Integrated Care
Pioneer
The view from Islington
Dr Josephine Sauvage
Vice Chair Islington CCG
In collaboration with NHS England
“We are sick of falling through the gaps. We are
tired of organisational barriers and boundaries that
delay or prevent our access to care. We do not
accept being discharged from a service into a void.
We want services to be seamless and care to be
continuous.”
Individual’s viewpoint on fragmented care
National Voices, May 2013
What do patients want?
Coordinated
care, centred
on me
Emergencies are
not treated as
isolated cases but
within the context of
my care plan
My goals and
desired outcomes
are understood by
all
Providers are
communicating with
one another about
me and my needs
Information is
common so I only
have to give it once
3
I do not have to
manage transitions
between providers
myself
My care is planned
to achieve my goals
/ desired outcomes
Decisions are made
based on my care
plan
Ethos of Pioneer
‘Integrated Care and Support: Our Shared Commitment’ (2013)
A collaboration of national partners set out an ambitious vision of making person-centred coordinated
care and support the norm across England over the coming years
Association of Directors of Adult Social Care, Association of Directors of Children’s Services, Care Quality Commission,
Department of Health, Health Education England, Local Government Association, Monitor, NHS England, NHS Improving Quality, National Institute for
Health and Care Excellence, Public Health England, Social Care Institute for Excellence, Think Local Act Personal
•
•
•
•
•
•
•
•
•
•
•
Support of better person-centred, coordinated care
Local innovation
Realisations of local aspirations on integrated care
Address barriers
Disseminate and promote learning
Focus on benefit for patients, services users, their carers and their local
communities
Provide bespoke expertise, support and constructive challenge
Range of national and international experts
This approach builds on the community budget pilots co-designing integrated
health and care at scale and pace.
Successive cohorts of Pioneers, supporting them for up to five years
Expectation of Pioneers to contribute to accelerated learning across the system
5 year Expectations from pioneers
•
Be regarded as exemplars:
– deliver improved outcomes, including better experiences for patients and people who
use services
– tackle local cultural and organisational barriers
– realise savings and efficiencies for re-investment
•
Have used the Narrative developed by National Voices, in association with Making it Real,
to help shape good, person-centred coordinated care and support for individuals in their area
•
Have demonstrated a range of approaches and models involving whole system
transformation across a range of settings
•
Have demonstrated the scope to make rapid progress
•
Have tested radical options, including new reimbursement models and taking the risk of
‘failure to integrate’ in some cases
•
Have overcome the barriers to delivering coordinated care and support
•
Have accelerated learning across the system to all localities
•
Have improved the robustness of the evidence base to support and build the value case for
integrated care and support
Selection criteria
(not prescriptive about models for adoption)
• Articulate a clear vision of innovative approaches to
integrated care and support
• Plan for whole system integration
• Demonstrate commitment to integrate care and support
across the breadth of relevant stakeholders
• Demonstrate the capability and expertise to deliver
successfully a public sector transformation project at
scale and pace
• Commit to sharing lessons on integrated care and
support across the system
• Demonstrate that its vision and approach are based on a
robust understanding of the evidence
Integration Pioneers
• The national collaborative announced details of an integration ‘Pioneer’
programme in May - over 110 applications were received nationally
• Significant interest in becoming a pioneer across London with 15
applications crossing 22 boroughs demonstrating London’s commitment to
integration
• 4 Pioneers (NWL, Islington, WELC, Greenwich) have been selected in
London covering approximately 1/3 of London’s population.
• London’s Pioneers vary significantly in scale with large system and borough
approaches.
• The Pioneer community in London provides a significant opportunity to help
London deliver integrated care at scale and pace, by sharing learning and
developing solutions to complex issues.
7
The London Landscape
Risk stratifying the population shows us that different patients have
different intensity and complexity of need
Very
high
risk
High
risk
(0.5-5%)
Moderate
risk
(5-20%)
~20% of the population
Care for people
with very
complex needs
Care for people
with manageable
long term
conditions
More complex (often multiple)
conditions and facing higher risks to
their health (end of life, frail elderly,
dementia, multiple long term conditions)
In frequent contact with multiple parts of
the health and social care system
i.e. the most complex and costly care
Low risk
(20-50%)
Very low
risk
(50-100%)
9
“Care at short
notice” for the
rest of the
population
SOURCE: NWL whole systems integrated care
The Case for Change
Groups for whom the case for integrating care is most
compelling
• Frailty
• Multiple co-morbidity
• End of life Care
• Dementia
10
The case for change for dementia
Trends
•
There are around 65,000 Londoners with dementia, this is forecast to rise by 16% to 2021 and by
32% to 2031 [8]
Outcomes and Experience
•
Half of all people with dementia never receive a diagnosis [9] - just 31% of the capital’s GPs believe
they have received sufficient basic and post-qualification training to diagnose and manage dementia
[10]
•
Earlier diagnosis and treatment can be critical in delaying the onset of dementia [6]
•
Carers and other family members of people with dementia are often older and frail themselves, with
high levels of depression, physical illness, and a diminished quality of life [11]
•
London is struggling to meet the needs of older black and minority ethnic Londoners who have
dementia [10]
Activity and Cost
•
Older people with dementia occupy 20% of acute hospital beds across England but 70% of these
may be medically fit to be discharged [12]
•
80% of people living in care homes have dementia or severe memory problems [13]
•
Estimated cost of dementia to the English economy is about £20 billion p/a
•
