This report came out late last year, building on the King’s Fund’s earlier work on systems leadership and models of care.
Since then, the planning guidance for the NHS in England has come out which makes this particularly relevant, with the current focus on agreeing footprints for sustainability and transformation plans (STP). However, there are useful insights too for the NHS across the UK.
The report is an analysis of the main challenges facing local health and care economies and sets out a series of design principles and options to support local system planning.
Ham and Alderwick argue that inherent “fortess mentality”, an unintended consequence of perverse system incentives, is a barrier to addressing increasing demand. A collaborative approach will enable a concerted effort to address wider determinants of health and to tackle the prevention agenda. There are also benefits from joined up planning and implementation, such as sharing skills, partnerships with third sector and independent organisations and development of new care models. There are some examples where this approach, or at least the overall principles, is already in evidence including: the acute care collaborations, multispeciality provider and integrated primary and acute system vanguards; DevoManc; and accountable care organisations.
The design principles are derived from work by Ostrom and others, on managing common pool resources, as well as earlier King’s Fund work. The key point underlying the work on common pool resources highlights how independent working leads to unsustainability, arguing for a collective and community-based approach to deciding how these limited resources are used.
The 10 design principles focus on:
- Defining the system and population;
- The partners and services who need to be involved;
- A shared vision and objectives;
- Appropriate governance;
- Identifying the leaders;
- How issues will be managed and resolved;
- A sustainable finance model;
- The management team;
- “Systems within systems”;
- Monitoring and evaluation.
Implications for commissioning
The report calls for more strategic and integrated commissioning, based on long term planning, capitated budgets and the use of outcomes based contracts to deliver real change. Ham and Alderwick suggest this shift from transactional to transformational commissioning is unlikely to be achieved on a CCG footprint and is going to need a balance of local insights alongside a larger planning footprint. It’s argued that the loss of Strategic Health Authorities has created a “vacuum” of fragmented leadership, with some examples of system approaches but overall a lack of capacity and capability.
A case study from the Veterans Administration (VA) in the US shares experiences of moving to population-based capitation budgets. A similar approach in the NHS could see NHS providers, NHS and local authority commissioners and third sector and community organisations working collectively to a long term strategy. Ham and Alderwick argue for a provider-led approach to place-based systems but it would seem more sensible to suggest the lead is is driven by local context and need.
NHS commissioners and providers have been tasked with defining the STP footprints by the end of January. Monitor has suggested 37 “local areas”; however it has been suggested that there is likely to be significantly more than 37 and organisations may feature in more than one footprint.
When these decisions are made, there will be considerable work in getting the plans ready. The design principles here may be useful in setting out the process to be followed, but it’s likely that the learning from new care models and other examples of system working will offer more actionable insights.
Ham C and Alderwick H (2015) Place-based systems of care: a way forward for the NHS in England, King’s Fund.
My latest blog now up “@CommissionElf: Fundamental changes to commissioning needed to address current challenges https://t.co/B0LGg4fNf3“
Morning @profchrisham @hughalderwick We’ve blogged about your report on place-based systems of care https://t.co/gRUadfvBsT Any comments?
Today @ali_pals blogs about @thekingsfund report on place-based systems of care https://t.co/gRUadfvBsT
Don’t miss: Fundamental changes to commissioning needed to address current challenges https://t.co/gRUadfvBsT
With NICE currently recommending clozapine and cognitive behavioural therapy (CBT) for persisting (positive and negative) symptoms of psychosis and specifically art therapy for negative symptoms (NICE, 2014), why is there no access to Proper art therapy or any real therapy in the NHS psychiatric hospitals apart from 10 sessions of CBT with outpatient mental health support?
The Royals #HeadsTogther campaign has done amazing things in the last year of raising people’s awareness of mental health, getting people to talk to the 5 main mental health charities and working to dispel the stigma by getting Royals and Celebrities to talk openly about their own mental health struggles.
What is the real long term cost to the NHS and society to not properly deal with and treat people with Mental Health issues? From what I have seen and experienced first-hand it’s a broken, revolving door system that benefits very few people and keeps most in a perpetual state of destitution reliant on the state.
