The Symphony Programme - PSNC Main site · 2016. 11. 16. · The Symphony Programme A New Vision...

The Symphony Programme A New Vision for South Somerset

Dr Berge Balian, Programme Board Chair

Visit: www.symphonyintegratedhealthcare.com Follow us @SymphonyProj

Our demographics are changing


Proportion of the Somerset population aged 65+ by LSOA - 2003


Proportion of the population aged 65+ by LSOA - 2033


NHS Plan: Five year Forward View

Future of General Practice: Five year Forward View

New care models: Piloted at ‘vanguard’ sites including South Somerset Symphony

New Community Pharmacy Contract

Capitated Outcome Based Commissioning (OBC) contracts in Somerset

Integrated Accountable Care Organisation (IACO) holding the OBC contract

Alignment of incentives and integration of care for all health and social care provision

Shift of work and resources from 2’ to 1’ to preventative care

Shared budgets and incentives reduce costs and improved care

Patient Centred Care: Right care by the right person in the right place at the right time. This improves care and cost-effectiveness

The Case for Change


Outcomes-based commissioning Somerset CCG have confirmed their desire to move to a capitated, outcome-based contract in South Somerset by April 2016

Outcomes-based commissioning in practice Definition of outcomes-based commissioning

• “The results people care about most when seeking treatment, including functional improvement and the ability to live normal, productive lives” (ICHOM,

2013)

• Starts from the perspective of the patient

• Challenges the culture not the structures

• Aims to makes best use of capped resources

Multiple commissioner and provider relationships

Lead provider(s) and simpler commissioning relationships


Potential impact on GP financials: average1 South Somerset practice Control over larger budget is an opportunity for GPs to improve care and benefit from shared savings

AC: I/P

elect

AC: O/P

GP income

Gain share

Prescribing

£m

AC: I/P

urgent

SC:Home+Day

MH: O/P

SC: Resi

SC: other

CC: other

CC: IP

AC: A&E

MH: I/P

Social care

Mental health

Acute care

List size 6,380 4,340 660 1,990 630 490 70 30 130 120 10 30 1,010

Cost per patient

£160 £210 £140 £340 £1,940 £2,770 £5,100 £12,500 £2,550 £2,230 £20,600 £9,790 £250

Community care

Pre

scri

bin

g2

1. Mean figures averaging across 19 South Somerset GPs. 2. Prescribing cost is extrapolated from Mar 2015 (HSCIC), with prescribing list for 2013-14 (Symphony data)

0

1

2

3

4

5

6

7

8

Po

ten

tial

ben

efit

fo

r G

Ps

via

savi

ngs

Total: £1.02m £0.93m £3.35m £1.02m £0.48m £0.58m £7.38m


78% ~90k

18% ~20k

4% ~5k

~15% ~£20m

~35% ~£55m

~50% ~£75m

% of population % of cost

Complex patients with many conditions

Less complex patients with fewer conditions

Mainly healthy patients

Population segmentation and new care models

Complex care hubs

Enhanced primary care

Proactive health and wellbeing support


Enhanced primary care

New model of primary care delivery

Health Coaches: Focus on long term conditions and support patients

Broader team: Physios, mental health workers, pharmacists , ECPs

GPs focus on complex patients

19 out of 20 practices in South Somerset involved in EPC and CC


Enhanced primary care model The patient and key worker are supported by the wider care team and a number of care programmes and services

Patient with Chronic

Condition

Key Worker / Health Coach

GP

Care Programmes

and Specialists

Other programmes…

Extended Care Team

Therapies e.g. Physio

Mental Health

Social Care

CHF

Respiratory

Diabetes

Dementia

Network of Services

Care Home Acute Care

Advanced Diagnostics

Inte

rfa

ce

Core Care Team Key Elements

Team Working and Huddle

Triage

Stratification and Proactive Outreach

Care Planning and Coordination

Defined Workflows and Programme Integration

Aligned Resources and Incentives

Shared Clinical Data and Population Health Analytics

Practice Nurse

Other services…



• Ensuring a stable and sustainable Primary Care

Service for the benefit of the whole healthcare economy

• Promotion of and innovation in Primary Care

(Participating and Integrated practices)

• Putting patients & their care are at the heart of the

service

• Developing and implementing New Models of Care

• Promoting integration of all health and social care

services

SHS Philosophy

12


• Formed on 7 April 2016

• Financially owned by YDHFT but set up as an “arms length” Primary Care

organisation driven and led by 1’ Care clinicians.

• Currently comprises of 3 practices, but with a further 9 practices actively

considering integration (1 in West Somerset, 2 in Mendip and 1 in Dorset)

• Current total patient population 13,500. Potential 85,000 patients.

• It currently holds a GMS, a PMS and an APMS contract.

• New Models of Care, expanded Primary Care team, skill mix are a priority

• Pharmacists could help with: Medicines reconciliation, minor ailments,

medicines reviews, therapeutic reviews, cost effective prescribing, etc.

Where we are now

13

The Symphony Programme - PSNC Main site · 2016. 11. 16. · The Symphony Programme A New Vision...

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