Actually, it’s not him I’m worried about, but what the healthcare services will do with and for him, which in turn seems to depend on how they classify him.
And it’s not him individually, it’s whether millions of people like him, with continuing health needs, will ever have access to the person centred and community based interventions that National Voices has helped to evidence and advocate.
It’s all to do with how the ‘system’ sees him (and them).
NHS England’s publication of its ‘model’ for the new Multispecialty Community Providers (MCPs) is the latest of several initiatives that are causing my wrinkled brow.
MCPs are basically scaled up and integrated primary and community care systems, serving populations of at least 50,000 people.
Is my Dad ‘complex’?
Ninety next year, my Dad is independent, relatively fit, culturally and physically active.
He has been lucky to avoid the most common chronic conditions (diabetes, heart and lung disease, stroke, asthma, arthritis, neurological conditions), but like most men over 65 has prostate cancer.
He is therefore much ‘simpler’, healthwise, than the vast majority of his surviving peers, who have several of these conditions together.
But when the GP contract changed, he was classified in the ‘most vulnerable 2%’ of older patients, for whom the GP should provide a ‘care plan’.
Why? Because repeated complications from a prostate operation had caused a number of (avoidable) emergency hospital admissions over the previous two years.
The Quest to find the ‘top 2%’
A quest to find, identify and manage differently the ‘top 2%’ of patients is increasingly occupying NHS managers.
The GP contract was the first step. Then came the Right Care programme – intended to find the promised £billions of NHS ‘efficiencies’ – which urges CCGs to identify the ‘2% most complex’ patients.
And now comes the multispecialty community provider (MCP) model, intended (along with the similar ‘PACS’ model) to cover a quarter of the country by 2018. The (joint) commissioners of both MCPs and PACS will be expected to target and segment the ‘small number’ of ‘patients who incur the very highest NHS costs’ using what is called an ‘extensivist’ approach.
Cost, admissions, indicators
The emphasis on costs here is revealing. According to Right Care, nationally the 2% most complex patients account for 15% of inpatient expenditure.
For Birmingham South and Central CCG, for example, 617 patients created £12.4m in costs through admissions in 2013-14.
The expectation (or hope) is to target these patients with more comprehensive preventive care, to avoid admissions and control costs.
Thus the Quest for the 2% ties in with the increasingly widespread prioritisation of indicators for emergency admissions and readmissions as the key focus of management at both national and local levels.
The Quest: good or bad for personalisation?
How will this emphasis on a few ‘costly’ patients affect the overall reform of care?
Better care for the target group?
A first effect ought to be that this group is the first to receive personalised ‘preventive’ approaches (care planning, coordinated care, etc).
In practice, that may not happen. My Dad’s (incorrect?) identification as ‘complex’ should have entitled him to ‘care planning’. Instead he had a short meeting with a practice nurse to complete a tick-box template designed, not for his needs, but for the practice to claim its income. His care and support didn’t change.
This illustrates the tendency of services, managers and professionals to interpret new forms of case or care management for complex individuals through their own priorities, not those of the person.
It is easily possible for the MCP model’s ‘extensivist’ approach to go the same way.
What is the ‘extensivist approach’?
This is not really defined.
The Fylde Coast service cited in the MCP model and described here does appear a genuine attempt to involve people in a ‘what matters to you?’, personalised approach, working with the voluntary sector to meet non-clinical as well as clinical needs.
As such it appears to follow some of the goals identified in the Narrative for person centred coordinated care and the Six Principles (which MCPs are expected to adopt and implement).
But it is not the only version among the existing vanguards; and these will be followed by second wave adopters. There is a risk that some of these ‘extensive care’ services become a rearrangement of the system furniture – pulling together clinical and service inputs in a new configuration, designed to create savings, without incorporating genuinely person centred interventions.
Will ‘extensivism’ work?
NHS England says the various versions will be assessed for ‘which works best’. Again, the system criteria for reducing admissions and costs are likely to be a decisive indicator.
Proving that this kind of segmentation can ‘save money’ will be contested and difficult.
As Geraint Lewis, a prominent expert on ‘risk stratification’ points out, ‘predictive’ tools to identify the people most ‘at risk’ of admissions are often inaccurate and can perform poorly.
It’s quite possible that people in the target group will, for example, not be amenable to the preventive approaches (ie they still finish up in crisis). Conversely, there will be those for whom a prediction of future admissions, based on past history, is ‘false’ – they would avoid future admissions even if not in receipt of prevention.
So proving that any given new model has reduced admissions (costs) is tricky.
And what happens to ‘extensive’ services that improve people’s quality of life and wellbeing… but don’t appear to reduce costs (in the short timescales often imposed)?
What about the rest of the population?
A final concern with these and other models – such as the Health 1000 bespoke GP practice for people with multiple conditions in north east London – is their very designation as distinct new services.
Here the risk is that the ‘top 2%’ are segmented out for a ’tailored’ approach (to use the term in the draft NICE guidance on multimorbidities), while everybody else’s care continues on old, biomedical models.
Right Care, for example, suggests that for people with Long Term Conditions other than this ‘complex 2%’, the CCG should focus on ironing out unwarranted cost variation from existing single disease clinical pathways.
So if my Dad got arguably the ‘right’ classification as a non-complex patient, he might continue to receive the reactive, episodic, sub-optimal care that allowed crisis episodes – and at one point almost drove him into frailty!
This stark distinction between new models for a few and old ones for the majority is certainly not the intention either of risk stratification approaches generally, or of the MCP model.
While the 2% make up a tiny top slice of the ‘pyramid’ of needs, the other, broader segments of the patient population further down should also have care redesigned for them.
There are many versions of this pyramid of needs. The MCP one looks like this:
