1. National Clinical Director for Integration & the Frail Elderly
Professor John Young
National Clinical Director for Integration & the Frail Elderly
nhsManagers.net

2. Integration and Older People with Frailty Bradford Hospitals Trust
John Young
Dept. Elderly Care Medicine
Bradford Hospitals Trust
& University of Leeds
National Clinical Director for Integration & Frail Elderly, NHS England

3. Integration and Older People with Frailty
What’s the problem?
How does integration fit in?
What’s the evidence?
What’s the plan?

4. PERFECT STORM: Increasingly clumsy health & social care system
Changing population:
simple needs highly complex (frailty)
The Austerity years
Health & Social Care System needs to be fit for purpose

5. By 2030, the number of people over 80 will have doubled…
Over the last decade, some 40% of the increase in emergency admissions is from over 65s
The rate of emergency readmissions has also grown faster for older people
In 2008, there were 1.9 million people with more than one long term condition. By 2026, 3 million people will have three long term conditions
Population estimates for frailty:
65-69  = 4%
70-74 = 7%
75-79 = 9%
80-84 = 16%
Over 85 = 26%

6. Multimorbidity in Scotland
(Scottish School of Primary Care Barnett et al Lancet May 2012)
The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions
More people have 2 or more conditions than only have 1

7. Frailty is loss of physiological reserve
Frailty syndromes present in crisis
FUNCTIONAL ABILITIES
Independent
Dependent
Hyper-acute Frailty syndromes:
Immobility
Falls
Delirium
Fluctuating disability
Incontinence
“Minor illness” eg UTI
(Clegg, Young, Rockwood Lancet 2013)

8. STRUCTURAL, RELATIONAL & CULTURAL FRAGMENTATION (SILOS OF PROVISION)
HOSPITALS
PRIMARY CARE
SOCIAL CARE
(LG funded & means tested)
COMMUNITY HEALTH SERVICES
COMMUNITY NURSING
AMBULANCE SERVICES
NURSING & CARE HOMES
MENTAL HEALTH SERVICES
PHARMACY
VOLUNTARY SECTOR
HOSPITAL-AT-HOME; “VIRTUAL WARDS; COMMUNITY HOSPITALS; HOME THERAPY TEAMS; COMMUNITY MATRONS; SPECIALIST NURSES; CARE HOME REHAB; PALLIATIVE CARE; “ENABLEMENT” SERVICES, etc, etc…

9. Does anybody want my patient?
Rapid Access Clinic = “Too ill”
Care home rehab = “Not ill enough”
Com hosp = “We’re full till Monday”
HaH = “You mean she’s got dementia!”
L.A. Enablement Service = “Send her along!”

10. We have a fundamental whole system failure
The Wrong Type of Patients:
“If we design services for people with one thing wrong at once but people with many things wrong turn up, the fault lies not with the users but with the service, yet all too often these patients are labelled as inappropriate and presented as a problem”
Prof Rockwood 2005
The Wrong Type of System:
“Systems designed to treat occasional episodes of care for normally healthy younger people are being used to deliver care for people who have multiple, complex and long term conditions. The result is often that they are passed from silo to silo without the system having ability to co-ordinate different providers”
Rt Hon Stephen Dorrell MP 2011

11. Integration and Older People with Frailty
What’s the problem?
How does integration fit in?
What’s the evidence?
What’s the plan?

12. NATIONAL VOICES (www.nationalvoices.org.uk)
A national coalition of health and social care charities in England
Voice of patients, service users, carers, their families  Over 150 members organisations
Connects with the experiences of millions of people
“We are sick of falling through gaps. We are tired of organisational barriers and boundaries that delay or prevent 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” 12

13. NATIONAL VOICES: What do we mean by “integration”?

14. Integration and Older People with Frailty
What’s the problem?
How does integration fit in?
What’s the evidence?
What’s the plan?

