery
& Support at Home, which has significantly improved the care of patients in health crisis
A community of general practice that has already made significant movements towards
federation and provision of some services at scale.
However our out of hospital care sector remains fragmented, differentially incentivised, and
burdened by years of accumulated experience and misunderstanding. The precise nature of this
differs from community to community, and our approach has therefore centred on the principle that
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to progress, we have to pay fastidious attention to ‘winning hearts and minds’. We view the
following as foundations in the structuring of our change model, evolution of delivery arrangements
and approach to development of this Value Proposition:

Front-line local clinical leadership of quality improvement and change is essential – The formal
and institutional ‘systems’ within Southern Hampshire are not controlling the fine detail of
clinical change. Rather we aim to create, build and sustain a social movement, united via a
partnership of local clinicians, care professionals, and the citizens they serve.

‘Good to go’ approach – We will align senior support in each of our natural communities of care
for a set of common principles which enable rapid and sustainable change. But we will not force
the pace of change. We have a target of practices with 50% of Southern Hampshire’s registered
population signed up to the ‘Good to Go’ principles by July 2015, and 90% by the end of
2015/16. These principles address whether localities have strong GP leadership, practices
working at scale and commitment to shared design

Value priorities informed by data – The model’s immediate focus is simple – improve access and
create headroom for GPs by supporting networks of practices to provide some services at scale,
and knit our practices back together with the other primary health and care services working in
the community, supporting them to become single, high performing teams. In the short term,
investment in team development will also unleash immediate innovation and ‘delayer’ pathways
of care that currently push patients from pillar to post – some of the examples of this ‘low
hanging fruit’ are set out in section 4.
But this alone is not enough. In our MCP we have adopted the mantra of Professor Don Berwick, to
“assume abundance and return the money” – into education, into social prescriptions, and into the
wider determinants of health. This means we need to not simply improve value for money, but
relentlessly maximise improvements in value for money. To ensure we target our attention at the
areas that release maximum value, we need to extend our actuarially based assessments of need
conducted in Fareham & Gosport to cover our whole population, to support clinical leaders to design
and evaluate the changes they make.
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3.3
The case for change
Most people locally and nationally remain loyal to their GPs - reporting high levels of satisfaction.
However, too many remain dissatisfied with access to appointments and continuity of care.
Demographics point to increasing numbers of people needing help with multiple complex health
problems. Nationally, the number of people with a long-term condition is expected to rise to 18
million by 2025, accounting by that point for at least half of all GP appointments. Some parts of our
geography in Southern Hampshire (e.g. Southwest New Forest) are ahead of national ageing
population trends. Overall, we expect to see a rise of 10% in the number of people aged over 75 in
our area by 2019.
Whilst we understand the complexity and potential implications of future population need, how can
we be sure that new care models will make a significant impact on the quality and sustainability of
the system? In South Hampshire we have undertaken actuarial analyses of population health need
with our partners Millimans to benchmark current outcomes against global best in class measures.
Early outcomes from this work have highlighted a compelling case for a significant efficiency gain.
This work is covered in more detail in section 4 below.
We cannot meet current and future demand for primary care if we continue to do ‘more of the
same’. These issues are shared across the country and in recent years a number of key documents
have been published which highlight the issues facing primary care in the coming years1. Both CCGs
and providers within our partnership have a range of mechanisms to engage with, and listen to the
views of member practices and local communities. Over the course of the last two years member
practices have reported an increasing pressure in general practice from high levels of vacancies,
increasing demand and a shift in workload to support more long term conditions. A recent LMC
survey indicated that GP recruitment and retention continues to be a problem nationally and also
locally within our Wessex region. Across Wessex2:
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About 14% of GPs plan to retire in the next 2 years – for 20% of these this is earlier than planned
Further 4% indicated that they are so disillusioned that they intend to leave the profession
In those who intend to retire early, 60% stated that workload was the key issue.
If all of the 300 GPs trained in Wessex in next 2 years went into general practice, numbers would
still be insufficient to replace those leaving
67% of practices had a GP vacancy and 28% of those practices failed to recruit
Nearly 40% of practices are currently are short of GP sessions in their practice
12% of final year GP trainees are intending to leave the country within the next 12 months
77% are opting for locum or salaried work as their initial preference
83% of comments made about their impression of General Practice were negative
6% of patients in South Eastern Hampshire and 10% in Fareham and Gosport reported they could not
get an appointment to at a convenient time (in the January 2015 GP Patient Survey report). 23% of
patients in South Eastern Hampshire and 29% in Fareham and Gosport reported that their surgery
wasn’t open at a time convenient for them.
During the development of the CCGs’ five year strategies extensive engagement with local
communities revealed that local people want to see more integrated health and social care services
in their local communities, with fewer ’hand-offs’ between agencies and professional groupings, and
more patient-centred ‘wrap-around’ care, especially for frail older people. Local people are also
keen to see a greater emphasis on prevention, with early intervention and local support to help
people stay in control of their own health.
1
2
The 2022 GP (RCGP, 2013);
2013 Survtu
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3.4
National & international evidence base
Those leading the Southern Hampshire MCP all feel part of the national and international movement
to share and learn from evidence and examples of best practice. This Value Proposition includes
footnotes referencing explicit evidence that has underwritten specific elements of our care model.
Fundamental to the development of our care model and vision are:
The New Zealand Midland Health Service’s Integrated Family Health Centre (IFHC) Approach
This new model of care has informed our approach to improving access and the developing the
Extended Primary Care Team. Features include a Patient Access Centre to provide a single point of
access and direct patients to the most appropriate member of an extended primary care team,
which can be face to face, telephone or email. They have a patient portal. They are offering longer
appointments and are proactively instigating appointments for certain groups of patients. They are
undertaking a 3 year evaluation of their new model of care and interim results include increased
patient satisfaction, increased use of electronic communication with doctors and high satisfaction
with a new clinical pharmacist role in the extended team.
McKinsey Integrated Care Systems Review
This is a review by McKinsey of 13 leading International Integrated Care systems informs our
development of the Extended Primary Care Teams and their approach to supporting the ‘at risk’
population. McKinsey identified four common interventions to all of these networks:
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Self-empowerment and education
Multi-Disciplinary Assessment and Care Planning
Effective Care Co-ordination and Care Navigation
Proactive Care
It reported strong, consistent published evidence of efficacy that reduced hospitalisations by 2530%. All of these systems reported improvements in patient satisfaction.
Professor Michael West’s (Aston University) research into collective leadership in healthcare
Running throughout our Value Proposition is reference to our 8-day Team Development approach,
which we believe is fundamental to found and expedite the development of a radically transformed
primary care offer. The approach, which is being designed in collaboration with the clinicians who
will be leading and contributing the process to redesign care in each of our natural communities, is
built on the experience of Southern Health’s Going Viral programme. This approach to strategic
cultural change in the NHS won a Guardian Innovation in Healthcare award, and was formally
evaluated by Professor West as part of the King’s Fund ‘Collective Leadership in Healthcare’ review
(2014)3. The research builds on the concept that the leadership capabilities required to deliver
transformational change in the context of our new, dynamic health strategies, cannot be delivered
by individual leaders on their own.
“Local by Default” research by John Seddon and Locality (2014)
Our emphasis on social movement, engagement and promoting self-care builds on
recommendations from this work which offers a compelling case for developing new ways of
designing, planning and delivering services to meet the needs of communities around principles that
services should be:
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3
Are ‘local by default’
Help people to help themselves
Ensure a focus on purpose, not outcomes
Manage value not cost
http://www.kingsfund.org.uk/publications/developing-collective-leadership-health-care
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3.5
Change model
The approach to change that we are taking in the MCP is based on the work of Kurt Lewin.
In his three stage model of change, he emphasises:
‘Unfreezing’ - Which is about overcoming inertia and supporting people to overcome their existing
mind-set or received wisdoms. The MCP is rolling out senior support to all natural communities of
care to help them travel this road, and in the early stages we are prepared to encourage but support
them at a pace with which they are comfortable.
‘Changing’ – Here, Lewin stresses the common difficulties encountered during a period of transition
and, often, confusion. This is a key consideration for a change programme operating at the massive
scale of the Southern Hampshire MCP, not least given our desire to achieve change at considerable
pace. This supports the approach we have taken to have change driven by empowered clinical
leaders working locally with the citizens they serve, and that process is now well underway in our
three early adopter localities.
‘Refreezing’ – This is fundamentally about sustainability. By having a strong central infrastructure
behind the MCP (including a skilled Delivery Unit, and strong senior operational support to clinical
leaders in each natural community of care), the MCP will be able to quickly aggregate and
disseminate learning, agree protocols and develop skills to drive world class quality assurance4,
design the corporate support package that frontline clinicians need, and approve of potential
economies of scale
In our MCP, we have adopted a simple rephrasing of these stages: Prepare & Enable, Transform &
Sustain. We have used these headings to set out our approach to the ‘Ask and Offer’ in section 8.
Using the Institute of Medicine’s 6 Quality Aims, as outlined in ‘Crossing the Quality Chasm’ (2001) https://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-QualityChasm/Quality%20Chasm%202001%20%20report%20brief.pdf
4
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4
Population based approaches and logic model
4.1
Introducing our population health management approach
Value can be improved by understanding the nature of the population and the underlying drivers of
health resource utilisation and in turn establishing a contracting approach that aligns financial and
clinical incentives, designed for specific sub-populations. Traditional risk stratification will only take
us so far, we need more predictive tools that integrate acute, primary care and prescribing data,
which has more predictive value and stability over time. Intelligent use of this data allows us to
identify those patients with certain characteristics who are at most risk of medical intervention,
rather than highlighting those people who currently have high care needs. Utilising an actuarial
company to extrapolate historic utilisation rates gives us an insight into the needs of our population
in a granular detail to anticipate need and plan services.
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Drill-down into sub-populations that drive utilisation of services - analyse co-morbidities
Understand the nature of financial risk within the health and care economy
Identify programmes offering best opportunity in terms of outcomes and return on investment
Develop contracting and payment mechanisms, with targeted outcome measures that
appropriately manage risk and places the incentive in the right places
Combine with risk stratification to identify what should be in/out of a capitation budget scope
Model scenarios to aid prioritisation of service transformation programmes
Scope capacity requirements, which can also inform workforce and estates requirements
We will drive value by:
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Using information to understand the effectiveness of current interventions and identify where
we can improve effectiveness and efficiency of care
Utilising evidence to drive quality and patient outcomes through best practice standardisation
Identifying at sub-population level where earlier intervention more effectively improves
outcomes, experience and safety for patients – this is a tailored approach to find interventions
that support specific groups rather than a one size fits all approach
Understanding ‘Per Member Per Month’ costs per clinical grouping and analysing trends in
utilisation over time
Understanding return on investment, giving us a clinical and financial evidence base to support
investment and dis-investment decisions
Providing information to enable us to develop a contracting approach which gives the MCP
financial and clinical incentives aligned for specific sub-population outcomes
Ensuring clarity of purpose by setting clear outcomes and goals based on clinical evidence
Changing the culture to focus on the needs of the individual, not organisationally led objectives
Changing service design and impact on activity
Using the evidence base to set specific expectation and benchmarks at sub-population level, aligned
to the contracting approach will ensure standardised outcomes and best value – enabling the MCP to
design service to meet those requirements. Based on our benchmarks, we expect to see reductions
in emergency admissions and reductions in unwarranted elective referrals. In time, we would expect
to see reductions in care home placements as we do more to support domiciliary care. The fine
detail of the actuarial assessments will enable us to develop detailed projections of where and how
these activity changes will be achieved, and to plan for the impact that they have on co-dependent
services.
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4.2
Benefits and outcomes
We have a plan in place to develop the outcomes and evaluation for the MCP alongside the
refinement of our care model. The metrics used for this evaluation will be informed by the national
work to identify and track the core MCP metrics. Although, wherever possible, we will use existing
national measures and metrics, we also expect to develop local ones where necessary, such as for
mental wellbeing. We have developed a work plan that culminates in the development of the
outcomes we will use in our shadow commissioning specification. The steps in the approach include:
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Defining the type of outcomes we will measure (health, client level, system)
Confirming and defining the specific cohorts
Assessing the baseline and data collection requirements (including actuarial data)
Defining what success looks like, in terms of both provider and commissioner outcomes
Finalising evaluation and draft shadow commissioning outcomes
The specific health outcomes will be determined as the MCP interventions are clearly defined, and
this will inform the continual refinement of our overall Value Proposition. We will select outcomes
that either measure the change anticipated by the intervention directly, or that can act as proxies (as
measuring change in many health outcomes requires large populations groups and prolonged
periods of time). As much as possible, we will measure the generic outcomes using routine data
sources, and extracting to the relevant geographies. In order to evaluate whether the outcome is a
result of an MCP intervention, we will use valid proxy measures to ensure that we are able to link the
intervention with health outcomes. Secondly we will use a comparator group, either by geographical
area or by comparing trends in the same area over time. We will also be able to measure change by
looking at patient level data for Chronic Condition Hierarchical Groups. Once analysis of the groups
which offer the most benefit in terms of intensive management have been identified, we will track
utilisations and outcomes at a person level.
4.3
Evaluating the new model & logic model approach
We are developing logic models for each of the key components of the new model of care as they
are developed and implemented in each locality. These models will describe the planned inputs and
intervention for each component and the outputs and measurable benefits/ outcomes that will feed
into the evaluation. The metrics used for this evaluation will be informed by the national work to
identify and track the core MCP metrics. Although, wherever possible, we will use existing national
measures and metrics, we also expect to develop local ones where necessary, such as for mental
wellbeing. Our logic model will be structured based on the following hierarchy that corresponds
with the core components of our emerging MCP model.
We are working with the Wessex Academic Health Sciences Network in the refinement of these logic
models and linking with the other Wessex Vanguards
4.4
Current iteration of logic model
The following table presents our current iteration of our emerging logic model for our care model at
domain level. Levels of outcomes projected within the tables will be subject to refinement through
the continued iteration of our approach alongside the care model development. The logic model is
based profoundly on our population health model and this will be developed on an iterative basis
alongside the further utilisation of this approach.
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Care model domain
Extended primary care team
Improved access
Current iteration of logic model
Whole system outcomes – including…
Inputs
Intervention
 All patients on registered  Establishment of
list
primary care access
centres with a clinical
 Practice staff and
skill-mix tailored to
resources.
meet urgent care
 Other associated services
demand
e.g. Lymington MIU
 Introduction of
 Booking systems and
enabler technologies
processes
including patient
 Governance processes,
accessible records /
referral criteria & triage
Web GP
 Patients at risk (e.g. Frail,
elderly, people with
multiple LTCs, people at
end of life)
 Practices - including staff
and resources
 Integrated Care teams
(including community,
AMH & social care)
 Voluntary sector
services
 Risk stratification
 Governance
arrangements
 Shared read/write
records
 Establishment of
enhanced extended
primary care teams
around natural
localities
 Systematic targeting
of patients most at
risk using data led
tools
 Shared care clinical
and social care
management of
patients at risk
 Strong local GP led
clinical leadership
Outputs
 Increased proportion of
people number of
people receiving support
from a primary care
clinician on the day of
first contact
 7 day 8-8 service
provided in primary care
access centres
 Increased number of
people with minor
illness having their issue
resolved remotely
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Short term (3-11 months)
For phase 1 localities :
 Improved patient
satisfaction with
daytime and early
evening access to
primary care
 1% in A&E paediatric
and adult attendances
for phase 1 localities
 Extended primary care
appointment slots used
for patients with
greatest clinical need
Medium term (12-24
months)
Longer term (2 years +)
 All participating
 40% of same-day
practices in top
interactions are
quintile for nationally
resolved through nonfor patient access
face to face service
delivery
 5% system reduction
in paediatric and adult  10% system reduction
attendances
in all A&E
attendances from
 Significant change in
baseline
A&E HRGs
 Significant change in
 Improved staff
the complexity of the
satisfaction
casemix seen in
secondary care
 Improved
attractiveness of
MCPs as the place to
work
For phase 1 localities:
Across South Hants :
Increased number of
people managed at
 High patient and carer
activation scores/
 High patient / service
home or closer to home  High patient / service
user satisfaction with
user satisfaction with
personal goal
90% patients in the top
achievement / control
coordinated care
coordinated care
5% assessed by the
over daily life
integrated care team
 Integrated team working  Significant reduction
and supporting out of
in adjusted admission  25% reduction in
Single, jointly agreed
acute emergency bed
hospital systems fully
rates for people aged
care plans implemented
functioning
>65 years/ >75 years
use from baseline for
Increased proportion of
people aged >65
 50% reduction in excess  Demonstrable shift in
patients with coyears/ >75 years /
bed days for a defined
locus of activity for at
produced care plan
defined patient
cohort of patients – non
risk patients to
cohorts
elective admissions
primary and
 50% reduction in
community based
 Statistically significant
emergency admissions
social care
reduction in NEL
>14 days Reduction in
admissions
system per patient
costs for defined
patient cohorts
Impact
 Improved healthy life
expectancy
 Decreased gap in life
expectancy between the
highest and lowest
deprivation deciles
 Reduced under 75 mortality
rate for CVD, respiratory
disease, liver disease, cancer
 Improved patient experience
and engagement in health &
care decisions
 Improved independence/
interdependence for people
with LTCs
 Improved access and
outcomes for people
requiring on-day / urgent
assessment
 Shift of care from acute to
community settings
 More sustainable local health
and care economy
 Improved staff experience
and opportunities
 Organisations & clinicians
aligned to provide the best
possible care
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Whole system outcomes – including…
Intervention
Outputs
Inputs
Short term (3-11 months)
Medium term (12-24
months)
Impact
Longer term (2 years +)
 Patients on registered list  Establishment and
requiring assessment /
further integration of
treatment for specific
specialists within
condition
extended primary
care hubs
 Practices - including
staffing and resources.
 Refined access to
specialist services
 Specialist clinicians and
 Introduction of
associated services e.g.
diagnostics &
Outpatients
technologies (e.g.
 Booking systems and
facetime)
processes
 Referral criteria & triage
 New services developed
 Increased number of
people accessing
specialist assessment
and intervention in
community setting
 Extended access to
specialist services /
opinion
 Greater degree of
speciality within primary
care at scale
For phase 1 localities:
 Agreed % care
delivered in
 Statistically significant
 Redirected outpatient
community hubs
reduction in referrals for
appointments for
 Demonstrable
defined diagnostics and
defined specialties
reduction in avoidable
top 8 specialities
activity and costs by
 Reduction in referrals
treatment speciality
 Redirected outpatient
for defined diagnostics
as identified by
appointments for
and top 3 specialities
defined specialties
actuarial analysis
 Improved clinical
competence in
 Reduced referrals for
 Statistically significant
primary care team
ENT, MSK and paediatric
reduction elective
specialities
bed days
 Clear patient journeys
for priority pathways
 Improved healthy life
expectancy
 Citizens and their
communities – existing
engagement,
organisation and social
capital
 Patients, carers and selfhelp
 Third sector
organisations
 Local clinical leaders
 Communication &
engagement resources
and methodologies
 Shift in culture with Codesign / co-production
becoming norm
 Increased focus on
lifestyle risk factors as
part of routine primary
care
 Increased number of
people diagnosed with
LTCs
 Intensive management
of patients at highest
risk of developing
morbidity in the short to
medium term
 Greater stake for third
sector partners in MCP
model (including
investment)
 Outcomes framework /
how MCP is measured is
relevant and meaningful
to patients & citizens

