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Slides from the workshop 'A modern vision of integrated care and support' led by Dr Martin McShane, Dr Damian Riley (NHS England) and David Pearson (ADASS) - NHS Medical Leaders Conference 2014. - See more at: http://www.icase.org.uk/pg/cv_content/content/view/98680#sthash.45Xs2o9r.dpuf
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NHS Medical Leaders Conference 11 February 2014
Integrated Care and Support
Martin McShane & Damian Riley – NHS EnglandDavid Pearson - ADASS
Content
• Context – “follow the money”• Integration – is it possible?• Three ‘wicked’ issues?• Next steps
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Patie
nts (
%)
Age band (Years)
Morbidity (number of ETGs) by age band
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Number ofconditions
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Gearing of investment across the system
Public HealthSocial Care(H&WB Board)
Primary Care£200
Comm/MH£500
Specialised£300
Acute£1000
£2000/head of population
NHS England CCGs
4
NHS Expo Seminar Domain 2
Gearing in activity into acute care
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Year of Care Costs
6
Relationship between number of long-term conditions and cost
LTC Year of Care Programme
Risk stratification versus no. of LTCs – do they select the same patients?
LTC Year of Care Programme
Do Integrated Care teams change service delivery?
LTC Year of Care Programme
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GP Specialist
1990
Specialist
2014
CARE GAP
Complexity
Qu
alit
y o
f li
fe
Integration is the answer to all our problems!
£1 £10 £100 £1,000
ICU
ACUTE CARE
0%
COMMUNITY CARE
Self-management
Long Term Condition Management incl Cancer
Third sector provision
Primary Care
100%
Consultant-led services
Specialist teamsSpecialty Clinic
Planned procedures
INTEGRATED CARE
Locality teams
SHIFT LEFT
£5,000
Cost of Care per Day
Risk profiling
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COMPLEX CARE
PRACTICE???
Problems for integration• Lack of common definitions and boundaries. For example: integrated, coordinated or
collaborative care, case management, continuity of care etc. The Kings Fund (2010) found 165 definitions of integration.
• Vertical and/or horizontal integration
• Patchy evidence and lack of focus on patients•Some evidence that certain integration models work but not clear whether this is a consequence of applying the model as a whole, or whether the same benefits can be achieved using only some of the components.•Inconclusive evidence that collaboration between health and social care improved service outputs and/or user outcomes. •Difficult to prove causal link between various components of collaboration and its effects.•No national picture on integration but lots of case studies
• Clinicians and commissioners convinced? When asked whether integration had the potential to produce desirable outcomes, respondents to a BMA survey (2011) answered as follows:
•Nearly half said ‘yes’ (47%)•Nearly half said ‘don’t know’ (45%)•The remainder said ‘no’ (8%)
Person centred coordinated care“My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes”
Communication
Information
Decision-makingCare planning
Transitions
My goals/outcomes
Emergencies
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A definition of integration
The House of Care
Engaged, informed individuals & carersEngaged, informed individuals & carers
CommissioningCommissioning
Organisational & clinical processes
Organisational & clinical processes
Person-centred, coordinated carePerson-centred, coordinated care
Health & care professionals committed to
partnership working
Health & care professionals committed to
partnership working
Plan
Study
Do
Act
The House supports:
– Informational continuity: by which people and their families/carers have access to information about their conditions and how to access services; health and social care professionals will have the right information and records needed to provide the right care at the right time.
– Management continuity: a coherent approach to the management of person’s condition(s) and care which spans different services, achieved through people and providers collaborating in drawing up collaborative care plans.
– Relational continuity: having a consistent relationship between a person, family, and carers and one or more providers over time (and providers having consistent relationships with each other), so that people are able to turn to known individuals to coordinate their care.
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The House of Care - Person centred, coordinated care at three levels:
National:What can national organisations and policy makers can do to enable construction of the House of Care at the next two levels.
Local:How local health economies ensure that the House of Care involves a whole system approach, including ‘more than medicine’ offers
Personal:How the House of Care gives professionals on the front line a framework for what they need to do for patients and ask local commissioners to secure for them
The House of Care in pounds p.a.£1.2bn:Avoid ambulatory care sensitive admissions though e.g. following NICE guidelines (1)
£2bn:Reduction of hospital admissions for common LTCs through integrated care esp frailty, cormorbid (2)
£0.8-1.2bn:Reduce use of low value drugs, devices and elective procedures using commissioning analytics and clinician education (3)
£0.2-0.4bn:Empower people in supportive self-management (4)
£1-1.6bn:Shift activity to cost effective settings e.g. pharmacy minor ailments (5)
c.£5.5bn:Incentivised wellness programmes in healthy pop & early stage LTCs inc. smoking cessation, salt ↓, exercise ↑(6)
£0.4-0.6bn:Avoidance of drug errors e.g. through electronic records/e-prescribing (7)
Long Term Conditions
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A collaborative approach
• 14 national organisations* published ‘Integrated Care and Support: Our Shared Commitment’ in May 2013, and committed to:
tackling barriers; encouraging innovation and experimentation; and enabling localities to make person-centred coordinated care
the norm• 14 pioneers are helping to test the way• Developing the evidence base and case for change
* NHSE, DH, LGA, Monitor, ADASS, ADCS, PHE, SCIE, TLAP, NV, NICE, CQC, NHSIQ, HEE
Information Sharing
• What are the real and perceived barriers to information sharing? – Information governance – Patient owned records– Integrated digital health record– Care planning
Changing the nature of the conversation….the biggest challenge?
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The soft stuff…is the hard stuffThe soft stuff…is the hard stuff
Needs (met or unmet)
Mindsets and beliefs
Values
Individual behaviours
What we seeand attemptto address
What we don’tsee and don’tknow how to
address
SOURCE: Scott Keller and Colin Price, ‘Performance and Health: An evidence-based approach to transformingyour organisation’, 2010.
Spend time on the professions,
politics and public
Investing in the capacity of patients
• Current model medical staff, tech and drugs create value. QIPP 1 model was pay and provider efficiency.
• More of the same model will mean unsustainable demands on staff.
• QIPP 2 – New model must build capacity of patients to add value into the health system.
• Increasing contribution of 53m patients. All other industries look do this (e.g. banks, supermarkets).
• Contribution of 3m volunteers in health and care
• Self management is key – increasing effectiveness of patients 5800 waking hours vs few hours with NHS
Does the NHS measure what matters to patients?
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Classic NHS measure
Finance
Process measures/waiting times
Clinical information
Patient safety data
Outcomes that matter to patients
Quality of life
Being supported to stay well
Being treated with dignity and respect
Seamless and coordinated care
Being supported to make decisions
Services that listen to feedback and improve
Measuring Integration• Patient/user experience of integrated care has been a
placeholder indicators in both the NHS and Adult Social Care Outcomes Frameworks
• Balance between national comparability and responsiveness to local populations
• Areas for indicators– Transformation of individual outcomes and experience– Transformation of local health, care and support systems– Change in process including effective engagement of housing
and other services in local authority sector and third sector
Panel Q&A
• Where do you see the opportunities? • What do you see as the barriers?• What could we do to overcome these?• Who could we engage?
