Integrating Health and Social Care in the UK: Progress, Policy and Practice

Dr Nick Goodwin CEO, International Foundation for Integrated Care

www.integratedcarefoundation.org

Paper to IBM Cúram Research Institute & IFIC Smarter Care Initiatives in Europe: Leadership Approaches, Care

Management Strategies, and Evidence-Based Practices 1st April 2014, Brussels

The United Kingdom 4 Countries = 4 Care Systems

Integrated Care in Northern Ireland, Scotland and Wales

Northern Ireland

• An integrated health and social care system since 1973

• Commissioner provider separation remains

• Dominated by acute hospital provision

• Surprisingly little programme with integrated care at a clinical and service level

Integrated Care in Northern Ireland, Scotland and Wales

Scotland • Integrated NHS structure

since 2004 when commissioner-provider split ended

• Health and social care now being brought together into single organisations with pooled budgets

• Significant progress on : – integrated care in rural areas

(e.g. NHS Highland) and – Integrated care for certain

chronic diseases as a result of managed clinical networks

Integrated Care in Northern Ireland, Scotland and Wales

Wales • Followed example of Scotland

to end commissioner-provider split in 2009

• Integrated care driven by unified local health boards

• Local authorities continue to have responsibility for social care

• Significant growth in joint health and social care organisations bringing networks of staff groups together to deliver care (e.g. in Pembrokeshire)

Integrated Care in Northern Ireland, Scotland and Wales

Key Observations • Structural solutions and payment

reforms are insufficient • Integrated care needs policies

that promote and support integrated care at a local level – e.g. governance arrangements that better enable health and social care to work together

• Organisational stability, leadership continuity and a willingness to introduce new models of care needs to be nurtured

• Policy, professional, organisational, cultural and behavioural barriers are persistent barriers to change

The NHS in England has 1.3m workers (1.7m in the UK. It is the fifth largest workforce in the world

Integrated Care in England: The English NHS

1. US Department of Defense – 3.2m 2. People’s Liberation Army, China – 2.3m 3. Walmart – 2.1m 4. McDonald’s – 1-.9m 5. UK NHS – 1.7m 6. China National Petroleum Corporation –

1.6m 7. State Grid Corporation of China – 1.5m 8. Indian Railways – 1.4m 9. Indian Armed Forces – 1.3m 10. Hon Hai Precision Industry (FoxConn) – 1.2m

Source: BBC News On-Line, 20 March 2012

An unprecedented financial challenge

The Structure of the English NHS, January 2014

Clinical

NHS ENGLAND

Clinical commissioning

groups Health and

Wellbeing Boards

NHS Future Forum

• Focus on integration and collaboration a dominant theme in consultation

• Recognition that current system too fragmented – NHS, public health, social care

– Primary, community, secondary care

• Need to better integrate care around needs of user

• But, fears that reforms will worsen fragmentation and undermine integrated care

• Recommendations to DH:

Collaboration essential for the delivery of high quality care

Future Forum 2!

Jan 2012

Ten Key Elements for Reform

1. Provide a compelling and supporting narrative for integrated care

– Keep patient and carers perspective at centre

– Recognise that integrated care is a key to a more sustainable system

– Outline what success looks like, be driven by clear and measurable goals that are evaluated

– Focus on clinical/service integration, not organisational/structural

Ten Key Elements

2. Allow innovations in integrated care to embed

– Time

– Permission to experiment

– Embed as a core way of working (not a side issue)

– Progress monitored to outcomes based on agreed, clear and measurable goals

– Help identify and remove barriers

Ten Key Elements

3. Align financial incentives

– Paying for good outcomes in care that avoid perverse incentives

– Alternatives to existing tariffs needed – e.g. bundled payments, ‘year of care’, pre-paid capitation

– Pooled budgets

– Quality-based incentives across care pathways

– Personal health budgets?

Ten Key Elements

4. Support commissioners in developing new types of contracts withy providers

– Prime contractor model (e.g. ICOs/ACOs)

– Population-focused

• For certain population groups (e.g. frail elderly)

• For patients with specific diseases (e.g. a long-term condition)

• For clients with specific problems (e.g. drug and alcohol)

Ten Key Elements

5. Allow providers to take financial risks

– Develop integrated care partnerships where health and social care professionals/ organisations take on financial responsibility for delivering services

– Enables ‘make or buy’

– Not-for-profit

– Incentives linked to quality of care and outcomes, not through budget-savings

Ten Key Elements

6. Develop system governance and accountability that support integrated care

– Central expectation for integrated care where this benefits individuals (i.e. across DH, NCB, Monitor, CQC, PHE)

– Adopt single outcomes framework (or at least ensure close alignment)

– Powerful lever for system change locally

– Clarity on regulatory and performance management essential

Ten Key Elements

7. Ensure clarity on the interpretation of competition and integration rules

– Means not ends – proportionate approach

– Integrated care ‘hard wired’ into future system

– Primary duty of Monitor to protect and promote interests of patients and the public

– NCB and Monitor to work closely and provide guidance to commissioners and providers

Ten Key Elements 8. Set a more nuanced interpretation of patient choice

– Patient choice intrinsic to integrated care when developing care and treatment options

– Policy too often used as a tool to promote competition, and mitigates against new forms of integrated care that may benefit people

“choice is much more than the ability to choose a different provider of elective surgery. It is about the choice of care and treatment, the way care is provided and the ability to control budgets and self-manage conditions.”

