System Integration Toolkit - Advancing Quality Alliance · Overview ©2014 Advancing Quality Alliance AQuA’s Integration Domains This diagram shows each of the domain areas Service

Overview ©2014 Advancing Quality Alliance

System Integration Toolkit

Domain Guides and Supporting Information

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Overview

Domain Guides &

Supporting Information

System Integration Framework

& Assessment Tool

System Integration Improvement Resources

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• Welcome • About the System

Integration Toolkit • Improvement

resources: - What is integration

and integrated care? - Initial reading - Policy context - Enablers and barriers - Change management - Vision development - Readiness assessment

• Glossary

• System Integration Framework Assessment Tool User Guide

• Interactive Assessment Tool

• Leadership • Culture • Service User and

Carer Engagement • Service and Care

Model Design • Workforce • Information and IT • Financial and

Contractual Mechanisms

• Governance • AQuA’s Integrated

Community Report • Operational Report • Literature Review

System Integration Toolkit

©2014 Advancing Quality Alliance 2


AQuA’s Integration Domains This diagram shows each of the domain areas

Service and Care Model

Design

Service User and Carer

Engagement

Leadership

Workforce

• Role design • Skills • Capacity

Information and Information

Technology

Financial and Contractual Mechanisms

Culture

Governance

Integration to Improve • Safety • Experience • Effectiveness • Population health • Use of resources

Healthcare

value

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In this section you can access the 8 Domain Guides by clicking on the appropriate box:

Leadership Culture Service User and

Carer Engagement Workforce

Service and Care Model Design

Governance Information and

Information Technology


Overview

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Overview

Integrated Care: Domain Guide

Leadership

Overview

Leadership

5 ©2014 Advancing Quality Alliance


“The evidence of the benefits, in particular to the experience of service users and their

families, seen when organisations and services work together, make a compelling case for care to be co-ordinated around the needs of people and populations. Developing integrated care means overcoming barriers between primary and secondary care, physical and mental health, and health and social care to provide the right care at the right time in the right place.”

Ham, C. Walsh N (2013) Lessons from experience: Making integrated care happen at scale and pace. The King’s Fund, London. p.1

Introduction At this stage people working on and responsible for system level integration should have completed the AQuA Integrated System Framework Assessment Tool. From your initial scores or reassessments you may want to consider the learning from the additional literature to support where your economy needs to be by a specific timescale. System level integration is hard, challenging, but the right thing to do.

The information in this guide has come from an extensive literature search, AQuA’s Integrated Care Faculty knowledge from working members, experts and thought leaders. The guide provides a framework of areas to consider and examples.

Leadership

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https://www.aquanw.nhs.uk/integrated-care/











Overview

•Financial and Contractual Mechanisms Domain Guide

•Information and IT Domain Guide

•Governance Domain Guide System Capability

•Service and Care Model Design Doman Guide

•Workforce Planning Domain Guide

•AQuA’s Integrated Discovery Community Report

•Operational Considerations for Integrated Care

Design

•Vision, aims, scope and measures (see vision development in Improvement Resources and Measurement Tool) Planning

•Service User and Carer Engagement Domain Guide

•System Integration Improvement Resources Foundation

•System Integration Framework and Assessment Tool

•Change management and readiness assessment

•Other System Integration Improvement Resources Readiness

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Roadmap

This roadmap provides a suggested order of implementation rather than a prerequisite, as it is acknowledged that all areas interlink and the local context may affect prioritisation

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Leadership

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1 Commitment

2 Enabling

3 Implementation

4 Embedding

5 Sustainable Delivery

Senior leaders have agreed to work on system integration and be personally engaged in leading integration activity.

There is consensus amongst senior leaders about the scale and scope of system integration with shared objectives and commitment to use resources differently to improve population level outcomes.

Senior leaders are highly visible and act as positive role models, meeting service users, carers and front line staff and giving a single consistent message about the purpose and aims of integration in order to win hearts and minds.

Senior leaders continuously build networks based on relationships with partners and wider stakeholders and build clinical and managerial capability to work effectively within organisations and across pathways.

Senior leaders address gaps or major problems relating to integration together, celebrate shared success and drive continuous quality improvement to achieve a shared purpose, vision and narrative, design a new system architecture and role model and coach desired behaviours.

Leadership

Leadership

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Leadership

Replace heroic models of leadership with ones that seek to distribute influence and decision-making throughout the organisation

(distributed leadership)

Successful leaders will be those who engage staff,

patients and partner organisations in improving

patient care and population health outcomes

Leaders should have commitment and enthusiasm for integration to help them overcome professional and

organisational barriers

Leaders should take a central role in establishing the vision,

goals and values and live these to engage and empower

others

Principles

Leaders can be at different levels within the new way of working – consider models of

collaborative leadership

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Resilience and peer support are vital for leaders to

implement challenging and complex changes


Leadership

Operational level – • Building integrated teams

through distributed leadership

• Innovation to overcome obstacles

Tactical Level – • Emphasis on distributed

leadership • Developing leaders with

the right skill set for successful integration

Strategic Level – • Creating an inspiring vision • System level enablers

Integrated

Teams

Integrated

Services

Integrated

Systems

Translating into practice

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Leadership

What works • “Leader attention should be focused on developing a full set of integrative

processes, with mutually supportive links between clinical, organisational, informational and financial processes, in order to enable the delivery of integrated care for patients” (Rosen et al, 2011, p. 39)

• Understanding roles and responsibilities at a strategic level

• Leadership should be co-ordinated between different professional groups

• Where possible there should be consistency of staff in leadership roles (i.e. longevity of leaders in key positions)

• Key characteristics of leaders should be resilience and persistence – keeping the faith

• Staff in leadership roles need to understand that integration takes time – need to keep focused!

• It is important to invest in leadership development

• Leaders having the ability to engage with staff

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Leadership

• Leaders should be able to work within “dynamic networks”:

– Achieve results through personal influence, not hierarchical power

– Compete in a way that enhances rather than undercuts

– Operate with the highest ethical standards

– Display humility

– Develop a process focus

– Be multi-faceted – spotting opportunities for synergies and alliances

– Gain satisfaction from results – improved systems outcomes as the over riding goal

(Moss Kanter, in presentation by Bradbury, 2012, slide 12)

What works cont.

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Overview

Skills, Knowledge and Behaviours of New Leaders

Technical Know-How - Service design - Governance arrangements - Innovative contracting and financial

mechanisms - Technology “savvy”

Improvement Know-How

- Systems thinking - Improvement science - Large scale change

Personal Effectiveness

- Interpersonal skills and behaviours - Coaching ability - A visionary and participative style - Resilience!

Information from Bradbury, E. (2012) The Clinical Leader’s Role in Integration: Why, what, and how. Salford: AQuA, slide 15

What works cont.

