Hannah Farrar: Integrated care – London's programme of change
Integrated careLondon’s programme of change
ELIC Referral Management The integrated care landscape in London is complex GP and Acute Consultant-led approach to improving theBrent Gynaecology pathway quality of GP referrals to OPDGP and Consultant jointly-led Waltham Forest Communityservice in the community UCLP Dermatology service Redbridge ICM Tariff research; whole pathway Royal Free Building on the B&D ICMBrent (LA led initiative) metrics; integrated cancer Post-acute care provided in a Whittington Health system, creating ‘patient pull’ community setting Care of elderly; enhanced recovery; co-morbidities in Tower Hamlets Primary CareNWL Ealing ICO Investment Programme LTCs (e.g. Diabetes, heart Camden ICO Camden Enfield failure; chromic pain) (235,000)NWL integrated care pilot Frail, older Community Care packages e.g.Diabetes and older people people with MSK service Diabetes, COPD, CVD, 0- Waltham Forest ICM Harrow multiple Barnet 5’s, MH, Community Virtual Building on the B&DH&F continuity of care pilot conditions Ward ICMbringing together social care Primary Care Dischargeand GP services for people Waltham Facilitation Service at Queen’swith high likelihood of hospital Haringey Forest A&Eadmissions GP and nurse-led service at Hillingdon Brent Redbridge A&E to redirect patients to theWestminster Diabetes most appropriate services inService Camden the community Islington City &Multi-disciplinary specialist Ealing Hackneydiabetes teams including Haveringprimary and secondary care Westminster Risk based support for Tower Barking andworking in two bespoke sites City Newham Havering patients over 65 through H&F K&C Hamlets Dagenham community Matrons whoK&C District Nursing Case Hounslow manage careManagementPractice-based MDT approach Southwark Barking and Dagenham ICMto avoiding unnecessary Targeted case management forhospital attendances Richmond Wandsworth Lambeth people at high risk of hospital Greenwich admissionsWandsworth Community Lewisham BexleyVirtual Ward Newham Community Virtual WardGP-led model for coordinating Risk based support for patients most Merton likely to need hospital treatmentcommunity services andpreventing admissions to Kingstonhospital Sutton & Merton Hip & Knee Bexley Care Navigation Team service Nursing/OT-led team within A&EWandsworth Diabetes Sutton at QMS and QEH to redirectService Bromley Admission patients to the most appropriate Your Healthcare Lambeth Living Well Avoidance ServiceVertical integration of services service Kingston Collective Croydon Builds on successBromley ofincluding secondary care with Integrated health and NESTA funded pilot – the PACE pilot QMS Bexley : Design a healthshared guidelines and social care services for co-design of mental campus focus on elderlyreferrals services older people health pathways care, integrated primary and Croydon Virtual Ward secondary servicesThe map is under development Lambeth & Southwark Co-ordinated services to King’s Community Diabetes Service patients at the highest risk of Health Greenwich Virtual Admissionsin partnership with clusters and Virtual clinics and hospital admissions using Partners ICO Avoidance Teamlocal authorities multidisciplinary intermediate processes and practices of Frail older Prevention of emergency team acute wards people admissions 1
Since 2010, NHS London has focused its support on developing threeintegrated care systems… Imperial AHSC UCL Partners KHP AHSC The original Darzi NWL Integrated Care Pilot Whittington Health Lambeth and Southwark Integrated Care pilot in London had • ~550k catchment ▪ 440k catchment ▪ 517k catchment limited vision and population population Catchment population engagement population ▪ Initial focus: diabetes ▪ Initial focus on older and frail elderly, c15k people, c49k over-65s diabetics and 26k over 75s ▪ Coordination of care ▪ Transfer of community ▪ King’s College Hospital, NHS London and across providers (acute, services from Haringey Guy’s & St Thomas’ the three AHSCs Operating community, primary, and Islington into and SLaM NHS FTs decided to pilot model social care) with shared Whittington Hospital working with NHS Integrated Care in clinical practices and Lambeth, NHS three geographies information Southwark and LBs ▪ In delivery stage ▪ Mobilisation and ▪ Full go-live of new ▪ Pilot ends June delivery phase pathway April 2012 Time- The aspiration was scales 30, 2012 ▪ Roll out through priority LTCs and broader to focus on population 2012/13 population health and work with all ▪ Avoid 1,753 admissions ▪ Improve outcomes for ▪ Better quality of care partners (ie. across pilot patients at the minimum and patient experience primary, secondary, Expected ▪ Avoid 3,700 necessary cost; with a reduction in social care, outcomes attendances across ▪ Reduce unnecessary system costs community and mental health). pilot hospital admissions and ▪ Saving of £12.3m from reduce utilisation of emergency admissions acute care and £0.2m from A&E 2