Real innovation in developing antipsychotic medication has stagnated. Treatment-resistant psychosis is a common clinical problem, leading to significant individual disability and costs to society. Clozapine remains the only medication licensed for treatment-resistant schizophrenia, a form of chemotherapy for schizophrenia – the most effective but possibly also seen as the most toxic in its class. “Clozapine: dangerous orphan or neglected friend?” Saeed Farooq, Mark Taylor. The British Journal of Psychiatry Mar 2011, 198 (4) 247-249; DOI: 10.1192/bjp.bp.110.088690
A few people have asked how my recovery suddenly took such sharp trajectory acceleration. It was a perfect spring. The opposite to a perfect storm, which had me 30 seconds from death on Dec 15th 2016 after a very serious suicide attempt.
I spent 4 weeks in 2 NHS hospitals with no real therapy. No art therapy, no CBT. Constant sirens going off. Bad airplane food. Being woken in the night every night. 5 mins of fresh air every couple of hours.. Very little Occupational Therapy. Utter hell. .Then by sheer determination and persistence my wife secured generous funding from our CCG to subsidize an inpatient stay at the Nightingale Capio private psych hospital in London.
I had 8 weeks of group therapy twice a day and Art therapy once a week at The Capio Nightingale. I did my own art therapy in my room in the NHS hospitals ( as there was not therapy there), and in the Capio. My Psychiatrist, Dr Craig trying drugs that the NHS does not try: being on Zyban for 2 weeks which was like a defibrillator (registered as an Anti-Depressant and for ADD in the US, but as a stop smoking drug in the UK). Doing cbt hypnosis privately with an external guy Felix Economakis, and quitting vaping suddenly and easily after years of it being a negative crutch. Starting working as a volunteer for a great mental health charity; Massive will power resulting in new self-belief = perfect spring. And it was lovely spring weather wise in March which has helped me a lot.
I’m not sure it’s easily replicated. But that’s my ‘secret recovery combination’. There hasn’t been a magic bullet it’s been a horrific, tortuous, ambivalent, struggle but things have improved exponentially in the last 4 weeks.
I was a high functioning middle class teacher who suffered a serious and debilitating clinical depression for a number of years which resulted in me almost killing myself. If I had stayed in the NHS psych hospitals would I ever have become as well as I am now? Would I ever have become a useful and dynamic functioning member of the community again? I really don’t think so.
I have been in several of these hospitals now and they just don’t have the resources to make people better. Other than give them medication and send them back out into the community once it is deemed safe enough, or the patients are low risk enough from harming themselves.
But a very high proportion of these patients are ‘regulars’. They are the ones that do not have an amazing wife determined to get me the help, the therapy that I needed to become well again.
How much does it cost to have these regulars in and out of the Psych hospitals? What is the cost of their regular visits to A&E? The cost in loss of productivity as a useful member of society To social services? To housing benefit, to incapacity benefit, disability benefit, x 10 / 15 /20 years??.. it must be more than it cost the NHS to pay for me to get intensive private therapy for 8 weeks.
As our society is becoming more aware of mental health, as we start to breakdown the stigma; as the government is being petitioned by 103,544 people to make Mental health education compulsory in primary and secondary schools. It is now recognized the increasingly high cost of lost productivity due to mental illness, 1 in 4 people will suffer with mental illness. Perhaps the average inpatient stay will increase with far more appropriate facilities, therapies and funding. The funding for outpatient care needs to similarly climb, and patients will then have a greater chance at wellness.
I hope my experience and work in mental health can in some small way change how we are treating people with mental health issues. Patch Adams the movie is an inspiring true story of a Dr who wanted to change how mental health was treated. He used laughter, humour and humanity to help heal people. Robin Williams played Patch. I had the honour of meeting the real Patch Adams last week.
I did a whole day workshop with him and Lottie on ‘living a life of joy’, using laughter yoga therapy. Patch at 72 still travels all over the world with his humanitarian clowns, bringing laughter and joy to some seriously sad and bleak places on earth.
I feel better than I have for years and I’m going to use my experience to help others and be a force for good and change. As John Belushi said in the Blues Brothers, “I’m on a mission from Dog” and I’m dyslexic.
Ashley Phillips 3.5.17