Phase 1 localities
 Culture of co-production
integrated into MCP
development
Phase 1 localities
Improved patient
activation scores for
people with LTCs
 Improved independence/
interdependence for people
with LTCs
 Improved care
management of people
with COPD and diabetes
(locality specific) with
other LTCs to follow
Practices in the top
quintile for care
processes and
outcomes in the
national diabetes audit
 Increased signposting
and utilisation of selfhelp for risk factor
modification and social
support
Rise in the ratio of
observed v’s expected
number of people
diagnosed with LTCs
 Significant reduction
in complications from
LTCs from
baseline(e.g.
amputations, stroke)
Systematic case
management for
population groups
identified in actuarial
analysis
 Improvement in
health life expectancy
at 65 years
Prom
oting
healt
h,
wellb
eing
and
Selfcare
De-layering specialist support
Care model
domain
Continued overleaf
 Developing social
movement for MCP
 Development and
application of
methods for coproduction of care
model
 Development of
initiatives to promote
independence, interdependence & selfreliance
 Promoting third
sector partnerships
for delivery
 Systematic case
finding for LTCs
 Systematic
intervention for
lifestyle risk factors
 Primary and
secondary prevention
considered as core
component of MCP
 Staff trained to Make
Every Contact Count and
enabled to address
lifestyle issues

For phase 1 localities:
 40% of all MCP clients
facilitated / supported
to self-service / care
 Reduced utilisation of
statutory services for
people with defined
health and care needs
 Decreased gap in life
expectancy between the
highest and lowest
deprivation deciles
 Reduced under 75 mortality
rate for CVD, respiratory
disease, liver disease, cancer
 Improved patient experience
and engagement in health &
care decisions
 Improved access and
outcomes for people
requiring on-day / urgent
assessment
 Shift of care from acute to
community settings
 More sustainable local health
and care economy
 Improved staff experience
and opportunities
 Organisations & clinicians
aligned to provide the best
possible care
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model
Fig 4.4 – Emerging high level Logic Model for South Hants MCP
14 | P a g e
4.5
Establishing the financial opportunity for MCP
Fig 4.6 - Analysis for Fareham & Gosport AND South Eastern Hants CCGs and indicative opportunity in £M’s
(for illustrative purposes only)
The graph above shows analysis for the entire registered populations of Fareham & Gosport and
South Eastern Hants CCGs combined. In a “do nothing” scenario the figures suggest a growth in
demand/costs of £136M in a do-nothing scenario over a 5 year period. Actuarial analysis of the data
shows good delivery of targeted transformational models (red line) could contain this growth to circa
£24M – indicating a potential opportunity of over £100M across the geography. Although further
consideration must be given to factors such as transformational costs, additional investment in
prevention and stranded costs within acute hospitals, the argument created by this work is highly
compelling. By developing these approaches and applying them universally across our geography we
will be able to develop highly specific cases for change to inform the new care models.
We believe our population health management approaches using actuarial analysis represent a
significant asset within the South Hampshire MCP and something that forms part of our offer to
NHSE and the Vanguard programme in terms of potential scalability and national spread.
4.6
Containing cost in pursuit of long term value
In the short-term we expect the care delivery costs associated with the MCP model to increase as we
establish new models of delivery, but incur double running costs in other parts of the system.
Particularly within acute care, it will take time for step cost reductions to be achieved from reshaping workforce and estate. To achieve our aim of shifting the focus of healthcare towards
15 | P a g e
prevention, wellbeing and wider determinants of health, we must achieve the significant cost
reductions that our ‘well managed’ system benchmarking indicate are possible.
As such, the MCP has attempted to generate as much as possible of the additional support required
for frontline redesign by creating resource from within the partnership. The measures we have
taken include:




