Consultant Medical Interview

GIRFT is a national programme designed to improve the quality of care within the NHS by reducing unwarranted variations.

It is the brainchild of Professor Tim Briggs at the Royal National Orthopaedic Hospital in London. The programme is pursuing the holy grail of modern medicine – higher quality at lower cost. The programme began with orthopaedics and is now being rolled out to 35 different surgical and medical specialties across the English NHS.

By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.

GIRFT methodology

The programme comprises a series of 35 surgical and medical work streams, each led by a prominent clinician chosen from the specialty they are reviewing. Each clinician heads a project to compile a data and insight driven report into their specialty, combining publicly available information, including Hospital Episode Statistics (HES), other relevant registry or professional body data, and the results of a questionnaire issued to all the trusts being reviewed. The report will look at a wide range of factors, from length of stay to patient mortality, and individual service costs through to overall budgets.

A report is produced and issued to every trust being reviewed, which is then followed by a meeting at the trust with medical staff and senior trust managers. At each meeting the clinical leads review the findings with their peers, which provides more context to unwarranted variations and opens up a discussion around individual practice and any challenges the trusts face. It is also an opportunity to share best practice and any solutions that have already helped reduce variations.

After at least 40 trust reviews have been completed, the clinical lead oversees the creation of a national GIRFT report into their specialty. The report presents the original data, GIRFT’s findings, examples of best practice and an action plan of proposed changes and improvements. Crucially this action plan provides detailed evidence of the benefits changes can bring and is supported by an implementation programme managed by GIRFT.

At trust level the recommendations found in each specialty are collated into a single implementation plan. Trust data is uploaded to the Model Hospital portal (https://model.nhs.uk/), which will be the gateway for accessing GIRFT information for all providers and commissioners.

How effective has it been?

It is led by frontline clinicians who are expert in the areas they are reviewing. This means the data that underpins the GIRFT methodology is being reviewed by people who understand those disciplines and manage those services on a daily basis. The GIRFT team visit every trust carrying out the specialties they are reviewing, investigating the data with their peers and discussing the individual challenges they face and are supportive and encourage change in behaviour and practice.

On the limited evidence to date, it is producing real gains in procurement, productivity and quality. The success of GIRFT will depend crucially on buy in from all stakeholders and sustained success will depend on engagement of both clinicians and managers and commitment to taking action.

Tip- before the interview check whether there is a GIRFT programme in your speciality and read it up on the website (ref 2 below)

Ref-

1. https://www.kingsfund.org.uk/publications/tackling-variations-clinical-care
2. https://gettingitrightfirsttime.co.uk/

NHS England’s 2014 Five Year Forward View (5YFV) and the subsequent Next Steps on the NHS Five Year Forward first introduced the concept of Accountable care organisation (ACOs) and Integrated care systems (ICSs) as an approach to integrate primary and acute medical care in the NHS.

They were cited as a similar model to the Primary and Acute Care Systems (PACS) and Multispeciality community providers (MCPs). Both of these models, MCPs and PACS were precursors to the development of ACOs/ICSs in the NHS. In PACS, hospitals often take the lead in joining up acute services with GP, community, mental health and social care services. The emphasis in MCPs is on GPs working at scale to forge closer links with community, mental health and social care services. Following the publication of 5YFV, NHS England established nine PACS and 14 MCP ‘vanguards’ to trial the models, covering around eight per cent of the population of England.

What are ACOs?

The term Accountable Care Organisations (ACOs) refers to an area-based model of healthcare provision, where a single body takes responsibility for the health needs of its entire population. Although there is no fixed definition of ACOs, most usually include the following elements:

• They involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population.

• These providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population.

• ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years.

The intention of ACOs is to operate in a more integrated manner than healthcare models that pay per procedure carried out, as well as a greater focus on prevention and health promotion.

What are ICSs?

ICSs would see CCGs and providers (such as NHS trusts, GPs and community healthcare providers) within a Sustainability and Transformation Partnership (STP) area working together to manage funding for their defined population.

