integrated care and support solihull...
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Integrated Care and Support Solihull (ICASS)
The case for change Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Version Control Version 81 30th April 2014
Summary of update Revised financial values following finance working group review
Inclusion of description of component groups Inclusion of impact on GPs of changes to care setting
Document Owner Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 2
Executive summary Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors bull Clinical and organisational leadership with Executive sign up bull Strong and deliberate engagement bull Business case approach bull Programme management bull Innovative finance and contracting
pound46m
Shortfallpound298m
pound51m
Net savings (bed reductions)
Residual gap pound201m
ICASS Case for Change v80
Page 3
ICASS Case for Change v80
Page 4
Contents Executive summary 2
Contents 4
Objective 5
The scale of the challenge for Solihull 6
The gap between funding supply and increasing demand ldquojaws of doomrdquo 6
National context 6
Solihull context 6
Current cost of provision older people 7
Key findings 7
Overall cost 7
Cost by cost sub-group 8
Summary 9
Potential programmes of work within the case for change 11
Current ICASS Programme of work 11
Other interventions with the potential to contribute 12
Financial impact of implementing integrated care 13
Impact of ICASS programme 13
Other interventions 14
Summary 15
Options for bridging the remaining gap 15
Transformed care scenario 16
Changing the nature of care provision 16
Delivering integrated care 17
Critical success factors 17
Enablers for change 18
Next steps 19
Programme of work 19
Appendix 1 Characteristics of sub-groups 20
Descriptive summary of sub-groups 20
Detailed analysis 20
ICASS Case for Change v80
Page 5
Objective Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre1 We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
bull The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
bull The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
bull The likely interventions that will deliver these changes bull Potential benefits associated with these and likely costs of implementation (based on
a set of agreed assumptions) Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
1 This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest
ICASS Case for Change v80
Page 6
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull2
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for
2 Detailed report available separately
ICASS Case for Change v80
Page 7
change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings3
Overall cost
bull There are approx 41394 people aged 65 and over living in Solihull bull 30805 individual service users were identified in the matched component data with a
total cost of pound1052m broken down as follows
3 Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately
ICASS Case for Change v80
Page 8
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups4 Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
bull Average age
bull Ratio of Females to Males
bull Average deprivation score
bull Average number of services used
bull Average number of contacts with services
bull Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
bull Service Type
bull Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
bull 43 of all service users had an inpatient admission during 201213
4 Please see Appendix 1 for a summary of the characteristics of each sub-group
Percentile No of People Activity Total Cost Cost Avge Cost
Very High (Top 2) 616 33359 pound24868675
236 pound40371
High (2 to 10) 2464 96092 pound36372609 346 pound14762
Medium (10 to 50) 12324 174418 pound39216104 373 pound3182
Low (Bottom 50) 15401 51118 pound4747647 45 pound308
No service 10682 0 pound0 00 pound0
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
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erm
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iss-
ions
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on a
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e 91
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ost d
isch
arge
Avo
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le
adm
issi
ons
Pat
ient
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erie
nce
Rat
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di
agno
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DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
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Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 2
Executive summary Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors bull Clinical and organisational leadership with Executive sign up bull Strong and deliberate engagement bull Business case approach bull Programme management bull Innovative finance and contracting
pound46m
Shortfallpound298m
pound51m
Net savings (bed reductions)
Residual gap pound201m
ICASS Case for Change v80
Page 3
ICASS Case for Change v80
Page 4
Contents Executive summary 2
Contents 4
Objective 5
The scale of the challenge for Solihull 6
The gap between funding supply and increasing demand ldquojaws of doomrdquo 6
National context 6
Solihull context 6
Current cost of provision older people 7
Key findings 7
Overall cost 7
Cost by cost sub-group 8
Summary 9
Potential programmes of work within the case for change 11
Current ICASS Programme of work 11
Other interventions with the potential to contribute 12
Financial impact of implementing integrated care 13
Impact of ICASS programme 13
Other interventions 14
Summary 15
Options for bridging the remaining gap 15
Transformed care scenario 16
Changing the nature of care provision 16
Delivering integrated care 17
Critical success factors 17
Enablers for change 18
Next steps 19
Programme of work 19
Appendix 1 Characteristics of sub-groups 20
Descriptive summary of sub-groups 20
Detailed analysis 20
ICASS Case for Change v80
Page 5
Objective Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre1 We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
bull The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
bull The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
bull The likely interventions that will deliver these changes bull Potential benefits associated with these and likely costs of implementation (based on
a set of agreed assumptions) Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
1 This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest
ICASS Case for Change v80
Page 6
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull2
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for
2 Detailed report available separately
ICASS Case for Change v80
Page 7
change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings3
Overall cost
bull There are approx 41394 people aged 65 and over living in Solihull bull 30805 individual service users were identified in the matched component data with a
total cost of pound1052m broken down as follows
3 Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately
ICASS Case for Change v80
Page 8
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups4 Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
bull Average age
bull Ratio of Females to Males
bull Average deprivation score
bull Average number of services used
bull Average number of contacts with services
bull Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
bull Service Type
bull Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
bull 43 of all service users had an inpatient admission during 201213
4 Please see Appendix 1 for a summary of the characteristics of each sub-group
Percentile No of People Activity Total Cost Cost Avge Cost
Very High (Top 2) 616 33359 pound24868675
236 pound40371
High (2 to 10) 2464 96092 pound36372609 346 pound14762
Medium (10 to 50) 12324 174418 pound39216104 373 pound3182
Low (Bottom 50) 15401 51118 pound4747647 45 pound308
