Integrated Care Pioneer The view from Islington

1. Integrated Care Pioneer The view from Islington Dr Josephine Sauvage Vice Chair Islington CCG In collaboration with NHS England

2. “We are sick of falling through the gaps. We are tired of organisational barriers and boundaries that delay or prevent our access to care. We do not accept being discharged from a service into a void. We want services to be seamless and care to be continuous.” Individual’s viewpoint on fragmented care National Voices, May 2013

3. What do patients want? Coordinated care, centred on me My goals and desired outcomes are understood by all Emergencies are not treated as isolated cases but within the context of my care plan Providers are communicating with one another about me and my needs I do not have to manage transitions between providers myself Information is common so I only have to give it once Decisions are made based on my care plan My care is planned to achieve my goals / desired outcomes

4. Ethos of Pioneer ‘Integrated Care and Support: Our Shared Commitment’ (2013) Acollaboration of national partners set out an ambitious vision of making person-centred coordinated care and support the norm across England over the coming years Association of Directors of Adult Social Care, Association of Directors of Children’s Services, Care Quality Commission, Department of Health, Health Education England, Local Government Association, Monitor, NHS England, NHS Improving Quality, National Institute for Health and Care Excellence, Public Health England, Social Care Institute for Excellence, Think Local Act Personal • Support of better person-centred, coordinated care • Local innovation • Realisations of local aspirations on integrated care • Address barriers • Disseminate and promote learning • Focus on benefit for patients, services users, their carers and their local communities • Provide bespoke expertise, support and constructive challenge • Range of national and international experts • This approach builds on the community budget pilots co-designing integrated health and care at scale and pace. • Successive cohorts of Pioneers, supporting them for up to five years • Expectation of Pioneers to contribute to accelerated learning across the system

5. 5 year Expectations from pioneers • Be regarded as exemplars: • deliver improved outcomes, including better experiences for patients and people who use services • tackle local cultural and organisational barriers • realise savings and efficiencies for re-investment • Have used the Narrative developed by National Voices, in association with Making it Real, to help shape good, person-centred coordinated care and support for individuals in their area • Have demonstrated a range of approaches and models involving whole system transformation across a range of settings • Have demonstrated the scope to make rapid progress • Have tested radical options, including new reimbursement models and taking the risk of ‘failure to integrate’ in some cases • Have overcome the barriers to delivering coordinated care and support • Have accelerated learning across the system to all localities • Have improved the robustness of the evidence base to support and build the value case for integrated care and support

6. Selection criteria (not prescriptive about models for adoption) • Articulate a clear vision of innovative approaches to integrated care and support • Plan for whole system integration • Demonstrate commitment to integrate care and support across the breadth of relevant stakeholders • Demonstrate the capability and expertise to deliver successfully a public sector transformation project at scale and pace • Commit to sharing lessons on integrated care and support across the system • Demonstrate that its vision and approach are based on a robust understanding of the evidence

7. Integration Pioneers • The national collaborative announced details of an integration ‘Pioneer’ programme in May - over 110 applications were received nationally • Significant interest in becoming a pioneer across London with 15 applications crossing 22 boroughs demonstrating London’s commitment to integration • 4 Pioneers (NWL, Islington, WELC, Greenwich) have been selected in London covering approximately 1/3 of London’s population. • London’s Pioneers vary significantly in scale with large system and borough approaches. • The Pioneer community in London provides a significant opportunity to help London deliver integrated care at scale and pace, by sharing learning and developing solutions to complex issues.

8. The London Landscape

9. Risk stratifying the population shows us that different patients have different intensity and complexity of need Care for people with very complex needs ~20% of the population More complex (often multiple) conditions and facing higher risks to their health (end of life, frail elderly, dementia, multiple long term conditions) In frequent contact with multiple parts of the health and social care system i.e. the most complex and costly care Very high risk High risk (0.5-5%) Care for people with manageable long term conditions Moderate risk (5-20%) “Care at short notice” for the rest of the population Low risk (20-50%) Very low risk (50-100%) SOURCE: NWL whole systems integrated care

10. The Case for Change • Groups for whom the case for integrating care is most compelling • Frailty • Multiple co-morbidity • End of life Care • Dementia

11. The case for change for dementia Trends • There are around 65,000 Londoners with dementia, this is forecast to rise by 16% to 2021 and by 32% to 2031 [8] Outcomes and Experience • Half of all people with dementia never receive a diagnosis [9] - just 31% of the capital’s GPs believe they have received sufficient basic and post-qualification training to diagnose and manage dementia [10] • Earlier diagnosis and treatment can be critical in delaying the onset of dementia [6] • Carers and other family members of people with dementia are often older and frail themselves, with high levels of depression, physical illness, and a diminished quality of life [11] • London is struggling to meet the needs of older black and minority ethnic Londoners who have dementia [10] Activity and Cost • Older people with dementia occupy 20% of acute hospital beds across England but 70% of these may be medically fit to be discharged [12] • 80% of people living in care homes have dementia or severe memory problems [13] • Estimated cost of dementia to the English economy is about £20 billion p/a • This is set to increase to over £27 billion by 2018 [14] • Delaying the on set of dementia by 5 years would reduce deaths directly attributable to dementia by 30,000 a year [13]

