1. Integrated Health and Social Care Commissioning Ken Fullerton

2. Outline Care for older people – a whole system Health and Social Care in N. Ireland Personal experience Potential benefits Potential issues Potential barriers

3. “A System produces exactly what it is (was) designed to produce”

4. What is our system designed to do? Differentiate between “Health” and “Social” care Ensure that care provided equates to assessed need Avoid hospital admission Reduce lengths of hospital stay Redress imbalance in favour of secondary care

5. Pathways for Increasing dependency Primary Care Acute Secondary Care Inpatient Rehabilitation “Intermediate Care” Lesser Dependency Greater Dependency Social Care Pressures for Increasing Dependency Insufficient Social SupportIllnessFrailtyFunctional Decline Care Home Long term Care Package Social Service Support Independent Living Comprehensive assessment and rehabilitation X Geriatric Day Hospital X

6. Increasing dependency Personal consequences –Lessening independence Health and social care consequences –Service provision –Increased cost (to the whole system) Increasing social care cost may be invisible to healthcare providers Healthcare interventions may be inaccessible to social care providers

7. Costs of stroke care to the system Budget costs Secondary Care: £ 636M Primary Care: £ 507M Formal social care: £ 1700M Informal social care: £ 2400M Budget costs Secondary Care: £ 636M Primary Care: £ 507M Formal social care: £ 1700M Informal social care: £ 2400M (10%) ( 7%) (24%) (34%) Costs to social care budget are 40% higher than total healthcare costs Personal/ family costs are two and a half times as high

8. Health and Social Care N Ireland Health & Social Care Trusts Integrated down to Service Group and increasingly at the level of delivery Common budgets for healthcare, domiciliary care and care homes Care Managers are employed by Trusts, as are social workers Single Regional Board, many Health & Social Care Groups (balance of commissioning unclear) No Primary Care Trusts (yet!)

9. Personal Experience Involvement in Integrated Care Teams Social care purchasers and providers –Complex packages of care provided at home Integrated with care management Some nursing and limited OT involvement Need for budgetary control Opportunity for intervention when care needs (costs) are rising.

10. HSC Commissioning - Potential Benefits Early detection of decline Effective method of case management Access to comprehensive assessment and rehabilitation Prevention of avoidable dependency Avoids premature commitment to high cost long term packages or institutionalisation

11. HSC Commissioning - Potential Risks Unwanted effects of integrated commissioning with disparate service provision (slicing the cake) Role of primary care unclear Further reduction of assessment and rehabilitation facilities

12. HSC Commissioning - Potential Barriers Structures do not exist Lack of recognition that Health and Social Care are parts of the same system Little direct experience, except local initiatives Information systems not linked Paucity of research evidence It doesn’t fit our current paradigm