Hugh Reeve draws on the lessons that can be learnt from the Alternative Quality Contract and shares how Cumbria Clinical Commissioning Group have started to put those lessons into practice.

1. How is the NHS in Cumbria
drawing on lessons from the
Alternative Quality Contract?
Hugh Reeve
Chair: Cumbria Clinical Commissioning Group
NHS Cumbria

2. In 2007 we embarked on a journey
In March 2011 this took us to Boston,
Massachusetts

3. Insurers
 Tufts Health Plan
 Blue Cross Blue Shield
Providers
 Atrius Health (multispecialty IPA)
 Mount Auburn and Cambridge IPA
(multispecialty) and Mount Auburn Hospital
 Hampden County IPA (primary care only)
These 3 providers all had extensive experience with risk
based contracts

4. Key take-aways from BCBS
 Contracts for the whole continuum of care, over 5 years
allowing time for the “tanker to turn”
 For organisations to hold an AQC a primary care provider
with sufficient patient base is essential to participation
 Risk (gain) share between insurer and provider, determined
by quality performance
 Financial incentives promote affordability and efficiency
 Performance incentives promote quality, safety and patient
centred care (process, outcomes and patient experience
measures)
 Significant investment by insurer in supporting AQC
providers (10-12 WTE middle to senior managers)

5. Key take-aways from Providers
 New paradigm of global risk based contracts (not just the
AQC) – “keeping my population healthy”
 Investment in areas that previously wouldn’t have
generated income
 Health coaches, case managers, hospitalists
 Data management systems + data analysis – clinician
performance, hospital utilisation rates, prescribing, and imaging
and lab rates
 Electronic Medical Records
 Strong clinical leadership and a culture of independent
physician practices working together
 Partnership with BCBS
 Regular performance feedback and support
 Collaborative, long term commitment in a 5 yr contract

6.  Collaboration with hospitals – formal and informal
partnerships, drives value throughout the delivery system
Atrius Health:
“We want to use hospitals that enable us to integrate our specialty
care into the fabric of the hospital to the greatest extent possible”
MACIPA and Mount Auburn Hospital:
 Managed care partners since 1985 with history of investing in
systems and programmes to manage costs
 Strong, long term relationship between the two senior leaders
 Each are independent entities with no joint legal structure
 Contracts with insurers signed separately as three-way
agreements and all parties at the table in discussions
 Risk share between IPA and hospital is defined and agreed
outside of the contract with insurers

8. A networked commissioning group in 2011
across a 500,000 population
Carlisle
Allerdale
Eden
Copeland Cumbria
CCG
Furness South
Lakeland
Commissioning Support Services

9. Immediate actions (0-6 months)
2011/12 contract
 50/50 split on any underspend on 11/12 PBR element
of contract
 Risk share on elective activity – marginal rates for
activity 0.5% or more above plan
 Risk share on non-elective admissions as nationally
This signalled a new style and approach
Primary care
 One CCG with devolution to six localities

10. Immediate actions (0-6 months)
2011/12 contract
 50/50 split on any underspend on 11/12 PBR element
of contract
 Risk share on elective activity – marginal rates for
activity 0.5% or more above plan
 Risk share on non-elective admissions as nationally
Primary Care
 One CCG with devolution to six localities
 Secondment of support staff to localities – data
analysis, referral support, medicines mx, project mx
 Roll out single EHR (Emis Web) across general
practice, community services and community
hospitals

11. Medium term (6-18 months)
 Develop our own narrative – culture, leadership
and a new paradigm (“keeping you healthy”)
 Honest discussions with partners (health, social
care and 3rd sector) about new ways of working
 Develop capacity within primary care
 Workforce – doctors, nurses, HCA’s, Mx, new roles
 Industrial scale long term condition management
 Education and training
 QOF+ incentives using Local Enhanced Services
 But long term … the real prize is clinically led,
multi-specialty groups taking on accountability
for the whole continuum of care.

13. A central “Payer” with a network of Provider
Federations
Carlisle
North East
Cumbria
Allerdale
Eden
Copeland CCG
“Payer”
Furness South
South Lakeland
Cumbria

14. Provider Federations
Consultants,
nurses,
therapists, etc.
Community Existing and
GP Specialists new roles
Practices
Out of Community
Hours Beds
Back office, Support
Ed/Training, Day care &
Services
Audit, etc Day case
Multi-specialty groups
Stand alone or joint ventures
Accountable for whole continuum of care – “make or buy”
Contracts that promote efficiency and high quality

15. Lessons from the AQC?
 Our current contracts for both general practice,
community services and specialist services need a
radical overhaul.
 Make change voluntary not compulsory; but make
staying still an increasingly difficult place to be.
 Perhaps our real challenge is creating a primary care
infrastructure fit for the 21st century.
 This is a 10-15 year programme – will our lords and
masters have the courage to let it happen?