What's New in Care Models: Measuring success (or otherwise)

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Tracking everything that’s new in care models and progress of the Five Year Forward View, by our senior correspondent on integration David Williams.

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The week in new care models

It is a year since the launch of the first vanguards. Celebrate with this excellent blog by Nigel Edwards on care home vanguards, this piece by Chris Ham at the King’s Fund, and this by new care models director Sam Jones, on the popularity of social prescribing among vanguards. For more on vanguards, see the main article below.

Cambridgeshire and Peterborough Clinical Commissioning Group tried to contract their way towards a new model of care and came spectacularly unstuck last year. Now, we’re a bit closer to knowing why, after an independent audit published its report on the fiasco. Here’s my leader column on the subject, in which I muse on whether tendering in the NHS is a bad idea by definition, and here’s NHS England revealing that there will be tougher scrutiny on big deals in future.

Linking competition and the vanguards: “Competition won’t help us deliver on the challenges we face, and the mindset is already changing,” writes Jeff Johnston, on behalf of the Cheshire and Merseyside children’s services acute care collaboration vanguard. “Those involved have gone from thinking about their own individual organisations, to collaborating across the entire footprint of the region.” It’s significant that this blog has appeared, under the headline “Best care will come from collaboration not competition” on the NHS England website.

Has NHS England given up on publishing performance data from the Better Care Fund? There should be plenty of evidence now for the government’s grand plan to save the NHS by pooling resource with social care. Sadly, NHS England has only published data up to quarter one of 2015-16.

What is the optimum scale for a primary care provider to operate on? And is scale everything? The reason I ask is that a new super partnership serving 540,000 has been mooted for Suffolk.

Vanguards: measuring success (or otherwise)

This week we published a story based on an interview I did with the director for new care models, Samantha Jones. The top line is about transformation funding. There’s no detail available yet, but there is a clear indication that not all vanguards will get the money they’re asking for: instead NHS England will prioritise the limited amount of cash they have available and direct it to those it has the most confidence in.

In the same session, I also talked to Ms Jones and Charles Tallack, head of NHS operational research and evaluation, about how the vanguards will be evaluated. How will vanguards know whether their new service models are successful, and how will national leaders know which innovations should be replicated across the country?

Progress on this front has been slower and quieter than some expected, but it is not fair to say there has been no progress at all.

The new care models team want to be able to assess vanguards in three domains: health and wellbeing; care and quality; and efficiency.

So far, the most progress has been made in the latter area: since October last year vanguards have been sent a quarterly dashboard tracking progress. For multispecialty community providers and primary and acute care systems this carries two main indicators: emergency admissions per head of population, and bed days per head of population.

The rest of this briefing will be about evaluating PACS and MCPs – the two forms of vanguards overtly about improving the health outcomes of a defined population.

The dashboard also includes demographic data on the vanguard’s registered population. I was initially surprised that all the vanguards didn’t already have that data about themselves, and that they needed the centre to send it to them.

The reason not all did is simple though: PACS and MCP vanguards are made up of GP registered list populations, and are therefore not necessarily CCG-shaped, or council-shaped. For those vanguards, existing CCG or council data would not have been sufficient to get any insight into the effect they were having on their defined population.

The new care models team is monitoring the performance of MCP and PACS vanguards as a whole, and is able to compare it with the performance of the rest of the country. Mr Tallack showed me a printout of emergency admissions data for MCPs from 2012 to November 2015: there was little difference in performance between vanguards and the rest of the country, although it is much too early in the project to draw any conclusions from that.

That MCPs tracked the national figure also suggests that collectively they were not ahead of everyone else when they began implementing new care models: the cohort doesn’t have a long history of strong performance. If they start beating the national figure, we’ll know there’s something interesting going on.

Indicators in the “health and wellbeing” and “care and quality” domains are less nailed down. Across these two domains, vanguards are only receiving information from the GP patient survey.

It is acknowledged that this is an interim measure and that it should be possible to get better and more frequent data than this. Frequency is important: the dashboards are quarterly and vanguards will want to know rapidly what is having an impact – and which innovations from other vanguards they should be learning from.

The national team is working on a new metric to assess patients’ experience of integrated care. That’s a complex piece of work, as it is a complex concept to measure.

An added complication is that for the data to be meaningful, it has to come from patients who are affected by the new model of care, and that has to be a representative sample – ie not just the ones who are motivated enough to complain, for instance.

Vanguards are identifying local metrics which are relevant to the improvements they are trying to make. These have yet to be revealed, but likely candidates might include indicators such as rate of dementia diagnosis, rates of injuries due to falls among older people, and how supported carers feel – all were popular choices when the better care fund required areas to pick local metrics.

The national leaders will also be tracking and rating vanguards on their progress in bringing about new care models. These “enabler metrics” might track progress towards implementing a new capitated budget, or changing the local workforce, or establishing an integrated care record.

Discussions are ongoing about what information to collect, and how it will be presented: They haven’t started being collected yet.

We reported in November that a full suite of 18 metrics would be ready in April. It is now fairly clear that the version of the vanguard dashboard that circulates next month will not be the finished thing.

More of this sort of thing next week. Keep in touch – as this weekly newsletter beds in, I’d be pleased to hear your feedback. If possible I’ll include as many responses and comments from readers as I can. So please let me know what you think.