Leadership

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Examples • Canterbury, New Zealand

Canterbury have developed a suite of programmes called ‘8’. David Meates (Chief Executive) states “they are a fundamental part of enabling, of developing the leadership capability, and continuing to expose and challenge those who work in health to look at the problems through a different context. They are the last thing we would cut if times get tough”. Information from Timmins, N., Ham, C. (2013) The quest for integrated health and social care: A case study in Canterbury, New Zealand. London: The Kings Fund. P. 16

• Trafford

“Unsurprisingly, the drive for large-scale change has been highly dependent on effective leadership. At the outset, visionary leaders who were able to paint the broad picture were required. Later, leadership focused on the detailed management of implementation became more critical. Both required credible and influential authority derived not only from their own personality, skills and the dynamics of their relationships with other individuals but also from their working knowledge of the local health system. Such leaders have been vital in persuading colleagues to change their practice, creating a more favourable climate for change, and adapting plans in the light of new developments.” Information from Shaw, S., Levenson, R. (2011) Towards integrated care in Trafford. London: Nuffield Trust. P. 21)

Leadership

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Culture


Culture

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“The evidence of the benefits, in particular to the experience of service users and their families, seen when organisations and services work together, make a compelling case for care to be co-ordinated around the needs of people and populations. Developing integrated care means overcoming barriers between primary and secondary care, physical and mental health, and health and social care to provide the right care at the right time in the right place.” Ham, C. Walsh N (2013) Lessons from experience: Making integrated care happen at scale and pace. The King’s Fund, London. p.1



Culture

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Overview








Design







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Culture



Culture 1

Commitment 2

Enabling 3

Implementation 4

Embedding 5

Sustainable Delivery

There is agreement to work together across partner organisations, including commissioners, all health and social care providers and the voluntary sector to create an enabling culture to support the delivery of integrated care.

All organisations are starting to describe common goals and see the need to work together and support cultural change through organisational development.

All partners are clear about, and committed to, what they will jointly achieve through integration and joint communications.

Integration partners are building trust and commitment in the local community and the voice of all partners has equal weight and value.

All staff are familiar with, and demonstrate, the shared values, and commitment to the vision across the organisations participating in system integration. The concept of “Our Service User” e.g. Mrs Smith is embedded in the culture.

Culture

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Culture

The values of staff need to mirror or be similar to the values of the organisation/

Integrated team

Culture needs to be adaptive to

meet the changing needs of

populations

Clarity is needed on what the new shared culture will look

like in order to deliver integrated care

Culture needs to be focused on meeting the needs of patients, carers and communities rather

than the needs of staff and organisations – build a social

movement

Principles All staff need to be

aware of the desired culture

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Culture

Integrated

Teams

Integrated

Services

Integrated

Systems


Strategic Level - • Focus on developing one

culture across the whole system

Tactical Level – • Leaders are

demonstrating desired cultural behaviours

• Culture audits are in place to measure its success

Operational level – • The new desired culture

is clearly articulated and communicated

• All staff understand and demonstrate the desired cultural behaviours

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Culture

What works

• Once clarity has been gained as to what the desired culture will look like you need to:

– understand what culture is in place now

– be clear as to how you are going to bridge the gap to meet the desired culture

– Develop a strategy to bridge this gap utilising the skills of your OD department

• Staff understanding expectations – make sure this is articulated and communicated

• Senior leader behaviours mirroring the desired culture – key individuals play an important role in linking organisations and cultures

• Recognise that organisations/teams will have developed different cultures and therefore there potentially may be clashes or differences of opinion when people are brought together to work in an integrated way - ensure time is made available so teams can get to know each other, build trust and mutual understanding

• Considering what the consequences are if staff deviate from the desired culture

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Culture

• Understanding how you are going to measure whether the new culture has been implemented and whether it supports meeting the needs of patients, carers and communities

• Ensuring that the behaviours which drive the desired culture remain constant – sometimes cultures develop because of positive or negative reasons (for example there might be a change in culture due to a crisis or an economic downturn)

• Understanding that leaders (whether formal or informal) are by far the most important influencers of culture and need to consistently role model the new behaviours

• Recognising the ‘unwritten rules’ and ‘sub cultures’ which influence behaviours - harness the good and remove or limit as far as possible the bad

• There need to be clear lines of responsibility otherwise strong and weak partners may emerge, changing the desired culture

What works cont.

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Examples • Canterbury, New Zealand

Promoting professional cultures that support teamwork, continuous improvement and patient engagement are key to Canterbury’s success and this is achieved through a suite of programmes called ‘8’ where staff are immersed in system-wide thinking. Information from Timmins, N., Ham, C. (2013) The quest for integrated health and social care: A case study in Canterbury, New Zealand. London: The Kings Fund.

• 6Cs

6Cs is the NHS culture of compassionate care: 1. Care

2. Compassion

3. Competence

4. Communication

5. Courage

6. Commitment Information from NHS (2013) Our Culture of Compassionate Care. London

Culture

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• Improvement Leaders’ Guide: Building and nurturing an improvement culture NHS Institute for Innovation and Improvement

This is a great guide in providing pointers to help you understand culture, its impacts and how to understand your own working culture. (Please note this guide is now only accessible with an existing NHS Institute for Innovation and Improvement log-in)

• Barcelona -

Examples cont.

Culture

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Service User and Carer Engagement









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Overview








Design







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1 Commitment

2 Enabling

3 Implementation

4 Embedding


All partners agree to actively engage service users in co-designing services to meet their needs.

Service user and carer needs and values have been sought and built into integration plans.

Service users and carers are partners in redesign and central to redesign.

Feedback mechanisms for service users and carers are built into integrated services, with appropriate changes being made as a result of this feedback.

Feedback mechanisms indicate significant, sustained improvement in care coordination and experience.



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Principles

Engagement should be a continuous process rather

than a one off event

Service users and carers should be informed as to how their engagement

has helped shape services

A variety of engagement

tools/forums should be used

Engaging service users and carers brings key insights as to

how services can be redesigned to meet their needs

Engagement needs to be meaningful, rather than

tokenistic. Service users and carers often share their

experiences willingly for little or no cost – don’t abuse their

goodwill

Service users and carers should be viewed as equal partners in the re-design of services



Integrated

Teams

Integrated

Services

Integrated

Systems


Tactical Level – • Identification of

potential changes through patient and carer engagement

Strategic Level - • Focus on engaging

communities as partners in redesign

• Agreement across all partners as to the level of engagement

• Use information to redesign services across communities

Operational level – • Collecting feedback • Making changes as a

direct result of feedback received

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Continuum of patient influence

Complaining Giving

information Listening and responding

Consulting and advising

Experienced based Co-design

Experience-based design: from redesigning the system around the patient to co-designing services with the patient

Paul Bate and Glenn Robert Qual Saf Health Care. 2006 October;

15(5): 307-310

What works

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Understanding the continuum of patient influence is a great starting point for service user and carer engagement.


What works cont.

• Be clear as to why patients, carers and communities need to be engaged, i.e. what will hopefully be achieved through this engagement.