15. Complete failure: Doesn’t work
Preventing admission of older people to hospital (D’Souza & Guptha BMJ 2013)
Mostly based on experimental RCTs
Case management
Community matrons
Integrated community teams
Targeted, specialist services
Complete failure:
Doesn’t work
And yet………………

16. Torbay and S. Devon Health Care Trust
Acclaimed service integration work:
Bed use reduced 33%
Emergency bed use >85y reduced 32%
Delayed transfers of care “negligible”
LTC use reduced
Home care use increased
“I have seen the future. It is Torbay”
David Nicholson NHS Chief Executive

17. Torbay and S. Devon Health Care Trust
Work started 2004
Pilot work: joint care manager and joint health and
social care team
Narrative: “Mrs Smith” (see BMJ March 2012)
Performance metrics: early successes
Staff: better experience
Service users: better experience

18. Preventing admission of older people to hospital (D’Souza & Guptha BMJ 2013)
Mostly based on experimental RCTs
Case management
Community matrons
Integrated community teams
Targeted, specialist services
Experimental control of one (albeit complex) thing
Short time-horizon of experimenters

19. WHOLE SYSTEMS THINKING

20. National Evaluation of (16) Integrated Care Pilots
RAND Europe; Ernst &Young 2012
Identified several “integrating activities”
Can you identify some “integrating activities” from this video?

21. National Evaluation of (16) Integrated Care Pilots
RAND Europe; Ernst &Young 2012
“Integrating activities” included:
Narrative/collective vision; strong leadership
Developing relationships & trust
Process improvements: care planning; new roles; MDT working
Locality based teams & co-location
Shared IT/ care records
Governance and performance management
Financial systems and incentives
What did they find?

22. National Evaluation of (16) Integrated Care Pilots
RAND Europe; Ernst &Young 2012
Headline findings:
Patient experience unchanged
Unexpected increase in acute admissions
Unexpected decrease in elective care
Changes more complex & took longer
Integration work not complete or mature
Mostly horizontal (not vertical) integration

23. What are characteristics of best integrated systems (1)?
Integrated Care:
What are the characteristics of best integrated systems (1)?
What are characteristics of best integrated systems (1)?
Strong clinical leadership across sectors and disciplines, e.g. Grouphealth (US), Jonkoping (Sweden)
Use of data-driven processes to guide quality improvement, e.g. Intermountain (US), Virginia Mason (US), CCNC (US), GRIPA (US)
Multi-disciplinary team around primary care practitioners, e.g. Kaiser (US), Dudley (UK), Torbay (UK), CCNC (US)
Strong investment in preventative services to improve self-management, e.g. Kaiser (US), Leeds (UK), On Lok (US)
Use of risk stratification and proactive assessment/ care planning, e.g. Tri-boroughs (UK), Kent (UK), North Lanarkshire (UK), Grouphealth (US) 23

24. What are characteristics of best integrated systems (2)?
Integrated Care:
What are the characteristics of best integrated systems (2)?
What are characteristics of best integrated systems (2)?
During crisis episodes, care co-ordination starts in A&E, including social care, right through to discharge e.g. Kaiser (US), Dudley (UK)
Seamless transfer between acute and community setting, backed up by continuous dialogue between GP & hospital consultant, e.g. RHZ (Netherlands), VHA (US)
Single electronic care record with patient access/interaction, e.g. RHZ (Netherlands), Kaiser (US)
Integration between physical and mental health services, with same access standards, e.g. United (US), Beacon (US)
Same incentives across system – outcomes, process, user experience, VFM; e.g. Intermountain (US) 24

25. Kings Fund Integrated Care 2011
“Organisational integration appears to be neither necessary nor sufficient to deliver the benefits of integrated care.”
“No single ‘best practice’ model of integrated care exists. What matters most is clinical and service-level integration that focuses on how care can be better provided around the needs of individuals, especially where this care is being given by a number of different professionals and organisations Moreover, integrated care is not needed for all service users or all forms of care but must be targeted at those who stand to benefit most.”

26. Integration and Older People with Frailty
What’s the problem?
How does integration fit in?
What’s the evidence?
What’s the plan(s)?

27. The National Collaboration for Integration National Partners: a major commitment
25 February 2013

28. Integrated Care and Support: Our Shared Commitment
Launched by MS(CS)14 May 2013
Sets out policy background
National Voices narrative prioritised
Call for ‘pioneers’
Sense of urgency within the
system to integrate
Information sharing
Accelerated learning across the system
National support to reduce/ eliminate barriers
No national blueprint – local innovation 28

29. Integration and Older People with Frailty: Policy and Plans
Focus is on:
Whole systems
Older people with multiple co-morbidities/frailty
Vulnerable Older People Plan
(Urgent care, primary care, integration)
Urgent and Emergency Care Review
Integrated Care Pioneers
“Year of Care” Pilots
Integration Transformation Fund (£3.8 billion)