Presentation on theme: "Integrated Care Pioneer The view from Islington"— Presentation transcript:
1 Integrated Care Pioneer The view from Islington Dr Josephine SauvageVice Chair Islington CCGIn collaboration with NHS EnglandIslington is delighted to be shortlisted.Let me introduce our panel.I want to start by telling you about Islington – Inner London, small but densely populated, among the 5th most deprived in London and 14th in the country, mobile. More than 1 in 10 have 1 or more long term condition and 30k have some form of mental health problem.The story so far – track record of partnership working (£68m in pooled budgets), however people were telling us that services not as joined up as should be and we could be better meeting people’s needs so there were problems that need to be resolved. 18 months ago we got together to redefine our approach. This formulated our vision………..
2 “We are sick of falling through the gaps “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 careNational Voices, May 2013
3 Coordinated care, centred on me What do patients want?Coordinated care, centred on meMy goals and desired outcomes are understood by allProviders are communicating with one another about me and my needsInformation is common so I only have to give it onceMy care is planned to achieve my goals / desired outcomesDecisions are made based on my care planI do not have to manage transitions between providers myselfEmergencies are not treated as isolated cases but within the context of my care plan
4 ‘Integrated Care and Support: Our Shared Commitment’ (2013) 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 yearsAssociation 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 PersonalSupport of better person-centred, coordinated careLocal innovationRealisations of local aspirations on integrated careAddress barriersDisseminate and promote learningFocus on benefit for patients, services users, their carers and their local communitiesProvide bespoke expertise, support and constructive challengeRange of national and international expertsThis 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 yearsExpectation of Pioneers to contribute to accelerated learning across the system
5 5 year Expectations from pioneers Be regarded as exemplars:deliver improved outcomes, including better experiences for patients and people who use servicestackle local cultural and organisational barriersrealise savings and efficiencies for re-investmentHave 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 areaHave demonstrated a range of approaches and models involving whole system transformation across a range of settingsHave demonstrated the scope to make rapid progressHave tested radical options, including new reimbursement models and taking the risk of ‘failure to integrate’ in some casesHave overcome the barriers to delivering coordinated care and supportHave accelerated learning across the system to all localitiesHave improved the robustness of the evidence base to support and build the value case for integrated care and support
6 Selection criteria (not prescriptive about models for adoption) Articulate a clear vision of innovative approaches to integrated care and supportPlan for whole system integrationDemonstrate commitment to integrate care and support across the breadth of relevant stakeholdersDemonstrate the capability and expertise to deliver successfully a public sector transformation project at scale and paceCommit to sharing lessons on integrated care and support across the systemDemonstrate that its vision and approach are based on a robust understanding of the evidence
7 Integration PioneersThe national collaborative announced details of an integration ‘Pioneer’ programme in May - over 110 applications were received nationallySignificant interest in becoming a pioneer across London with 15 applications crossing 22 boroughs demonstrating London’s commitment to integration4 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.
9 Risk stratifying the population shows us that different patients have different intensity and complexity of needCare for people with very complex needs~20% of the populationMore 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 systemi.e. the most complex and costly careVery high riskHigh risk(0.5-5%)Care for people with manageable long term conditionsModerate risk(5-20%)Low risk(20-50%)“Care at short notice” for the rest of the populationVery low risk(50-100%)SOURCE: NWL whole systems integrated care
10 The Case for ChangeGroups for whom the case for integrating care is most compellingFrailtyMultiple co-morbidityEnd of life CareDementia