The major difference between ACSs and ICSs is that with ACOs “there will be a single contract with a single organisation for the majority of health and care services in the area.” ICSs also involve CCGs as commissioners, getting them to work more closely together with providers such as NHS trusts and GPS, to plan care for their populations. ACOs however only integrate providers, with no formal role for CCGs.

What are the main forms of integrated care?

There are three main forms of integrated care:

•            Integrated care systems (ICSs) have evolved from STPs and take the lead in planning and commissioning care for their populations and providing system leadership. They bring together NHS providers and commissioners and local authorities to work in partnership in improving health and care in their area.

•            Integrated care partnerships (ICPs) are alliances of NHS providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and GPs. Social care and independent and third sector providers may also be involved.

•            Accountable care organisations (ACOs) are established when commissioners award a long-term contract to a single organisation to provide a range of health and care services to a defined population following a competitive procurement. This organisation may subcontract with other providers to deliver the contract.

ICPs are at various stages of development across England and ICSs have been established in ten areas, two of which – Greater Manchester and Surrey Heartlands – are part of the government’s devolution programme.

Why are these controversial?

The language of accountable care originated in the United States at the time of President Obama’s health care reforms, and its use in the NHS has raised concerns that it could result in health and care services coming under the control of private companies. However, if ACOs are established in the NHS, they will be a means of delivering care and not funding it. The principles of a universal and comprehensive NHS funded through taxation and available on the basis of need and not ability to pay will not be affected.

The proposed ACO contract could result in more NHS services being managed by private companies but this seems unlikely to happen in many cases because:

The experience of Hinchingbrooke Hospital in Cambridgeshire, where the private company, Circle, had to hand back its contract to provide NHS services because of insufficient funding suggests that there are limited opportunities to generate profits from NHS contracts. This is not surprising when deficits are endemic among NHS organisations following several years of austerity. It is hard to envisage how private companies would perform better financially than NHS organisations when they would be taking responsibility for the services provided by these organisations if they competed successfully for an ACO contract.

Rather than opening up the NHS to increased privatisation and competition, as some have claimed, these developments are likely to have the opposite effect. The vestiges of market-based reforms remain, but they have taken a back seat as the need for NHS commissioners and providers to work together to make decisions on the use of resources has been given higher priority. The risk this creates is the possibility of legal challenges from private companies who feel that commissioners are not using competitive procurement as required under the law and instead are keeping contracts within ‘the NHS family’.

Why is the change needed?

NHS is under severe pressure due to rising demand and funding constraint. It has been clear for some time that simply working our current hospital-based model of care harder to meet rising demand is not the answer. Rather, the NHS needs to work differently by providing more care in people’s homes and the community and breaking down barriers between services. The NHS also needs to give greater priority to the prevention of ill health by working with local authorities and other agencies to tackle the wider determinants of health and wellbeing.

This aim is being pursued through the new care models, STPs and the evolution of some STPs into integrated care systems. These developments hold out the promise of a different way of working in the NHS with an emphasis on places, populations and systems. Successful integrated care systems will take more control of funding and performance with less involvement by national bodies and regulators.

Will these changes lead to cuts in NHS budget?

While financial issues are very important, it would be wrong to see these developments as a means of the NHS balancing its books. Recognising that the NHS is required by parliament to keep within its spending limit, and that this is proving difficult, these developments are primarily about improving health and care, and in so doing seeking opportunities to deliver its financial objectives. Integrated care and population health should not be expected to save money but have the potential to enable resources to be used more effectively.

This is an attempt to give local leaders more control over the use of the collective resources at their disposal, thereby enabling them to back the ambitions set out in STPs with flexibility to move money around.

What has this way of working achieved?

Early evidence from the new care models suggests some progress is being made in moderating rising demand for hospital care.

