Mark Kewley shares some lessons from the Southwark and Lambeth Integrated Care programme

1. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Ensuring success for new models of
care: recent experience and evidence
Lessons from SLIC
Nuffield Trust – November 2016
Mark Kewley
Director of Transformation, NHS Southwark CCG

2. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Contents
3. How
5. Lessons
6. Next
steps
4. When
2. What
1. Who

3. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
St Thomas’s
Hospital
King’s College
Hospital SLaM
Guy’s
Hospital
• Two diverse inner city London
boroughs covering 600,000 people
• Some world class medical
institutions and research power
• Significant health inequalities and
worse than average outcomes and
deprivation
• Three FTs covering acute and
community services for physical
and mental health
• >90 GP practices including chains,
merged practices and single
handers
Local CCGs and LAs LAs, GPs and FTs AHSC
Southwark and Lambeth Integrated Care
Independent assets
Citizens’ Board
&
Citizens’ Forum
Who

4. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
What
• A quite familiar integrated care programme
• Focused on Older People (>65s)
• Emphasis on reducing unplanned hospital
admissions and care home admissions
 Case finding/risk stratification, holistic
assessment and care management
 Community MDT approach
 Admission avoidance team and Hospital-at-
Home team (@home)
 Redesign of some more proactive pathways
for high prevalence admissions (falls, UTI,
dementia, malnutrition)
N.B. a more detailed pathway description is provided in the appendix

5. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
• The SLIC OPP was one of a variety of
transformation projects being
undertaken by the partners in the
partnership
• Some great innovations happening
alongside: 3D4D, DMI, Lambeth Living
Well, SAIL
• The Programme team did not oversee all
of these inter-dependent strands of work
• The programme was therefore trying to
harness the existing capacity for
innovation, and to bring some
coordination to this as a whole system
What

6. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
How
Phase 1
Integrated Care
Pilot (ICP)
Business case
to GST Charity
Implement
work streams
Agree shift
in resources
Owned by PMO
central team
• A relatively linear approach to pathway redesign and implementation: deliberate
strategy
• Resource shifts allowed investment and new incentives within community services
and in the primary care contracts; these were activity related
• Programme governance in place; emphasis on ‘delivery’ and implementation rather
than an overall culture change and shift in accountability

7. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Phase 2
Build whole
system approach
Leadership
development focus
Focus more on
changing mindsets
Agree alignment
of accountability
Owned by teams
supported by PMO
• A more emergent / adaptive approach
• Needed to build a collective recognition about a collective problem that can only be
solved by formal collaboration and joint accountability
• Had to invest in leadership development, and encourage federations in general
practice (coincident with PM Challenge Fund)
• Had to go beyond piece-rate incentives towards more joint-incentive schemes, but
using the pre-existing and disparate contractual forms
How

8. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
When
CCGs
established
BCF
introduced
FYFV
launched
GPFV
launched
AUA DES
launched
Routine CQC
inspections
Vanguard
applications
PM
Challenge Fund
MCP
framework
AHSNs
designated
2011 2012 2013 2014 2015 2016
Launched
ICP
Launched SLIC
OPP
ERR / @home
commissioned
Strategy
Plan
Resources
Phase 1
Adapt &
Adopt
‘Whole system’
business case
Falls service
commissioned
Activity payments
in LES contracts
GP Emerging
Leaders Prog
Phase 2

9. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Lessons
Changing
people’s
individual
care
Changing
system
measures
Clinicians in
general practice and our local
hospitals have unanimously
been singing [the LCR’s]
praises and saying what a
huge difference it has made
to their working lives and the
safety, quality and experience
of patients.
Changing
IT!!
EHI Award for 'Best use of IT to support integrated care’

10. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Lessons
“Some of us formed really strong
networks. Having headspace outside
of the practice was really helpful, and
being challenged in different ways
was really useful, it allowed me to do
things on a bigger scale.”
Changing
leadership
capacity
Changing
involvement
and
participation
“Citizens’ involvement in SLIC is
something to be proud of. Working on
an equal footing with professionals to
co-design projects and being
represented at every level of
governance meant we could play an
important role in improving care for
local people.”

11. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Lessons
Local Care Record Conditions for success
• Agreement about the problem, and a
commitment to co-design the solution
• Clear description of the resources
required, non-recurrently and recurrently
• Dedicated operational teams owned the
task, supported by a coordinating PMO
• Clear lines of accountability
• Service innovations were linked to
funding changes in routine contracts
GP Emerging Leaders Programme

12. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Lessons
• Co-create a vision that is
meaningful to all –
burning ambition as well
as burning platform
• Produce a strong
business case – know
what are your relative
priorities and timescales
• Create the conditions
for change – invest in
people’s time to think
and work together
• Identify interventions
and system enablers
• Facilitate and encourage
co-design
• Identify programme
support – and be explicit
about expectations and
mandate
• Use available expertise
• Develop lateral
leadership and change
skills
• Use measurement – and
think about how to
capture ‘intangibles’
• Evaluate continuously –
this is an adaptive
process not an RCT
• Learn and adapt as you
go – prototype, test, fail
fast and improve
• Have strong governance
– be explicit about
accountability
These are the formal ‘lessons’, but most of these would have been recognised as important at
the start. The big unanswered question remains: why is this so hard to do in practice?

13. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Next

14. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
“The [PMO] team was expected
to ‘step into the gulf’ because of
a lack of agreement between
partners, only to be criticised for
the lack of agreement”
Create a dedicated ‘engine room’ to drive
and manage the local transformation
programme, with adequate dedicated
resources and capabilities. This is not just
a programme management office and it
needs your best people
PMO provides capacity and
skills but cannot assume an
operational mandate
Operational teams need to
see themselves as leaders
across a wider system
Best of both: A mandated
operational ‘engine room’
supported by a PMO
Next

15. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Thank you &
Questions

16. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
Appendix

17. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
What

18. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
No of
Conditions
per person
Base: People registered at practices that allow PHMCC access
Source: LTCs from acute inpatient data (11/12) & PHMCC
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
people(%)
Age band (Years)
Morbidity (number of LTCs) by age band
0
1
2
3
4
5
6
7
8+
What
Over time we have moved away from an
age-based and ‘PARR-type’ risk-
stratification and towards a model based
on complexity of need for people with a
high burden of planned and unplanned
care. This includes medicines, OP appts,
GP appts (i.e. not just NEL admissions)

19. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
How
Rank Practice / Intervention Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Total % of total
1 CMDTs X X X X X X 6 13%
2 Holistic Health Assessment of need X X X X X 5 11%
2 KCH Volunteering X X X X X 5 11%
2 Community + Social care have universal access to each others records X X X X X 5 11%
5 Rotations of nursing staff to community nursing service X X X X 4 9%
5 Community geriatricians X X X X 4 9%
5 Connect + Care X X X X 4 9%
8 Care co-ordinator roles such as Integrated Care Manager X X X 3 7%
9 Red Cross X X 2 4%
9 My Health Locker X X 2 4%
9 Local availability of investigation results X X 2 4%
12 Home share X 1 2%
12 Wheel of wellbeing X 1 2%
12 Every pound counts X 1 2%
15 Extension of access to specialist advice through 24 hour TALK hotlines 0 0%
Total 8 9 8 7 6 7 45
6
5
5
5
4
4
4
3
2
2
2
1
1
1
0
CMDTs
Holistic Health Assessment of need
KCH Volunteering
Community + Social care have universal…
Rotations of nursing staff to community…
Community geriatricians
Connect + Care
Care co-ordinator roles such as…
Red Cross
My Health Locker
Local availability of investigation results
Home share
Wheel of wellbeing
Every pound counts
Extension of access to specialist advice…
Count of 'votes' for each practice
Discuss long list from ICAN #1 Initial short list Detailed appraisalA B C
• At the ICAN#1 workshop a host of approaches
were identified and discussed, with each
considered in terms of its readiness for
adoption based on defined criteria
• Five categories of intervention were identified
• Within which 15 interventions/practices were
listed for discussion within the ICAN#2
workshop
• At the ICAN#2 workshop six mixed tables
discussed the long list of
interventions/approaches. There was an
opportunity to amend or add at that stage.
• In discussions the tables selected a small subset
of interventions using a set of criteria:
— Suitability, Feasibility, Viability, Inter-
dependence
• Following the workshop the core team counted
the frequency with which each practices was
selected, and ranked the practices
• For the top half of the ranked list (7
interventions) the core team have subsequently
collated more detailed analysis of the models
• These summaries were used to inform
discussion within the provider group about
which practices should be priorities for
adaptation and adoption across the boroughs

20. Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care
How
Agree the ‘package’ of
3-4 practices
Work collaboratively to codify the
characteristics of each practice
Work on detailed local blueprints to
adopt and adapt at scale
D E F
• Representing a large proportion of the provider
interests in the local system, the Provider
Group has identified interventions that offer
the most suitable, feasible, viable and
complementary package to enable integrated
care
• For each practice selected the Provider Group
will oversee a cross-borough working group to
define/codify the most important
characteristics of the practice
• Alongside this the workgroups will consider
what factors need to be considered to support
effective adoption at local level
• At local level (where applicable) neighbourhood
teams will be supported to undertake detailed
planning to successfully adopt and adapt the
chosen practices within and between their
organisations.
• This involves operational leaders working
together to create their own ‘blueprint’ for
service delivery, supported by PMO-type staff
• Case finding
• Named person
• Care planning
• Self-mgmt.
• MDT working