12. INTEGRATED CARE: THE KEY INGREDIENTS WHY WHAT HOW OUTCOMES POOR PATIENT EXPERIENCE Lack of independence and control Fragmented services that are difficult to navigate POOR OUTCOMES Poor quality of life for people and carers Too many people living with preventable ill-health and dying prematurely Avoidable emergency and residential care admissions/readmissions Unsafe transfers and transitions INCREASING DEMAND Aging Population Medical innovation Poor population health UNSUSTAINABLE MODELS OF CARE “30%” of people in hospital and care institutions who do not need to be there Insufficient prevention/early intervention Unrealised citizen and community capacity Limited primary care offer Limited community services Uneven quality across many services UNPRECEDENTED FINANCIAL CHALLENGE NHS – flat in real terms Local Government - 28% NHS in London expected to save £3.1bn by 2015 (15.5% of the national £20bn savings requirement) NHS nationally - £30bn funding gap by 2020 Financial system not fit for purpose, encouraging acute activity and cost-shunting GREATER INTEGRATION OF SERVICES AROUND THE PERSON Risk profiling Care coordination and care planning Integrated case management Single point of access 24/7 urgent response Admission avoidance and timely transfers of care Reablement A GREATER EMPHASIS ON SELF & HOME CARE Personal budgets Expert patient Carers strategy Technology for independence Support related Housing BUILDING COMMUNITY CAPACITY TO MANAGE DEMAND Early diagnosis Care navigators Mutual support Micro enterprises Information for all Population Health A NEW PRIMARY CARE OFFER Accessible Proactive Coordinated RECONFIGURATION OF ACUTE SERVICES Reduced activity in acute / realigned acute services • WHOLE HEALTH AND CARE SYSTEM LEADERSHIP • Joint Governance • Political alignment • Joint Outcomes • Joint public / patient engagement strategy • 3-5 YEAR LOCAL PLANS signed off by Health and Wellbeing Boards • LOCAL & CITY WIDE COHERENCEAcute Service reconfiguration • SCALE / FOCUS • Those at highest risk of needing urgent health and/or social care (adults and children) • COMMISSIONINGAlignment between LA/CCG/NHS England • Engagement of providers • Release of primary care commissioning to CCGs • A WAY TO MOVE MONEY AROUND THE SYSTEM to address the perverse effects of activity-based payments. That might include: • contracting for populations and outcomes • Risk-sharing by commissioners and providers • SHARED INFORMATION ACROSS AGENCY BOUNDARIES • FLEXIBLE, ENGAGED WORKFORCE AND IMPROVED TRAINING • TRANSPARENT MEASUREMENT OF OUTCOMES • A DEVELOPING EVIDENCE BASE IMPROVED CITIZEN EXPERIENCE People “in control and independent” IMPROVED HEALTH AND CARE OUTCOMES Enhanced quality and safety of services – to agreed standards IMPROVED SUSTAINABILITY OF THE HEALTH AND CARE SYSTEMS Increased investment in, quality of and productivity of primary and community services Large scale reduction in unplanned attendances, admissions to hospital and length of stay Reduction in admissions to residential Care EFFECTIVE DEMAND MANAGEMENT Management of demand at the front door of care and support services,

13. The main aims & objectives of the Islington pioneer: ‘I want to have longer appointments with someone who is well prepared so that I do not have to tell my story again ‘I want to be treated as a whole person and for you to recognise how disempowering being ill is’ ‘I want to feel supported by my community and get the most out of services available locally’ ‘I want my care to be coordinated and to have the same appointment systems across services’‘Better access to health care through social services and vice versa” ‘No clear systems and processes through all healthcare services’ ‘I want to be listened to and be heard’ ‘Helping people to help themselves’

14. Successful delivery from partnership working: COPD: NHS Innovation Challenge Prize 2013 ~ • OUTCOMES • 25% increase in diagnosed prevalence between 2010 - 2013 • 93% increase in referrals to pulmonary rehabilitation between 2010-2012 • 72% of people on COPD register now have self management plan • 16% decrease in emergency admissions in 2011/12 vs 2010/11

15. Plans for development:

16. Clear pathways of accountability: Supported by UCLP Clinical Leadership Rigour and challenge Supported by PMO approach Patient Engagement Reporting arrangements Working across North Central London (e.g. value based commissioning) Link to Making It Real Board

17. Measures of success:When, and who, will assess impact? Interim reporting to HWBB & ICPB: provide challenge, rigour & development. Acknowledge we won’t get it all right first time - embed learning & iterative approach. What Who How • Linked datasets • Matched case-control • Clearly defined intentions • Qualitative & quantitative • PMO Approach • The whole pathway • Total costs • Quality & Experience • Health outcomes • Process • Collaboration • Patients and carers: co-production • Academic insight • Frontline staff experience

18. Opportunities and Challenges:

19. What are the important contextual factors: • Inequalities • Whittington ICO • UCLP • Collaboration on value based commissioning • Financial drivers • Making prevention a reality for population • Ambition • Commitment • Track record • Co-production • Pooled budgets • Information exchange • Information governance • PAM • Work force development strategy • Recognition & challenge • Peer to peer learning • Support & technical advice • “Permission” to do things differently

20. How our plans can have a practical impact on the care of individuals?

21. Aligning Education and Service Re-design in Primary Care Sanjiv Ahluwalia Head, London School of General Practice HENCEL Non-executive Primary Care GP, North London

22. Challenges • Primary care workforce data • Population need and workforce planning • Workforce development and education needs • Emerging service models • Level of geography • Changing workforce roles • Centralisation versus localisation

23. Potential solutions • Link population needs to workforce and education planning • Borough/CCG level information • Service commissioners and providers at the heart of this process • Future and current workforce needs • Multiprofessional and lay engagement • Locally owned with LETB facilitation

24. Community Educational Provider Networks Ahluwalia et al (2013). Education for Primary Care

25. Back to Dementia • Improve quality of care for the most vulnerable in our society • Empower and entrust our workforce to make the best possible decisions • Recognise the intimate relationship between quality and costs • System turbulence is a challenge but also an opportunity