No service 10682 0 pound0 00 pound0
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
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Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 3
ICASS Case for Change v80
Page 4
Contents Executive summary 2
Contents 4
Objective 5
The scale of the challenge for Solihull 6
The gap between funding supply and increasing demand ldquojaws of doomrdquo 6
National context 6
Solihull context 6
Current cost of provision older people 7
Key findings 7
Overall cost 7
Cost by cost sub-group 8
Summary 9
Potential programmes of work within the case for change 11
Current ICASS Programme of work 11
Other interventions with the potential to contribute 12
Financial impact of implementing integrated care 13
Impact of ICASS programme 13
Other interventions 14
Summary 15
Options for bridging the remaining gap 15
Transformed care scenario 16
Changing the nature of care provision 16
Delivering integrated care 17
Critical success factors 17
Enablers for change 18
Next steps 19
Programme of work 19
Appendix 1 Characteristics of sub-groups 20
Descriptive summary of sub-groups 20
Detailed analysis 20
ICASS Case for Change v80
Page 5
Objective Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre1 We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
bull The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
bull The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
bull The likely interventions that will deliver these changes bull Potential benefits associated with these and likely costs of implementation (based on
a set of agreed assumptions) Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
1 This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest
ICASS Case for Change v80
Page 6
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull2
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for
2 Detailed report available separately
ICASS Case for Change v80
Page 7
change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings3
Overall cost
bull There are approx 41394 people aged 65 and over living in Solihull bull 30805 individual service users were identified in the matched component data with a
total cost of pound1052m broken down as follows
3 Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately
ICASS Case for Change v80
Page 8
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups4 Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
bull Average age
bull Ratio of Females to Males
bull Average deprivation score
bull Average number of services used
bull Average number of contacts with services
bull Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
bull Service Type
bull Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
bull 43 of all service users had an inpatient admission during 201213
4 Please see Appendix 1 for a summary of the characteristics of each sub-group
Percentile No of People Activity Total Cost Cost Avge Cost
Very High (Top 2) 616 33359 pound24868675
236 pound40371
High (2 to 10) 2464 96092 pound36372609 346 pound14762
Medium (10 to 50) 12324 174418 pound39216104 373 pound3182
Low (Bottom 50) 15401 51118 pound4747647 45 pound308
No service 10682 0 pound0 00 pound0
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 4
Contents Executive summary 2
Contents 4
Objective 5
The scale of the challenge for Solihull 6
The gap between funding supply and increasing demand ldquojaws of doomrdquo 6
National context 6
Solihull context 6
Current cost of provision older people 7
Key findings 7
Overall cost 7
Cost by cost sub-group 8
Summary 9
Potential programmes of work within the case for change 11
Current ICASS Programme of work 11
Other interventions with the potential to contribute 12
Financial impact of implementing integrated care 13
Impact of ICASS programme 13
Other interventions 14
Summary 15
Options for bridging the remaining gap 15
Transformed care scenario 16
Changing the nature of care provision 16
Delivering integrated care 17
Critical success factors 17
Enablers for change 18
Next steps 19
Programme of work 19
Appendix 1 Characteristics of sub-groups 20
Descriptive summary of sub-groups 20
Detailed analysis 20
ICASS Case for Change v80
Page 5
Objective Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre1 We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
bull The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
bull The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
bull The likely interventions that will deliver these changes bull Potential benefits associated with these and likely costs of implementation (based on
a set of agreed assumptions) Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
1 This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest
ICASS Case for Change v80
Page 6
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull2
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for
2 Detailed report available separately
ICASS Case for Change v80
Page 7
change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings3
Overall cost
bull There are approx 41394 people aged 65 and over living in Solihull bull 30805 individual service users were identified in the matched component data with a
total cost of pound1052m broken down as follows
3 Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately
ICASS Case for Change v80
Page 8
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups4 Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
bull Average age
bull Ratio of Females to Males
bull Average deprivation score
bull Average number of services used
bull Average number of contacts with services
bull Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
bull Service Type
bull Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
bull 43 of all service users had an inpatient admission during 201213
4 Please see Appendix 1 for a summary of the characteristics of each sub-group
Percentile No of People Activity Total Cost Cost Avge Cost
Very High (Top 2) 616 33359 pound24868675
236 pound40371
High (2 to 10) 2464 96092 pound36372609 346 pound14762
Medium (10 to 50) 12324 174418 pound39216104 373 pound3182
Low (Bottom 50) 15401 51118 pound4747647 45 pound308
No service 10682 0 pound0 00 pound0
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 5
Objective Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre1 We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
bull The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
bull The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
bull The likely interventions that will deliver these changes bull Potential benefits associated with these and likely costs of implementation (based on
a set of agreed assumptions) Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
1 This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest
ICASS Case for Change v80
Page 6
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull2
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for
2 Detailed report available separately
ICASS Case for Change v80
Page 7
change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings3
Overall cost
bull There are approx 41394 people aged 65 and over living in Solihull bull 30805 individual service users were identified in the matched component data with a
total cost of pound1052m broken down as follows
3 Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately
ICASS Case for Change v80
Page 8
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups4 Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
bull Average age
bull Ratio of Females to Males
bull Average deprivation score
bull Average number of services used
bull Average number of contacts with services
bull Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
bull Service Type
bull Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
bull 43 of all service users had an inpatient admission during 201213
4 Please see Appendix 1 for a summary of the characteristics of each sub-group
Percentile No of People Activity Total Cost Cost Avge Cost
