Integrating Health and Social Care in the UK: Progress, Policy, and Practice

1. Integrating Health and Social Care in the
UK: Progress, Policy and Practice
Dr Nick Goodwin
CEO, International Foundation for Integrated Care
www.integratedcarefoundation.org
Paper to IBM Cúram Research Institute & IFIC
Smarter Care Initiatives in Europe: Leadership Approaches, Care
Management Strategies, and Evidence-Based Practices
1st April 2014, Brussels

2. The United Kingdom
4 Countries = 4 Care Systems

3. Integrated Care in Northern Ireland,
Scotland and Wales
Northern Ireland
• An integrated health and
social care system since
1973
• Commissioner provider
separation remains
• Dominated by acute
hospital provision
• Surprisingly little
programme with integrated
care at a clinical and service
level

4. Integrated Care in Northern Ireland,
Scotland and Wales
Scotland
• Integrated NHS structure
since 2004 when
commissioner-provider split
ended
• Health and social care now
being brought together into
single organisations with
pooled budgets
• Significant progress on :
– integrated care in rural areas
(e.g. NHS Highland) and
– Integrated care for certain
chronic diseases as a result of
managed clinical networks

5. Integrated Care in Northern Ireland,
Scotland and Wales
Wales
• Followed example of Scotland
to end commissioner-provider
split in 2009
• Integrated care driven by
unified local health boards
• Local authorities continue to
have responsibility for social
care
• Significant growth in joint
health and social care
organisations bringing
networks of staff groups
together to deliver care (e.g. in
Pembrokeshire)

6. Integrated Care in Northern Ireland,
Scotland and Wales
Key Observations
• Structural solutions and payment
reforms are insufficient
• Integrated care needs policies
that promote and support
integrated care at a local level –
e.g. governance arrangements
that better enable health and
social care to work together
• Organisational stability,
leadership continuity and a
willingness to introduce new
models of care needs to be
nurtured
• Policy, professional,
organisational, cultural and
behavioural barriers are
persistent barriers to change

7. The NHS in England has 1.3m workers (1.7m in
the UK. It is the fifth largest workforce in the
world
Integrated Care in England: The English NHS
1. US Department of Defense – 3.2m
2. People’s Liberation Army, China – 2.3m
3. Walmart – 2.1m
4. McDonald’s – 1-.9m
5. UK NHS – 1.7m
6. China National Petroleum Corporation –
1.6m
7. State Grid Corporation of China – 1.5m
8. Indian Railways – 1.4m
9. Indian Armed Forces – 1.3m
10. Hon Hai Precision Industry (FoxConn) – 1.2m
Source: BBC News On-Line, 20 March 2012

8. An unprecedented financial challenge

9. The Structure of the English NHS, January 2014
Clinical
NHS
ENGLAND
Clinical
commissioning
groups
Health and
Wellbeing Boards

10. NHS Future Forum
• Focus on integration and
collaboration a dominant theme
in consultation
• Recognition that current system
too fragmented
– NHS, public health, social care
– Primary, community, secondary care
• Need to better integrate care
around needs of user
• But, fears that reforms will
worsen fragmentation and
undermine integrated care
• Recommendations to DH:
Collaboration essential for the
delivery of high quality care
Future Forum 2!
Jan 2012

12. Ten Key Elements for Reform
1. Provide a compelling and supporting
narrative for integrated care
– Keep patient and carers perspective at centre
– Recognise that integrated care is a key to a more
sustainable system
– Outline what success looks like, be driven by
clear and measurable goals that are evaluated
– Focus on clinical/service integration, not
organisational/structural

13. Ten Key Elements
2. Allow innovations in integrated care to
embed
– Time
– Permission to experiment
– Embed as a core way of working (not a side
issue)
– Progress monitored to outcomes based on
agreed, clear and measurable goals
– Help identify and remove barriers

14. Ten Key Elements
3. Align financial incentives
– Paying for good outcomes in care that avoid
perverse incentives
– Alternatives to existing tariffs needed – e.g.
bundled payments, ‘year of care’, pre-paid
capitation
– Pooled budgets
– Quality-based incentives across care pathways
– Personal health budgets?

15. Ten Key Elements
4. Support commissioners in developing new
types of contracts withy providers
– Prime contractor model (e.g. ICOs/ACOs)
– Population-focused
• For certain population groups (e.g. frail elderly)
• For patients with specific diseases (e.g. a long-term
condition)
• For clients with specific problems (e.g. drug and
alcohol)

16. Ten Key Elements
5. Allow providers to take financial risks
– Develop integrated care partnerships where
health and social care professionals/
organisations take on financial responsibility for
delivering services
– Enables ‘make or buy’
– Not-for-profit
– Incentives linked to quality of care and
outcomes, not through budget-savings

17. Ten Key Elements
6. Develop system governance and
accountability that support integrated care
– Central expectation for integrated care where
this benefits individuals (i.e. across DH, NCB,
Monitor, CQC, PHE)
– Adopt single outcomes framework (or at least
ensure close alignment)
– Powerful lever for system change locally
– Clarity on regulatory and performance
management essential

18. Ten Key Elements
7. Ensure clarity on the interpretation of
competition and integration rules
– Means not ends – proportionate approach
– Integrated care ‘hard wired’ into future system
– Primary duty of Monitor to protect and promote
interests of patients and the public
– NCB and Monitor to work closely and provide
guidance to commissioners and providers

19. Ten Key Elements
8. Set a more nuanced interpretation of patient
choice
– Patient choice intrinsic to integrated care when
developing care and treatment options
– Policy too often used as a tool to promote
competition, and mitigates against new forms of
integrated care that may benefit people
“choice is much more than the ability to choose a different provider of
elective surgery. It is about the choice of care and treatment, the way
care is provided and the ability to control budgets and self-manage
conditions.”