• Have clarity as to which patients, carers and communities need to be engaged (i.e. age, geographical area, users of particular services etc).

• Understand what patient, carer, community involvement is already going on, what works well, what doesn’t, and what networks are available to tap into. Don’t forget there is already information out there: www.patientopinion.org.uk, www.iwantgreatcare.org, NHS friends and family test, annual surveys, complaints, Healthwatch etc which can help start building a picture of what people value and want they don’t.

• Be clear as to who will engage with patients, carers and communities. Consider using staff which are experts in this such as Patient and Public Involvement Officers etc.

• Patient, carer and community involvement should be a continual process in the development, implementation and sustainability of redesign but levels of engagement and engagement activity may change at particular points in time. Think about how to engage with service users and carers at each step of the way.


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• A decision needs to be made as to how patients, carers and communities will be engaged with:

Ideally services need to be designed in partnership and through the eyes of the user - consider using experienced based design

Service-user and staff capability to co-design and work constructively as partners can be helped by shared decision making techniques. (see service and care model design domain guide)

Involvement Partnership

Examples: Written,

online, public meetings

Examples: Workshops, meetings, webchats

Examples: Decision making

workshops, meetings etc

Information giving

Information gathering

Consultation

Examples: direct mail, factsheets, newsletters

Examples: User groups,

surveys/ opinion polls,

online forums

What works cont.


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http://www.institute.nhs.uk/quality_and_value/experienced_based_design/the_ebd_approach_(experience_based_design).html



• Ensure organisational policies and procedures aid rather than restrict engagement.

• Look at different ways of engaging hard to reach groups/communities – such as going out into the community instead of expecting people to come to you, use of social media etc.

• Ensure surveys/questionnaires are written properly – it can be easy to unwittingly produce skewed data.

• Consider from the outset how you will measure the impacts of patient, carer and community involvement.

What works cont.

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Examples • Inner North West London Integrated Care Pilot

Representatives from the Patients and Users Committee were appointed full members of the Integrated Management Board and its committees, and have contributed to the development of the Integrated Care Pilot’s policies and

processes. Information from Nuffield Trust. (2013) Evaluation of the first year of the Inner North West London Integrated Care Pilot: Summary. London.

• Trafford

Change on the scale proposed in Trafford has necessitated significant patient and public engagement. This comprised six key elements: – Assessing public/patient opinion through engagement events, neighbourhood forums and a

residents’ survey

– Developing Patient Congress Events

– Recruitment of, and training for, two to three patient representatives within each of the six clinical panels

– Developing a programme of accessible community engagement events

– Increasing resources available to support he establishment of GP-attached patient forums

– Tracking patient experience

For more information see page 16:

Shaw, S., Levenson, R. (2011) Towards Integrated Care in Trafford. London: Nuffield Trust

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Workforce


Workforce

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The information in this guide has come from AQuA’s Integrated Care Faculty knowledge from working with members, experts and thought leaders including The Kings Fund and Health Education North West for the Workforce Domain guide. The guide provides a framework of further areas to consider and examples.

Workforce

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Overview








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Workforce



Workforce 1

Commitment 2

Enabling 3

Implementation 4

Embedding 5

Sustainable Delivery

All partners agree to develop their workforce to support new models of integrated care.

Workforce planning is developed to support new models of care. Education and training is planned to develop a workforce with the skills and values to deliver integrated care, organised around the needs of service users.

New roles and integrated service structures are being developed. Staff share records and are being co-located, making the best use of the combined real estate across partners.

The integrated workforce accesses and uses guidelines to standardise, coordinate, deliver best practice and reduce unwarranted variations or gaps in care Workforce redesign supports integration with new roles/ responsibilities.

Multi specialty generalist and specialist groups of health and social care professionals are accountable for delivering integrated care and demonstrate improved outcomes for their defined population. Shared values creates a single team ethos and continuity of care.

Workforce

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Workforce

Principles

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Utilise skills of health and social care, voluntary and

community assets

Staff need to be engaged from the

start

Within their daily

practice staff need to be given the freedom to

innovate and the improvement skills and

capability to do so

Train staff in new ways of working and develop measurable standards of practice

Co-locate teams wherever possible

Time needs to be given to build trust and understanding

of different roles

Design the workforce model around the principles of self-

management support


Integrated

Teams

Integrated

Services

Integrated

Systems


Tactical Level – • Co-location of staff • Education and training • Shared policies and

procedures • Development of

standards across teams

Strategic Level – • Compelling vision to

engage and empower staff

• Design of workforce to meet demand

Operational level – • Clear lines of

responsibility • Making time to build

trust and understanding • Embrace new way of

working

Workforce

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Workforce

What works

• Engaging and ‘selling’ the vision to staff so they understand and buy-in to the benefits of working in a different way.

• Seeking to bring about change by empowering staff to take responsibility

• Mapping the current workforce (including voluntary and community assets) across all sectors to understand capacity and gaps.

• Planning for the future state through capacity, demand and gap analysis – there needs to be alignment between workforce planning and service/financial planning.

• Starting from community assets build up to ensure you make appropriate and effective use of the most expensive and scarce staff.

• Co-location of teams – building trust and relationships will help new ways of working emerge which can then be developed further through the application of improvement science.

• Establishing clear lines of accountability for staff.

• Developing joint policies and procedures.

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Workforce

• Developing standards for integrated teams to work to.

• Providing training to support staff in the new way of working – training should be delivered collectively to integrated teams rather than in specific clinical groups and the training budget should not be cut when times are tight.

• Staff need clarity on expectations and performance should be continually assessed to ensure embedding and sustainability of the new way of working.

• Continually assessing workforce provision in light of the needs of the integrated model of care co-designed with service users – needs to be less about predictive precision for the future and more about an adaptive and flexible process.

• Pre-empt staffing issues and decide how these can be dealt with (e.g. potential issues around PAYE, staff contracts).

• Design the workforce around principles of self management support and self care. Read more on the principles of self care here on the Skills for Care website. View examples of how self-management has been implemented in practice in ‘People Powered Health’ by NESTA

What works cont.

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http://www.skillsforcare.org.uk/Skills/Self-care/Self-care.aspx













http://www.nesta.org.uk/sites/default/files/health_for_people_by_people_and_with_people.pdf






Workforce

Examples

• Canterbury, New Zealand

Canterbury took the view that their staff were critical to making integrated care happen. An event called the ‘Showcase’ was held where staff were taken through the challenges that the system was facing and they were asked what could be done to make things better, with their ideas being captured by a graphic artist. The showcase lasted for 6 weeks and involved more than 2,000 staff. The information gained from this was instrumental in developing integrated teams and gaining staff buy-in.

In addition, Canterbury has reinvested in the professional pride of clinicians and other staff – taking significant steps to re-empower staff to make changes themselves.

Training has been crucial to Canterbury’s success, where a series of ‘8’ programmes are run, aimed at developing and supporting staff.