Very High (Top 2) 616 33359 pound24868675
236 pound40371
High (2 to 10) 2464 96092 pound36372609 346 pound14762
Medium (10 to 50) 12324 174418 pound39216104 373 pound3182
Low (Bottom 50) 15401 51118 pound4747647 45 pound308
No service 10682 0 pound0 00 pound0
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 6
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull2
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for
2 Detailed report available separately
ICASS Case for Change v80
Page 7
change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings3
Overall cost
bull There are approx 41394 people aged 65 and over living in Solihull bull 30805 individual service users were identified in the matched component data with a
total cost of pound1052m broken down as follows
3 Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately
ICASS Case for Change v80
Page 8
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups4 Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
bull Average age
bull Ratio of Females to Males
bull Average deprivation score
bull Average number of services used
bull Average number of contacts with services
bull Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
bull Service Type
bull Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
bull 43 of all service users had an inpatient admission during 201213
4 Please see Appendix 1 for a summary of the characteristics of each sub-group
Percentile No of People Activity Total Cost Cost Avge Cost
Very High (Top 2) 616 33359 pound24868675
236 pound40371
High (2 to 10) 2464 96092 pound36372609 346 pound14762
Medium (10 to 50) 12324 174418 pound39216104 373 pound3182
Low (Bottom 50) 15401 51118 pound4747647 45 pound308
No service 10682 0 pound0 00 pound0
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 7
change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings3
Overall cost
bull There are approx 41394 people aged 65 and over living in Solihull bull 30805 individual service users were identified in the matched component data with a
total cost of pound1052m broken down as follows
3 Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately
ICASS Case for Change v80
Page 8
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups4 Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
bull Average age
bull Ratio of Females to Males
bull Average deprivation score
bull Average number of services used
bull Average number of contacts with services
bull Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
bull Service Type
bull Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
bull 43 of all service users had an inpatient admission during 201213
4 Please see Appendix 1 for a summary of the characteristics of each sub-group
Percentile No of People Activity Total Cost Cost Avge Cost
Very High (Top 2) 616 33359 pound24868675
236 pound40371
High (2 to 10) 2464 96092 pound36372609 346 pound14762
Medium (10 to 50) 12324 174418 pound39216104 373 pound3182
Low (Bottom 50) 15401 51118 pound4747647 45 pound308
No service 10682 0 pound0 00 pound0
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 8
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups4 Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
bull Average age
bull Ratio of Females to Males
bull Average deprivation score
bull Average number of services used
bull Average number of contacts with services
bull Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
bull Service Type
bull Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
bull 43 of all service users had an inpatient admission during 201213
4 Please see Appendix 1 for a summary of the characteristics of each sub-group
Percentile No of People Activity Total Cost Cost Avge Cost
Very High (Top 2) 616 33359 pound24868675
236 pound40371
High (2 to 10) 2464 96092 pound36372609 346 pound14762
Medium (10 to 50) 12324 174418 pound39216104 373 pound3182
Low (Bottom 50) 15401 51118 pound4747647 45 pound308
No service 10682 0 pound0 00 pound0
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 9
bull 86 of Services Users in the High Group had an inpatient admission in 201213
bull This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndash How the cohorts compare against the average
Very High
High
Medium
Low
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbull More likely to have any Long Term Condition particularly Depression and Dementia
bull Higher than average number of condition groups contacts with services and dependency on HampSC services bull High ratio of females to males and higher average age and deprivation score bull More likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbull More likely to have any Long Term Condition particularly CKD and Heart Failure
bullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebull Less likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and Hypertension
bullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebull Less likely to receive any of the services particularly Social Care Packages and Continuing Healthcarebull Less likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this I At least two main approaches will be required by the health and social care economy bull A range of measures aimed at pro-actively managing the very high cost group to
realise potential benefits that come from significantly reducing the unit cost of provision bull A range of interventions aimed at the high cost group that will achieve savings by a
small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 10
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 11
Potential programmes of work within the case for change There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
P
erm
anen
t adm
iss-
ions
to R
H a
nd N
H
Pro
porti
on a
t hom
e 91
da p
ost d
isch
arge
Avo
idab
le
adm
issi
ons
Pat
ient
exp
erie
nce
Rat
e of
dem
entia
di
agno
sis
DTO
C
Early intervention and information Management of falls
Implement an integrated pathway
Advice and information hub
Increased knowledge of appropriate services and programmes
Telecare telehealth
Introduction of technology into certain HampSC pathways
Carers strategy Review of carers needs and carers support
Dementia strategy Improving diagnosis of dementia across Solihull
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
Care navigation frailty screening
Currently building a research project
Out of hospital care Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
Virtual wards Thorough review and new model design for current service
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
Hospital transformation Urgent care Improve and integrate UC services on
Solihull site
Ambulatory care Develop AC service for patients with
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 12
multiple morbidities frail elderly Mental Health Review access to urgent mental
health service within UC
Other interventions with the potential to contribute This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways5
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme6
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes Remote monitoring telehealth Integrated discharge to assess Management of the declining patient End of life care Self-care Enhanced carer support Falls prevention Recovery reablement and rehabilitation Integrated Urgent Care management structure Single point of access
Elective care
Potential Intervention Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
Single referral structure including GP decision aid
Site consideration for service delivery
5 This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis 6 This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 13
Financial impact of implementing integrated care
Impact of ICASS programme The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
