Daniel Elkeles: Making the business case for integrated working

Integrated care inNorth West LondonMaking the business case ‘stack up’Daniel ElkelesDirector of Strategy NHS NW London10 January 2012 Serving the North West London Cluster

Producing our business case required us to address 5 areas 1 Joint governance Integrated Management Board with a shared performance and evaluation framework 2 Aligned incentives through an innovative financial model 3 Information sharing to access and analyse data in a timely fashion 4 Patient, user and carer engagement and involvement 5 Organisation and culture development Serving the North West London Cluster

The NWL Integrated Care Pilot Improve the quality of patient care for patients with diabetes and the elderly Local Multi-Disciplinary Groups… …working in a Multi-Disciplinary System Group 1 5 Sub-Group Patient Care registry delivery Practice Social care 2 6 Specialist Risk Case stratification conference GP District Community nurse matron Mental 3 7 Health Clinical  Performance Specialist protocols &  review  care packages Practice Social Community 4 nurse care Mental Acute Care plans worker Health Specialist 1) Improve patient outcomes and experience through collaboration and coordination care What are we across providers (4 hospitals, 3 community providers, 93 GP practices, 5 social care trying to organisations) with shared clinical practices and information achieve in 2) Over 5 years decrease hospital usage including emergency admissions by 30% and NWL? nursing home admissions by 10% for diabetics and frail elderly through better more proactive care 3) Reduce the cost of care for these groups by 24% over 5 years Serving the North West London ClusterSOURCE: NWL ICP Operations Team

A large number of providers taking part in this pilot Ealing CCG Great West CCG (Hounslow) West London CCG (K&C) Westminster CCG Hammersmith and Fulham CCG Serving the North West London Cluster 3

Over the last 6 months, the ICP providers have organised themselves into10 multi-disciplinary groups (MDGs) that reach over 550K patients K&C North CLH H&F Small Practices Acton ▪ Practices: 11 ▪ Practices: 17 ▪ Practices: 13 ▪ Practices: 12 ▪ Diabetes: 1221 ▪ Diabetes: 2,109 ▪ Diabetes: 2,723 ▪ Diabetes: 1,551 ▪ Elderly: 1325 ▪ Elderly: 3,407 ▪ Elderly: 3,420 ▪ Elderly: 2,845 ▪ Total patients: 37,951 ▪ Total patients: 74,370 ▪ Total patients: 63,636 ▪ Total patients: 54,917 Chiswick ▪ Practices: 9 X Victoria ▪ Practices: 8 ▪ Diabetes: 1,015 ▪ Diabetes: 1,225 ▪ Elderly: 2,218 ▪ Elderly: 2,618 ▪ Total patients: 41,630 ▪ Total patients: 47,674 H&F North Central ▪ Practices: 9 ▪ Diabetes: 2,134 ▪ Elderly: 2,528 ▪ Total patients: 72,486 H&F Central H&F South Fulham K&C South ▪ Practices: 5 ▪ Practices: 6 ▪ Practices: 14 ▪ Diabetes: 1,113 ▪ Diabetes: 688 ▪ Diabetes: 1,667 ▪ Elderly: 1,790 ▪ Elderly: 1,700 ▪ Elderly: 3,635 ▪ Total patients: 39,908 ▪ Total patients: 38,302 ▪ Total patients: 73,492SOURCE: NWL ICP Operations Team Serving the North West London Cluster

A simple way of describing the ambition GP Practice Pilot CatchmentUnit ofmeasurementacross pilotReduction in ▪ Avoid 7 ▪ Avoid 28 ▪ Avoid 1,753 ▪ Avoid 2,080 admissions per admissions per admissions admissions acrossemergency ~2,000 patients ~8,000 patients across pilot of catchment ofadmissions 506,000 600,000 population population ▪ Avoid 15 ▪ Avoid 59 ▪ Avoid 3,700 ▪ Avoid 4,390Reduction in attendances per attendances per attendances attendance acrossA&E ~2,000 patients ~8,000 patients across pilot of catchment ofattendances 506,000 600,000 population populationTotal ▪ Saving of £50,000 ▪ Saving of ▪ Saving of ▪ Saving of £14.6mreduction in from emergency £200,000 from £12.3m from from emergencyemergency admissions and emergency emergency admissions andcare £1,250 from A&E admissions and admissions and £0.4m from A&E £5,000 from A&E £0.2m from A&E Serving the North West London Cluster 5