11 The case for change for dementia TrendsThere are around 65,000 Londoners with dementia, this is forecast to rise by 16% to 2021 and by 32% to 2031 Outcomes and ExperienceHalf of all people with dementia never receive a diagnosis  - just 31% of the capital’s GPs believe they have received sufficient basic and post-qualification training to diagnose and manage dementia Earlier diagnosis and treatment can be critical in delaying the onset of dementia 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 London is struggling to meet the needs of older black and minority ethnic Londoners who have dementia Activity and CostOlder people with dementia occupy 20% of acute hospital beds across England but 70% of these may be medically fit to be discharged 80% of people living in care homes have dementia or severe memory problems Estimated cost of dementia to the English economy is about £20 billion p/aThis is set to increase to over £27 billion by 2018 Delaying the on set of dementia by 5 years would reduce deaths directly attributable to dementia by 30,000 a year 
12 INTEGRATED CARE: THE KEY INGREDIENTS WHYWHATHOWOUTCOMESPOOR PATIENT EXPERIENCELack of independence and controlFragmented services that are difficult to navigatePOOR OUTCOMESPoor quality of life for people and carersToo many people living with preventable ill-health and dying prematurelyAvoidable emergency and residential care admissions/readmissionsUnsafe transfers and transitionsINCREASING DEMANDAging PopulationMedical innovationPoor population healthUNSUSTAINABLE MODELS OF CARE“30%” of people in hospital and care institutions who do not need to be thereInsufficient prevention/early interventionUnrealised citizen and community capacityLimited primary care offerLimited community servicesUneven quality across many servicesUNPRECEDENTED FINANCIAL CHALLENGENHS – flat in real termsLocal 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 2020Financial system not fit for purpose, encouraging acute activity and cost-shuntingGREATER INTEGRATION OF SERVICES AROUND THE PERSONRisk profilingCare coordination and care planningIntegrated case managementSingle point of access24/7 urgent responseAdmission avoidance and timely transfers of careReablementA GREATER EMPHASIS ON SELF & HOME CAREPersonal budgetsExpert patientCarers strategyTechnology for independenceSupport related HousingBUILDING COMMUNITY CAPACITY TO MANAGE DEMANDEarly diagnosisCare navigatorsMutual supportMicro enterprisesInformation for allPopulation HealthA NEW PRIMARY CARE OFFERAccessibleProactiveCoordinatedRECONFIGURATION OF ACUTE SERVICESReduced activity in acute / realigned acute servicesWHOLE HEALTH AND CARE SYSTEM LEADERSHIPJoint GovernancePolitical alignmentJoint OutcomesJoint public / patient engagement strategy3-5 YEAR LOCAL PLANS signed off by Health and Wellbeing BoardsLOCAL & CITY WIDE COHERENCE Acute Service reconfigurationSCALE / FOCUSThose at highest risk of needing urgent health and/or social care (adults and children)COMMISSIONING Alignment between LA/CCG/NHS EnglandEngagement of providersRelease of primary care commissioning to CCGsA WAY TO MOVE MONEY AROUND THE SYSTEM to address the perverse effects of activity-based payments. That might include:contracting for populations and outcomesRisk-sharing by commissioners and providersSHARED INFORMATION ACROSS AGENCY BOUNDARIESFLEXIBLE, ENGAGED WORKFORCE AND IMPROVED TRAININGTRANSPARENT MEASUREMENT OF OUTCOMESA DEVELOPING EVIDENCE BASEIMPROVED CITIZEN EXPERIENCEPeople “in control and independent”IMPROVED HEALTH AND CARE OUTCOMESEnhanced quality and safety of services – to agreed standardsIMPROVED SUSTAINABILITY OF THE HEALTH AND CARE SYSTEMSIncreased investment in, quality of and productivity of primary and community servicesLarge scale reduction in unplanned attendances, admissions to hospital and length of stayReduction in admissions to residential CareEFFECTIVE DEMAND MANAGEMENTManagement of demand at the front door of care and support services,
13 The main aims & objectives of the Islington pioneer: ‘Person Centred Co-ordinated Care:The Islington Way’Care planningInformationCommunicationDecision makingTransitionsMy goals / outcomes‘I want to have longer appointments with someone who is well prepared so that I do not have to tell my story again‘I want to be treated as a whole person and for you to recognise how disempowering being ill is’‘I want to feel supported by my community and get the most out of services available locally’‘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’‘I want to be listened to and be heard’‘Helping people to help themselves’
14 Successful delivery from partnership working: COPD: NHS Innovation Challenge Prize 2013~Focus: Early diagnosis & management to prevent further illness & death Multi-disciplinary partnership: instrumental to introducing & promoting coordination & integration of COPD careIntegrated respiratory consultant across secondary & primary careClinical leadership & supportIncentivised GPs to proactively identify, diagnose & manageSupportive self-managementEmphasis on self-care & lifestyleFocus on community assetsSkill-building, networks & clinical championsEducation in primary careThe issue: 3rd highest cause of deaths in Islington - key reason life expectancy lower than England, 2nd highest rate of emergency hospital admissions - could be avoidedOUTCOMES25% increase in diagnosed prevalence between93% increase in referrals to pulmonary rehabilitation between72% of people on COPD register now have self management plan16% decrease in emergency admissions in 2011/12 vs 2010/11