Alternative Service Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care 1242 10656 2992849 2179474 1003229 Psychiatric Inpatient 31 220 65014 54670 83279 Nursing Home 174 1284 374852 305294 117069 Residential Home 99 808 229591 173227 54663 Bed-based EoLC 0 0 0 0 0 Home-based Im care 36 368 99563 63887 34531 Home Psychiatric 18 184 49781 31943 6700 Home clinical 410 3676 1022010 720556 185893 Home care 203 1764 493731 355670 35033 Home 317 3016 826967 556546 0 Other 18 184 49781 31943 49781 Total 2548 22160 6204139 4473211 1570179
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
bull A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
bull This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
bull For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
bull 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds7
7 95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 14
Length of stay
Alternative Service Acute Bed
Days Commissioner
savings8
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care 18750 806267 3255968 1765215 Psychiatric Inpatient 291 12511 50522 99503 Nursing Home 4770 205118 828334 434769 Residential Home 2364 101640 410457 159889 Bed-based EoLC 582 25021 101044 54781 Home-based Rehab Im care 812 34917 141005 76214 Home Psychiatric 406 17458 70503 4466 Home clinical 6266 269439 1088082 745656 Home care 8061 346623 1399777 160090 Home 7042 302801 1222808 0 Other 406 17458 70503 70503 Total 49750 2139253 8639003 3571086
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
bull A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
bull An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
bull The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
bull 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
8 Savings via excess bed days and short stay tariffs
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 15
Summary The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
The total gap between income and expenditure for older peoplersquos services will be pound298m
Net savings from the avoided admissions (including cost of provision of alternative) pound46m
Net savings from reduced length of stay (including cost of provision of alternative) pound51m
Likely potential gap remaining will be pound201m
This breakdown is shown in the table diagram below
Options for bridging the remaining gap The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
pound46m
pound201m pound298m
pound51m
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 16
Transformed care scenario This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Very high to high 14 patients per GP High to medium 55 patients per GP Medium to Low 271 patients per GP
Low to ldquoout of cohortrdquo 336 patients per GP
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 17
Delivering integrated care Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 18
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
bull The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
bull The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
bull The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 19
significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
bull ICASS Board to consider (accept reject modify) the Case for Change bull Programme team to determine overall approach to designing the new integrated care
model and set out a high level project plan bull Design clinical service blueprint (incorporating existing work programme) bull Programme Board sign off high level design bull Detailed design process to provide service specifications bull Programme Board sign off detailed design bull Implementation and or procurement process
Programme of work The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 20
Appendix 1 Characteristics of sub-groups The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 21
Solihull Profiles
Profile of Health and Social Care Service Users
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 22
Solihull Service Profiles
Solihull Disease Cohorts
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
ICASS Case for Change v80
Page 23
- Executive summary
- Contents
- Objective
- The scale of the challenge for Solihull
-
- The gap between funding supply and increasing demand ldquojaws of doomrdquo
- National context
- Solihull context
- Current cost of provision older people
-
- Key findings2F
- Overall cost
- Cost by cost sub-group
-
- Summary
-
- Potential programmes of work within the case for change
-
- Current ICASS Programme of work
- Other interventions with the potential to contribute
-
- Financial impact of implementing integrated care
-
- Impact of ICASS programme
- Other interventions
- Summary
- Options for bridging the remaining gap
-
- Transformed care scenario
-
- Changing the nature of care provision
-
- Delivering integrated care
-
- Critical success factors
- Enablers for change
-
- Next steps
-
- Programme of work
-
- Appendix 1 Characteristics of sub-groups
-
- Descriptive summary of sub-groups
- Detailed analysis
-
- Profile of Health and Social Care Service Users
- Solihull Profiles
- Profile of Health and Social Care Service Users
- Solihull Service Profiles
-
ICASS Case for Change v80
Integrated Care and Support Solihull (ICASS)
The case for change
Delivering sustainable and high quality health and social care services to the people of Solihull through integrated care interventions
Executive summary
Health and social care is facing increased pressure of real term cuts and increased demand within Solihull For the over 65 age group alone the gap in funding supply and cost of providing care will be approx pound298m by 201819 should services remain in their current form
The Solihull health and social care economy through ICASS is developing a range of interventions that will impact on the cost of provision across Solihull These savings will predominantly be realised from bed reductions in the acute sector as a result of admissions avoidance and length of stay reductions
The impact of these changes may still result in a residual gap of pound201m
Existing programmes are consistent with the broader approach of integrated care being based on the cost of provision and benefits that come from addressing the care provision for older people through improved proactive management and urgent care
Further work is required to develop greater ambition within the existing interventions and identify and design a broader programme of work to further bridge this gap A scenario has been set out that describes the impact of reducing the cost of care to 25 of the population of 65+ age group
Delivering integrated care in Solihull is dependent on five critical success factors
middot Clinical and organisational leadership with Executive sign up
middot Strong and deliberate engagement
middot Business case approach
middot Programme management
middot Innovative finance and contracting
Contents
2 Executive summary
4 Contents
6 The scale of the challenge for Solihull
6 The gap between funding supply and increasing demand ldquojaws of doomrdquo
7 Current cost of provision older people
9 Summary
10 Potential programmes of work within the case for change
10 Current ICASS Programme of work
11 Other interventions with the potential to contribute
12 Financial impact of implementing integrated care
14 Summary
14 Options for bridging the remaining gap
15 Changing the nature of care provision
19 Next steps
20 Appendix 1 Characteristics of sub-groups
20 Descriptive summary of sub-groups
Objective
Integrated Care and Support Solihull (ICASS) have made the pledge to help shape and deliver a better model of health and social care for the people of Solihull As leaders of the partnering organisations we are committed to working together in partnership with the people of Solihull to create and deliver a health and social care system that we can be proud of with better outcomes reduced inequality and the patients at the centre
We believe that integrating care can drive the local health system to providing higher quality care in the most appropriate setting and at the right time for the people of Solihull
It is important that we reach a consensus within our partnership as to the specific interventions that would achieve the best results in terms of improving quality access and cost of care