20. Ten Key Elements
9. Support programmes for leadership and
organisational development
 Unlikely to happen at ‘scale and pace’ without a wide range of
support including:
• Leadership, engagement, trust, legitimacy, vision
• Networks that share learning and ideas
• Skills and competencies
– Procurement process, contract currencies, incentive
schemes, prime contractor model, risk-sharing
– Information technology – governance, interoperability and
shared patient records

21. Ten Key Elements
10. Evaluate the impact of integrated care
– Triple Aim – patient experiences, care outcomes,
cost-effectiveness
– Important for accountability and quality
improvement purposes
– Clearly defined and measurable goals essential
– Baseline data, comparative studies
– In-depth investigation of care co-ordination

22. The ‘Narrative’ by National Voices
• Consultation process with public
and patients on what integrated
care should mean to them
• Creation of ‘I’ statements on what
people should expect
• Reframing of integrated care to
read: “people-centred care co-
ordination”
Core Statement
“I can plan my care with people who
work together to understand me and
my carer(s), allow me control and
bring together services to achieve the
outcomes important to me.”

23. National Collaboration for Integrated Care

24. National Collaboration for Integrated Care
The national partners will
be part of an on-going and
sustained collaboration to
remove national barriers,
develop new tools, and
facilitate local efforts [for
integrated care]

25. National Collaboration for Integrated Care
Some Key Commitments
• Align information and governance
systems
• Develop a pioneer programme
with funding to support
acceleration of integrated care in
key localities and accelerate
learning across the system
• Systematic evaluation of progress
and impact over time
• New ways of measuring people’s
experiences of integrated care
and support
• New funding support
• A national resource – Integrated
Care and Support Exchange
(ICASE) – to bring together
practical experiences

26. The Integrated Care
Pioneers
Barnsley
Cheshire
Cornwall
Greenwich
Islington
Kent
Leeds
London WELC
North Staffs
North West London
South Devon & Torbay
South Tyneside
Southend
Worcestershire
In May 2013, the
national partners
established an
invitation to tender
to support
innovative people-
centred care co-
ordination. Over
100 expressions of
interest provided.
In November 2013,
14 pioneers were
selected:
Further details at: https://www.gov.uk/government/news/integration-pioneers-leading-
the-way-for-health-and-care-reform--2
Characteristics:
Mostly health and social
care partnerships rather
than NGOs that bring
together primary and
secondary care with local
authority services.
Main focus is on :
- Older people with
complex needs
- Care planning
- Holistic care
- Coordinated care
- Joint emergency
response teams
- Children

27. Measures of Integrated care
• No single indicator –
existing measures and
indicators do not
capture the concept of
person-centred care co-
ordination
• New survey to be
developed
• Focus on tangible
experiences with care
co-ordination
http://www.pickereurope.org/assets/content/pdf/Project_Reports/P2636_Integrated%20care%20report_post%20final%20edits
_v7%200.pdf

28. Better Care Fund
Key performance metrics:
• Reduce admissions to hospital
and residential care homes
• Effectiveness of re-ablement
• Delayed transfers of care
• Avoidable emergency
admissions
• Patient/service user experience
In 2015/16 existing budgets will
be pooled to create a £3.8bn fund
Health and wellbeing boards and
CCGs get first ‘go’ at bids which
must:
- Prevent admissions, especially
at weekends
- Better data sharing between
health and social care
- Joint assessments and care
planning
- User engagement and political
buy-in
- Sound business plans to
reduce utilisation of
institutional care

29. Typical Examples of Integrated Health and
Social Care in the UK
To illustrate who integrated care is for, the following slides look at some key care groups to whom
integrated care is most suitable. Examples of integrated care from around the UK are provided to
illustrate how integrated care has been achieved.