4.7
Identifying CCG staff to be seconded to Southern Health to deliver senior operational support to
our MCP natural communities of care
Committing to a reduction in the complexity and bureaucracy of contract monitoring and system
management processes, with a significant reduction in time spent in meetings
Shared leadership across our CCGs on some of our enabling programmes, including alignment of
provider resources behind these priorities
Agreeing to align organisational approaches behind partners who have ‘already cracked it’
Redistribution of investment within the health & care system
The national balance of spending in our health and care sector is not what you would plan if you
were starting with a blank sheet of paper. Around 50% of health spend currently flows into
hospitals. GPs, who see around 90% of individual contacts with the NHS, receive around 20% of the
pie. Incentives within our payment structures have not helped – national tariffs have encouraged
hospital providers to become efficient treatment services, while deflating block contracts have
resulted in divestment in many of the services aligned to primary care than are intended to support
health, wellbeing and independence. Adult Social Care - possibly one of the most important cogs in
the wheel - has been hit harder financially than even its partners in the health sector.
Our MCP aims to create the conditions to redress this imbalance. We aim to move the balance of
future health and care expenditure into community delivery and, more importantly, into preventive
services that support people to remain healthy and independent, focussed on education, social
prescription, and the wider determinants of health. Evidence we have heard in discussions with US
healthcare providers such as Group Health (Optum UK) indicates that, under their insurance-based
model, the case for investment in such areas has provided a positive Return on Investment.
MCP Balance of Spending Aspirations by 2020/21 (%)
Total 2015/2016
Total 2020/2021
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Hospital Care
Mental Healthcare
Community
Healthcare
Primary Care
Continuing Care
Other
Commissioning
Centrally Managed MCP Physical and
Programmes
Mental Healthcare
Fig 4.7 – showing projections for re-distribution of resource across local health system by 2020/21
16 | P a g e
Fig 4.7 shows projected re-distribution of health resource across the system with the shift to MCP
over 5 years. It is assumed that separate investments into primary and community care are
integrated and increased in new MCP contracts. This would also include a net increase in investment
on mental health services, some of which would be an integral component of the MCP mode. The
table is illustrative and does not take into account the significant investments associated with the
commissioning of Social Care in Hampshire. Partnership with our Local Authority is key within our
MCP and we would expect a further iteration of this work to include a comprehensive mapping of
resource re-distribution across the health and social care system. Similarly the table does not show
the anticipated shift in investment to services to promote health and wellbeing and prevention of
disease.
It is essential that our acute partners are fully engaged in the development and delivery of our MCP.
While it is difficult at this stage to accurately model the impact that our interventions will have on
activity and financial flows, it is our clear intention to move the percentage of commissioning spend
on hospital care below 50%, and pushing below 40%, within a five year period. To be clear this
represents a reduction in commissioning of hospital care and our emerging new models are likely to
involve the commissioning of acute care partners to deliver care in a different way out of hospital.
5
Providing for the future – care model
5.1
Change on multiple fronts
Conversations we have had with our colleagues in the Northeast Hampshire & Farnham PACS
Vanguard have clarified our thinking around high level structuring of our Vanguard, and the crosscutting enabling themes we will need to address. Working at a countywide scale, we hope to be able
to resolve some of these issues together. The table below shows our high level MCP organisation
with the organisation of workstreams under 4 major programme areas.
Working with local people to codesign, pilot, and fully implement
a new model of care
Designing and introducing a new
commissioning model that pools
resources and aligns incentives
Developing a new provider
model to deliver the new models
of care
Enabling the new model to deliver
effectively for local people, and
evaluating change
Fig 5.1 – Organisation of South Hampshire MCP through four inter-dependent programme areas
We have begun work within the programme to consider the synergies between the MCP programme
and other related programmes of work – such as Better Care fund and the associated partnership
programme between Southern Health NHS FT and Hampshire County Council (both partners in MCP)
to establish more integrated working at locality level. Equally we are also in discussions with our
partners in the North East Hampshire and Farnham PACS Vanguard about the possibility of aligning
some of our core programme workstreams to promote pace and shared learning.
5.2
Our MCP care delivery model
Fundamentally, we are developing a new model of care that develops wider primary care at scale
across all the natural communities of Hampshire, and undertaking that design with people in those
communities. When we say ‘natural communities of care’, we refer to the way people live their lives
– where they shop, where they work, which contains their local social and familial networks. We
believe that, to be effective, the new models have to be informed by how people want to access
services, not only what makes apparent sense for organisations or institutions. The programme will
centre upon four overriding redesign domains, namely:
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Improving access to primary care
Extending the primary care team to proactively manage people at risk
De-layering specialist support to patient care
Engagement, prevention and self-management
The detail of each of these components is provided in sections 5.4 to 5.7, below.
5.3
Who will benefit from the changes we deliver?
We are starting with the three ‘early adopters’ communities of Gosport, Southwest New Forest, and
East Hampshire, all of whom worked with us to develop the ‘Good to Go’ principles. Already, work is
at an advanced stage with a further cohort of natural communities, confirming our intention to have
sign-up from practices covering at least 90% of Hampshire’s registered population by March 2016.
Our approach is founded on supporting care professionals and the public in each community to take
responsibility for the detailed design and delivery of the new model of care, building local
arrangements around evidence of what is needed, and what works.
Our MCP is about using our ability operate and transform at scale the face of primary care for
everyone. That is why one of the founding ‘Good to Go’ principles is that we must retain a focus on
the whole registered list. But in planning the interventions we will make, we have used the fourstage continuum below to think about how our populations health needs are currently segmented.
Changes we are planning will provide a whole-population benefit, by making better use of resources
and freeing the time of clinical specialists to focus on the people who most need their expertise.
Nevertheless we have attempted in the sections below to identify which segments of the population
18 | P a g e
will benefit most from each. This is the cornerstone against which our growing Value Proposition
will be quantified, measured, and evaluated.
5.4
Improving Access to Care
What is this all about?
A key priority for our communities is securing more convenient and timely access to primary care
and support. Our new model of care must offer people the opportunity to get local access to the
advice and support they need for health issues on the same day, or very first thing the following
morning. A core component of the new model of care for each community will be the development
of a series of primary care access centres or hubs, bringing together a team of GPs and other care
professionals to provide access to ‘on-day’ primary care from 8am to 8pm, 7 days a week. This could
move up to 40% of individual patient contacts out of the individual practices, into settings where the
greater scale levels patterns of demand and makes better use of the skills of the multidisciplinary
team.
People who use the services will have no less continuity of care than they would experience at their
own surgery. The hubs will have direct access to the patient’s electronic GP record and be linked to
the local practices by an integrated telephony system. The use of innovative triage tools such as
Web GP will facilitate ‘first time fix’ for more patients, putting them immediately in contact with the
right care professional to resolve their issue and make more productive and proportionate use of
stretched medical time.
The precise design and range of services available through these hubs will vary by locality (according
to facilities and population need), but they will operate to a common core specification that we are
building in Gosport and Southwest New Forest. In some of our more rural locations, we may operate
primary and secondary hubs, providing more local access to the service during traditional working
hours, and reverting to the primary hub for the whole population in the evenings and at weekends.
We have started work with our partners in South Central Ambulance Service to explore how, as
these arrangements become embedded across our natural communities of care, we can interface
and strengthen existing services such as 111 to deliver a seamless primary and urgent care
arrangements around the clock.
Which patient groups will benefit from this approach?
This approach will directly benefit the general population in each community by increasing access.
But, a major potential benefit of these hubs is the release of capacity for our expert local GPs who
with the support of their Extended Primary Care Team may be able to focus more of their time in
areas where their skills are most needed. This will include people ‘at risk’, people with long term
conditions, and people at the end of their lives. By creating headroom for our GPs and other senior
primary care clinicians they can contribute more to designing further fundamental changes.
What are the key benefits that will accrue from this core component of our model?
Our ‘Access’ priority will:




Improve people’s access to a local team of care professionals who know and have a direct
relationship with your registered GP
Create capacity for stretched GP’s to lead development of other elements of our new model, by
giving them access to and leadership of a skilled and varied interdisciplinary team of
professionals to make better use of medical time in the treatment of ‘on-day’ demand
Level out demand for primary care across the seven-day period
Reduce the need for people to attend ED for urgent care issues that could have been resolved
out of hospital, particularly during the evenings and on Sundays and Mondays
19 | P a g e

Help us to create a strong and operationally resilient model around primary care for the
provision of early support to promote people’s physical and mental wellbeing, independence
and recovery skills
Case Study: The Southwest New Forest Primary Care Access Centre
An example of this component is in the South West New Forest community, where we are developing our
Primary Care Access Centre (PCAC) in our local community hospital, and it will be co-located and integrated
with our Minor Injuries Unit. It will be staffed by GPs from the 7 local practices, nurses, clinical pharmacists
and MSK extended scope practitioners. There will be mixture of urgent care and routine appointments
available for patients, who will be able to book them direct or via their practice. The GP electronic health
record will be available and a Voice Over IP communications system will link the local system together. The
service goes live in September 2015. A Web GP system is being explored to further support improving access.
This would enable a single point of access at the PCAC to book telephone and video consultations with patients
for proactive follow-up. A patient portal could allow patients to securely message their GP, and GPs will build
in time to their timetable to respond.
Case Study: The Gosport Hub
The town of Gosport has a population of 83k and is served by 11 GP practices that are challenged through
rising demand from a significantly deprived community and an inability to recruit GPs to vacancies. Through a
series of engagement events the practices have identified the need to develop a same day appointment hub.
The hub will provide a more coordinated approach to managing the 600 requests for on-day appointments.
More detailed plans for the hub are now being worked up including shared clinical system with visibility among
the local practices. The hub will release 2 GP sessions per day across the peninsula. As the hub matured,
protected GP time will be released for management of long term conditions. The hub will be multi-disciplinary
and include advanced nurse practitioners, health care support workers, physiotherapists and pharmacists.
5.5
Extended Primary Care Teams
What is this all about?
The Extended Primary Care Team (‘EPCT’) pools the care resources of primary care, community and
mental health services, social care, not-for-profit organisations and pharmacists to manage the
population health of their community. They will operate in a single team under the leadership of our
local GPs.
An EPCT may operate at the level of a large practice, a group of smaller practices within a natural
community of care, or at a whole-natural community of care level. This will be for local
determination, but with the underlying principle in our ‘Good to Go’ criteria that the arrangements
must secure maximum benefit for the whole population by leveraging the benefits of primary care
working at scale (however that looks for each locality).
Our EPCT redesign builds from a strong base:




GP federations having worked with public and not-for-profit partners through local
transformation funding to improve primary care input to identified target groups (e.g. people
living in nursing homes)
Southern Health’s Integrated Community Teams having brought together community nursing,
therapies and mental health professionals into single teams
Hampshire County Council and Southern Health having developed an Integrated Care Alliance to
streamline and improve assessment and case management arrangements, develop shared
capacity, and leverage experience and capabilities to work more efficiently and effectively
CCGs having commissioned high performing integrated services for people with long term
conditions, with community-based specialist support wrapped around our local practices
20 | P a g e