This document is an important step in reaching this consensus through understanding the current state of services provided across Solihull understanding the cost of provision across the largest users of health and social care services and identifying and evaluating the range of integrated interventions that we could deliver across the three work streams The document sets out
middot The financial gap that exists between the projected available resources across health and social care and the likely cost of provision should current trends continue
middot The programmes of work that the health and social care economy consider most appropriate to deliver a step change in service provision over the next 5 years
middot The likely interventions that will deliver these changes
middot Potential benefits associated with these and likely costs of implementation (based on a set of agreed assumptions)
Integrated care offers the opportunity to provide higher quality more accessible and cost effective care The aim of this document is to make the business case for change for integrated care to support ICASS in making future decisions on how best to develop integrated care within Solihull
The scale of the challenge for Solihull
The gap between funding supply and increasing demand ldquojaws of doomrdquo
There is a projected recurrent gap in the funding supply and cost of providing care This is likely to be in the region of pound298m by 201819 for the over 65 age group alone
Detailed analysis by Central Midlands Commissioning Support Unit has set out the likely gap between funding supply and increasing demand for this age group within Solihull
The projected income assumptions to 201819 were provided by the CGG and LA Given the rate of growth in recent years of the NHS spend on Continuing Healthcare (CHC) the projection was based on the cost pressures estimated by the CSU Continuing Healthcare team in line with the CCG CFO request
National context
The national context for the health and social care has been well described elsewhere At the highest level NHS funding is increasing at a rate significantly below that of demand (measure in activity and complexity) and following the 2013 Spending Review social care funding is seeing real terms cuts of 25 or more This gap between static declining funding and pressures on the system is commonly referred to as the ldquojaws of doomrdquo ie the difference between funding for supply and ever-increasing demand There is a need to do different things not just the same things differently
Solihull context
Every health economy is different with differing barriers and enablers for change Solihull and CCG are broadly coterminous and Community Services are already integrated with Heart of England Foundation Trust (HEFT) These represent a significant enabler for change However the provision of acute care across Heartlands Good Hope Solihull and University Hospitals Birmingham provide a level of complexity
The local population also offers a degree of complexity Solihull has a mix of urban and rural communities with very diverse health needs Additionally Solihull has a broad range of relative affluence with some pockets of deprivation
Current cost of provision older people
Detailed analysis by Central Midlands CSU has matched data for Health and Social Care in Solihull The full report is available separately and summarised here
Key findings
Overall cost
middot There are approx 41394 people aged 65 and over living in Solihull
middot 30805 individual service users were identified in the matched component data with a total cost of pound1052m broken down as follows
Cost by cost sub-group
The CSU report has split the cost of provision by a range of cost groups Each patient is assigned to a group based on the total cost of all of the services that individual receives
In appendix 1 service users falling into each of the 4 cohorts have been compared to the profile of all Solihull over 65 year olds service usage of Health and Social care services The following variables were analysed
middot Average age
middot Ratio of Females to Males
middot Average deprivation score
middot Average number of services used
middot Average number of contacts with services
middot Average number of condition groups assigned to
Appendix 1 also compares each of the 4 cohorts with all users in terms of
middot Service Type
middot Disease Cohorts
The methodology used to compare each cohort against all service users is indexing against the average based on the percentage of service users in each group for example
middot 43 of all service users had an inpatient admission during 201213
middot 86 of Services Users in the High Group had an inpatient admission in 201213
middot This gives an index 200 (ie people in the high group are twice as likely to have an inpatient admission than average)
The summary is as follows
8
Summary ndashHow the cohorts compare against the average
Very HighHighMediumLow
bullRelatively higher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments packages of care and Continuing Healthcare are particularly highbullMore likely to have any Long Term Condition particularly Depression and DementiabullHigher than average number of condition groups contacts with services and dependency on HampSC services bullHigh ratio of females to males and higher average age and deprivation score bullMore likely to receive any service other than outpatients Social care assessments and packages of care are particularly highbullMore likely to have any Long Term Condition particularly CKD and Heart FailurebullHigher than average number of condition groups and dependency on HampSC services bullLower ratio of females to males and slightly higher average age Deprivation score in line with averagebullLess likely to receive Social Care Packages and Continuing Healthcare but more likely to receive the other servicesbullMore likely to have any Long Term Condition particularly Diabetes and HypertensionbullLower than average number of condition groups and dependency on HampSC services bullRatio of females to males in line with average and lower average age and deprivation scorebullLess likely to receive any of the services particularly Social Care Packages and Continuing HealthcarebullLess likely to have any Long Term Condition
It is clear that some of these factors are more less amenable to successful intervention for example some of the service usage patterns and the disease profiles in the lsquovery highrsquo cohort may difficult to alter whereas there may be many effective interventions in the lsquomediumrsquo cohort the clinicalprofessional leadership across all sectors in Solihull are best placed to determine this
I At least two main approaches will be required by the health and social care economy
middot A range of measures aimed at pro-actively managing the very high cost group to realise potential benefits that come from significantly reducing the unit cost of provision
middot A range of interventions aimed at the high cost group that will achieve savings by a small reduction in unit cost but delivered across a high volume of activity The benefits that come from transformational change in this area are also likely to realise benefits in the medium cost group
Summary
The challenge within Solihull is well understood and similar to the challenges facing all health and social care economies This document sets out the scale of the challenge and the context of the cost of provision to the older age group
The next section describes the quantification of the potential interventions that will have an impact on the cost of provision
Potential programmes of work within the case for change
There are a range of interventions currently under development within ICASS that will impact on the cost of provision across Solihull This section summarises the programme of work underway within ICASS and interventions with an evidence base for delivery that are not currently included within ICASS The financial impact of these is also considered
