What are the barriers and solutions to cross boundary working?

Airedale, Wharfedale and Craven
Health Partnership
21st February 2012
Integrated care delivery……………..
What are the barriers and solutions to
cross boundary working?
Nick Morris
Director of Strategy, Performance and Governance
Bradford District Care Trust
• Pressure:
– Economic
– Demand v capacity
• Leading to:
– Defensive mentality
– Short term-ism
• Interpretation of rules and
– Divergent visions and
– Different populations
• Enabling issues:
– Shared information, IT, etc..
• Lack of any unifying objectives
– Organisational imperatives
• Finance as a driver
• Lack of good will…..
• Times of growth and optimism
• Common and agreed understanding
of the problem
• A jointly held vision – that is
customer focused
– Integrated teams that have a
common focus
• Good will – people with the right
– willingness to do it together
• Leading to:
– Shared risk taking
– ‘Pooled budgets’
– Mutual benefits rather than
personal/organisational benefits
The Health Economy
The whole health economy needs to establish new models of care
• Drivers:
– A shift from hospital care requires community services to be more
effective and proactive – greater capacity and productivity – delivered
through partnership
– Growing demand/populations require earlier - preventative
– Growing demand requires increased capacity at the primary and
community interface to prevent un-due escalation in responses
– A lean approach to care coordination (across partners) – reduce:
bureaucracy, ineffective handovers, risk,
improve: patient experience and effectiveness
• We need a new approach for the delivery of care to the economy
A Vision for Community Services
Acute Hospital Care
Pro-active case mgt
Social Care
Pro-active case mgt
A Comprehensive - Integrated health and social care services
that provides coordinated care to individuals and their
Communities - horizontal integration
Pro-active case mgt
Pro-active case mgt
Primary care based services (99%+ of people registered with GP’s)
The local population – social care need
Locality Management
Acute Hospitals
Airedale, Wharfedale and Craven
Patient flows predominantly from
this locality into Airedale NHS FT
Clinical Commissioning Groups
Airedale and Craven CCG
Local Authority
North Yorkshire (Craven DC) and
BMDC (Keighley)
BDCT – MH/LD and community
Specialist District-wide Services
(Acute care pathway, Crisis services, in-patient
and residential)
A common understanding
of the population to be
served allows planners
to develop joint
Registered and Resident
Population issues are
Of less significance at this
Level – hence joint plans
Agreements will become
A New Model of Care Delivery
Community staff aligned to practice populations
Primary Care
A management and supervisory structure
supports the coordinated work of a range of different
practitioners working to deliver integrated care
DN’s, HV’’s IAPT
Primary Care
School nursing,
Gateway worker, etc
CMHT, OPMH staff
Podiatry, etc
Geographic ‘Zone’
Primary Care
The link to primary care allows for integrated planning with
primary care management and supervisory systems
Staff visible at this level – ‘autonomous’ in delivery to
defined case loads mapped to GP practices
Association to ‘neighbourhood’ concept allows for
integration of health need with population ‘social’ need
Potential integration of social care within joint integrated teams
Fully aligned with Intermediate Care +
Potential for benefits across other care pathways
Note: some specialist staff/teams will
be deployed across teams (locality and district)
But accessible to support the delivery at practice group level
A New Model of Care Delivery
Practice Population
1,000 – 15,000
A Primary
Volume of need is sufficient to allow for staff to be allocated to the
practice population – i.e. their case load is drawn from this population entirely:
example – District Nursing, HV’s, Counselling
Integrated delivery – practice staff work together to support the practice population
Combined Practice Population
Approx 15,000 – 30,000
A Group of
1 large Practice – 4 or 5 small single
Handed practices
Staff resources too thin to delegate to individual practices – hence staff allocated
to a group of primary care practices - population is sufficient to support a case
load drawn from this population entirely: example – CMHT staff, ACCT, …
Integrated delivery – practice staff work together to support the practice population
A Locality
aggregated from a larger
number of practice
(Scale approx 100,000 pop)
Some specialist staff/teams will be deployed across larger groupings
of practices at locality scale
They will support integrated work at practice level populations
Note: There are some specialist staff who will retain a Trust wide remit
The benefits have been identified as:
– Improved focus of care at community – earlier interventions, closer to home
– Improved patient experience
• Horizontal integration, reduced handoffs/handovers, single assessment, shared care.
Also enables mobile (agile) working practices
– Enhanced relationship
• Patient – customer focused care – simple access
• practice staff/systems (care model) – integration with primary care practice
• Neighbourhood level – integrated health and social care – population focus rather
than diagnosis
• Planning and provider systems - partner organisation – Integration benefits
– Reduced risk – less handoff, shared information
– Improved Quality – speed of referral/intervention, responsiveness and access
to information/support
– Efficiency gains
• Financially – Locality Mgt Structure
• Productivity at Community level – meeting demographic challenges head on