Data collected by NHS England, for example, shows that PACS and MCPs in aggregate have seen lower growth in per capita emergency admissions to hospitals than the rest of England. Some new care models have reported absolute reductions in emergency admissions per capita.

What do these developments mean for commissioning?

One of the consequences of these developments is that the commissioner/provider split that has underpinned health policy since the early 1990s is unravelling. Providers and commissioners are working together to establish ICPs and ICSs. Clinical commissioning groups (CCGs) are either merging or agreeing to collaborate and are working closely with local authorities in many areas to develop joint or integrated commissioning.

Commissioning in the future is likely to make use of longer term, outcome-based contracts. The current system of Payment by Results, which was designed for an environment in which choice and competition predominated, will then be superseded, in many cases, by population-based budgets. Commissioning will become more strategic and concerned with the funding and planning of new models of integrated care rather than the annual contract round that has added little value to the NHS in recent years. Commissioners will have a key role in holding providers to account for delivering outcomes agreed in contracts.

What next?

The NHS long term plan released in Jan 2019 commits that By April 2021 ICSs will cover the whole country, growing out of the current network of Sustainability and Transformation Partnerships (STPs). ICSs will have a key role in working with Local Authorities at ‘place’ level and through ICSs, commissioners will make shared decisions with providers on how to use resources, design services and improve population health (other than for a limited number of decisions that commissioners will need to continue to make independently, for example in relation to procurement and contract award). Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single CCG for each ICS area. CCGs will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and Long Term Plan implementation.

Ref

1. https://www.kingsfund.org.uk/publications/making-sense-integrated-care-systems#cuts
2. https://researchbriefings.files.parliament.uk/documents/CBP-8190/CBP-8190.pdf

The NHS Long Term Plan was published in January 2019. It is a new 10 year plan for the NHS to improve the quality of patient care and health outcomes. There’s been concern – about funding, staffing, increasing inequalities and pressures from a growing and ageing population. NHS Long Term Plan takes all three of these realities as its starting point to redesign patient care to future-proof the NHS for the decade ahead.

The NHS Long Term Plan aims to make sure the NHS is fit for the future, providing high quality care and better health outcomes for patients and their families, through every stage of life.

It details how this would be achieved through three main themes:

1.    Giving everyone the best start in life;

• reducing stillbirths and mother and child deaths during birth by 50%
• ensuring most women can benefit from continuity of care through and beyond their pregnancy, targeted towards those who will benefit most
• providing extra support for expectant mothers at risk of premature birth
• expanding support for perinatal mental health conditions
• taking further action on childhood obesity
• increasing funding for children and young people’s mental health
• bringing down waiting times for autism assessments
• providing the right care for children with a learning disability
• delivering the best treatments available for children with cancer.

 2.    Delivering world-class care for major health problems to help people live well;

• Providing education and exercise programmes to tens of thousands more patients with heart problems, preventing up to 14,000 premature deaths
• Faster and better diagnosis, treatment and care for the most common killers, including cancer, heart disease, stroke and lung disease, achieving survival rates that are among the best in the world.
• Supporting families and individuals with mental health problems, making it easier to access talking therapies and transforming how the NHS responds to people experiencing a mental health crisis (by spending at least £2.3bn more a year on mental health care)

3.    And helping people age well by

• increasing funding for primary and community care by at least £4.5bn
• bringing together different professionals to coordinate care better
• helping more people to live independently at home for longer
• developing more rapid community response teams to prevent unnecessary hospital spells, and speed up discharges home.
• upgrading NHS staff support to people living in care homes.
• improving the recognition of carers and support they receive
• making further progress on care for people with dementia
• giving more people more say about the care they receive and where they receive it, particularly towards the end of their lives.

The NHS Long Term Plan also describes the actions that will need to be taken at local, regional and national level to make the ambitious vision a reality.