Current ICASS Programme of work
ICASS have identified three priority areas (urgent care dementia and frailty) that will deliver financial and quality benefits through a programme broken down into three workstreams early intervention and information out of hospital care and hospital transformation
Each of these workstreams has a series of interventions within their programme of work at varying levels of deployment Benefits are clearly identified in a small range of areas as described below Quantification has not been consistently identified
Other interventions with the potential to contribute
This case for change is based on the cost of provision and benefits that can come from addressing the care provision for older people through improved proactive management and urgent care There are a suite of other interventions that can help support the delivery of integrated care across the elective and womenrsquos amp childrenrsquos pathways
This section reviews the interventions which have an evidence base of success and considers whether they are included within the ICASS work programme
Other proactive management and urgent care
Evidence from other health economies provides a range of options the majority of which are included within the existing programme of work within ICASS The broad range of options are described below along with consideration of whether they are currently included within ICASS work
Elective care
Financial impact of implementing integrated care
Impact of ICASS programme
The quantifiable potential benefits identified from the existing ICASS programmes of work are focused around admissions avoidance and length of stay This is consistent with the focus on moving patients care closer to home
Detailed analysis by the CSU has identified the potential savings realisable from admissions avoidance and length of stay within HEFT as a result of these three programmes of work
The cost of alternative analysis is calculated using cost assumptions agreed by a finance working group incorporating nominated finance leads from each ICASS organisation Full details of these assumptions are available upon request
Admission avoidance
This table outlines that the total savings and costs that may result from admissions avoidance The savings would be demonstrated as
middot A pound6204k saving from the commissioner spend with the current providers Alternative cost of provision would be pound1570k leaving a net benefit of pound4634k
middot This would result in a loss of pound6204k income to the providers Assuming that the appropriate marginal costs can be extracted from the cost base a pound4473k saving is realisable This is a shortfall to the provider of pound1731k between lost income and potential costs avoided
middot For the purposes of this analysis the commissioner saving has been used to calculate cost out of the system However it should be recognised that the provider would not be able to extract cost out of the system as a direct result of admissions avoidance
middot 22160 bed days at 95 bed occupancy is the equivalent of 64 acute beds
Length of stay
This table outlines that the total savings and costs that may result from length of stay reductions The savings would be demonstrated as
middot A pound2139k saving from the commissioner spend with the current providers as a result of the impact on excess bed days and short stay tariffs
middot An pound8639k saving as a result of reduction in length of stay to the providers with a cost of alternative of pound3572k A potential saving of pound5068k is therefore available This would be partially off-set in lost income of pound2239k leaving a net saving to the provider of pound2929k
middot The total net saving to the health economy is assumed to be the commissioner savings (pound2139k) and the provider savings minus the lost income (pound2929k) which equates to pound5068k
middot 49750 bed days at 95 bed occupancy equates to 143 acute beds
Other interventions
Other interventions have been described within this case for change either as further developments to the ICASS programme or within other pathways These will have the opportunity to develop additional savings from the implementation of integrated care
These savings are not included within the savings analysis below but will be an important component of how the remaining gap will be bridged
Summary
The diagram below shows the financial gap and the impact of the proposed interventions This shows that by 201819
This breakdown is shown in the table diagram below
Options for bridging the remaining gap
The existing programme of work within older peoplersquos services is likely to leave a residual gap of pound201m The scale of this challenge will require genuine transformational system wide change
To demonstrate the scale of change required the following section sets out the impact on the health and social care system of an assumed scenario of transferring 25 of each sub-group of patients (as described in the cost of care section above) into the next lowest level of cost By transferring 25 of each sub-group a potential saving of pound245m could be realised
Transformed care scenario
This scenario assumes care is provided in a way that moves the cost of provision down a sub-group and details what this would mean at practice level
This is calculated by applying the growth assumptions included in the income analysis to identify the project activity levels in 201819 and then applying a 25 reduction in the very high cost group This will then increase the numbers in the high cost group This revised value is then reduced by 25 This approach continues down the triangle
Changing the nature of care provision
This table sets out some detailed financial analysis that is based heavily on primary care increasing interventions in a way that moves patients to a lower acuity cost group This will require fundamental change within primary care To help describe what this will entail the table below shows the volume of patients that each individual GP within Solihull would need to manage into a different sub-group
Essentially this will require each GP to provide more intensive care to a range of patients that will allow a material impact on the cost of care for 676 patients per GP Further work will be required to ensure the programmes of work will deploy the resource required within primary care to deliver this impact
Delivering integrated care
Significant progress is being made towards improving the efficiency and quality of services through integration There is a major programme of work underway One major component of this is the Solihull Urgent Care Business Case The process that the health amp social care economy has been through to deliver the sign off of the Business Case demonstrates the positive outcomes that can be delivered within the integrated care agenda The lessons learnt from this will be critical to the success of delivering benefits through integrated care
Critical success factors
Clinical and organisational leadership with Executive sign up
Leadership is the single biggest contributory factor to the success or failure of a complex change programme Everyone in the health and social care economy needs to understand believe in and support the delivery of an integrated approach to care
The leadership of the health amp social care economy must build consensus around the clinical models of care The existing ICASS governance structure is a robust vehicle to take this forward and design of a detailed future blueprint and implementation strategy
Leadership at different levels within the economy will deliver the changes ICASS should consider how to build or develop further effective networks which will help create sustainable services Multi-disciplinary teams will be required to promote prevention self-management risk stratification pro-active assessment and rapid management of deteriorating patients
Strong and deliberate engagement