A range of local public and not-for-profit partners having worked to support the creation of
health and wellbeing cafes across Southern Hampshire, delivering integrated support for people
with chronic conditions
The population served by each EPCT will be risk stratified to identify people at greatest risk of health
crisis. The Adjusted Clinical Grouping (‘ACG’) tool is already in place at to support this and will be
supplemented by integrated informatics (e.g. analytical tools that cross-map risk scores against
service data), professional judgment and local knowledge. The EPCT will work with this ‘at risk’
population to co-design care and support plans that meet their needs and goals, and to support the
delivery of these plans. The intention is that EPCTs also give focus and support to activities that
promote healthy lifestyles and prevent ill-health for the whole of their community.
By becoming a single team we will achieve a significant efficiency gain, reducing the paperwork and
reassessments associated with multiple ‘hand offs’ of care, improving patient safety as a result of the
development of single care records and better communication between professionals, and enabling
better use of our people by allowing them to concentrate not on what they are paid to provide, but
on who they are best placed to support, and how. While EPCTs will have a focus on the sicker and
more dependent people in our communities, these benefits will bring a gain for the whole
population registered with our GPs because they will allow best use of resources.
The success of the new arrangements will be contingent on helping new teams develop common
purpose, build trust and confidence, and jointly succeed in the design and delivery of new services.
A key part of our Value Proposition is the delivery of an 8-day team development and service
redesign support package for each EPCT (the ‘Team Development Programme’). At the point a
‘Good to Go’ locality starts its journey on this programme, the leadership of the Southern Health
staff within the EPCT will be devolved to the local GPs and senior primary care clinicians, with the
support of our senior operational leads. The design of the programme is well underway with input
from partners across the MCP, and the first EPCTs will ‘go live’ in September 2015
Which patient groups will benefit from this approach?
This approach will directly benefit the 5% of patients with the most elevated risk of health crisis,
patients with chronic health conditions, and people who are at the end of their lives. But as stated
above, the improved efficiencies that we plan will yield a benefit for the whole practice population.
What are the key benefits that will accrue from this core component of our model?
Our ‘Extended Primary Care Team’ priority will:






Support people ‘at risk’ to manage their conditions and reduce crises
Provide proactive appointments for people with their EPCT, which give enough time to support
them to deliver the goals in their care and support plan
Improve the health and wellbeing of patients receiving this new model of care
Increase the proportion of people living independently and reducing permanent admissions to
nursing and residential homes
Reduce acute emergency activity
Raise the job satisfaction of our people working in the EPC
Case Study: Forton Road Medical Centre, Gosport
Forton Medical Centre and Southern Health have formed a new partnership, which has enabled an innovative
approach to managing the health and wellbeing of the local population. The primary design principle is to
ensure the patient is supported by the clinician with the most appropriate skills to best meet their needs.
-
Patients requiring support with mild to moderate mental health needs will be supported by either mental
health nurses or psychologists within the practice
21 | P a g e
-
5.6
Patients presenting with MSK conditions will be assessed by physiotherapist in the practice
The practice and community nursing teams will be integrated
The rotation of Emergency Nurse Practitioners into the acute triage and assessment services
GPs will be supported in acute home visits by senior members of the community nursing team
Health visitors and School Nurses will be integrating services with children’s clinics in the surgery
De-layering Specialist Support
What is this all about?
Through this third component the MCP will redesign thinking around ‘specialist’ care and how those
services are provided to local populations. Our intention is to radically reduce the number of
separate steps in care pathways, to shape care around patients’ whole need and not just their
condition, and to bring services as close to patients in their communities as possible.
This will include redesigning the working relationships between GPs and consultants, such that some
consultants develop local roles embedded within General Practice, and more effective methods are
developed for communication, advice and guidance, and self-help. For example, a delayered service
for respiratory patients may look something like this:
At this stage, early priorities have been identified for designing ‘delayered’ care. Emerging from
discussions in each of our three early implementer localities, there was significant consensus around
the case to prioritise redesign around the following three clinical areas:



Mental health (where successive studies have shown the significant comorbidity between
physical and mental health for many people5, and where care professional experience has
highlighted significant gaps in both skills and capacity to adequately meet mental health need in
primary care)
Musculoskeletal conditions (which local audit work has shown can account for 20% of GP
consultations in some practices)
Hot, sick children (The Milliman analysis suggests that we over admit children into acute care
and therefore there are significant opportunities to improve the paediatric pathway)
But our goal is not simply about improvement. As a Vanguard, we have to maximise improvement,
using a hard health economics evidence base to show us where focussed redesign work can produce
the largest gain, freeing resources to reinvest in the sustainability of our model and, ultimately, in
paving the way for our goal to shift a larger percentage of funding from treatment into prevention.
Section 4 above describes the work our MCP has undertaken to develop actuarially-based
5
http://www.kingsfund.org.uk/projects/mental-health-and-long-term-conditions-cost-co-morbidity
22 | P a g e
projections of health need and local opportunity assessment, and our plans as part of the Vanguard
to extend and develop this approach across our whole geography. Placed alongside the locality
resourcing statements that we are developing, this data provides a powerful tool for local clinical
leaders and their teams to identify where the greatest opportunities lie.
By definition, this is not something the out-of-hospital sector can achieve in isolation. Nor, indeed,
do we believe that the MCP will be best placed to directly provide all of the ‘delayered’ services in
our future model. We have therefore worked via the Sponsor Group to agree modules within our
Team Development Programme that will focus explicitly on the opportunity and solutions for
delayering in each natural community of care. Senior hospital leaders have been actively engaged in
the design of this part of the programme, committing time from their clinical experts to drive this
process as part of the team.
Which patient groups will benefit from this approach?
As yet, we don’t have a comprehensive answer to this question without extrapolating our data
across a wide population. Once we have progressed further with our population health
management approach we will be able to give a much more detailed view.
However, we believe a lot of the benefit will come for people in the general population, people who
currently have relatively straightforward health needs met via an overly complicated and processdriven system of handoffs and referrals.
What are the key benefits that will accrue from this core component of our model?
Our ‘De-layering’ priority will:




Simplify care pathway for patients, reducing multiple appointments and the overall time taken to
receive specialist input to their care
Increase the amount of specialist support provided in the community and for this to be
integrated alongside the EPCT
Improve communication between GPs and Consultants
Target reductions in utilisation and cost in areas of specialist support identified by our actuarial
model
Case Study: Arnewood Medical Centre Physiotherapy Pilot
This development was initiated following identifying high numbers of patients accessing primary care with MSK
problems. A senior Physio will be based in the practice as part of the practice team. The Physio will be
available one session per week to assess and treat patients with MSK presentations – including NSAIDs, steroid
injections, patient information and onward referral to other parts of MSK pathway. Evaluation of the pilot will
consider patient outcomes, satisfaction and cost effectiveness of this approach beyond current arrangements.
Wider impact on onward referral for surgery will also be evaluated
5.7
Engagement, prevention and self-management
What is this all about?
We want to put people in control of their own health and wellbeing and we know that, to achieve
that, we need to change the dynamic of the relationship between health professionals and patients.
As 60 to 70 per cent of premature deaths are caused by behaviours that could be changed
(Schroeder 2007), it is essential that patients and the general public become more engaged with
adopting positive health behaviours. We will adopt a patient activation6 approach to engage local
people in positive health behaviours and to manage their health conditions more effectively. Our
6
Kings Fund: Supporting people to manage their own health. Hibbard and Gilburt, 2014.
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model seeks to embrace ‘co-production’ in its fullest sense by recognising the skills, knowledge and
resources that patients and our wider communities bring and deciding when a non-clinical
intervention will produce the best experience and outcomes for patients.
We will combine data available through our clinical systems and the Milliman analysis to profile risk
factors and health behaviours in our localities. This will allow us to systematically address the
lifestyle risk factors that increase our populations’ risk of ill-health and equip our clinicians to
support patients. We will also ensure that for those who wish to make changes, support is in place.
We will pay particular attention to people with multiple risk factors.
We will improve the detection of chronic conditions by opportunistic case finding and proactive
management for people at greater risk of complications, informed by our actuarial analysis. We will
build on existing work to enable people to manage their own condition, linking them with social
support systems in their community. Adopting a prevention and self-management model at scale
involves moving patients, primary and community care away from a ‘medical model’ and we do not
underestimate the change in culture, practice and commissioning behaviour this will entail.
For patients, we need to provide viable alternatives that give them the skills, knowledge and means
to self-manage. By working with the local voluntary and community umbrella bodies, we will
identify the ‘basket’ of interventions that people can access in their locality and link these into the
Extended Primary Care team via Care Navigators or Surgery Sign-posters. We will also explore the
use of digital solutions like Buddy App or the Self-Care Hub to enable patients with long-term
conditions to build the skills and techniques to self-manage 24-hours a day, all-year round as a
complement to their clinical care and to live healthier lifestyles. We will also work closely with MCP
partners Hampshire County Council to consider evolution of the role of their services as a core part
of our offer – in particular their Community Independence Teams.
For primary and community care, we need to support practitioners to take a whole person approach
in every interaction. In the first year we will embed Making Every Contact Count into primary care
delivery. We will also test the Wellbeing Plans that have been developed as part of Building Blocks
to Integration project in West Hampshire. We will also develop the capability of primary and
community care to deliver brief lifestyle interventions and motivational interviewing techniques.
For voluntary and community organisations, we need to understand the additional demand that this
approach will place on them and address any barriers to realising their potential. We understand
that their resources are not finite, and their ability to meet the demands of their communities
depends on more than social capital alone. We will support voluntary and community providers to
work alongside health and, in partnership with local Councils for Voluntary Service, put in place a
package of support to understand and overcome barriers around culture, quality, safety, monitoring
and evaluation and sustainability.
We will create the evidence base for the social return on investment in prevention and selfmanagement and will make the case for change in flow of funding towards prevention/selfmanagement on an incremental basis.
Which patient groups will benefit from this approach?
This approach will benefit the ‘general’ and ‘at risk’ populations, and those with long-term
conditions, but we expect to segment populations to allow us to target interventions to those with
greatest opportunity to benefit.
We know that there are many thousands of people in our population with undiagnosed long-term
conditions, as well as those with a diagnosis. We will pay particular attention to areas of deprivation
are know there are areas of relative deprivation in the areas we serve. We will work with partners to
develop innovative services to work with seldom heard communities and link with community
development initiatives.
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What are the key benefits that will accrue from this core component of our model?

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An increase in the number of local people able to take control over their own health and
wellbeing
More focus on defining ‘good outcomes’ for the patient leads to more creative, non-clinical
interventions
Improved self-management reduces demand on primary and community care
Engaged patients and clinicians set clearer goals and expectations
Knowledge, skills, resources and social capital of local voluntary and community organisations is
maximised
Reduced complications from long-term conditions such as foot amputations
What are the key benefits that will accrue from this core component of our model?