Ten Key Elements

9. Support programmes for leadership and organisational development

Unlikely to happen at ‘scale and pace’ without a wide range of support including:

• Leadership, engagement, trust, legitimacy, vision

• Networks that share learning and ideas

• Skills and competencies

– Procurement process, contract currencies, incentive schemes, prime contractor model, risk-sharing

– Information technology – governance, interoperability and shared patient records

Ten Key Elements

10. Evaluate the impact of integrated care

– Triple Aim – patient experiences, care outcomes, cost-effectiveness

– Important for accountability and quality improvement purposes

– Clearly defined and measurable goals essential

– Baseline data, comparative studies

– In-depth investigation of care co-ordination

The ‘Narrative’ by National Voices

• Consultation process with public

and patients on what integrated care should mean to them

• Creation of ‘I’ statements on what people should expect

• Reframing of integrated care to read: “people-centred care co-ordination”

Core Statement

“I can plan my care with people who work together to understand me and

my carer(s), allow me control and bring together services to achieve the

outcomes important to me.”

National Collaboration for Integrated Care

National Collaboration for Integrated Care

The national partners will be part of an on-going and sustained collaboration to remove national barriers,

develop new tools, and facilitate local efforts [for

integrated care]

National Collaboration for Integrated Care

Some Key Commitments • Align information and governance

systems • Develop a pioneer programme

with funding to support acceleration of integrated care in key localities and accelerate learning across the system

• Systematic evaluation of progress and impact over time

• New ways of measuring people’s experiences of integrated care and support

• New funding support • A national resource – Integrated

Care and Support Exchange (ICASE) – to bring together practical experiences

The Integrated Care Pioneers

Barnsley

Cheshire

Cornwall

Greenwich

Islington

Kent

Leeds

London WELC

North Staffs

North West London

South Devon & Torbay

South Tyneside

Southend

Worcestershire

In May 2013, the national partners established an invitation to tender to support innovative people-centred care co-ordination. Over 100 expressions of interest provided. In November 2013, 14 pioneers were selected:

Further details at: https://www.gov.uk/government/news/integration-pioneers-leading-the-way-for-health-and-care-reform--2

Characteristics: Mostly health and social care partnerships rather than NGOs that bring together primary and secondary care with local authority services.

Main focus is on :

- Older people with complex needs

- Care planning

- Holistic care

- Coordinated care

- Joint emergency response teams

- Children

Measures of Integrated care

• No single indicator – existing measures and indicators do not capture the concept of person-centred care co-ordination

• New survey to be developed

• Focus on tangible experiences with care co-ordination

http://www.pickereurope.org/assets/content/pdf/Project_Reports/P2636_Integrated%20care%20report_post%20final%20edits_v7%200.pdf

Better Care Fund

Key performance metrics: • Reduce admissions to hospital

and residential care homes • Effectiveness of re-ablement • Delayed transfers of care • Avoidable emergency

admissions • Patient/service user experience

In 2015/16 existing budgets will be pooled to create a £3.8bn fund Health and wellbeing boards and CCGs get first ‘go’ at bids which must: - Prevent admissions, especially

at weekends - Better data sharing between

health and social care - Joint assessments and care

planning - User engagement and political

buy-in - Sound business plans to

reduce utilisation of institutional care

Typical Examples of Integrated Health and Social Care in the UK

To illustrate who integrated care is for, the following slides look at some key care groups to whom integrated care is most suitable. Examples of integrated care from around the UK are provided to

illustrate how integrated care has been achieved.

Integrated care for frail older people

Torbay Care Trust Integrated health and social care teams, using pooled budgets and serving localities of c.30,000 people, work alongside GPs to provide a range of intermediate care services. By supporting hospital discharge, older people have been helped to live independently in the community. Health and social care co-ordinators help to harness the joint contributions of team members.

The results include reduced use of hospital beds, low rates of emergency admissions for those over 65, and minimal delayed transfers of care. (Thistlethwaite, 2011)

North Somerset As one of 29 sites involved in the DH Partnership for Older People Project (POPP), four fully integrated and co-located multi-disciplinary teams provide case management and self-care support to older people. The aim is to prevent complications in diseases and deterioration in social circumstances.