This case for change is sets out the overarching financial benefits that can be delivered from an integrated care programme The detailed blueprint required to implement changes is still to be developed with some major components already underway However ICASS should consider a strong and deliberate approach to engagement beyond this case for change
Meaningful engagement with patients service users carers and service providers should take place at the design phase Much positive work is taking place through the existing workstreams and ICASS could consider how to expand this into a cohesive approach to patient public and organisational engagement to ensure that new service models are genuinely built from the bottom up
Business case approach
A robust and detailed business case will be a key tool the system to underpin any changes within the system This document will need to make the financial case for change through integration It also outlines the interventions that will be required to deliver this change However a detailed business case will enable the programme to be rigorous in its pursuit of clinical outcomes and financial benefits The business case can only be delivered on the back of the strong and deliberate engagement in designing new models
Programme management
A rigorous programme management is essential to make sure that a detailed business case is delivered and subsequently implemented
Innovative finance and contracting
Solihull will need to consider how the key commissioners (Local Authority Local Area Team CCG) can use contracting mechanisms to promote provider collaboration The benefits identified within Solihull and the evidence from elsewhere clearly demonstrates the benefits delivered at an economy level will significantly impact on the acute providers Finance and contracting arrangements will need to recognise the impact that this will have on HEFT
Enablers for change
ICASS will need to consider four specific enablers to delivering integrated care
Finance and contracting
As described above any blueprint for change is likely to require system wide change where the cost income and profitability of individual organisations is materially affected The contracting mechanism for delivering services in an integrated environment needs to promote collaboration to allow a more cost effective delivery model This will drive improved value for money and improved clinical outcomes
Example models that Solihull should consider in detail include
middot The prime contractor model The Local Authority Solihull CCG or a Joint Commissioning body holds the commissioning contract with the prime contractor The prime contractor is then responsible for delivering the service through a range of other partner organisations sub-contracting organisations
middot The joint venture model The commissioning management board (LA CCG or Joint Commissioning body) holds the commissioning contract with the Joint Venture Provider
middot The alliance contract All parties would share the Alliance agreement with common objectives and outputs
Each of these models should be considered in detail as part of a detailed business case It is important that the model of care is designed first in order that the relative benefits of each model can be assessed against delivering the required model
Workforce
To deliver a large reduction in service cost will require a significant change in workforce roles structure and organisational location In an integrated environment a system wide workforce model will be required that delivers the right roles in the right numbers Employees may also need to be flexible in their hosting organisation to support the transfer of costs
Estates
Current models of care across the NHS and local authority landscape are often designed around buildings The estate footprint of an integrated care economy may change significantly ICASS will need to consider how and where services are located in acute and other settings The impact of the Urgent Care Business Case is a good example of this
IMT
Further details to follo
Next steps
A great deal of work is underway within Solihull and under the ICASS Board and significant progress is being made across the health and social care economy
The ICASS Board are asked to consider this case for change and agree the potential next steps These could include
middot ICASS Board to consider (accept reject modify) the Case for Change
middot Programme team to determine overall approach to designing the new integrated care model and set out a high level project plan
middot Design clinical service blueprint (incorporating existing work programme)
middot Programme Board sign off high level design
middot Detailed design process to provide service specifications
middot Programme Board sign off detailed design
middot Implementation and or procurement process
Programme of work
The diagram below is a summary of the existing work programme identifying the relative benefits and ease of implementation for each intervention This demonstrates the areas that the Programme Team can prioritise resources on
Appendix 1 Characteristics of sub-groups
The table below describes the key characteristics of each group Each group is best described as to how those contained within the sub-group compare to the average of a number of indicators The sections below provide a brief descriptive summary along with a more detailed analysis of this data
Descriptive summary of sub-groups
Detailed analysis
Profile of Health and Social Care Service Users
Solihull Profiles
Profile of Health and Social Care Service Users
Solihull Service Profiles
Solihull Disease Cohorts
Residual gap pound201m13
13
pound46m13
13
Shortfallpound298m13
13
pound51m13
13
Net savings (bed reductions)13
13
pound46m13
13
pound201m13
13
pound298m13
13
pound51m13
13
13
This is the commitment set out by the combined leadership of the Solihull health and social care economy and included within Pioneer expression of interest13
Detailed report available separately13
Please note significantly greater depth of detail is provided in the Solihull Cost of Care Report available separately13
Please see Appendix 1 for a summary of the characteristics of each sub-group13
This case for change is focused on older peoplersquos care The costs and benefits attributable to womenrsquos and childrenrsquos services are excluded from this analysis13
This case for change considers whether these interventions are being delivered through the ICASS programme Individual organisations and other major change programmes may be addressing interventions in another way but not under the umbrella of providing a co-ordinated approach to integrated care13
95 bed occupancy has been used as to reflect the current costs incurred by HEFT based on the existing bed occupancy levelx 13
Savings via excess bed days and short stay tariffs13
13
Very high to high
14 patients per GP
High to medium
55 patients per GP
Medium to Low
271 patients per GP
Low to ldquoout of cohortrdquo
336 patients per GP
The total gap between income and expenditure for older peoplersquos services will be
pound298m
Net savings from the avoided admissions (including cost of provision of alternative)
pound46m
Net savings from reduced length of stay (including cost of provision of alternative)
pound51m
Likely potential gap remaining will be
pound201m
Alternative Service
Acute Bed Days
Commissioner savings
Marginal Provider Saving
Cost of Alternative
Bed-based Rehab Im care
18750
806267
3255968
1765215
Psychiatric Inpatient
291
12511
50522
99503
Nursing Home
4770
205118
828334
434769
Residential Home
2364
101640
410457
159889
Bed-based EoLC
582
25021
101044
54781
Home-based Rehab Im care
812
34917
141005
76214
Home Psychiatric
406
17458
70503
4466
Home clinical
6266
269439
1088082
745656
Home care
8061
346623
1399777
160090
Home
7042
302801
1222808
0
Other
406
17458
70503
70503
Total
49750
2139253
8639003
3571086
Alternative Service
Acute Spells
Acute Bed Days
Commissioner spend (pound)
Marginal Provider spend (pound)