HealthPathways, which are in essence local agreements on best practice, have been implemented widely. Information from Timmins, N., Ham, C. (2013)

The quest for integrated health and social care: A case study in Canterbury, New Zealand. London: The Kings Fund.

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Workforce

• Nottingham City Care Partnership

Qualified nurses, social workers, occupational therapists and physiotherapists are all trained in each other’s disciplines up to the level of a general assistant practitioner. This may sound simple, but it is in fact ground-breaking and makes sense to a person in crisis.

Information from HSJ ‘Teach each other holistic care’, 07/02/2014

• Torbay

The use of the fictitious Mrs Smith was instrumental in gaining buy-in from staff. Information from Thistlethwaite , P. (2011) Integrating health and social care in Torbay: Improving care for Mrs Smith.

London: The King’s Fund.

This approach to using a fictitious person is being adopted elsewhere including Salford with the adoption of Sally Ford.

• Health Education West Midlands

The West Midland’s Older Adult Workforce Integration Programme (OAWIP)1 commissioned an evaluation of the evidence and best practice lessons for the workforce for older adult integrated care. View it here

Examples cont.

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http://wm.hee.nhs.uk/files/2014/06/Scoping-Best-Practice-Full-report-11-04-14-HEWM.pdf


Framing the options for workforce redesign

Redistribution - Handing off existing tasks to other workers

Creation - Creating new jobs for work previously not done by anyone

Capacity expansion - Increasing the numbers of nurses, doctors, and other health professionals

Retraining - Changing the job descriptions of existing workers

New (alternative)

worker

Old worker

Old work

New work

Source: Bohmer and Imison Health Affairs, November 2013

Workforce

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1 Commitment

2 Enabling

3 Implementation

4 Embedding


There is agreement to improve care co-ordination as part of a system level plan to develop new services and models of care.

There is agreement about the scale, scope and pace of the integration work, including mapping all community assets, including the estate. The target service user population is clearly identified and risk stratified, and integrated service specifications state the aims and outcomes of clinical redesign of each strata.

New service models are being designed and tested which make the best use of all available resources and community assets to deliver improved quality and costs. The consequence of integration on other parts of the system has been assessed and a contingency plan developed to avoid unintended consequences.

Incentives and mechanisms are in place across integration partners. Clinical practices are aligned and guidelines/pathways have been implemented and embedded.

A systematic programme of economy system level service redesign is well established and resourced by integration partners through the shared governance process.



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Health of the Population

Value for Money

Staff well being and development

Individual Quality of

Care

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Increased access and responsiveness

Aim of improving health and wellbeing, rather than disease

focussed – Triple Aim+1 Services designed around stratified populations of 15

– 50,000

Increasing generalist rather than specialist provision as first

intervention

Principles

Moving whole population focus to address mental

health, homelessness, drug and alcohol dependency


Integrated

Teams

Integrated

Services

Integrated

Systems



Strategic Level - • Ultimately accountable for

care model design and allocation of resources

• Governing body responsible for reviewing system level performance and ensuring the care model is meeting the needs of service users, carers and communities

Tactical Level – • Management across the

care continuum ensuring that service users benefit from integration by receiving integrated care

Operational level – • Multi-disciplinary teams

working together to improve outcomes for patients

• Delivery of evidence based care

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What works • Utilising existing primary and community services and consider links to housing,

criminal justice system, education etc. to support population wellbeing

• Neighbourhood/locality based multidisciplinary teams, including nursing and therapy with:

multidisciplinary team meetings

collaborative goal planning

shared decision making and self management support

shared clinical responsibilities

care co-ordination function for people with complex care needs

case management for people with highest risk

falls prevention & medicines management

• and access to:

‘step up’ facilities including virtual wards, care home and hospital beds with early supported discharge

Specialist decision making

• Defining the role of the acute hospital including virtual consultant and rapid access clinics

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• Case finding to identify unmet and early preventive work

• Range of providers, starting with mobilising informal and voluntary services

• Wide partnerships for planning including police and housing to address social determinants of health and wellbeing

• Sharing of information so it is accessible to all carers and professionals that need the information

• Positive attitudes and behaviours that increase trust and risk sharing

• Investment in workforce development

• Influencing training and education provision to support generalist and team based care

• Growing a stronger community and support for families

What works cont.

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Creating a continuum of care for complex needs

Longitudinal care Episodic care

Primary Care Specialty care Hospital care

Access to care Extended hours and same day appointments Define role of acute and intermediate care facilities

Rapid access, virtual clinics & decision support

Design of care Named GP and Case Manager Shared decision making & self management support

Collaborative goal setting Shared records

Chronic condition management Medicines management

Falls prevention End of life care management

Care co-ordination

Managing emergency activity, discharge planning & post discharge support

Intermediate care, re-ablement & rehabilitation

Measurement • Reduce variation • Improved clinical outcomes • Improved satisfaction • Reduced care home admissions • Reduced population care costs • Reduced episode of care costs

• Reduce ambulatory care sensitive condition admissions

• Reduce Length of Stay • Reduce readmissions • Reduce hospital

acquired conditions


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Adapted from Milford, CE, Ferris TG (2012) A modified “golden rule” for health care orgnisations. Mayo Clin. Proc. 87(8):717-720


• Torbay

Torbay’s integration for older people evolved from small-scale to system-wide change through the development of integrated health and social care teams. The appointment of health and social care co-ordinators has been an important innovation within the care model, with some excellent outcomes being achieved to date.

Information from Thistlethwaite , P. (2011) Integrating health and social care in Torbay: Improving care for Mrs Smith.

London: The King’s Fund.

• North West London

This pilot has undertaken a considerable amount of work in pooling information and using an IT tool which allows for the identification of patients needing intensive case management, while multidisciplinary groups of local care providers meet on a regular basis to review and plan people’s care.

Information from Nuffield Trust. (2013) Evaluation of the first year of the Inner North West London Integrated Care Pilot:

Summary. London. p. 2

Examples


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• Canterbury, New Zealand

Canterbury provides integrated care that crosses primary, community hospital and social care. Canterbury has been innovative in its approach to integrated care including, but by no means limited to, the establishment of HealthPathways (local agreements on best practice), Acute Demand Management System (ADMS) aimed at preventing hospital admission, and Community Rehabilitation Enablement and Support Team (CREST) which supports reducing length of stay once a person is in hospital.

Information from Timmins, N., Ham, C. (2013) The quest for integrated health and social care: A case study in Canterbury, New Zealand. London: The Kings Fund.

• Kaiser Permanente

Kaiser Permanente is the largest non-profit-making maintenance organisation in the United States. It is a virtually integrated system which combines the roles of insurer and provider, and providing care both inside and outside hospitals. Care integration enables patients to move easily between hospitals and the community facilitated by a model of multispecialty medical practice in which specialists work alongside generalists. Information from Curry, N., Ham, C. (2010) Clinical and Service Integration: The route to improved outcomes. London: The Kings Fund.