… on this basis, we can now define the key characteristics of anintegrated care systemDefinitionIntegrated care systems address specific patient needs using case management. They enable improvementsin the care provided to individuals with long term conditions or high users of services. Integrated care systemsneed to be supported by multidisciplinary groups working across health and social care. They focus onpopulation health and use risk stratification to provide evidence-based care on a proactive and planned basis.Integrated care systems should deliver: Better patient experience Better clinical outcomes Lower cost, better productivity Five enablers needed to make integrated careSeven core components of an integrated care systems a successsystems A patient registry Clear accountability and joint decision-making Risk stratification Patient, user and carer engagement and Common clinical protocols and defined but involvement tailored care packages Clinical leadership and cultural development Individual care plans Aligned incentives Proactive and planned care delivery Information sharing Case conferences by multidisciplinary teams for only the most complex patients Clinical audit and performance management by multidisciplinary teams of their performance and that of their peers 3
…which has the potential to deliver the aspects of co-ordinated care thatare most important to patients and communities24/7 Out of Named care Support for Participative Access to hours care coordinator self care tailored management planning information and care record 4
Across London, integrated care systems could support theachievement of commissioner QIPP savings £ At least Up to 1m £474m Londoners could potential commissioner benefit from case savings across London management1 1 Total population with Long Term Conditions (LTC) from GP QOF registries, with age profile based upon national prevalence rates by age quintile (Decision Resources). Elderly (75+) estimated from PCT primary care populations by age quintile (Department of Health). The proportion of individuals with co-morbidities estimated from hospital admissions for patients aged 19-74 with one or more LTC diagnosis on any admission in that year (HES 2009/10 for all London). This figure excludes the children’s segment. 5
Implementing integrated care systems across London could savecommissioners up to £474m Commissioner (all London PCTs) Acute Providers (18 acute NHS Trusts plus FTs )Level of ▪ £0.9bn reduction in spend required to ▪ £1.4bn to £1.6bn cost saving required tofinancial remain within budget achieve financial viability (1% netchallenge to surplus) for 18 acute NHS Trusts2014 / 2015 ▪ Gross saving in acute £663m ▪ Reduction in acute -£643m spend1 income1 -£160m +£40mFinancial ▪ Investment in new ▪ Income from newimpact of community proactive care community proactive careIntegrate Care -£29m +£489m ▪ Integrated care ▪ Change in costs (includes programme costs +£474m £52m from LOS -£115m improvement2)SOURCE: SaFE 2011, Sector 5-year strategic commissioning plans 20111 £20m difference in the reduction in acute spend by commissioners and the reduction in acute income for providers corresponds to a reduction in payments by the commissioner to NHS London for emergency activity above threshold2 Total potential saving from LOS reduction through integrated care is estimated at £52m; however, the potential reduction by 2014/15 shown in subsequent analysis is limited to £29m due to 20% cap on cost savings 6
Integrated care systems are emerging across London… Enfield Harrow Barnet Waltham Haringey Forest Hillingdon Brent Redbridge Camden Islington City & Ealing Hackney Westminster Tower Newham Barking and H&F K&C City Hamlets Dagenham Havering Hounslow Southwark Richmond Greenwich Wandsworth Lambeth Lewisham Bexley Merton Kingston Bromley Sutton Croydon 7
But learning suggests setting up an integrated care system takes timeand requires careful planningSetting up a pilot requires up to 12 months of planning alongside considerable clinical and managerialengagement. Five steps have been identified as key to setting up an integrated care community. Operational launch Sign-up by A detailed all parties operational A plan business case A coalition of leadership 8
NHS London has developed a programme of support and jointlearning for the integrated care system coalitions of leadership… Electronic community A series of problem Monthly of practice solving workshops teleconferences • Relevant policy documents • Finance modelling – health • National and regional • Discussion forum and social care policy updates • Information on forthcoming • Integrated IT • Cluster updates events • KPIs for integrated care • Joint problem solving • A toolkit on setting up • Patient experience and opportunities, on key integrated care systems involvement topics • Aligning incentives www.networks.nhs.uk/nhs- • Integrated commissioning networks/london-integrated- care-peer-learning-forum 9
… and is supporting establishment of whole-population integrated caresystems Key questions being addressed Most appropriate operating/governance model Financial model that best delivers both quality and efficiency across the whole system Integration of health and social care Commissioning models for integrated care Inner North West London approach North Central London approach Procuring external consultancy support Development of a long-term programme to extend the current pilot and design a to develop a whole population integrated framework for whole population care system and address system-wide integrated care enablers: Informatics solution Links to Inner NWL Community Budget Year of Care funding/tariff model pilot that is reviewing public sector Commissioning/contracting model spend and developing a business case Workforce requirements for whole population re-design. 10
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