Integrating Health and Social Care – Completing the Jigsaw

1. Integrating Health and Social Care – Completing the Jigsaw David Pearson Corporate Director, Adult Social Care, Health and Public Protection, Nottinghamshire County Council and Vice President of Association of Directors of Social Services

2. Purpose of the workshop To explain the local and national incentives and barriers to integration and how we might overcome them

3. Snapshot of integrated working 2013 • Survey between April and May 2013 by ADASS and NHS Confederation of CCG leaders and Directors of Adult Social Services • Positives: • Integrated care had reduced pressure on services in many localities • 48% demonstrated financial savings with 29% seeing cashable savings • 46% saw improved quality of life for people with long term conditions • 45% saw improved patient/service user satisfaction • What has helped integrate care? • Leaders matter – 84% said leadership important; 81% identified commitment from the top • Joint planning/strategy (71%), collaborative working between commissioners and providers (70%) and joint vision (68%) also important

4. Snapshot of integrated working 2013 • What has hindered integration of care? • Data and IT systems were most often cited as a hindrance – by 50% more people than in 2010 survey • Organisational complexity and changing leadership are often seen as barriers • Half of respondents saw different cultures as a hindrance – again more important since 2010 • Payment mechanisms and financial pressures are another key area • Themes for increasing scale and accelerating pace of integration • Share examples of good practice • Shift financial resources / address financial incentives • Evidence of what works • IT / information sharing solutions • Organisational stability / no more restructuring

5. Incentives for integration (1) • Care Bill – duty on local authorities to integrate services with Health by 2018 • 111 Pioneer bids – indicates level of ambition in health and social care communities and progress of pioneers will provide learning for all of us • Integration Transformation Fund - balance in the use of funding for integrating health and social care; protecting social care, and meeting the conditions and performance targets. Some complexity to these arrangements but a desire to see all areas succeed. • Conditions for integration are ripe

6. Health has moved towards a service where large area of activity and cost is in meeting the needs of older people with a number of long term conditions Strong evidence that 30% of those occupying hospital beds are older people who could be cared for in the community with right kind of proactive multidisciplinary care. In Nottinghamshire this would release £200m of expenditure GPs in a crucial position as commissioners with a greater appreciation of the ingredients of successful community care and the significance of social care Introduction of Health and Wellbeing Boards - opportunity for health and local government to change the way services are provided rather than clinical and political context being geared towards maintaining the status quo Incentives for integration (2)

7. Increased power of local Members to achieve change - last few years local government at the forefront in responding to reductions in funding with some significant new responsibilities, such as Public Health and Health and Wellbeing Boards Despite strong drive towards integration on a national scale, emphasis is on local solutions based around the needs of the individual and carers. This recognises different ways of integrating - not led by structures but by focus on outcomes Voices of user and carers have been growing stronger. Concerns about uncoordinated, fragmented and unresponsive system. As number of people who experience health and social care services as carers increases, a more powerful lobby for change emerges Incentives for integration (3)

8. Evidence base for integration is mixed. Where it works well in clearly focussed areas with specified outcomes it can deliver benefits, but there are examples where this is not the case. Need to plan and focus with care. Task more complex as the number of organisations increase. Some areas have only one CCG but several acute providers. Large counties have numerous CCGs and Trusts - possible to integrate in all these circumstances, but common vision and objectives require relentless determination and fantastic relationships Perverse financial incentives - tariff system and need for Foundation Trusts to prove their worth can work against objectives to transform how services are delivered. Increasing recognition of the need to align incentives Barriers to integration (1)

9. Funding reductions in local government and profile of expenditure creates some differences in priorities. Financial pressure for the health service is the increasing numbers of older people. In social care, funding pressure for younger adults with complex needs is greater. CCGs understandably focussed on work with older people, but failure to consider the funding arrangements for younger adults does not work as local government grapples with maintaining essential services Information sharing is an essential prerequisite for integration - much can be done by local leaders to break down the barriers to information sharing but some moderate changes to legislation are required We require changes in culture at all levels of health and social care and amongst the public who are used to a very buildings based model of care Barriers to integration (2)

10. Pieces of the jigsaw • A clear vision, outcomes and objectives agreed by all partners through the Health and Wellbeing Board • Personalised approaches throughout social care and health which invest in independence and enhance choice and control • Whole system budgeting • United primary, community and secondary health alongside adult social care • Arrangements for sharing personal and performance information • IT connectivity to support information sharing • Multidisciplinary teams around those most at risk • Single access to the provision of advice and information • Integrated arrangements for crisis response • Integrating commissioning arrangements which are focused on quality, outcomes and cost effectiveness • Focus on jointly commissioning or providing services that are known to work, e.g. reablement, holistic assessment, identification and proactive support for those most at risk

11. Importance of leadership • Key vehicle in integration is joined up commissioning and delivery – being clear about the evidence for what works and ensuring that bold decisions are made between different priorities • As leaders this will require us • to be brave and discerning • to be clear with our citizens what we can and cannot do, and • to be clear about the role that individuals and communities can take in promoting their own wellbeing

12. Questions/issues for discussion • Have you got examples of good leadership and outcomes in integrated working in your area? • What do you think are the ingredients of developing good leadership in integrated care? • What are the challenges for you personally and for your health and local government community in leading integrated care?