5.8
An increase in the number of local people able to take control over their own health and
wellbeing
More focus on defining ‘good outcomes’ for the patient leads to more creative, non-clinical
interventions
Improved self-management reduces demand on primary and community care
Engaged patients and clinicians set clearer goals and expectations
Knowledge, skills, resources and social capital of local voluntary and community organisations is
maximised
Reduced complications from long-term conditions such as foot amputations
Team and leadership development
Both structural and cultural change is required for primary care teams and their supporting
infrastructure to be embedded To enable this change a variety of organisational development
interventions including team development will be required. The overarching aim of this will be to
create a ‘space’ that enables teams and service users to redesign, adopt and embed a new clinical
model. More specifically team development will be designed to:

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
accelerate the formation, capacity and capability of extended primary care teams
build new and sustainable structures, processes and cultures across teams
embed a model of care and way of working that can be scaled up at pace
empower teams and service users to shape services around the needs of their local population
share the latest ideas and thinking both locally and nationally
create a safe environment that enables teams to leave behind old models of care
Team development will start with a ‘team diagnostic’ which will gauge the teams current level of
readiness and which areas they may need to focus on first. Following modules will be based on a
combination of common pre-designed elements and bespoke activities (based on the outputs of
each team’s diagnostic). Figure 5.8 below summarises the modules that will be run for each primary
care team and will comprise on average 20 people including 12 GP’s and practice staff and 6
members of the integrated community team
25 | P a g e
Fig 5.8 showing modules for extended primary care team development programme
Each of these modules will be run approximately 1 month apart which will enable teams to receive
development support over a 6 month period. These events will be facilitated by Chartered
Occupational psychologists and supported by multiple external contributors. Summarised below are
the key principles that will underpin the team development modules.
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Each will be bespoke and based around the unique requirements / challenges facing each team
Significant external input from local and national ‘experts’, key leaders and service users
Progress and ‘readiness’ of each team will be measured and shared throughout the programme
Learning will be shared across and between teams through the utilisation of social media
Clarity of boundaries within which teams need to work. E.g. what is up for change and what is not
Leadership development for those taking on leadership roles within newly merged teams
We believe our team and leadership development approaches represent a significant asset within
the South Hampshire MCP and something that forms part of our offer to NHSE and the Vanguard
programme in terms of potential scalability and national spread.
5.9
Creating a social movement for change
The South Hampshire Vanguard is a complex and fast moving programme of change, working in a
complex system with multiple stakeholders – all with varying degrees of engagement, buy-in and
commitment to the aims and activities of the programme. To succeed, we will need to engage and
involve at all levels without compromising on pace and momentum. Amongst the core team, the
team and leadership development enabler will play a critical role in building the emotional
intelligence and core communication skills to engage colleagues within the system, and patients,
with change. Our public communications and engagement work will also help to create a positive
platform for change by taking ‘movement building’ approach. We will build on what is already
strong in our local NHS to mobilise a critical mass of the workforce and local population behind a
movement for Better. Local. Care. The approach is founded on a fundamental principal that the
movement is owned by its members, for its members.
We will raise specific challenges and issues and enable people to develop and own local solutions.
The local NHS and social care workforce and local population can all ‘join’ the movement and we
provide a platform for them to come together and contribute insight, ideas, best practice and
resources around specific issues and challenges. Challenges might include (for example), how we
rethink care for frail, elderly people in West New Forest, or what a ‘good outcome’ is at end of life.
Platforms might include online ‘calls for evidence’, or a series of facilitated co-production workshops.
26 | P a g e
We will test commitment to this approach by calling key stakeholders and the public to ‘pledge’ their
action for Better. Local. Care. These pledges will be carried on our website and on social media and
also help to capture data about members’ interests and priorities.
The practical tools we will provide to facilitate the ‘movement’ and support localities include:

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
5.10
A web platform, with locality specific areas, to inform and involve
Support for local content creation and communication (e.g. newsletters, social media
content, media training for key spokespeople)
Support for local insight generation (e.g. local engagement events, online evidence review,
seeking insight held by voluntary sector and other partners)
Creation and placement of local stories in the media
Support for localities to develop ‘key messages at key moments’ of development or change
A framework of internal and external co-design and co-production facilitators
Support for compliance with legal obligations to consult and engage
Designing the future workforce
Our MCP is all about people. To deliver the leading edge care to which we aspire, we need not only
talented leaders within strong teams (see Section X), but also the right staff, with the right skills,
motivated and supported to support people who use our services to achieve the goals that are
important to them. While individual organisations have adopted highly innovative approaches to
designing their workforce, too often we are constrained by a series of factors that, working in
isolation, are beyond our control. These include:
 Skills shortages in key professional groups (general practitioners, nurses) that sit at the
cornerstone of our current care models
 Competitive labour market pressures between organisations in a local health economy, for
example Safer Staffing, creating high workforce mobility and turnover
 Traditional, paternalistic care ethos within many NHS organisations
 Financial pressures creating deflation in wages and supply in key areas such as social care
The design of the workforce is not something we can, or should, solve working in isolation. On this
critical theme, the MCP has benefitted from cross-cutting senior coordination (in the form of
Southern Health’s Director of People & Communications, and Hampshire County Council’s Director
of Workforce), between three major and aligned programmes of change in the county.
Fig 5.10 – we are collaborating with other
key programmes on our approach to
delivering innovative and fit for purpose
workforce solutions
27 | P a g e
Adopting this approach, we hope to get greater traction on a number of important issues, such as:
 Defining the integrated workforce model required to deliver the MCP, including stimulation of the
training, education and workforce pipeline for new roles (e.g. extended scope practitioners)
 Professionally steering the approach to leadership and team development, quality assuring the
interventions undertaken in support of service redesign
 Researching and designing common workforce framework plans, using terms and conditions as a
lever to drive integration, productivity and effective change management
 Resolving system-wide workforce problems, including recruitment shortages and cross-over in
duties and functions
 Exploiting system-wide workforce opportunities, such as new role design, new career structures,
and new ways of working
 Developing and embed a common system to evaluate the impact of workforce change
We have commenced engagement with our partners at Health Education Wessex and will seek to
include them and other local stakeholders such as the Wessex Deanery in scoping wider implications
of MCP and its workforce components. We anticipate the need for early intervention in education
programmes to supply new workforce requirements for our planned whole-sale implementation of
MCP within 2 years. This work will also benefit from engagement with our acute sector partners
who will also inevitably need to re-structure their own workforce requirements based on the new
transformational models.
5.11
Provider development and primary care at scale
We recognise the strength of the registered list that exists in general practice – but to achieve
sustainable change the MCP will work with practices at scale. Do date this has been a particular
strength of our local vanguard and we have secured strong GP leadership and engagement across all
three fast implementer localities and have relevant GP provider companies as partners in the MCP
programme.
In other parts of the country some models of wider primary care are emerging. In July 2013 The
Kings Fund and Nuffield Trust conducted research about how GPs and their teams are responding to
pressures by forming new models to allow care provision at a greater scale, reflecting that the move
towards networked and larger scale primary care provision is mirrored in countries such as New
Zealand, the Netherland, Canada and the USA. The report Securing the future of general practice7
considers what is required if primary care is to be fit for the future and concluded that highperforming primary care organisations need to be capable of fulfilling the five following functions:
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improving population health, particularly among those at greatest risk of illness or injury
managing short-term, non-urgent episodes of minor illness or injury
managing and coordinating the health and care of those with long-term conditions
managing urgent episodes of illness or injury
managing and coordinating care for those who are nearing the end of their lives.
The report then reviewed 12 models of primary care from the UK and further afield. Analysis of
these models was undertaken to identify those which have the greatest potential to enable the
provision of high-quality primary care, in particular the:
 ability to offer an extended range of services in primary care, including rapid and local access to
specialist advice
 focus on population health management as a way of addressing inequalities in health
 extent of organisational scale to enable new forms of care for people with multi-morbidity
7
Securing the future of general practice: New Models of Primary Care
28 | P a g e
 capacity to offer career options and development for professional and other staff
 overall scale to permit peer review and the development of strong clinical governance
infrastructure.
According to the report the four organisational types that showed greatest promise were:

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

networks or federations
super-partnerships
regional and national multi-practice organisations
community health organisations
These models are defined by their desire to use greater organisational scale to extend the range of
services offered and to diversify income streams, thus enhancing the sustainability of practices. They
develop more sophisticated management support to undertake strategic planning and service
development, and create new professional, management and leadership roles that offer a new range
of career opportunities for professional, managerial and support staff in primary care. It is striking
that despite their differing origins and philosophical underpinning, the models of care share a desire
to improve and extend primary care services, develop management and leadership capacity, and
assume a more significant role in the local health system.
Critically, they all emphasise the need to balance the benefits of organisational scale with preserving
the personal and local nature of general practice. Each of the ‘at scale’ primary care models
examined in the report had preserved local practices as the first point of contact for patients,
strengthened the network of wider advice and support available, and used organisational scale to
enhance (and not undermine) the local accessibility and nature of primary care. The CCGs will not
dictate any particular model of service delivery but we are are committed to supporting general
practice and wider primary care providers to explore a range of local solutions that have the support
of local communities. Since 2013 our approach to supporting local member practices to explore
these options has focused on:

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
Listening to and involving practices and communities
Building and using an evidence base
Leadership and workforce development
Developing new models of delivery
Quality
IT and estates
Commissioning and contracting reform
In some areas of Hampshire GP practices have signalled wishes to enter into formal partnership with
Southern Health NHS Foundation Trust to create the necessary scale and sustainability required to
deliver the future model of care required by the local populations. As a programme we do not see
such formal alliances as a necessary pre-requisite for the scale of change we wish to deliver through
the MCP. Rather we are maintaining a focus on our “Good to go” principles and where such support
can assist localities to achieve primary care at scale, we are working hard to develop the framework
to enable that. The key elements of this framework will include:
 The creation of a due diligence framework for assessing the key aspects of the business including
the delivery of financial, quality, performance and infrastructure requirements.
 Core job descriptions for both employed GPs and employed partners. We have made contact with
and are seeking support from Vitality MCP Vanguard around these employment models.
 A base standard legal contract to support and enable each transaction
 Creation of a standard staff consultation document to support the TUPE process
29 | P a g e
 The arrangement with the current process will result in the novation of the current building lease
and the TUPE of all the non-medical staff employed by the partnership. Clinicians from Southern
Health NHS Foundation Trust will join the partnership agreement to support the continuation of
the GMS agreement, with the current GPs taking a base salary and performance payment.
This approach is currently being road tested with a surgery in Gosport. A clinical lead for the practice
will be appointed and they will support the day to day running of the surgery. The business will
transition into and under the leadership of the team running the respective natural community of
care and will be mainstreamed into core service delivery in line with the evolving clinical model.
5.12
Infrastructure & enablers
Information Systems & Interoperability
Extensive work has been undertaken in collaboration with the commissioning and provider
organisations in Hampshire to understand and refine the requirements of future care models around
information systems and interoperability.
The Hampshire Health Record, which has been in place for over 10 years, provides us with a strong
base in terms of data sharing and analytical capabilities. It now covers approximately 1.9 million
patient records and holds 20 million documents including discharge letters and pathology tests.
Approximately 85% of GP practices upload daily extracts in HHR.
Fig 5.12 – Technical schematic
from our emerging specification
for system wide interoperability
solutions
However HHR largely remains a data repository, without a workflow platform to support a much
needed integrated approach to patient care and to fully exploit population health approaches. So it
is our intention to utilise this strong base to move to the next level, of our care transformation being
driven by new information and communications capabilities.
The current care records landscape within Hampshire is complex. 200 practices operating from four
principal Systems (EMIS, TPP SystmOne, Vision and Microtest), and while there are steps in place to
consolidate, there is little prospect of a single GP system in the county in the immediate future.
Southern Health’s community and mental health services use instances of RIO, while across (and
within) the other health and social care organisations, there is a variety of other care record systems.
Our work to scope requirements has revealed that there are three principal issues that need to be
addressed by the work we do to strengthen information systems and interoperability within the
MCP. These are:
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Common care record - The extent of care record access required varies between parties in the
system. However, it is clear from our design that for the staff forming the Extended Primary Care
Team, they will be fairly comprehensive. There is also an absolute requirement to ensure people
who use services have access to their own care records.
Integrated workflow - The requirement is to be able to extract from the Health and Care Record (or
repository supporting it) cohorts of patients or Service users with similar characteristics in terms of
risk, presentation, behaviour or circumstance in order to be able to collectively manage (plan, do,
and review) their care. This requirement is particularly important in a Vanguard scenario where the
very basis of commissioning will be population health, capitated budgets and risk management. Our
care model will succeed or fail as a result of its ability to work in this way.
Alerts & triggers - This relates to our ability to identify and notify relevant members of the team, and
the patient themselves, to a change in circumstances. The most important area of requirement for
triggers and alerts to work effectively is on admission or discharge but many other examples were
quoted in our user stories. Some of our Interviewees estimated that 15%-20% of GP referrals were
inappropriate and could have been dealt with in primary care.
Within the MCP we believe that the first two requirements are critical enablers for the construction
of high performing Extended Primary Care Teams. The development of the MIG has enabled far
more integrated operation between our two principal primary care systems, EMIS and TPP, this
serving as a crucial component in agreeing our care record approach within our first wave Primary
Care Access Centres. In order to understand the quality gain that could result from use of an
integrated care record system within the Extended Primary Care Team Southern Health has
partnered with the practices in New Milton (Southwest New Forest) to pilot common use of the TPP
SystmOne community module alongside the primary care system that is used by all three practices in
the town. This goes live in September 2015, with early findings expected within 3 months.
The current specifications for our GP systems, however, do not currently support the same quality of
structured data extraction as RIO, through which Southern Health has been able to deliver leading
edge performance and analytical information. Further, while developments are planned by the
leading suppliers, these systems do not currently provide functionality for some core functions
within the Extended Primary Care Team (for example, a Care Programme Approach module for
mental health services). Our current best estimates show that transition from RIO to the two leading
primary care systems could result in an additional cost of as much as £5m over the next five years.
Alongside the work around system consolidation, therefore, the MCP has also aligned its approach to
the emerging work, commissioned by the ‘Hampshire 5 Commissioners’ and led by South Central
CSU, to scope a comprehensive interoperability solution. The intervention-level Value Proposition
developed for this work suggests a potentially significant return on investment over a five-year
period, and strong alignment with the overall Value Proposition for the MCP. To scope this fully,
however, we need to understand:

Capabilities and functionality against the three principal requirements outlined above, and the
timeframe within which these can be delivered (noting the co-dependency with clinical and
cultural change)

‘Double counting’ of benefits between this enabling programme and our clinical transformation
logic models
31 | P a g e
Estates
The health systems within the footprint of the MCP have undertaken comprehensive estates reviews
to understand the physical condition, functional suitability, and current utilisation of health
buildings. These reviews, however, have focussed almost exclusively on freehold properties, and on
leasehold properties leased either to, or by, NHS organisations. While this does include some health
centres leased by the NHS, it excludes a systematic appraisal of the totality of primary care estate,
and indeed any social care sites without a health presence.
There is considerable joint action in these local systems, sponsored by the Chief Officers of
commissioner and provider organisations, and supported by Community Health Partnerships, to
drive forward opportunities to improve utilisation and rationalise our assets. Much of this is driven
by strong bilateral efforts between organisations, for example the work that Southern Health has
undertaken with Hampshire County Council on projects such as Havant Plaza and Totton Hub. To
exploit the full benefits of the MCP, however, we need to develop a far more comprehensive and
strategic approach to our estate. This is important, not solely because it will make our cost base
more efficient, but because it will drive new clinical ways of working and help deliver our outcome
goals (such as our plan to increase non-face to face activity). Working at a whole-MCP scale, our CCG
partners are leading work to enable this level of strategic review.
On a day-to-day basis, however, estate (and particularly primary care estate) is a major issue for
development of our provider model. As part of the work with Forton Road Medical Centre, Southern
Health is developing an approach to support practices to deal with transition of leasehold
arrangements, as part of our plan to help primary care operate at scale. However, where properties
are in GP ownership, or where the quality of leasehold estate is not so strong, the MCP is working
apace to identify options to overcome these blockages. This is an area where we will need to
develop financial and legal solutions, and would look to the support of the National New Care
Models programme for support.
Fig 5.13 – South Hampshire
MCP Care model in
summary
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6
Commissioning for the future
6.1
The overarching plan for commissioner development
The MCP has profound implications for the models of care delivered, for how providers are
organised, and for how we commission. The transformation can only be achieved through CCGs,
Hampshire County Council and providers working closely and collaboratively, managing the interdependence between all of us, and moving forward together. We aim to deploy our commissioning
expertise to support, enable and accelerate delivery of our aims in a way that is complementary to
the parallel development of the MCP care models and organisational structures. Our work will
include:
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Developing arrangements to commissioning across health and social care for our population
Designing the way we commission all out of hospital care, including primary care, community
care, mental health, social care and public health (including voluntary sector care provision)
A shift to outcome-based, capitated contracts, centred initially around target population groups
Definition of a new operating model of strategic commissioning and supporting functions, with
appropriate infrastructure and management of the transition
2017-18
2016-17
Capitated outcome based
contracts for agreed
population groups
March 2016
Outcome based contracts
running 'in shadow'
7-9 year term
Parallel running alongside
existing (but streamlined)
contract arrangements
Milliman work extended to
cover MCP footprint
Test and refine risk share and
incentives
One Rehab, & Recovery offer
(SHFT/HCC HICA)
BCF priority redesign
complete (e.g. Continuing
Healthcare)
Population health resource
statements developed
(PMPM)
Fig 6.1 – target timeline for commissioning reform
6.2
Managing risk
The success of the MCP is contingent to a large extent on the development of these arrangements,
which will be designed to align incentives and create a platform for the managed transition of spend
towards primary health and social care, and then onto prevention, wellness, and the wider
determinants of health. There will however be risks, and a number relating to Commissioning &
Contracting reform are contained explicitly within our programme risk register (Appendix C).
The commissioners within our MCP partnership rely on the new service models to be developed in
such a way that costs are managed, and that there is no adverse impact on services that currently
deliver high value-add. Similarly, the transition may raise significant implications for our provider
partners, and we need to work hard to ensure that services are not unintentionally destabilised.
33 | P a g e
Furthermore, our new MCP will need to ensure it has all of the appropriate skills and competencies
to manage a capitation-based contract, some of which do not currently reside in depth within many
provider organisations. In this regard, we benefit from a wide representation of senior partners at
our Sponsor Board and the opportunity to regularly consider and mitigate risks and exploit benefits.
6.3
Implications of the commissioning journey
Moving to capitated outcome based contracts placed against new care models and organisational
forms will trigger a change to how, as well as what, we commission. Our expectation is that
elements of commissioners’ current functions will be more effectively incorporated within the MCP,
e.g. monitoring and management of performance of providers within the MCP, and we are already
taking steps to align these skills within a single team. It will also require a fundamentally different
approach to the market and competition.
This will only be successful with the full collaboration of providers and commissioners – we will work
in a spirit of partnership and co-production. Work is underway through BCF and commissioning
plans for 2016 to further integration. These plans will contribute on the journey towards Vanguard
with the Integrated Commissioning Board providing oversight to ensure they remain aligned.
Our approach is characterised by five key aims and associated work-streams:
1. To develop a population health and care data set to inform the model of care and economic
model underpinning the MCP with a robust evidence base. Further detail at section 4.
2. To develop an agreed set of outcomes for the defined population group(s) that will form the
basis of outcomes based contracts informed by what people in our communities want, alongside
robust population health and care data. Further detail at section 4.
3. To establish the system wide financial model to underpin vanguard/MCP. To develop and refine
approach to risk share and incentives to support an outcome based contract in shadow from
2016 and live in 2017. To put in place pooled budget arrangements as required.
4. To ensure quality surveillance and improvement capacity and capabilities are strengthened
within the new models of care, that we meet our statutory duties, and that we remain assured
we are delivering the highest possible quality care to the people of southern Hampshire.
5. To define the new operating model for strategic commissioning including smooth transition of
some traditional commissioning functions to MCP.
By 2016-17 we will aim to deliver our capitation based budget in shadow form. In order to achieve
this we will need to have:
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Defined the attributed population
Developed a baseline per person per month (PPPM) cost
Mutually agreed on an appropriate trend and project the baseline cost to the performance year
Measured the actual PPPM cost
Risk-adjusted the result for population health differences (either through a simple demographic
adjustment or more complex predictive model approach)
Calculated the net savings/loss
Applied any agreed upon adjustments for quality parameters
Shared the savings/loss
Completed health population modelling
Review and seek to align current system incentives through an agreed framework by articulating
how joined up working impacts/benefits the system.
Development of provider reimbursement approaches
34 | P a g e
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Identify options around payment mechanisms and increase
understanding of potential contracting mechanisms through workshop being held in Q1
Enhance and test the outcomes we need to achieve through the contracts across health and
social care commissioners
Identify an approach to monitoring the outcomes
Develop a business case for approach
Engage/ test with providers
Agree the financial envelope of spend
Allocate individual budgets
We recognise that if we move to a capitated & outcome based model, the role of commissioning will
change, we need to ensure we firstly understand then put in place the skills and competencies that
are required for the future of commissioning. Benefits of the changes include: We won’t be
managing so many contracts, reduced duplication for commissioning
The initial work from Millimans has enabled us to understand the true nature of the financial risk,
identify which care management programmes are most likely to have an impact and financial ROI.
From the initial work we have done it would suggest that the greatest returns are in Admission
Avoidance Programme based on surgical interventions, reducing length of stay programme for
medical and surgical areas and referral management. This data is helping to advise on the
opportunities at a strategic level and we now need to drill down to sub populations that are really
driving utilization in health and care services to share with the local MCPs.
35 | P a g e
7
MCP delivery and spread
7.1
Fast followers and anticipated milestones for MCP roll out
We have significant ambition around the spread of MCP across the South Hampshire Locality and
beyond. We are currently engaged with at least six further localities across the patch who are
interested in becoming part of the programme – including Fareham, Havant & Hayling Island, Totton
and Winchester. Progression of these geographies as MCP localities is likely to be achieved by end
Q2 and we have high levels of confidence around hitting our original milestones of 90% Southern
Hampshire registered population covered by practices engaged in MCP. A summary of our current
MCP programme and some illustrative milestones, including spread across the geography is included
in appendix A.
7.2
Shared learning and wider replicability
Our MCP will promote a culture of shared learning that will be facilitated through fit for purpose
programme governance arrangements, engagement and communications workstreams. Our
emerging outcomes framework will form the basis for evaluation of components of the MCP model
and we will engage with partners such as Wessex AHSN to ensure that evaluation informs design and
refinement of our model.
We are fully committed to engagement with the NHSE Vanguard programme and have already taken
active role in peer review and supporting NHSE team with the development of the central team. We
will continue to participate and share learning and feel that there are many components of our MCP
programme that have scalability and the potential to “lift and shift” into other areas – both in terms
of our surrounding geographies and on a national level through the Vanguard programme and its
fast followers. Some of these components are highlighted in our “offer” section below.
8
Ask and offer
8.1
Our “ask” including investments required to enable transformation
We have looked at examples of best practice elsewhere in the world which reflect the principles of
the Lewin change model and have chosen to adopt the ‘Prepare and Enable; Transform and Sustain’
approach used in Hawkes Bay, New Zealand. (add reference). ‘Preparing and Enabling’ will take
place until the end of 2015/16 and will be used as a period of ‘unfreezing’ current models of
operating in our local system. The initial investment required from the New Care Models programme
will be to support this crucial ‘Prepare and Enabling’ stage and deliver the conditions, mind-sets and
infrastructure foundations for transformation to occur. Initial investment will also cover the early
stages of ‘Transform’ work up until Q4 2015/16, particularly in implementing and testing our access