Based around clusters of GP practices, the service brings together community health and social care workers, community nurses, adult social care services, and mental health professionals.

(Windle et al, 2010)

Integrated care for people living with multiple long-term health and social care needs

Hereford An integrated care organisation

In Hereford, an integrated care organisation based on eight health and social care neighbourhood teams is in development to support the personal health, well being and independence of frail older people and those with chronic illnesses such as diabetes, stroke and lower back pain.

Early successes include lower bed utilisation and reductions in delayed discharges from hospitals

(Woodford, 2011)

Wales Chronic Care Demonstrators

In Wales, three Chronic Care Management (CCM) Demonstrators in Carmarthenshire, Cardiff and Gwynedd Local Health Boards have pioneered co-ordinated care for people with multiple chronic illness. By employing a ‘shared care’ model of working between primary, community, secondary and social care the three demonstrators were able to reduce the total number of bed days for emergency admissions for chronic illness by 27%, 26% and 16.5% between 2007-2009. This represented an overall cost-reduction of £2,224,201 . (NHS Wales, 2010)

Integrated care for people with specific diseases

NW London Integrated Care A ’virtually’ integrated care organisation

In NW London, a large scale change programmes was developed with the aim of integrateing care to people with diabetes (also for older people more generally) . It involved (in 2012) 103 GPs, 2 hospitals, 2 MH providers, 2 NGOs. The organisation works as a ‘virtual’ and voluntary organisation with the separate organisations having contractual agreements between them. The members, the majority of which are GPs, can utlilise an innovation fund of c.£0.5 million per year. The focus on care planning has revealed greater awareness of people with conditions that need treating. No evidence of reduced hospitalisations but some of better management risk factors Curry et al, 2013 in IJIC http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN%3ANL%3AUI%3A10-1-114735/2018#r10

http://www.kingsfund.org.uk/publications/co-ordinated-care-people-complex-chronic-conditions

• 99% of those wishing to die at home do so • High satisfaction amongst family, carers, staff • Significant cost reduction (c.25%) compared to

‘usual’ care in hospices/hospital settings

Awareness-raising and relationship-building GPs, community staff, hospital consultants, volunteers and local people strengthening its ability to ‘capture’ people nearing the end of life before, or very soon after, a hospital admission.

Holistic care assessment and personalised care plan A single assessment process examines both the health and social care needs of the patient and their family. It also takes into account their personal choices about future care and treatment options.

Multiple referrals to a single-entry point The service accepts referrals from any health professional and also local people. All referrals come into the service and are assigned to a clinical nurse specialist from a single-entry point.

Dedicated care co-ordination The care co-ordinator has a number of roles: acting as the principal point of contact with the patient and their family; effectively co-ordinating care from within a multidisciplinary team and liaising with the wider network of care providers.

Rapid access to care from a multidisciplinary team Both professionals and volunteers can be rapidly deployed by the service to provide care or support to meet the needs of people living at home. The service operates 12 hours a day, with access to an on-call clinician out of hours.

Meeting the Challenge : Key Lessons in the UK Context

Personal Level

• Holistic focus that supports users and carers to live well and be resilient

• Management in the home environment

• Co-producers of care, even at end of life

Clinical & Service Level

• Early and multiple referral points for care co-ordination

• Named care co-ordinators

• Continuity of care

• Multi-disciplinary teams

• Flexible working practices – subsidiarity of role

Community Level

• Role of community integral to care-giving process

• Build awareness, legitimacy and trust

• Volunteers

Functional Level

• Effective communication

• Shared electronic health records helpful

• High-touch / low tech care – need for face-to-face interaction and conversations

Organisational Level

• Effective targeting

• Localised – work in neighbourhoods

• Long-term commitment from local clinical and managerial leaders

• Shared vision – challenge silos

• Operational autonomy

System Level

• Integrated purchasing

• Long-term strategies

• Political narrative

• Aligned incentives

• Focus on improving quality, not reducing cost

Summary of Current Position in England • Great controversy remains over the Government’s integrated care policies

as they combine integration and competition

• However, government has genuinely accepted the narrative on integrated care:

– Cross-government paper pledging long-term support for integration

– The NHS Mandate requires care to be ‘co-ordinated’ around individuals’ needs

– Monitor, the economic regulator, must support integration where this is of benefit to patients

– Measures of integration, specifically from the users’ perspective, are being developed to assess progress and support change

– Evaluation, specifically of the new DH pioneers of integrated care, set up to derive key transferable lessons for other

– The Better Care Fund ‘enforces’ partnership working by asking health and social care agencies to bid for funds top-sliced from their budgets

• There is a groundswell of activity in developing new approaches to integrated care across England

Contact

Dr Nick Goodwin

CEO, International Foundation for Integrated Care

nickgoodwin@integratedcarefoundation.org

www.integratedcarefoundation.org

@goodwin_nick @IFICinfo