This is set to increase to over £27 billion by 2018 [14]
•
Delaying the on set of dementia by 5 years would reduce deaths directly attributable to dementia by
30,000 a year [13]
11
INTEGRATED CARE: THE KEY INGREDIENTS
WHY
POOR PATIENT EXPERIENCE
Lack of independence and control
Fragmented services that are difficult to
navigate
POOR OUTCOMES
Poor quality of life for people and carers
Too many people living with preventable
ill-health and dying prematurely
Avoidable emergency and residential care
admissions/readmissions
Unsafe transfers and transitions
INCREASING DEMAND
Aging Population
Medical innovation
Poor population health
UNSUSTAINABLE MODELS OF CARE
“30%” of people in hospital and care
institutions who do not need to be there
Insufficient prevention/early intervention
Unrealised citizen and community
capacity
Limited primary care offer
Limited community services
Uneven quality across many services
UNPRECEDENTED FINANCIAL
CHALLENGE
NHS – flat in real terms
Local Government - 28%
NHS in London expected to save £3.1bn
by 2015 (15.5% of the national £20bn
savings requirement)
NHS nationally - £30bn funding gap by
2020
Financial system not fit for purpose,
encouraging acute activity and costshunting
WHAT
GREATER INTEGRATION OF
SERVICES AROUND THE PERSON
Risk profiling
Care coordination and care planning
Integrated case management
Single point of access
24/7 urgent response
Admission avoidance and timely
transfers of care
Reablement
A GREATER EMPHASIS ON SELF &
HOME CARE
Personal budgets
Expert patient
Carers strategy
Technology for independence
Support related Housing
BUILDING COMMUNITY CAPACITY
TO MANAGE DEMAND
Early diagnosis
Care navigators
Mutual support
Micro enterprises
Information for all
Population Health
A NEW PRIMARY CARE OFFER
Accessible
Proactive
Coordinated
RECONFIGURATION OF ACUTE
SERVICES
Reduced activity in acute / realigned
acute services
HOW
WHOLE HEALTH AND CARE SYSTEM
LEADERSHIP
Joint Governance
Political alignment
Joint Outcomes
Joint public / patient engagement strategy
3-5 YEAR LOCAL PLANS signed off by
Health and Wellbeing Boards
LOCAL & CITY WIDE COHERENCE
Acute Service reconfiguration
SCALE / FOCUS
Those at highest risk of needing urgent health
and/or social care (adults and children)
COMMISSIONING
Alignment between LA/CCG/NHS England
Engagement of providers
Release of primary care commissioning to
CCGs
A WAY TO MOVE MONEY AROUND THE
SYSTEM to address the perverse effects of
activity-based payments. That might include:
• contracting for populations and outcomes
• Risk-sharing by commissioners and
providers
SHARED INFORMATION ACROSS AGENCY
BOUNDARIES
FLEXIBLE, ENGAGED WORKFORCE AND
IMPROVED TRAINING
TRANSPARENT MEASUREMENT OF
OUTCOMES
A DEVELOPING EVIDENCE BASE
OUTCOMES
IMPROVED CITIZEN
EXPERIENCE
People “in control and
independent”
IMPROVED HEALTH
AND CARE OUTCOMES
Enhanced quality and
safety of services – to
agreed standards
IMPROVED
SUSTAINABILITY OF
THE HEALTH AND
CARE SYSTEMS
Increased investment in,
quality of and productivity
of primary and community
services
Large scale reduction in
unplanned attendances,
admissions to hospital
and length of stay
Reduction in admissions
to residential Care
EFFECTIVE DEMAND
MANAGEMENT
Management of demand
at the front door of care
and support services,
The main aims & objectives of the Islington pioneer:
‘I want to be treated as
a whole person and for
you to recognise how
disempowering being ill
is’
‘I want to have longer appointments with
someone who is well prepared so that I
do not have to tell my story again
Care planning
My goals /
outcomes
‘I want my care to be
coordinated and to
have the same
appointment systems
across services’
‘Better access to
health care through
social services and
vice versa”
‘No clear systems and
processes through all
healthcare services’
Information
‘Person Centred
Co-ordinated Care:
The Islington Way’
‘I want to feel supported
by my community and
get the most out of
services available locally’
‘I want to be listened to
and be heard’
Communication
Transitions
Decision
making
‘Helping people to help
themselves’
Successful delivery from partnership working:
COPD: NHS Innovation Challenge Prize 2013
~
Integrated respiratory consultant across
secondary & primary care
Clinical leadership & support
Incentivised GPs to proactively identify,
diagnose & manage
Supportive self-management
Focus: Early diagnosis & management to prevent further illness & death
Multi-disciplinary partnership: instrumental to introducing & promoting coordination &
integration of COPD care
Emphasis on self-care & lifestyle
Focus on community assets
Education in primary care
Skill-building, networks & clinical champions
OUTCOMES
 25% increase in diagnosed prevalence between 2010 - 2013
 93% increase in referrals to pulmonary rehabilitation between 2010-2012
 72% of people on COPD register now have self management plan
 16% decrease in emergency admissions in 2011/12 vs 2010/11
Plans for development:
2013/14
2014/15
2015/16
Service
model
Established
population
based
community
teams
Single point of
contact,
reablement &
rehabilitation
Enhanced Care
at home
Self-care
Motivational
interview
training/LT6
PAM scores
facilitating
targeted
commissioning
Systematic,
supported selfmanagement
based on need
Prevention
Closing the
prevalence gap
Utilisation of
systematic care
pathways
Goal orientated
personalised
care plans
Enablers
Risk
stratification
tool
Information
governance
/workforce
development
Linked &
shared
information /
data
Clear pathways of accountability:
Clinical Leadership
Supported by PMO
approach
Supported by UCLP
Health & Wellbeing Board
Chair: Leader of the Council.
Members: Council, CCG,
Healthwatch, Public Health,
NHS England
Rigour and challenge
Patient Engagement
Reporting arrangements
Link to Making It Real Board
Area specific workstreams
(linking to four localities)
Integrated Care Board
Chair: CCG Vice-Chair.
Members: patients, social
care, Public Health,
providers, UCLP, voluntary
sector
Area specific workstreams
(linking to four localities)
Working across North
Central London (e.g. value
based commissioning)
Area specific workstreams
(linking to four localities)
Area specific workstreams
(linking to four localities)
Measures of success:
When, and who, will assess impact?
1. Pilot
2. Project
evaluation
3. Whole-system
Interim reporting to HWBB & ICPB: provide challenge, rigour & development.
Acknowledge we won’t get it all right first time - embed learning & iterative approach.
What