centres in the SW New Forest and Gosport.
A further Value Proposition for the second stage of our ‘transform’ work (Q1 – Q4 2016/17) will be
submitted in October 2015. The outline timetable for the Prepare and Enable; Transform and
Sustain stages of our programme is below:
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A more detailed breakdown of the direction, intention, major programme milestones and products
of each stage of our programme is set out in the tables on the following pages, along with indicative
investment requirements and our proposals for NHSE Transformation fund.
In some areas,
particularly in relation to Prepare and Enable Stage 2 and Transformation Stage 1 we have a discreet
understanding of costs and our “Ask” of NHSE Transformation and these are summarised in fig 8.1
below:
2015-16
£1000's
Phase 1 & 2 Team development
Phase 1 Avocet programme funding
Primary care engagement, mobilisation and PMO Q1
Primary care engagement, mobilisation and PMO Q2
Primary care engagement, mobilisation and PMO Q3
Phase 1 Millimans Analysis
Co-production & engagement
Interoperability and IM&T
Phase 3 Team development
Phase 2 Millimans Analysis
1,520
500
346
687
937
250
140
854
1520
250
2015-16 Total
7,004
Fig 8.1 – showing summary of initial proposals for NHSE Transformation fund for 2015-16. Further
more detailed proposals will be contained in reiteration of this Value Proposition @ Oct 15
37 | P a g e
8.2
Our “offer” to NHSE and the vanguard programme
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
Strength of GP provider leadership at scale – with wide-scale GP signup (28 practices and
growing – we feel that this is a core foundation to our success to date and confidence in ability
to deliver
SHFT commitment & experience in leadership development – including nationally award winning
and proven methodologies that will form a vital component of our MCP and something that we
are keen to offer our peer Vanguards and NHSE
Actuarial work to support population based commissioning will form a vital component of our
MCP and something that we are keen to offer our peer Vanguards and NHSE
CCG exemplar engagement with patients & communities
Peer led / self improving organisation – track record of creating flexible new roles
Commitment to common read/write care record
HCC work-styles experience
Flexible expertise in developing outcome measures
38 | P a g e
Prepare and enable Stage 1
Up to Q1 2015/16
Direction
Clinical engagement
and development
Locality
development;
clinical engagement
and involving local
GPs and community
teams in
considering and
addressing local
issues
‘Using data to
understand our
population
Intention
Product
Local
investment
NCM
investment
Listen to and understand
primary care issues
56 CCG membership
(clinical and management)
engagement meetings in
place pa.
NHSiQ Transforming care
programme completed by
Q2 14/15.
Phase one AVoCET nonmedical workforce
programme complete by
Q4 15/16. Roll out phase
two Q 3-4 15/16
Three fast implementer
localities in place by Q1
15/16
£320,446pa
-
£20,000
-
£135,000
-
PMO and
primary care
engagement
backfill in
1415 Q4 and
1516 Q1
£418,491
-
Phase 1 Millimans analysis
of care management
programmes that will give
the greatest improvement
in outcomes and financial
return on investment
complete by May 2015.
Phase two Millimans
analysis of (describe)
complete by July 2015
CCG engagement
mechanisms embedded.
Six month CCG strategy
engagement programmes
identify priorities in
2014/15.
Urgent care engagement
programme identifies key
themes in 2014/15.
Engagement programmes
in place to support fast
implementer localities by
Q2 2105/16.
£120,000
-
In-house
specialist
communicatio
ns input
£114,500
-
Social movement
approach underway by Q3
15/16.
Specialist
communicatio
ns input
£30,000
-
Developing GP, PM and
community team
500k local population
covered by MCP by Q3
15/16.
Adopt actuarial approach to
understand utilisation of
services, analyse associated
illness and co-morbidities
and understand the nature
of financial risk within the
health and care economy
Listen to and
understand the
voice of local people
Identify what’s important to
local people
Change health
behaviours
Work with local people to
understand and influence
health behaviours
39 | P a g e
Surgery sign-posters in
place in Gosport by Q3
2015
Create the team to
‘make it happen’
Support localities to come
together and begin
transformation
Establish governance
processes
Prepare
infrastructure for
transformation
Short term clinical system
migration to move general
practice to one platform; to
be able to share patient
records with community
teams
Subject matter experts for
estates, commissioning,
data and IT supported by
an overarching technical
director to harmonise
learning
Initial governance
structures with Enabling
Board, Provider Steering
Group, Delivery Unit and
Locality Boards in place by
Q1 2015/16.
Fast implementer to move
to single clinical system by
Q4 2015. Fast followers to
move to single clinical
system by Q2 2016. GPIT
migration costs
£20,000 from
AHSN and
£39,000 from
SE Hants and
FG CCGs
£147,679
-
As above
-
£140,000
-
-
Prepare and enable Stage 2
Up to Q2 2015/16 – Q4 2015/16
Direction
Intention
Product
Local
investment
NCM
investment
Listen to and understand
primary care issues
56 CCG membership
(clinical and management)
engagement meetings in
place pa.
Phase one and two
bespoke MCP team
development programme
running from Q2 to 4,
15/16.
Phase one AVoCET nonmedical workforce
programme complete by
Q4 15/16. Roll out phase
two Q 3-4 15/16
Three fast implementer
localities in place by Q2
15/16
£320,446pa
(as above
stage 1)
-
Clinical engagement
and development
Locality
development;
clinical engagement
and involving local
GPs and community
teams in
considering and
addressing local
issues
500k local population
covered by MCP by Q4
15/16.
£1,520,000
£500,000
As above
(stage 1)
£128k NHSE
Transformation
funding for
Gosport
locality.
PMO and
primary care
engagement
backfill for
three localities
in Q2
£346,000
40 | P a g e
An additional five fast
follower localities in place
by Q3 15/16.
-
PMO and
primary care
engagement
backfill for
eight localities
in Q3
£687,000
An additional three fast
follower localities in place
by Q4 15/16.
-
PMO and
primary care
engagement
backfill for
eleven
localities in Q4
£937,000
‘Using data to
understand our
population
Adopt actuarial approach to
understand utilisation of
services, analyse associated
illness and co-morbidities
and understand the nature
of financial risk within the
health and care economy
Listen to and
understand the
voice of local people
Identify what’s important to
local people
Change health
behaviours
Work with local people to
understand and influence
health behaviours
Phase 1 Millimans analysis
of care management
programmes that will give
the greatest improvement
in outcomes and financial
return on investment
complete by May 2015.
Phase two Millimans
analysis of (describe)
complete by July 2015
CCG engagement
mechanisms embedded.
Six month CCG strategy
engagement programmes
identify priorities in
2014/15.
Urgent care engagement
programme identifies key
themes in 2014/15.
Engagement programmes
in place to support fast
implementer localities by
Q2 2105/16.
Social movement
approach underway by Q3
15/16.
Surgery sign-posters in
place in Gosport by Q3
2015
As above
(stage 1)
£250,000
In-house
specialist
communicatio
ns input
£114,500pa
-
In-house
specialist
communicatio
ns input
£30,000
Codesign/produc
tion
facilitators
£20,000 from
AHSN and
£39,000 from
SE Hants and
FG CCGs
FYE
£140,000
-
41 | P a g e
Continue offering
the team to ‘make it
happen’
Support localities to come
together and begin
transformation
Establish governance
arrangements
Prepare
infrastructure for
transformation
Major System
Interoperability to
go further than
‘preparing the
infrastructure’ (row
above)
Short term clinical system
migration to move general
practice to one platform; to
be able to share patient
records with community
teams
Major system
interoperability solution
across health and social care
Subject matter experts for
estates, commissioning,
data and IT supported by
an overarching technical
director to harmonise
learning
Initial governance
structures with Enabling
Board, Provider Steering
Group, Delivery Unit and
Locality Boards in place by
Q1 2015/16.
Fast implementer to move
to single clinical system by
Q4 2015.
Initial mobilisation of
infrastructure and
consolidation of systems
in early implementer
localities
£147,679 per quarter (*this is
included in locality support
costs above)
-
-
£140,000
£854,000
42 | P a g e
Transform
Q4 2015/16 (lead in period costs included above) Q1 2016/17 – Q4 2016/17
Direction
Intention
Product
Local
investment
NCM
investment
Create a new way
of caring for local
people
Improving primary care
access
SW Forest and Gosport
access centres live by Q3
15/16
£901,000 (PM Challenge fund SW
Forest)
£500,000 (NHSE infrastructure
funding Gosport).
These elements will require
additional resource estimated at
circa £1,650,000. Proposals for this
to be worked up for October 2015
Create integrated locality
primary care teams
Locality
development;
clinical
engagement and
involving local
GPs and
community teams
in considering and
addressing local
issues
Continue offering
the team to
‘make it happen’
500k local population
covered by MCP by Q3
15/16.
Using data and
evidence to
creating
population and
outcome based
contracting
Further develop contracts
that improve people’s
health, tackling
inefficiencies and targeting
resources when and where
they are needed. Q1
2016/17 – Q4 2016/17
Access centres live in East
Hants and three fast
follower localities by Q2
2016/17
These element s will require
additional resource for pump
priming estimated at £2,954,000.
Proposals for this to be worked up
for October 2015
Phase three bespoke MCP
team development
programme running Q4,
15/16 to Q1 16/17.
Phase four roll-out Q2-Q4
16/17.
Roll out phase three - four
AVoCET non-medical
workforce programme
Q3-4 15/16
-
An additional two fast
follower localities in place
by Q1 16/17.
PMO and primary care engagement
backfill for eleven localities in Q1
1617
Phase three
£1,520,000
Phase four
£960,000
These element s will require
additional resource for pump
priming estimated at £800k.
Proposals for this to be worked up
for October 2015
Circa £3- 4M Proposals for this to be
worked up for October 2015
Support localities to come
together and begin
transformation
Subject matter experts for
estates, commissioning,
data and IT supported by
an overarching technical
director to harmonise
learning
 develop contracting
and payment
mechanisms, with
targeted outcome
measures that
appropriately
manage risk and
£147,679 per quarter (*this is
included in locality support costs
above)
£250,000
43 | P a g e
Genuinely working with
local people as partners in
transforming their health
and the services that
support them
place the incentive in
the right places
 combine with risk
stratification to
identify what should
be within or outside
the scope of a
capitation budget
 model scenarios to
aid prioritisation of
service
transformation
programmes
 scope capacity
requirements, which
will also inform
workforce and
estates requirements
Programme to co-produce
agreed health outcomes
for each locality
commences Q3 2015 and
runs until Q4 2016.
Change health
behaviours
Work with local people to
understand and influence
health behaviours
Social movement
approach refined and
developed.
Prepare
infrastructure for
transformation
Short term clinical system
migration to move general
practice to one platform; to
be able to share patient
records with community
teams.
Major system
interoperability solution
across health and social
care
Fast followers to move to
single clinical system by
Q2 2016. Remaining
localities by Q4 2016.
Listen to and
understand the
voice of local
people
Major System
Interoperability to
go further than
‘preparing the
infrastructure’
(row above)
WHERE WILL WE BE BY Q4
1617?
In-house
specialist
communications
input £114,500
pa.
In-house
specialist
communications
input £30,300pa
£180,000
Communications
support to
localities
FYE
£132,000
-
-
£135,500pa for 16/17, 17/18,
18/19, and 19/20
Indicative at this stage – to be
developed refined for Oct 2015
44 | P a g e
Appendix A – Programme Governance Structure
Our programme delivery structure for service change has been established to support strong local clinical
leadership within natural localities and appropriate programme level structures and resources to share
learning, deliver pan-geographic elements, drive system wide reform and remove blockages to progress.
Fig a– showing South Hampshire MCP programme governance arrangements
Local Clinical Delivery Groups (LCDGs)
These sit at the top of our MCP structure. Each is a locality ‘executive’, comprising a frontline GP Chair, a
