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

2. 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

3. Part 1 - The case for change

4. 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

5. 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

6. 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

7. It’s tempting to do this:

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

9. Part 2 – the concepts that are emerging

10. 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

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

12. Four “buckets” for care closer to home

13. 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

14. A significant one is;

15. 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.

16. 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

17. 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

18. 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

19. Part 3 – building on what we already have

20. 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’

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

22. Part 4 – how will we continue to develop?

23. 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?