1. Doing things differently:  by giving people more control over their own health and the care they receive, encourage more collaboration between GPs, their teams and community services, as ‘primary care networks’, to increase the services they can provide jointly, and increase the focus on NHS organisations working with their local partners, as ‘Integrated Care Systems’, to plan and deliver services which meet the needs of their communities (see chapter on Accountable Care Organisation)

2. Preventing illness and tackling health inequalities: NHS will increase its contribution to tackling some of the most significant causes of ill health, including new action to help people stop smoking, overcome drinking problems and avoid Type 2 diabetes, with a particular focus on the communities and groups of people most affected by these problems.

3. Backing the workforce:  continue to increase the NHS workforce, training and recruiting more professionals – including thousands more clinical placements for undergraduate nurses, hundreds more medical school places, and more routes into the NHS such as apprenticeships. We will also make the NHS a better place to work, so more staff stay in the NHS and feel able to make better use of their skills and experience for patients.

4. Making better use of data and digital technology: provide more convenient access to services and health information for patients, with the new NHS App as a digital ‘front door’, better access to digital tools and patient records for staff, and improvements to the planning and delivery of services based on the analysis of patient and population data.

5. Getting the most out of taxpayers’ investment in the NHS: continue working with doctors and other health professionals to identify ways to reduce duplication in how clinical services are delivered, make better use of the NHS’ combined buying power to get commonly used products for cheaper, and reduce spend on administration.

What happens next?

The local NHS organisations will work with each other, local councils and other partners to develop and implement their own strategies for the next five years. These strategies will set out how they intend to take the ambitions that the NHS Long Term Plan details, and work together to turn them into local action to improve services and the health and wellbeing of the communities they serve – building on the work they have already been doing.

The local NHS organisations are expected to publish local plans for 2019-20 by April 2019 and publish local five year plan by autumn 2019.

Ref: https://www.longtermplan.nhs.uk/

BMA response to NHS long term plan

“While the Government has highlighted plans to expand capacity and grow the workforce, very little has been offered in the way of detail. Given that there are 100,000 staff vacancies within the NHS, the long-term sustainability of the NHS requires a robust workforce plan that addresses the reality of the staffing crisis across primary, secondary and community care. This will require additional resources for training, funding for which has not been mentioned in the long-term plan.

“There is also a pressing need to address immediate and short-term pressures given that doctors and NHS staff are routinely struggling to cope with rising demand and, as a result, are subject to low morale, stress and burnout. As well as the toll on wellbeing, this has a detrimental impact on recruitment and retention and, unless this is addressed, we risk a workforce plan without the doctors in the future to deliver it.

“The BMA supports increased investment in general practice and community care. This is imperative for effective future planning given the ageing population and the fact that doctors are treating patients with more complex needs, though we await further detail on how this will be delivered.

 “With patients experiencing unacceptable waits in A&E, and with waiting lists for surgery and appointments growing, we also need immediate, practical solutions and the necessary investment for hospitals to deliver both in the long and short-term. 

 “A renewed focus on prevention is welcome but the reality of the situation is that we are seeing a significant increase in obesity and related diseases along with worsening health inequalities exacerbated by years of cuts to public health budgets. The Government must go further than what is outlined in the long-term plan and commit to population-wide measures, such as a minimum unit price for alcohol, restricting sugar levels in food, and greater restrictions on junk food marketing, if we are to achieve necessary improvements to the health of the public. 

“Narrowing inequalities cannot occur without adequate provision of social care which is not covered in the long-term plan. The BMA eagerly awaits the publication of the green paper on social care this year which must fully align with the long-term plan for the NHS.

 “Ultimately, there is a need for honesty about how far the £20.5 billion over five years will stretch. This is well below the 4% uplift that independent experts have calculated is required and below historic spending levels since inception of the NHS. World class care requires world class funding and the investment in the long-term plan will still leave the UK falling behind comparative nations like France and Germany.

 “If we are to truly transform the care we give to patients, and create a sustainable, world-class health service, this long-term plan must deliver beyond grand ambition and address the realities faced by doctors, NHS staff and patients today.” deWhenU