senior operational leader, and a small group of local health, social care and not-for-profit sector leads.
Southern Health and the CCGs are working together to create the joint pool of senior leaders who can
operationally drive the LCDGs in each of our natural communities of care, working with citizens and local
primary care professionals, to make change happen apace.
Clinical Reference Groups (CRGs)
Each LCDG is supported by a CRG. They comprise representatives from each of the local practices, other
primary care clinicians, acute sector clinicians and local social care and not-for profit sector representatives.
The CRGs have two main roles – to work with local communities to plan care redesign, and to hold the LCDG
to account for its decisions.
Provider Steering Group
This meets fortnightly and comprises LCDG chairs, key members of the Southern Health executive, and CCG
clinical leaders with responsibility for provider development. Its role is to ensure that as many obstacles to
the development of our MCP approach in localities as possible are resolved ‘close to source’, and to oversee
the process that joins up and standardises our emerging MCP clinical model.
MCP Delivery Unit
This team, which comprises individuals from across the partner organisations in our MCP, is there to manage
the programmes of work that will enable the new care model, and to ensure that alignment is maintained at
all times between each of our Programme Priorities.
MCP Sponsor Board
This team comprises both our LCDG clinical chairs, and the chief organisational, system and sector leaders
that have committed to support our MCP. There is currently representation from Southern Health, the
CCGs, NHS England, Hampshire County Council, South Central Ambulance Service not for profit sector, and
our two largest acute hospital partners). It is currently meeting every six weeks, its objective being to
remove persistent system obstacles to change, provide senior critical reflection, and to ensure the strategic
alignment of the programme with national, local and organisational developments.
45 | P a g e
Appendix B – High level programme milestones plan for 2015 – 2018
2015 - 16
Spread
Q1
3 fast implementer localities
3 fast implementer localities
engaged
developing models
220k registered list
Discussions with 4+ phase II
2016 - 17
Q3
Q4
NF Access centre live
Design of Gosport, NF and East
Mobilisation of Gosport & East
Hants transformation
Hants Access centres
programme priorities
Q1
Q2
Q3
2017-18
Q4
6 localities engaged
12 localities engaged
14 localities engaged
14 localities engaged
15 localities engaged
16 localities engaged
circa 500k registered list
circa 800k registered list
circa 1M registered list
circa 1M registered list
circa 1M registered list
circa 1M registered list
Potential engagement with
Potential engagement with
Potential engagement with
Potential engagement with
geography surrounding South
geography surrounding South
geography surrounding South
geography surrounding South
Hants
Hants
Hants
Hants
16 localities in Southern Hants
circa 1M registered list delivering
new care models under live
MCP contracting arrangements
localities
Mobilisation of NF access centre
Care model
Q2
Gosport and East Hants Access
Mobilisation of phase II care
Delivery of comprehensive MCP
Delivery of comprehensive MCP
Evaluation, refinement and
Evaluation, refinement and
Evaluation, refinement and
centres live
model transformation schemes
care model in all Phase I and
care model in all Phase I and
spread of MCP care model core
spread of MCP care model core
spread of MCP care model core
Phase II localities
Phase II localities
design components using co-
design components using co-
design components using co-
design / co-production with
design / co-production with
design / co-production with
MCP communities
MCP communities
MCP communities
Design & mobilisation of East
Integration of AMH components
Hants Paeds service
within extended teams
Application of common design
Application of common design
and local interpretation within
and local interpretation within
Evaluation of early wins
Phase III & IV localities
Phase III & IV localities
Design of care model
components for frailty, LTCs and
Co-design of phase II care
extended teams (including
model transformation schemes
Commissioner development
Provider development
social care & voluntary sector)
Alliances in all 3 localities part of
Development of "good to go"
Developing options for JV and
Developing options for JV and
Go live in shadow MCP JV
Shadow MCP contract / risk
Shadow MCP contract / risk
Shadow MCP contract / risk
Live MCP contract / risk share
MCP partnership
approach
risk share in collaboration with
risk share in collaboration with
arrangements and contracts /
share arrangements
share arrangements
share arrangements
arrangements
commissioners
commissioners
risk share arrangements for
Refine JV and risk share
Refine JV and risk share
Refine JV and risk share
Continue to refine JV and risk
SHFT developing local
SHFT developing local
arrangements
arrangements
arrangements
share arrangements
partnership with some practices
partnership with some practices
Final approvals for JV / new
Mobilisation of new
Go live of new organisational
organisational form
organisational form / JV
form / JV arrangements
Initial discussions within early
Feasibilities into partnering
adopter localities on
options / provider form
organisational form options
Phase I & II localities
SHFT developing local
Outline business cases for new
form / JV arrangements
partnership with some practices
arrangements
Milliman health actuarial work
Milliman work extended to
Milliman work extended to
Development of outcome
Outcome based contracts
Outcome based contracts
Outcome based contracts
Outcome based contracts
Capitated outcome based
undertaken on localities in East
cover MCP footprint
cover MCP footprint
based contracts and risk share
running in shadow
running in shadow
running in shadow
running in shadow
contracts for agreed
Test and refine risk share
Test and refine risk share
Test and refine risk share
Test and refine risk share
contracts
of county
arrangements
populations with 7-9 year
One Rehab & recovery offer
One Rehab & recovery offer
and BCF priority redesign
and BCF priority redesign
Population health resource
Population health resource
statements developed
statements developed
Initial design of team &
Mobilisation of team &
First cohort team development
Second & third cohort team
Fourth cohort team
Fifth cohort team development
Delivery of new workforce plans
Conclusion of initial team
Full go live of MCP models
leadership development
leadership development
programme commences
development programme
development programme
programme commences
for model of care
development programme for all
across South Hampshire with:
programme
programme
commences
commences
Planning single care record for
Single record live in New Forest
Single care record live for all
Single care record
New Forest
(pilot)
Phase I localities
implementation for Phase II
Development of
Interoperability spec design
Single care record mobilisation
for other Phase I localities
Enablers
Interoperability procurement
communication & engagement
plans
Application of new Tech to
Co-production methodologies
Development of new workforce
new model
Delivery of new workforce plans
Full system interoperability with
for model of care
fully visible and client accessible
Mobilisation of delivery plans for
care record across geography
MCP estates strategy
Mobilisation of delivery plans for
MCP estates strategy
for model of care
Interoperability mobilisation
Refinement & approval of MCP
Delivery of new workforce plans
integrated estates strategy
for model of care
support self care
built into model design
Workforce scoping for emerging
localities
Delivery of new workforce plans
South Hants localities
High levels of community &
stakeholder engagement
Strong leadership
Mobilisation of delivery plans for
MCP estates strategy
Fit for purpose workforce including volunteers
plans in response to new model
Fit for purpose modern
accessible estate
Mobilisation of delivery plans for
MCP estates strategy
Full advantage of available
technology system
interoperability with fully visible
and client accessible care
record
46 | P a g e
Appendix C – High level programme risk register @ Jun 15
Ref
001
002
003
004
005
006
If
Individual organisations and partnerships perceive threat
and/or loss of control from the development of MCP
arrangements
The development of financial contracting arrangements does
not enable medium-term risk taking by ‘unlocking’ provider
financial efficiencies for reinvestment into the new way of
working
Workforce and culture development continues to take place
in siloes defined by organization and/or profession
A coherent approach to information systems interoperability
and common care records is not developed across the MCP
area
The development of strong, fully integrated commissioning
arrangements, founded on the Better Care Fund objectives
and focused around population health management
principles, is not accelerated
GP engagement & ability to recruit appropriate back-fill to
“release time to lead”
007
Strict, transactional application of provider contract terms is
applied throughout the course of MCP development
008
The Provider Steering Group does not achieve the requisite
level of concordance between each of the MCP sites
009
Financial and political considerations around the utilisation of
estate impact the system readiness to pursue some elements
of proposed change
Then
Engagement in the programme will wane, diminishing
trust, undermining strategic ambition, and potentially
damaging existing relationships
There will be a potential skew in the outcome priorities
pursued by the MCP, diminishing the system benefit
Impact
Likelihood
Score
5
4
20
5
4
20
Frontline buy-in to change will be impossible to secure,
limiting innovation, and threatening the ability to plan a
sustainable workforce ‘pipeline’
The scale of potential patient and system benefits will be
reduced, impacting on efficient utilization of clinician time
and impeding integrated team development
This will prove to be a rate limiting step in the
development of integrated provision
5
4
20
4
4
16
5
3
15
Significant sub-risks associated with “hearts and minds”
and significant supply issues re GP workforce particularly
in some geographies
Providers will take fewer risks, impeding development of
more integrated clinical models and threatening the
clinical relationships needed to deliver change
The effectiveness of the MCP approach will be diminished,
including inability to benefit from scale, difficulty applying
strong and consistent clinical governance, and obstacles to
the systematic engagement of patients and citizens in coproduction and self-management
A significant shift in the model of care will be made more
difficult, potentially destabilizing some providers, and
impeding co-design of the model with natural
communities of care
5
4
20
4
3
12
4
3
12
3
4
12
47 | P a g e
Ref
010
If
Elected members are not properly engaged by, and involved
with, the development of these arrangements
011
The development of skilled service leaders and their teams is
not then supported by an enabling approach from system
leadership
The governance structure becomes ‘top down’ and/or
bureaucratic, as a result of a perceived need for parties to be
represented around every table or excessive documentation
and programme management
The MCP cannot achieve its stated objective of achieving
rapid change, most notably in the areas of ‘extended primary
care at scale’ and ‘delayering’ (shifting the boundary
between primary and secondary care)
The development of extended primary care teams (MCP) is
not fully aligned with the work of the Hampshire Integrated
Care Alliance (HCC & SHFT)
The MCP seeks to accelerate structural change discussions
(except by willful agreement), particularly in general practice,
before clinical transformation has been achieved
012
013
014
015
Then
The MCP will lack democratic legitimacy and potentially
develop in a way which is unaligned to the Hampshire
Health & Wellbeing Strategy
The solutions emerging from MCP will be unambitious,
traditional and thereby unsustainable in nature
Impact
Likelihood
Score
5
2
10
4
2
8
The pace of change will be slowed, with loss of clinical
engagement
4
2
8
Ability to benefit, both financially and politically, from
Vanguard status will be diminished, with reputational risk
for the Hampshire system
4
2
8
The MCP will adopt a traditional health focus in its design
and strategic ambition, limiting benefit to system, patients
and citizens
The ‘bottom up’ approach of professionally led
transformation will be undermined, resulting in loss of
trust and GP engagement / leadership
4
1
4
4
1
4
48 | P a g e