How are we doing so far?Very preliminary data Emergency admissions April 2011 - September 2011 SLA base line activity 2011/12 5,561 Actual emergency admissions 5,040 Difference 521 Compared to April 2010 - September 2010 Emergency admissions across NWL -1% Emergency admissions in ICP cohort -4% Serving the North West London Cluster

Joint governance –We created a virtual organisation to run the pilot Serving the North West London Cluster 7

We set out clearly the responsibilities of each provider in the ICP Actively participate at case conferences Support and take part in care planning ▪ Identify and prepare patient cases for ▪ Support MDGs in creating initial care plans discussion (e.g., inpatients, social service for all diabetic patients and 50% of patients users with health issues, etc.) aged 75 and over (e.g., by providing seconded nurses to the MDG) ▪ Give specialist input on patient cases brought by other participants ▪ Modify care plans with patients’ GPs as needed ▪ Be the expert for the MDG on the full range of available services and resources ▪ Follow-up on questions and actions generated through the case conference ▪ Discuss MDG performance, identify opportunities for improvement, and allocate out-of-hospital investment ▪ Use the ICP IT tool to see range of patient data and history across multiple settings ▪ Identify system gaps and ▪ Complete “actions” (referrals) and regularly opportunities monitor activity ▪ Collaborate with MDG partners on day-to- ▪ Identify best practice across MDGs day basis (e.g., direct phone call to GP upon A&E attendance) Change how care is delivered Review performance & identify improvement Serving the North West London Cluster

Aligning financial incentives –Funds flow from the Commissioner directly for guaranteed paymentsfunded recurrently without taking from providers up front Funding flows (2011/12) 70% marginal rate for emergency activity over 08/09 Commissioner Infrastructure / IT baseline held by SHA Providers paid for activity MDG using existing contracts – Resource Readmissions top PbR for acute and block slide held by PCTs for MH / Community Does the IC pilot deliver Integrated improvements? Management Board allocates funding No Yes Commissioner x/2 x/2 Balance QIPP savingSOURCE: Integrated Care Project Steering Group Serving the North West London Cluster 9

The costs of running the pilot are £3.4m Estimated cost, £ ‘000 Commissioner 1,200 Retained Infrastructure2 1,800 OOH 22% MDG Performance 8% 51% Care 2,500 reviews planning Out of Hospital3 18% Case conference Total Funding 5,500 Full year cost for MDGs in the pilot will need to1. Commissioners retained £1.2m for other work streams increase to £2.8m2. Includes non-recurring set-up costs3. Resource envelope available for Care Planning, Case Conference and Performance ReviewsSOURCE: NWL ICP Operations Team Serving the North West London Cluster

Information –We put in place an IT solution that enables providers to work together1 2 Patient Risk Stratification Integrated Patient Care Planning Action: Review by falls service Care plan Action 1 Action 2 Action status: Action 3 Completed  Identify high risk patients using population  Plan care for patients, share these plans segmentation and risk stratification across settings, and monitor progress  This enables proactive care to be planned  This helps better coordinate care3 4 Patient Medical Information Sharing Performance Evaluation Patient records: GP Hospital Community  View patient medical information from multiple  Track and evaluate the performance of GP’s settings surgeries and Multi-Disciplinary Groups  This enable integrated care to be provided  This helps spread best practice in patient care Serving the North West London Cluster 11

Things we learnt en route… • Ground conversations by reminding people we are doing this because we want to improve patient care and make professional’s jobs better • Be able to explain the concept simply and agree a single performance metric • Identify patient cohorts which aligned to NWL PCTs clinical case for change • Build a ‘bolt on’ to the existing NHS infrastructure and rules • Don’t try and redesign the NHS financial payment mechanisms • Don’t create a new organisation • Don’t challenge existing or emergent NHS policy • Take the minimum of funding out of providers up-front • Invest sufficient resource to set up the pilot and deliver operationally on the ground the new ways of working Serving the North West London Cluster

What’s next for integrated care in North West London?▪ Enhance integration with local authorities and other providers▪ Continue to develop and enhance the IT tool▪ Conduct robust evaluation at the end of the pilot year to understand impact▪ Scale up within North West London – Additional +10 practices in INWL already added, including Chelsea Pensioners – Roll out across more practices in Inner North West London and include Hounslow – Roll out across more Pathways in North west London (COPD, CHD and Mental Health) – Replicate in Outer North West London▪ Expand beyond North West London – Commercial interest in IT toolSOURCE: NWL ICP Operations Team Serving the North West London Cluster 13

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Daniel Elkeles: Making the business case for integrated working

by The King's Fund on Jan 13, 2012

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Daniel Elkeles: Making the business case for integrated working Webinar Transcript