The whole pathway
Total costs
Quality & Experience
Health outcomes
Process
Who
 Collaboration
 Patients and carers: coproduction
 Academic insight
 Frontline staff experience
How





Linked datasets
Matched case-control
Clearly defined intentions
Qualitative & quantitative
PMO Approach
Opportunities and Challenges:
Opportunities
Challenges
•
•
•
•
•
•
•
•
•
•
•
•
Collaboration – national & London
Flexibility to trial new approaches
Accelerated learning
Increased pace of mobilisation
Opportunity to apply academic rigor
Whole system approach
Strengthen collaborative leadership
Participate in and inform the
development of future models of care
• Recognition and peer challenge
• Permission to “do things differently”
• Harnessing rich diversity of
voluntary sector
•
•
•
•
•
Information governance
IT resolution
Revising contacting mechanisms
Development of greater value based
approach, with focus on outcome
Models for workforce development
Empowering people at population
level to embrace behaviour change
as a preventative strategy
Provider capacity, capability & focus
Understanding financial flow and
impact
Polarised demographic
What are the important contextual factors:
What help
do we
need?
Contextual Factors






Inequalities
Whittington ICO
UCLP
Collaboration on value
based commissioning
Financial drivers
Making prevention a
reality for population




Recognition & challenge
Peer to peer learning
Support & technical
advice
“Permission” to do things
differently
What we can
offer?









Ambition
Commitment
Track record
Co-production
Pooled budgets
Information exchange
Information governance
PAM
Work force development
strategy
How our plans can have a practical impact on the care of
individuals?
Aligning Education and Service
Re-design in Primary Care
Sanjiv Ahluwalia
Head, London School of General Practice
HENCEL Non-executive Primary Care
GP, North London
Challenges
•
•
•
•
•
•
•
Primary care workforce data
Population need and workforce planning
Workforce development and education needs
Emerging service models
Level of geography
Changing workforce roles
Centralisation versus localisation
Potential solutions
• Link population needs to workforce and
education planning
• Borough/CCG level information
• Service commissioners and providers at the
heart of this process
• Future and current workforce needs
• Multiprofessional and lay engagement
• Locally owned with LETB facilitation
Community Educational Provider
Networks
Ahluwalia et al (2013). Education for Primary Care
Back to Dementia
• Improve quality of care for the most
vulnerable in our society
• Empower and entrust our workforce to make
the best possible decisions
• Recognise the intimate relationship between
quality and costs
• System turbulence is a challenge but also an
opportunity