Examples cont.


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Overview


Governance

Governance








Governance

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Governance



1 Commitment

2 Enabling

3 Implementation

4 Embedding


All partners have agreed about how to establish an infrastructure to integrate teams, structures and processes to achieve a shared purpose.

All partners are clear about, and committed to, what they will jointly achieve through integration, programme governance has been agreed. System governance structures are still embryonic.

Shared accountability for performance and joint governance structure is in place between partner organisations including a programme management structure accountable to a shared board.

Choice, competition and contestability in the context of integration have been considered and addressed and governance arrangements allow for this.

Joint governance has proved effective in accounting to stakeholders for improvements in quality and in resolving or averting major problems that could compromise one or more integration partner(s).

Governance

Governance

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Governance

62

Principles

Align drivers and incentives

Share risk and reward

Create mechanisms for holding each

partner to account

Set strategy, manage and measure

operational delivery and performance

Ensure clarity of responsibility and accountability across

partners


Integrated

Teams

Integrated

Services

Integrated

Systems


Strategic Level - • Governing body • Key decision makers health

and social care system • Policy and resource

allocation • Accountability framework

Tactical Level – • Management co-

ordination of care services maintaining care continuum – interface between providers

Operational level – • Clinical MDT assessment

and delivery of evidence based care - NCTs

Adapted from PRISMA model of integrated care governance

Governance

63


Governance

What works • Create a partnership board:

– equity across partners

– clarity of scope, mandate and decision making authority

– terms of reference, including quoracy and voting rights

– role of the Chair, consider an independent chair or rotating the chair across the partnership

• Delivery structure from partnership board that details the roles measures and reporting arrangements for reference and task and finish groups, considering accountabilities within partner organisations

• Continuously manage the relationships outside the formal meeting structure

• Create mechanisms to deal with problems that arise through cultural differences to ensure:

– effective decision making

– manage relationship and conflict

64


Governance

• Maintaining engagement of all partners across different organisations: size, maturity and readiness.

• Developing leadership capabilities for partnership working.

• Avoiding protectionism whilst managing performance and risk for own organisation.

• Keeping it simple – create clarity and ‘simple rules’ to support reducing complexity

• Recognising that flexibility is required as integration continues though each stage of implementation and beyond.

What works cont.

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• Inner North West London

Sophisticated governance structures were put in place for the pilot, reflecting the complex nature of integration. These structures have worked well and have been critical to the engagement of stakeholders across North West London. The challenge ahead is to embed these arrangements for the longer term, and to balance local autonomy and freedom (with multidisciplinary groups) with overall accountability for delivering the pilot’s aims.

The business case details the governance arrangements (from page 42). Information from

Nuffield Trust. (2013) Evaluation of the first year of the Inner North West London Integrated Care Pilot: Summary 2013, London. p. 6

North West London Integrated Care Pilot Business Case, 2011

• International Case Studies

Box 4.3 and pages 27-28 of this research report outlines the different governance arrangements adopted by these four international case studies. Information from Nuffield Trust. (2011) integration in action: four international case studies – research report, London

Examples

Governance

66

http://www.northwestlondon.nhs.uk/publications/?category=1671-Integrated+Care+Pilot+(ICP)-d



http://www.nuffieldtrust.org.uk/sites/files/nuffield/integration-in-action-research-report-jul11.pdf















• Roles and responsibilities of Health and Wellbeing Boards

http://www.kingsfund.org.uk/sites/files/kf/media/richard-humphries-role-of-health-wellbeing-boards-jan14.pdf

• Further examples of governance arrangements and structures:

– Salford Integrated Care programme http://www.partnersinsalford.org/icp-structure.htm

– Living Longer Living Better - Integrated Care Blueprint for Manchester http://www.manchester.gov.uk/download/meetings/id/14900/5_integrated_care_blueprint_for_manchester

Examples cont.

Governance

67




























http://www.partnersinsalford.org/icp-structure.htm












http://www.manchester.gov.uk/download/meetings/id/14900/5_integrated_care_blueprint_for_manchester

http://www.manchester.gov.uk/download/meetings/id/14900/5_integrated_care_blueprint_for_manchester

Overview


Information and Information Technology








The information in this guide has come from AQuA’s Integrated Care Faculty knowledge from working with members, experts and thought leaders including The Kings Fund and The Public Service Transformation Network specifically for the Information and Information Technology Domain guide. The guide provides a framework of areas to consider and examples.


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http://publicservicetransformation.org/










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1 Commitment

2 Enabling

3 Implementation

4 Embedding


All partners agree to share information to support integrated care, planning, delivery and evaluation.

Risk stratified has been undertaken and information about who would most benefit from care co-ordination is shared and acted upon. Analysis has taken a population focus to enable a 100% population focus.

IT workarounds have been developed to support integrated working e.g. shared records and clinical decision support, performance and outcome measures. Information sharing is information governance and Caldicott 2 compliant.

Information and IT backroom functions are fully integrated between all partner organisations and provide information to continuously assess quality and outcomes.

Fully integrated health and social records are accessible by service users, carers and all staff involved. There is a "full disclosure" culture between partners enabled by innovative IT solutions.



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72

Determine information needs (i.e. what needs to be included or excluded)

Create and implement an Information/

Information Technology Strategy

Information to plan, deliver, evaluate care – relevant/proportional,

only share what is necessary

Individual and population needs should be

considered for both economy planning and

person-centred care

Maintain Information Governance standards

Principles


Integrated

Teams

Integrated

Services

Integrated

Systems



Tactical Level – • Implement assistive

technology across whole pathways

• Measure the impact • Review clinical data to

identify where processes need improvement or there is evidence of clinical outliers. After target areas are identified make improvements

• Clinical leaders and managers practice standard use of information and technology and crucially co-design with patients and carers

Strategic Level – • Take a whole systems perspective • Commission information systems and

assistive technology at scale across whole pathways/populations

• Identify the outcome of what the use of assistive technology will contribute to

• Address organisational and system barriers to use

Operational level – • Staff are trained to use

clinical information systems in practice to deliver standard care e.g. checklists, decision making tools

• Staff and patients work together to agree how and where assistive technology can be used in a care setting and then evaluate that experience

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What works • Determining information needs – what we use the information for, how we use the

information

• Designing and implementing an ‘Information Sharing Agreement’ between integrated care partner organisations

• Having designated funding to invest in information and information technology systems and implementation

• Having a dedicated project team to respond to issues of implementation and establishing a professional reference group to discuss and resolve challenges

• Thinking wider and more strategically about information systems, data collection, reporting, information governance

• Not waiting for the perfect IT system:

– Consider how existing systems could talk to each other

– Consider working with existing systems and data sharing arrangements wherever possible (for example, enabling staff to review information held on others’ systems, but not being able to amend their records)

• Engaging system users in design and implementation

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• Using risk stratification – tools for frail elderly e.g. Tri Boroughs, North West London

• Implementing teleheath and telecare at scale and appropriate for service users

• Having single joint assessment of clinical need between heath and social care professionals

• Considering use of language and abbreviations across different sectors e.g. health, social care, voluntary sector

• Understanding the legal requirements around data sharing

What works cont.

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Population Risk Stratification

Risk stratification are tools to help determine which people in a population are at high risk of

experiencing outcomes, such as unplanned hospital admissions, that are simultaneously: undesirable for

patients; costly to the health service; and potential markers of low-quality care. Also known as predictive

risk models, these tools are used widely in the NHS, both for:

• Analysing the health of a population (“risk stratification for commissioning”)

• Targeting additional preventive care interventions, such as the support of a community matron, to

high-risk patients (“risk stratification for case finding”). Information from: Thompson, K L. & Lewis, G. (2013) Information and Risk Stratification: Advice and Options for CCGs and GPs. NHS England

• Tri Boroughs Example

Contracted on casemix

based on client

needs/complexity

Provider

Network level “provision

entities”

Community care

Social care

Mental health

Primary care

practices

…into out of hospital provider

networks…

Reimbursement

Fee

Management

services

…with a fixed capitation for all out of hospital

services, acute and management costs.

Capitation

allocated to cover

provider activity

Community

care

Social care

Mental health

Primary care

-

-

=Provider savings (or risk)

Block contract or

network agreed

tariff

Outpatient /

A&E / UCC / Dx

Any planned

acute

admissionsPbR tariff

Scope

Focus on top three highest risk

cohorts…

Overall population

▪ 466,921population

▪ Approx £413m healthcare

spend

▪ Approx £177m social care

spend

▪ Average per capita spend

£1,090

Focus

▪ 103,000

people

▪ £454m

total

spend

▪ Average

per capita

spend

£4,407

Out of focus

▪ 364,000 people

▪ £136m total

spend

▪ Average per

capita spend

£374

Commissioning

Local Authority

CCGs

▪ Pooled budget net of LA/CCG

savings for whole system IC

paid as capitation (average

£145m per borough)

▪ Locks in required savings for

commissioner balance and

lower future growth rate

▪ £154m social care funding

for target population

▪ Average £51m per borough

▪ Top sliced by 4% for

reducing ASC budget

£147m

▪ £300m health care funding

for target population

▪ Average £100m per CCG

▪ Top sliced by 4% leaves

£288m

…pooling budgets from health

and social care…

Example figures for each

JV/LLP (if 10 across tri-

borough as example)

• 10,300 target population from

Network size of approx 50,000

Total revenues

▪ £28,8m health care

▪ £14.7m social care

Budget per capita

▪ £2,796 health care

▪ £1,427 social care

-Integrated long

term care at

home packages

Acute: A&E,NEL,

specialist

Residential/

Nursing Home

(PBR Tariff)

What works cont.

Information from: Webster, A. (2013) Person-centred, coordinated care London’s progress and learning Presentation

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• Hampshire Health Record

Case study

• Pennine

Pennine have agreed that prior to any patient having their case for a self-care plan reviewed by the integrated care team, the GP practice must first seek consent from the patient. This approach has been agreed so that patients are not alarmed by the introduction of social care partners when they access health services.

Information from Roberts, L. Cameron, G. (2014) Evaluation of the Integrated Care Communities 2 Programme

(incorporating the Integration Discovery Community) Interim report: Wave 2 findings. London: OPM

Examples


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http://informationsharing.co.uk/wp-content/uploads/2013/11/Hampshire-Health-Record-case-study.pdf




• Barnsley

The example on the right shows Barnsley’s approach to information sharing and management and links directly to the tiered integrated care model. Teams should reflect on their population needs at the various steps, their current use, opportunities to improve, and actions to implement.

Click here for further information

Examples cont.


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• Wigan

Wigan have developed an IT strategy that will support their integrated neighbourhood teams through electronic record sharing, enabling practitioners to make better informed decisions about their patients.

Information from Roberts, L., Cameron, G. (2014) Evaluation of the Integrated Care Communities 2 Programme

(incorporating the Integration Discovery Community) Interim report: Wave 2 findings. London: OPM

http://www.innovation.nhs.uk/pg/cv_blog/content/view/26395/network










• The King’s Fund

See Section C - Rob Kenyon (Leeds) and Jeremy Kenyon (South Somerset) presentations at the Integrated Care Health Summit 2014

• Cheshire Fire and Rescue Service

Work undertaken in Cheshire and Merseyside Fire and Rescue Services (FRS) has seen both authorities developing bespoke targeted services that make clients safer from fire and increase the chances of the uptake in services improving health and social care outcomes. In 2013 due to National Health reforms, Cheshire Fire and Rescue Service had to re-apply to NHS England to renew their existing data sharing agreement dating back to 2007, which had been with local PCTs. The renewal was through the local Commissioning Support Group which was co-terminus with Merseyside Fire and Rescue Service. Since 2013 significant gains have been made and Sir Bruce Keogh, Caldicott Guardian for NHS England has written to CFOA supporting the project in reaching a successful conclusion

http://www.cheshirefire.gov.uk/partnerships/age-concern

Examples


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http://www.kingsfund.org.uk/events/integrated-care-summit-2014?dm_i=21AC,2XG8P,I8YDIX,AKSVN,1#presentations






















Useful Information

Title Author Year Publication/site/ Company

IT Managed Service Agreement

NHS North West London Integrated Care Pilot

2011 Beachcroft

Memorandum of Understanding


2011 Beachcroft

Hosting Agreement NHS North West London Integrated Care Pilot

2011 Beachcroft

Establishment Agreement


2011 Beachcroft

Potential for Change Carers UK 2013 Carers UK

Information: To Share or not to Share Government Response to the Caldicott Review

Department of Health 2013 Department of Health

Risk Stratification Techniques

AQuA – companion document 2011 AQuA


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http://www.nwcahsn.nhs.uk/media/documents/IT Managed Service agreement - NHS North West London Integrated Care Pilot.pdf

http://www.nwcahsn.nhs.uk/media/documents/IT Managed Service agreement - NHS North West London Integrated Care Pilot.pdf

http://www.nwcahsn.nhs.uk/media/documents/Memorandum of Understanding.pdf

http://www.nwcahsn.nhs.uk/media/documents/Memorandum of Understanding.pdf

http://www.nwcahsn.nhs.uk/media/documents/Hosting Agreement.pdf

http://www.nwcahsn.nhs.uk/media/documents/Establishment Agreement.pdf

http://www.nwcahsn.nhs.uk/media/documents/Establishment Agreement.pdf

http://www.carersuk.org/for-professionals/policy/policy-library/potential-for-change-transforming-public-awareness-and-demand-for-health-and-care-technology

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/251750/9731-2901141-TSO-Caldicott-Government_Response_ACCESSIBLE.PDF







https://www.aquanw.nhs.uk/members/resource.htm?postid=8110

https://www.aquanw.nhs.uk/members/resource.htm?postid=8110

Overview ©2014 Advancing Quality Alliance 81









The information in this guide has come from AQuA’s Integrated Care Faculty knowledge from working with members, experts and thought leaders including The Kings Fund and Wragge and Co specifically for the Financial and Contractual Mechanisms Domain guide. The guide provides a framework of areas to consider and examples.