Cost of Alternative
Bed-based Rehab Im care
1242
10656
2992849
2179474
1003229
Psychiatric Inpatient
31
220
65014
54670
83279
Nursing Home
174
1284
374852
305294
117069
Residential Home
99
808
229591
173227
54663
Bed-based EoLC
0
0
0
0
0
Home-based Im care
36
368
99563
63887
34531
Home Psychiatric
18
184
49781
31943
6700
Home clinical
410
3676
1022010
720556
185893
Home care
203
1764
493731
355670
35033
Home
317
3016
826967
556546
0
Other
18
184
49781
31943
49781
Total
2548
22160
6204139
4473211
1570179
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Single end-to-end integrated service for individual pathways
(
Single referral structure including GP decision aid
(
Site consideration for service delivery
(
Potential Intervention
Included within programme
Within programme greater opportunity available
Not included within programme
Management of patients in care homes
(
Remote monitoring telehealth
(
Integrated discharge to assess
(
Management of the declining patient
(
End of life care
(
Self-care
(
Enhanced carer support
(
Falls prevention
(
Recovery reablement and rehabilitation
(
Integrated Urgent Care management structure
(
Single point of access
(
Permanent admiss-ions to RH and NH
Proportion at home 91da post discharge
Avoidable admissions
Patient experience
Rate of dementia diagnosis
DTOC
Early intervention and information
Management of falls
Implement an integrated pathway
(
(
Advice and information hub
Increased knowledge of appropriate services and programmes
(
(
(
(
(
Telecare telehealth
Introduction of technology into certain HampSC pathways
(
(
(
(
Carers strategy
Review of carers needs and carers support
(
(
(
(
Dementia strategy
Improving diagnosis of dementia across Solihull
(
(
(
(
(
Healthcare support to NHRH
GP input to RHs and NHs including ward rounds healthcare assessment
(
(
(
(
Care navigation frailty screening
Currently building a research project
(
(
(
(
(
(
Out of hospital care
Home based intermediate care
Integrate amp expand home based inter-mediate services inclg reablement
(
(
(
(
(
Bedded intermediate care
Review capacity criteria and commissioning of interim beds
(
(
(
(
(
Joint commission-ing of NHRH beds
Review commissioning of long term amp CHC beds Improved service spec
(
(
Virtual wards
Thorough review and new model design for current service
(
(
(
(
(
(
Integrated LTC pathways
Vertical integration of each pathway including virtual wards
(
(
(
(
(
(
Hospital transformation
Urgent care
Improve and integrate UC services on Solihull site
(
(
(
Ambulatory care
Develop AC service for patients with multiple morbidities frail elderly
(
(
Mental Health
Review access to urgent mental health service within UC
(
(
(
Percentile
No of People
Activity
Total Cost
Cost
Avge Cost
Very High (Top 2)
616
33359
pound24868675
236
pound40371
High (2 to 10)
2464
96092
pound36372609
346
pound14762
Medium (10 to 50)
12324
174418
pound39216104
373
pound3182
Low (Bottom 50)
15401
51118
pound4747647
45
pound308
No service
10682
0
pound0
00
pound0
Version Control
Version 81
30th April 2014
Summary of update
Revised financial values following finance working group review
Inclusion of description of component groups
Inclusion of impact on GPs of changes to care setting
Document Owner
Gareth Robinson garethdrobinsonukpwccom
Chart1
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
| 201213 | 201213 | 201213 | |||
| 201314 | 201314 | 201314 | |||
| 201415 | 201415 | 201415 | |||
| 201516 | 201516 | 201516 | |||
| 201617 | 201617 | 201617 | |||
| 201718 | 201718 | 201718 | |||
| 201819 | 201819 | 201819 |
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
Sheet3
Chart1
Sheet1
Sheet1
Sheet2
Sheet3
_1463380147xls
Chart1
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
| 201213 | 201213 | 201213 | |||
| 201314 | 201314 | 201314 | |||
| 201415 | 201415 | 201415 | |||
| 201516 | 201516 | 201516 | |||
| 201617 | 201617 | 201617 | |||
| 201718 | 201718 | 201718 | |||
| 201819 | 201819 | 201819 |
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
| 201213 | 201213 | 201213 | |||
| 201314 | 201314 | 201314 | |||
| 201415 | 201415 | 201415 | |||
| 201516 | 201516 | 201516 | |||
| 201617 | 201617 | 201617 | |||
| 201718 | 201718 | 201718 | |||
| 201819 | 201819 | 201819 |
Sheet1
Sheet1
Sheet2
Sheet3
_1463380147xls
Chart1
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
| 201213 | 201213 | 201213 | |||
| 201314 | 201314 | 201314 | |||
| 201415 | 201415 | 201415 | |||
| 201516 | 201516 | 201516 | |||
| 201617 | 201617 | 201617 | |||
| 201718 | 201718 | 201718 | |||
| 201819 | 201819 | 201819 |
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
Sheet1
Sheet2
Sheet3
_1463380147xls
Chart1
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
| 201213 | 201213 | 201213 | |||
| 201314 | 201314 | 201314 | |||
| 201415 | 201415 | 201415 | |||
| 201516 | 201516 | 201516 | |||
| 201617 | 201617 | 201617 | |||
| 201718 | 201718 | 201718 | |||
| 201819 | 201819 | 201819 |
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
Sheet2
Sheet3
_1463380147xls
Chart1
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
| 201213 | 201213 | 201213 | |||
| 201314 | 201314 | 201314 | |||
| 201415 | 201415 | 201415 | |||
| 201516 | 201516 | 201516 | |||
| 201617 | 201617 | 201617 | |||
| 201718 | 201718 | 201718 | |||
| 201819 | 201819 | 201819 |
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
Sheet3
_1463380147xls
Chart1
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
| 201213 | 201213 | 201213 | |||
| 201314 | 201314 | 201314 | |||
| 201415 | 201415 | 201415 | |||
| 201516 | 201516 | 201516 | |||
| 201617 | 201617 | 201617 | |||
| 201718 | 201718 | 201718 | |||
| 201819 | 201819 | 201819 |
Chart1
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
| 201213 | 201213 | 201213 | |||
| 201314 | 201314 | 201314 | |||
| 201415 | 201415 | 201415 | |||
| 201516 | 201516 | 201516 | |||
| 201617 | 201617 | 201617 | |||
| 201718 | 201718 | 201718 | |||
| 201819 | 201819 | 201819 |
Sheet1
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
| Inflation | 250 | ||||||||||||||||||||||||||||||||||
| Spend | Budget CCG | Budget MBC | Total Budget | Budget CCG Real | Budget MBC Real | Total Budget Real | Increased Spend | Reduced Income (Real) | Forecast Income (Real) | Net Pressure | Health | Social care | |||||||||||||||||||||||
| 0 | 201213 | 108322727 | 84503000 | 25723589 | 110226589 | 84503000 | 25723589 | 110226589 | 0 | 0 | 0 | 0 | 201213 | ||||||||||||||||||||||
| 1 | 201314 | 112515579 | 85777558 | 24200000 | 109977558 | 83685422 | 23609756 | 107295178 | 4192853 | -2931411 | 201314 | -7124263 | 201314 | -817578 | -2113833 | ||||||||||||||||||||
| 2 | 201415 | 116047257 | 87247601 | 24100000 | 111347601 | 83043523 | 22938727 | 105982250 | 7724531 | -4244339 | 201415 | -11968870 | 201415 | -1459477 | -2784862 | ||||||||||||||||||||
| 3 | 201516 | 119384898 | 88982623 | 23879977 | 112862600 | 82629211 | 22174933 | 104804144 | 11062171 | -5422444 | 201516 | -16484616 | 201516 | -1873789 | -3548656 | ||||||||||||||||||||
| 4 | 201617 | 122977360 | 90514690 | 24085423 | 114600113 | 82001842 | 21820204 | 103822046 | 14654634 | -6404543 | -6404543 | -21059176 | 201617 | -2501158 | -3903384 | ||||||||||||||||||||
| 5 | 201718 | 126648328 | 92072735 | 81378882 | 21102793 | 102481674 | 18325602 | -7744914 | -26070516 | -4620796 | |||||||||||||||||||||||||
| 6 | 201819 | 130340605 | 80851347 | 20489548 | 101340895 | 22017879 | -7744914 | -29762793 | |||||||||||||||||||||||||||
| -7124 | |||||||||||||||||||||||||||||||||||
| -11969 | |||||||||||||||||||||||||||||||||||
| -16485 | |||||||||||||||||||||||||||||||||||
| -21059 |
Sheet1
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
Sheet2
Sheet3
| Total allocation (Dan Gils) | ||||||
| CCG | Spend OP | |||||
| 201213 | 260227 | 84503 | ||||
| 201314 | 264152 | 857775575017 | ||||
| 201415 | 268679 | 87247601275 | ||||
| 201516 | 274022 | 889826231175 | ||||
| 201617 | 27874 | 905146899438 | ||||
| 201718 | 283538 | 920727350121 | ||||
| 201819 |
