From the Sustainability & Transformation Plan (STP) to local delivery – Care Closer to Home

Where did STP’s come from? STP’s are a key part of the plan to transform the NHS (and make the £22bn saving) Based on rationale that health and care is an inter-dependent system - planning will have most impact if it is done in collaboration Our STP is trying to achieve; better health outcomes for our population less variation in the offer and outcomes Financial balance

Part 1 - The case for change

Why are we doing this? People in NCL are living longer but in poor health Whilst overall life expectancy is increasing for all NCL residents, people in NCL on average live the last 20 years of their lives in poor health; for Islington this is much worse than the rest of England There are different ethnic groups with differing health needs Health needs vary across BME communities, e.g, there is a greater risk of diabetes, stroke or renal disease for some BME people compared to White English people There is widespread deprivation and inequalities Poverty and deprivation are key causes of poor health outcomes, 30% of NCL children grow up in child poverty and 6% live in households where no-one works There is significant movement into and out of NCL Camden, Islington and Haringey experienced the highest population churn, with around 10% of people in these boroughs moving out in 2014 There are high levels of homelessness and households in temporary housing Lifestyle choices put local people at risk of poor health and early death Smoking, alcohol consumption and poor diet contribute to poor health – alcohol related hospital stays are much higher than average in Islington and number of overweight children is much higher than national average

Also: There is not enough focus on prevention Islington has high levels of avoidable deaths with around a quarter of deaths considered preventable Disease and illness could be detected and managed much earlier Many people in NCL are unwell but do not know it as they have undiagnosed conditions, eg. there are thought to be around 20,000 people who do not know they have diabetes and, in a Whittington Hospital audit of A&E attendance a quarter of people attending from one area because of COPD did not know they had the condition Lack of integrated care and support for those with a long term condition there are many people with long term health conditions who end up in hospital, especially in Islington Many people are in hospital beds who could be cared for closer to home Hospitals are finding it difficult to meet increasingly demanding emergency standards There are challenges in mental health provision There are very high levels of mental illness in NCL, both serious mental illness and common mental health problems, with high rates of premature mortality, particularly in Haringey and Islington

And the financial challenge: Our spend across health and care in NCL is c£2.5bn The “do nothing” scenario across NCL means that we would be in deficit by £876m by 2021 The consequence of doing nothing is that local health and social care services would not be maintained

It’s tempting to do this:

But we have a plan & the best bit is it isn’t new – it’s building on what we’ve done!!

Part 2 – the concepts that are emerging

The STP – a framework to be delivered at a local level through co-design Many aspects of the STP build on work we have already started There is still work to do to finalise the granularity of our delivery plans We want to engage providers, clinicians and patients to shape these plans and to make sure that what we design makes sense on the ground Today’s forum is one opportunity to talk to people about the plans – but this is one of many

This is NOT about Closing A&E departments Expecting primary care to do more for less Cost shunting to local authorities Rationing care

Four “buckets” for care closer to home

This IS about - service transformation (health and care closer to home) Ensuring that people receive care in the best possible setting at a local level and with local accountability At the heart of the care closer to home model is a ‘place-based’ population health system of care delivery which draws together social, community, primary and specialist services Will be underpinned by a systematic focus on prevention and supported self-care

A significant one is;

Features of a Care closer to home Integrated Networks May be virtual or physical, and will most likely cover a population of c.50,000 people will be home to a number of services including the voluntary and community sector To provide a more integrated and holistic, person-centred community model Includes health and social care integrated multi-disciplinary teams (MDTs), care planning and care coordination for identified patients Interventions focussed on the strengths of residents, families and communities Improving quality in primary care and reducing unwarranted variation This includes Quality Improvement Support Teams (QIST) to provide hands-on practical help for individual GP practices to ensure a consistent quality standard and offer to all patients.

What would look different if we did this? A Care closer to Home Integrated Network would potentially cover an Islington locality At a sub locality level integrated networks would still work to identify those most at risk and co-ordinate care for complex patients But at locality level we would have: Agreed patient outcomes that all providers – health and social care – would be working towards A richer “team around the practice” including therapists, psychologists and independent prescribers More focus on prevention building further on links with voluntary sector but also having more systematic approach to case finding Alignment of wider range of community and specialist services to support patients Hubs that could offer particular services to a wider range of patients Rapid access to support when needed – both in terms of rapid response but also hot lines to consultants An LCS to support practice engagement in the Care closer to Home Integrated Networks

Plus a focus on continuous quality improvement Aim to reduce variation so that all residents of NCL have equal access to care To support this we have additional capacity through the Quality Improvement Support Teams (QIST’s) This will include clinician, business intelligence and project management support Specialist support for practices to innovate and improve Real time business intelligence so everyone knows where the pressure points are and where focus in needed Investment has been requested for this work - £14m for integrated teams and £14m for quality improvement support teams

And links to the MH work stream - Increasing Access to Primary Care Mental Health Services Detail Modelling Recurrent Cost Recurrent Savings More accessible mental health support is delivered locally within primary care services Enabling both physical health and mental health needs to be supported together Robust multi-disciplinary mental health offering at a locality level Key component of providing more care out-of-hospital level Specialist psychological therapies: £4.0m- approx. 4,800 patients * £1,200/patient *70%1 IAPT: £3.1m- approx. 12,500 additional patients * £360/patient (includes 15% cost per treatment savings) Psychiatric led health & social care teams: £7.5m- 1 CCG Business case £1.9m * 5 CCGs *70%1 (approx. 5,000 new treatments) Service navigators: £0.3m- 2 navigators per Borough * £29k per FTE Alcohol & Drugs: £0.7m (approx. 60% increase in 15/16 spend) £15.6m £6.1m (£3m to physical health, £2.5m to MH, £0.6m wider benefits) Shared outcomes and KPIs are to be agreed across NCL, but the service may be delivered differently across the 5 boroughs, building on the great work already underway Learning will be shared across the boroughs to enable continuous improvement

Part 3 – building on what we already have

Local ‘I’ Statements Person Centred Coordinated Care Care planning Information Communication Decision making Transitions My 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’ Jo Sauvage: – quick – broad consensus – I statements are fundamental – systematically applied ‘Helping people to help themselves’

Links with our other work I-hub Integrated networks Practice based pharmacists Teams around the practice Practice based mental health

Part 4 – how will we continue to develop?

Discussion Questions What do you think are the opportunities for local communities? Are there particular areas care closer to home should focus on that would best support local communities? What are your concerns for local communities? What do you think your role as a sector might be in Care closer to home? And what are some of the barriers to achieving this?