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©2014 Advancing Quality Alliance


1 Commitment

2 Enabling

3 Implementation

4 Embedding


There is agreement to develop joint financial and contractual mechanisms to support the delivery of integrated care.

Integration partners agree the set-up investment costs, including dedicated programme management.

Financial levers and incentives are developed to address barriers to large scale integration. Shared outcomes and joint performance measures are developed and being implemented across partner organisations.

New contractual models, financial levers and incentives to deliver system integration and care closer to home are in place. Structures are in place to support financial governance across partner organisations.

Budgets and finance processes have been aligned across integrated services by all partners in a way that continually promotes the benefits of integrated working. Return on investment benefits are realised.

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Structure in place to support financial governance


Values and working principles – need to agree what they are

and why they are needed

Everyone has equal say regardless of future impact and proposed

changes

Accountability

Implementation of performance

management to continually measure return on investment

Consideration given to investment costs - relevant

action taken

Principles


Contracting and Funding Working Principles

Principles Set of principles agreed by all parties

Typical principles – from an Alliance contract: • No harm • Best for project decisions • Accountable for actions • Open honest communication • Collective responsibility and mutual support • Trust, integrity and respect • Proactive pursuit of innovation / outstanding

performance

We will not tolerate: • Bullying, dominating behavior • Unsafe work practices

Have the working principles for the programme been

decided?

Are all parties signed up to and agree with the

working principles?

Breedon, R. (2013) Contracting and Funding Workshop. Wragge and Co. London



Principles – examples from actual contracts and agreements

Construction alliance contract Infrastructure alliance contract Health alliance agreement

Accountability;

Collective responsibility for all decisions

and outcomes;

Co-operative resolution of

disagreements;

Consensus, principle-based decision-

making on all key project issues;

Decisions on a ‘Best for System’ basis;

Use of most appropriate resources in all

activities;

Open and transparent communication;

Encouragement of innovation and

challenge of the status quo;

Collective sharing and management of

the risks and benefits arising from the

Alliance Activities;

Win/win or lose/lose.

Health and safety are paramount –

everyone should go home each day in the

same or better health than they arrived

The role of the leadership team is to create

and sustain an environment that supports

and encourages peak performance

Your problem is my problem (collective

responsibility and mutual support)

Everyone’s view is valid

Systems must serve a clear purpose

We are accountable for the consequences

of our actions

Best for project decision making

Openness and honesty in all our

communications

We value trust, integrity and respect

Unfailing proactive pursuit of innovation

and outstanding performance

we will support clinical leadership and, in particular, clinically-led service development;

we will adopt a patient-centred, whole-of-system approach, and make decisions on a Best for System

basis;

we will conduct ourselves with honesty and integrity, and develop a high degree of trust;

we will promote an environment of high quality, performance and accountability, and low

bureaucracy;

we will strive to resolve disagreements co-operatively and, wherever possible, achieve consensus;

we will seek to make the best use of finite resources in planning and delivering health services to

achieve improved health outcomes for our populations;

we will adopt and foster an open and transparent approach to sharing information;

we will monitor and report on our Alliance’s achievements, including public reporting;

we will be collectively responsible for all decisions and outcomes of our Alliance;

we will operate as a unified team providing mutual support, appreciation and encouragement;

we will conduct ourselves in accordance with Best Practice;

we will support professional behaviour and leadership;

we will remain flexible and responsive to support an evolving health environment;

we will develop, encourage and reward innovation and challenge our status quo;

we will actively support and build on our successes; and

we commit to fully exploring the collective sharing and management of the risks and benefits arising

from our Alliance Activities. Where we cannot manage risk collectively, our principle is to allocate

responsibility for each risk to those of us who can best manage it.




Contracting and Funding Options

Contracting options to consider: • Do nothing • Informal network • Accountable Care Organisation • Integrating Pathway Hub • Prime Contractor • Integrated Care Organisation (ICO) • Alliance contract • Other form of joint venture

Funding models to consider: • Activity based payments – PbR

• Block contract payments

• Cap and collar

• Capitation budget

• Outcome based risk/reward mechanism?

Other considerations: • Pooled or aligned budgets • Contract duration – longer term will permit investment to drive efficiencies




Do Nothing and Informal Networks

Do nothing:

• What currently works well and what doesn’t?

• What is driving the desire for change?

• What are the benefits of changing contracting and funding agreements?

• What are the risks of changing contracting and funding agreements?

Evaluate option but decide to stay STATUS QUO

Informal network:

• Theoretically easy to implement but how sustainable?




Accountable Care Organisation (ACO)

Accountable Care Organisation:

• A network of provider organisations

• Provider partners collectively agree with the Commissioner to share in a proportion

of savings – on the condition they meet certain quality standards. If no savings are

evident then they should also share in the downside.

• The underlying theory of the model is that cost savings are more likely if the

partners work together

• Seen in the US for insured populations: e.g. Medicare




Integrating Pathway Hub Integrating Pathway Hub:

• A single entity/provider takes

on responsibility for the

management of other providers

along a care pathway.

• The Commissioner procures an

integrating pathway service

based on programme budgets

where the clinical and financial

accountability will rest with the

IPH provider.

• Example: Pennine MSK

Partnership Breedon, R. (2013) Contracting and Funding Workshop. Wragge and Co. London



Prime Contractor Clinical

Commissioning Group

Prime Contractor

Third Party

Provider (s)

(multiple providers?)

Prime Contractor:

• CCG holds contract with Prime Contractor

• Prime Contractor subcontracts some of the services to

Third Party Provider(s)

• Relationship governed by terms of subcontract

including payment to Third Party

• Prime Contractor liable for actions of sub-contractor

• Consider Clinical Governance issues

• Clinical negligence cover




Single Integrated Care Organisation (ICO)

Single Integrated Care Organisation (ICO):

• The creation of an integrated care organisation under one management structure

combining community, acute and adult social care as far as is practicable.

• Considered in some areas – e.g. (1) Weston Area NHS Acute Trust, (2) Ealing and

Harrow, (3) Hounslow Council, Hounslow Clinical Commissioning Group (CCG),

Richmond Council and Richmond Clinical Commissioning Group (CCG) along with

Hounslow and Richmond Community Healthcare NHS Trust (HRCH) considered a

business case for integration of some adult health and social care services for the most

vulnerable residents at their respective board and cabinet meetings during 2013.