15 Plans for development: 2013/142014/152015/16Service modelEstablished population based community teamsSingle point of contact, reablement & rehabilitationEnhanced Care at homeSelf-careMotivational interview training/LT6PAM scores facilitating targeted commissioningSystematic, supported self-management based on needPreventionClosing the prevalence gapUtilisation of systematic care pathwaysGoal orientated personalised care plansEnablersRisk stratification toolInformation governance /workforce developmentLinked & shared information / data
16 Clear pathways of accountability: Chair: Leader of the Council. Members: Council, CCG, Healthwatch, Public Health, NHS EnglandHealth & Wellbeing BoardIntegrated Care Board Chair: CCG Vice-Chair. Members: patients, social care, Public Health, providers, UCLP, voluntary sectorArea specific workstreams (linking to four localities)Clinical LeadershipSupported by UCLPSupported by PMO approachRigour and challengePatient EngagementReporting arrangementsWorking across North Central London (e.g. value based commissioning)Link to Making It Real BoardHWBB – chaired by Leader, one of core objectives, recent workshop out of which agreed to develop our Pioneer proposalICB working for 18 months. Building on track record of working together.PMO with identified leads, contributors etcWe are already working collaboratively (sharing, learning and evaluating) – working with neighbouring CCGs, UCLP cover a population of 6mExternal support to take us forward faster, collectively with providers
17 Measures of success: When, and who, will assess impact? 1. Pilot2. Project evaluation3. Whole-systemInterim reporting to HWBB & ICPB: provide challenge, rigour & development. Acknowledge we won’t get it all right first time - embed learning & iterative approach.WhatWhoHowThe whole pathwayTotal costsQuality & ExperienceHealth outcomesProcessCollaborationPatients and carers: co-productionAcademic insightFrontline staff experienceLinked datasetsMatched case-controlClearly defined intentionsQualitative & quantitativePMO Approach
18 Opportunities and Challenges: Collaboration – national & LondonFlexibility to trial new approachesAccelerated learningIncreased pace of mobilisationOpportunity to apply academic rigorWhole system approachStrengthen collaborative leadershipParticipate in and inform the development of future models of careRecognition and peer challengePermission to “do things differently”Harnessing rich diversity of voluntary sectorChallengesInformation governanceIT resolutionRevising contacting mechanismsDevelopment of greater value based approach, with focus on outcomeModels for workforce developmentEmpowering people at population level to embrace behaviour change as a preventative strategyProvider capacity, capability & focusUnderstanding financial flow and impactPolarised demographic
19 What are the important contextual factors: What help do we need?What we can offer?Finally we have the track record, commitment and ambition to be a successful Pioneer.Thank you and we would be pleased to answer your questionsInequalitiesWhittington ICOUCLPCollaboration on value based commissioningFinancial driversMaking prevention a reality for populationRecognition & challengePeer to peer learningSupport & technical advice“Permission” to do things differentlyAmbitionCommitmentTrack recordCo-productionPooled budgetsInformation exchangeInformation governancePAMWork force development strategy
20 How our plans can have a practical impact on the care of individuals?
21 Aligning Education and Service Re-design in Primary Care Sanjiv AhluwaliaHead, London School of General PracticeHENCEL Non-executive Primary CareGP, North London
22 Challenges Primary care workforce data Population need and workforce planningWorkforce development and education needsEmerging service modelsLevel of geographyChanging workforce rolesCentralisation versus localisation
23 Potential solutionsLink population needs to workforce and education planningBorough/CCG level informationService commissioners and providers at the heart of this processFuture and current workforce needsMultiprofessional and lay engagementLocally owned with LETB facilitation
24 Community Educational Provider Networks Ahluwalia et al (2013). Education for Primary Care
25 Back to DementiaImprove quality of care for the most vulnerable in our societyEmpower and entrust our workforce to make the best possible decisionsRecognise the intimate relationship between quality and costsSystem turbulence is a challenge but also an opportunity
Your consent to our cookies if you continue to use this website.