Person-centred, co-ordinated care

London’s progress and learning

|McKinsey & Company

London is developing integrated care systems that serve whole populations

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BromleyCroydon

Barking and Dagenham

Barnet

Bexley

Brent

Camden

Ealing

Enfield

Greenwich

City & Hackney

H&F

Haringey

Harrow

Havering

Hounslow

Islington

K&C

Lambeth

Lewisham

Newham

Redbridge

Richmond

Tower Hamlets

Waltham Forest

Wandsworth

Westminster

Southwark

Hillingdon

Kingston Merton

Sutton

Waltham Forest and East London• 3 Clinical

Commissioning Groups

• 3 local authorities• 1 acute trust• 3 community

providers• 193 GP practices• Population: 910,000

Barking and Dagenham, Havering and Redbridge• 3 Clinical

Commissioning Groups

• 3 local authorities• 2 acute trusts• 1 mental health

and community provider

• 142 GP practices• Population:

660,000

Outer North West London• 4 Clinical Commissioning

Groups• 4 local authorities• 3 acute trusts• 2 mental health trusts• 2 community provider• 231 GP practices (193 co-

opted)• Population: 1.2million (whole

population covered, with 113k receiving specific interventions)

Croydon• 1 Clinical Commissioning

Group• 1 local authority• 1 acute trust• 1 mental health trusts• 1 community providers• 61 GP practices• Population: 381,010

Greenwich• 1 Clinical

Commissioning Groups

• 1 local authority• 1 acute trust• 1 mental

health/community provider

• 47 GP practices• Population: 277,710

Inner North West London• 4 Clinical

Commissioning Groups

• 4 local authorities• 2 acute trusts• 2 mental health trusts• 2 community providers• 184 GP practices (92

co-opted)• Population: 889k (470k

covered, 21k with a care plan)

Kings Health Partners• 2 Clinical Commissioning

Groups• 2 local authorities• 2 acute trusts• 1 mental health trusts• 1 community provider• 95 GP practices (56 co-

opted)• Population: 600k (400k

covered in full, remaining 200k by CMDTs

London Cancer N&E• 12 Clinical Commissioning

Groups• 12 Acute Trusts• Population: 3.3m

London Cancer Alliance S&W• 20 Clinical Commissioning

Groups• 17 Acute Trusts• Population: 3.9m

Borough-level projects

|McKinsey & Company

Our proposal for whole system integration gives health and social care commissioners the opportunity to define a new joint commissioning framework and to transform the way providers work together to deliver high quality integrated care

3

Potential feature

Carer

Multi-skilled health and social care worker (for high

risk/dependence)Family

Personalised patient carePersonalised patient care

Multi-agency provider coordination

Multi-agency provider coordination

Information systemsInformation systems

Reimburse-ment

Governance

GP Practice

Impact

Capitated budgetCapitated budget

▪ Incentivises proactive and preventative care to avoid unnecessary admissions

Pooled health and social care resources

Pooled health and social care resources

▪ Creates flexibility to redesign delivery model to make doing the right thing the right thing to do

Provider networksProvider networks

▪ Encourages joint decision making based on shared systems, records and governance

Care coordinatorsCare coordinators

▪ Manages patient care plan, out of hospital support and discharge from hospitals

Shared staffingShared staffing▪ Allows new specialist roles

shared across providers, e.g., health and social care workers

Micro-commissioningMicro-commissioning

▪ Ensures rapid, targeted response to patient/users need rather than delays triggering admissions

Personalised responsePersonalised response

▪ Tailors care to individual, e.g., 30 minutes with the same GP each month, not 10 minutes a week

Care Coordinator

Community care

Specialist care

Mental health

Third sector

Housing Employment Probation

Patient/User

Education

ReablementAssistive

technologySupport services

Care at home

Supporting platformSupporting platform

|McKinsey & Company

Contracted on casemixbased 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 admissions

PbR 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 50,000Total revenues▪ £28,8m health care▪ £14.7m social careBudget 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)

Who are we doing this for?

JoanLives on her own and has a

personality disorder

FrankRecently bereaved, suffers from chronic obstructive

pulmonary disease

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Care for people with manageable long term conditions

“Care at short notice” for this population

Care for people with very complex needs

Low risk(20-50%)

Very low risk

(50-100%)

Very high risk

Highrisk

(0.5-5%)

Moderate risk

(5-20%)

Description

▪ Ask the top 0.5% of the population (10 people per GP, 250 people per network, ~4,400 people across the patch) to opt into a special programme that focuses explicitly on delivering coordinated controlled care for the very complex needs of this population (typically, at the end-of-life stage)

▪ Ask the next 20% of the population (400 people per GP, 10k people per network, ~175k people across the patch) to opt into a special programme delivering more proactive/responsive, better coordinated, more consistent care

▪ 4-5 centres with critical mass for multidisciplinary staff teams - a 1:5 GP-to-support staff ratio and with consultants on hand to provide specialist opinion

▪ Retain the remaining 80% of the population utilising the current “care at short notice” model of GP care

▪ With more than 50% of GP contacts coming from the top 3 strata, we would expect “mainstay” GP services to have more than half of capacity released

Example:50,000 population12-13 practices with ~4k people each

These take a whole population perspective and focus on those at highest risk

1

|McKinsey & Company

|McKinsey & Company

© 2013 Deloitte MCS Limited. Private and confidential.

Key facts about 111 in London so farPatient stories gathered to date indicate a range of patient experiences

9 NHS England - London Region: 111 Easter Review

Health Advisor provided patient with reassurance

Quickly accessed the right service, swiftly

Assessment of patient took too long

Required service was not available

Insufficient clinical knowledge

https://www.patientopinion.org.uk/

A whole population approach, to identify risks early; interventions tailored to levels of risk and the individual

Specific goals and investment for falls, dementia, nutrition and infection pathways

50,000 Older People: All risk stratified

25,000 proactively assessedannually

5,000 case managedGeneric approach based on level of risk

Prioritises action for those interacting heavily with the system

Picks up issues for those not yet interacting heavily with the system

Coordination of care for those with multiple needs

Preventative model of care

Urgent care model

| 13

Patient Risk Stratification

The ICP IT supports 4 key processes

Care plan

Action 2

Action 3

Action 1

Plan care for patients, share these plans across settings, and monitor progress

This helps better coordinate care

Identify high risk patients using population segmentation and risk stratification

This enables proactive care to be planned

Track and evaluate the performance of GP’s surgeries and Multi-Disciplinary Groups

This helps spread best practice in patient care

Action: Review by falls service

Action status: Completed

1 Integrated Patient Care Planning

Performance Evaluation

Patient records: GPHospitalCommunity

View patient medical information from multiple settings

This enable integrated care to be provided

Patient Medical Information Sharing

2

43

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Integrated Care Plans help coordinate the care for patients within the Pilot

Text

The Portal can be used to create and manage Integrated Care Plans for patients

Standard care packages can be selected by clicking on any of the template buttons, the actions in this care plan will then be selected

Individual actions can then be added or removed from the care plan