Click here for further information.



http://www.hrch.nhs.uk/news-and-publications/news/integrated-care-organisation-update/


Alliance Contracting

Alliance Contracting

• An alliance contract is one contract between the owner/financier/commissioner

and an alliance of parties who deliver the project or service. There is a risk share

across all parties and collective ownership of opportunities and responsibilities

associated with delivery of the whole project or service.

• Any ‘gain’ or ‘pain’ is linked with good or poor performance overall and not to the

performance of individual parties.

• Used in other industries in the UK. Used in healthcare in New Zealand

• Being actively considered in Salford, Oldham, Leicester, Somerset




Traditional contract

Commissioner

P

P

P P

P P

• Separate contracts with each party

• Separate objectives for each party

• Commissioner is the co-ordinator

• Expectation of dispute

• Change not easily accommodated

Alliance contract

Alliance

Commissioner

P

P P

P P P

• One contract, one performance framework

• Shared risk and reward framework

• Aligned objectives, collective accountability

• Expectation of trust – no fault, no blame

• Change and innovation in delivery are expected




Other Contracting Options

Other Joint Venture possibilities:

• More formalised collaborative working

• Alliancing and ACOs are variations of joint ventures



Overview

Funding Options

• Need to consider outcome based risk/reward mechanism • Generally speaking, each of the above models can be used with the contracting

structures. Some are clearly more compatible with others e.g. capitation budget for ACO model

Funding Model Description Example

Activity based payments Payment by results (PbR) is where activity is commissioned on outcomes at a standard tariff price

Agreed set tariff price for hip operations

Block contract payments A set amount of activity and price is identified and the contract managed against this

Community Contracts i.e. 300K District Nurse budget, 10,000 face to face activities commissioned

Cap and collar These contracts pay providers for activity using national prices, but only to a certain contract value, beyond which the commissioner will no longer pay

Capitation budget A fixed payment for a specific patient population size

‘Cobic’ case study for Milton Keynes



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Procurement, Patient Choice & Competition

• NHS (Procurement, Patient Choice and Competition) (No 2) Regulations 2013

- To advertise/tender the opportunity or not?

- How do we identify the provider(s) most capable of delivering the objective in

the Regulations?

• Anti-competitive behaviour is prohibited “unless it is in the interests of healthcare

service users”

- Balance of “costs” versus “benefits”

- Commissioners expected to identify and describe the benefits to be achieved

through new service models

• Obligation to ensure that service users are offered a choice of provider where

Patient Choice applies




Other legal/regulatory considerations

• NHS Standard Contract 2014/15

- What will it say about contract duration?

- Other modifications to fit different solutions?

• Monitor review of National Tariff and payment mechanisms

- Commissioners encouraged to explore different payment models

• Is the collaboration…

- Open and transparent?

- For the ultimate welfare of patients and improving outcomes?

- Driven by commissioners (who must abide with S75 Regulations)?

- Intended to share best clinical knowledge and practice?




Integrated

Teams

Integrated

Services

Integrated

Systems


Tactical Level – • Periodically measure the

impact of the new arrangements

• Test contracts by running them in shadow form

• Review service level activity data

• Engage and inform clinical leaders, managers and staff with the new contracting and funding arrangements

• Identify benefits, risk and investments required

Strategic Level – • Take a whole systems perspective

around contracting and funding accountability

• Create and adhere to working principles within Memorandum of Intention (MOI)

• Options appraise different contracting and funding models

• Make a decision on preferred models and implement

• Design and introduce an effective performance monitoring framework to monitor contract arrangements

• Consider how new models may impact on workforce requirements and new care model

Operational level – Review contracts at team level and monitor performance

100



What works

• Considering different contracting and funding options taking into consideration the benefits and risks

• Identifying a strategic delivery group who can take actions forward and have the power to make decisions

• Seeking legal advice

• Identifying case study examples of areas who are working on similar deliverables and contact them to learn from their experience

• Involving staff, unions, human resources and the relevant care population to seek feedback and communicate changes

• Establishing a process for measuring the impact of the new contacting and funding arrangements

• Prioritisation

• It is easier to introduce change when there are coterminous organisations working together i.e. one council, acute trust, community service/trust and mental health trust



• Fully engaging with primary care

• Gaining clarity about what services, organisations and service users are in scope

• Working with and being adherent to patient choice, competition and procurement

• Creating working principles that are suitable for all leadership roles and organisational cultures

• Engaging and informing staff at all levels so they understand the impact of any changes to contracting arrangements and funding options

What works cont.



Examples • Canterbury, New Zealand Canterbury adopts the mantra ‘one system, one budget’ and uses alliance

contracting to support care that crosses the boundaries between primary, community, hospital and social care.

• South Somerset “Year of care” style weighted per capita

South Somerset “Year of care” style weighted per capita budget and alliance contract arrangements for integration models Click here for further information

• Scotland Scotland has had an integrated NHS structure since 2004 when the commissioner-provider separation was ended and unified health boards created but local authorities continue to have responsibility for social care.

• The King’s Fund See examples and case studies in their publication entitled

Commissioning and contracting for Integrated Care


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http://www.hsj.co.uk/Journals/2013/08/01/h/j/m/South-Somerset-integration-plan.pdf









http://www.kingsfund.org.uk/publications/commissioning-contracting-integrated-care












• Productive Nottinghamshire

Productive Nottinghamshire is an alliance of the NHS commissioner, provider and local authority organisations within Nottinghamshire. It was formed in 2009 and a number of shared governance functions have been developed, including financial and risk management. Productive Nottinghamshire is a Board level commitment to work together on key projects that will best be delivered through a collaborative approach. Being part of Productive Nottinghamshire enables organisations within the health and social care community to achieve together what they cannot achieve as individual organisations.

• NHS Highland

The Highland Council and NHS Highland agreed that the most appropriate single lead agency for the delivery of Adult Care is NHS Highland and that the most appropriate single lead agency for Children’s Services is The Highland Council.

Examples


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Useful Information Title Author Date Publication/Site/

Company

Future payment systems in the

NHS

John Appleby 29/08/2013 The King’s Fund

A Cap that Fits. The ‘capped cost

plus’ model

James Lloyd Sept 13 Strategic Society Centre

Local price setting and contracting

practices for NHS services without

a nationally mandated price A

research paper

Monitor Sept 13 Monitor


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http://www.kingsfund.org.uk/blog/2013/08/future-payment-systems-nhs

http://www.kingsfund.org.uk/blog/2013/08/future-payment-systems-nhs

http://strategicsociety.org.uk/wp-content/uploads/2013/09/A-Cap-that-Fits.pdf

http://strategicsociety.org.uk/wp-content/uploads/2013/09/A-Cap-that-Fits.pdf

http://www.monitor-nhsft.gov.uk/sites/default/files/publications/LocalPricingReport23Sept13.pdf




Documents

System Integration Toolkit - Advancing Quality Alliance · Overview ©2014 Advancing Quality Alliance AQuA’s Integration Domains This diagram shows each of the domain areas Service