30. Integrated care for frail older people
Torbay Care Trust
Integrated health and social care teams, using
pooled budgets and serving localities of
c.30,000 people, work alongside GPs to
provide a range of intermediate care services.
By supporting hospital discharge, older people
have been helped to live independently in the
community. Health and social care co-
ordinators help to harness the joint
contributions of team members.
The results include reduced use of hospital
beds, low rates of emergency admissions for
those over 65, and minimal delayed transfers
of care. (Thistlethwaite, 2011)
North Somerset
As one of 29 sites involved in the DH
Partnership for Older People Project (POPP),
four fully integrated and co-located multi-
disciplinary teams provide case management
and self-care support to older people. The aim
is to prevent complications in diseases and
deterioration in social circumstances.
Based around clusters of GP practices, the
service brings together community health and
social care workers, community nurses, adult
social care services, and mental health
professionals.
(Windle et al, 2010)

31. Integrated care for people living with multiple long-term
health and social care needs
Hereford
An integrated care organisation
In Hereford, an integrated care organisation
based on eight health and social care
neighbourhood teams is in development to
support the personal health, well being and
independence of frail older people and those
with chronic illnesses such as diabetes, stroke
and lower back pain.
Early successes include lower bed utilisation
and reductions in delayed discharges from
hospitals
(Woodford, 2011)
Wales
Chronic Care Demonstrators
In Wales, three Chronic Care Management
(CCM) Demonstrators in Carmarthenshire,
Cardiff and Gwynedd Local Health Boards have
pioneered co-ordinated care for people with
multiple chronic illness. By employing a
‘shared care’ model of working between
primary, community, secondary and social care
the three demonstrators were able to reduce
the total number of bed days for emergency
admissions for chronic illness by 27%, 26% and
16.5% between 2007-2009. This represented
an overall cost-reduction of £2,224,201 .
(NHS Wales, 2010)

32. Integrated care for people with specific diseases
NW London Integrated Care
A ’virtually’ integrated care organisation
In NW London, a large scale change
programmes was developed with the aim of
integrateing care to people with diabetes
(also for older people more generally) . It
involved (in 2012) 103 GPs, 2 hospitals, 2 MH
providers, 2 NGOs. The organisation works as
a ‘virtual’ and voluntary organisation with the
separate organisations having contractual
agreements between them. The members,
the majority of which are GPs, can utlilise an
innovation fund of c.£0.5 million per year.
The focus on care planning has revealed
greater awareness of people with conditions
that need treating. No evidence of reduced
hospitalisations but some of better
management risk factors
Curry et al, 2013 in IJIC
http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN
%3ANL%3AUI%3A10-1-114735/2018#r10

33. http://www.kingsfund.org.uk/publications/co-ordinated-care-people-complex-chronic-conditions

34. • 99% of those wishing to die at home do so
• High satisfaction amongst family, carers, staff
• Significant cost reduction (c.25%) compared to
‘usual’ care in hospices/hospital settings

35. Awareness-raising and relationship-building
GPs, community staff, hospital consultants, volunteers and
local people strengthening its ability to ‘capture’ people
nearing the end of life before, or very soon after, a hospital
admission.
Holistic care assessment and personalised care plan
A single assessment process examines both the health and
social care needs of the patient and their family. It also takes
into account their personal choices about future care and
treatment options.
Multiple referrals to a single-entry point
The service accepts referrals from any health professional
and also local people. All referrals come into the service and
are assigned to a clinical nurse specialist from a single-entry
point.
Dedicated care co-ordination
The care co-ordinator has a number of roles: acting as the
principal point of contact with the patient and their family;
effectively co-ordinating care from within a multidisciplinary
team and liaising with the wider network of care providers.
Rapid access to care from a multidisciplinary team
Both professionals and volunteers can be rapidly deployed
by the service to provide care or support to meet the needs
of people living at home. The service operates 12 hours a
day, with access to an on-call clinician out of hours.

36. Meeting the Challenge :
Key Lessons in the UK Context
Personal Level
• Holistic focus that supports users and carers
to live well and be resilient
• Management in the home environment
• Co-producers of care, even at end of life
Clinical & Service Level
• Early and multiple referral points for care co-
ordination
• Named care co-ordinators
• Continuity of care
• Multi-disciplinary teams
• Flexible working practices – subsidiarity of
role
Community Level
• Role of community integral to care-giving
process
• Build awareness, legitimacy and trust
• Volunteers
Functional Level
• Effective communication
• Shared electronic health records helpful
• High-touch / low tech care – need for face-
to-face interaction and conversations
Organisational Level
• Effective targeting
• Localised – work in neighbourhoods
• Long-term commitment from local clinical
and managerial leaders
• Shared vision – challenge silos
• Operational autonomy
System Level
• Integrated purchasing
• Long-term strategies
• Political narrative
• Aligned incentives
• Focus on improving quality, not reducing
cost

37. Summary of Current Position in England
• Great controversy remains over the Government’s integrated care policies
as they combine integration and competition
• However, government has genuinely accepted the narrative on integrated
care:
– Cross-government paper pledging long-term support for integration
– The NHS Mandate requires care to be ‘co-ordinated’ around
individuals’ needs
– Monitor, the economic regulator, must support integration where this
is of benefit to patients
– Measures of integration, specifically from the users’ perspective, are
being developed to assess progress and support change
– Evaluation, specifically of the new DH pioneers of integrated care, set
up to derive key transferable lessons for other
– The Better Care Fund ‘enforces’ partnership working by asking health
and social care agencies to bid for funds top-sliced from their budgets
• There is a groundswell of activity in developing new approaches to
integrated care across England

38. Contact
Dr Nick Goodwin
CEO, International Foundation for Integrated Care
nickgoodwin@integratedcarefoundation.org
www.integratedcarefoundation.org
@goodwin_nick @IFICinfo