This document discusses integrating health and social care services in Kent, England. It outlines localities and implementation of the Kent Health and Social Care Integration Programme (HASCIP). Key points include co-located and flexible multidisciplinary teams, single assessment processes, and proactive care programs reducing hospital admissions and costs. Challenges include information governance, integrated care plans, and ensuring capacity to support long-term condition objectives. The vision is to make life-changing improvements to experiences and outcomes through collaboration.

1. Kent Health Economy
Integrating Community and Social
Care Service
Lesley Strong, Kent Community Health
Trust
Hazel Carpenter, Accountable Officer
South Kent Coast CCG

2. Localities
South Kent
Coast
Thanet
C4G
Ashford
Swale
West Kent
DGS

3. • There are no gaps in my care
• I was always kept informed
• The team always talked to each other to get me the best care
• I always knew who was in charge of my care and who to contact
• I didn’t have to keep repeating myself to lots of different people
• I didn’t have to wait in all day for lots of different people to come at
different times
• I was fully involved in the decisions and knew what was in my care
plan
• There was a plan in place to help me cope if I thought things were
getting worse and make sure I stayed at home and didn’t have to go
into hospital or long term care
• My GP knew who she was dealing with in the team
What we want to achieve,
so our clients say

4. Introducing HASCIP
• Care pathways first
• Focusing on ‘function’ and how we make integration work at the front-line
of our services - swiftly
• Not discounting structural integration, it is not our starting point
• It’s about practical measures - by bringing our teams and systems
together today
• Medium term - we may move towards greater unity, e.g. joint roles and
appointments, joint accountabilities, joint training and pooling resources
through developing concepts such as the ‘trusted assessor’.
• This approach allows us to remain agile and flexible, able to respond to
the wider policy and commissioning landscape changes
Our Vision for Integration: Tripartite Compact,
KCC, KCHT, KMPT
Making life-changing improvements to the experience and outcomes of
people using health and social care services in Kent

5. Model

6. Implementation
• Implementation phase – Nov 2011 to date
• CCGs began to share their commissioning intentions and engage in
detailed discussions about the models of integration that would
best support the needs of their local populations
• Single county wide ‘one size fits all’ approach now is not
appropriate
• Programme management was devolved from a county-wide,
centralised approach to the locality led implementation groups
aligned to the 7 CCGs
• HASCIP now driven by locality led implementation groups,
underpinned by and delivering local Operational Frameworks

7. What is in place since the compact was agreed?
• Risk stratification for health and social care; we are beginning to see what
the joint 5 % caseload is
- challenge: what does that mean for the joint caseload, change in practice
• Co-located, mobile and flexible teams: CCG locality lead development
multi-disciplinary teams
• Single assessment process and FACE documentation rolled out within
teams and some acute providers; digital pens project; Trusted Assessors
- challenge: information governance and IT solutions
- challenge: how to implement integrated anticipatory care plans
• Health and social care co-ordinators appointed in some localities
- challenge: will MDTs be able to use them to achieve LTC objectives
• Self care e.g. assistive technology at the core of single assessment and
provision of care – Pathfinder for 3 Million Lives , Industry providing a
managed service. Health Trainers, Patient Knows Best

8. Key example
Proactive care: 12 week intensive package of support.
“The foundation of the model is to place the individual at the centre of
all decision making. Individuals and their carers and families are
supported by a wrap around clinical team to become experts in their
particular long-term condition”.
Dr Tuan Nguyen, Folkestone GP

9. Outcomes of proactive care
• 15% reduction in A&E attendances.
• 55% reduction in non elective admissions.
• 37% of the cohort has reduced admission risk score.
• Total saving to date £225,938.
• 75% patients reporting improvement in functional quality.
• Plus, 86% no longer anxious about condition from baseline of 46%.

10. Top tips to make it work
• GP clinical engagement from the outset is crucial.
• Risk stratification to identify appropriate patients requires a joint
approach between the GP and matron.
• Administration support to manage the MDT meetings and
communication links is essential.
• MDT reviews must be well planned and fully engage the patient and
their families in the goal setting.
• Nursing caseload reviews need to be completed prior to roll out to
ensure capacity is built into the system.

11. An ageing population with
significant pockets of
deprivation and rising
inequalities

13. NHS South Kent Coast
Clinical Commissioning Group
“To ensure the best health and care for our community”
..which will be delivered through:
Keeping the patient at the heart of everything we do
Ensuring that all commissioning is led by clinicians
Making the most of all the resources at every opportunity
Keeping a strong focus on working closely with all of our
partners
Ensuring that services are as integrated as possible
Keeping services as local as possible

14. We are NOT a
PCT!
• Different scope of responsibilities
• Membership organisation
• Clinically led
• Duty and powers to collaborate and deliver integrated service
models around the patient
We need to realise: the impact clinicians can have on
commissioning delivery and clinical outcomes of commissioning
well; the potential patient benefits of integration and collaboration;
the benefits of a membership

15. Commissioning context
Opportunities
1. CCG values focus on:
– Integration
– whole population
– working with
partners
– Distributive Clinical
Leadership with
whole member
engagement
2. Pathfinder tier two Health
and Wellbeing Board
3. GP evangelists for
– Patient Knows Best
– Telecare
– Pro-active care and
risk stratification
Challenges
1. Wave 4 CCG late in developing
member focused governance –
impact on adoption
2. Historically under doctored with a
variation a resulting inconsistent
primary care model – impact on
spread
3. Modelling costs to inform
investment at ‘tipping point’
4. Aligning incentives

16. • 24/7 integrated single points of access: challenge to design,
implement, fund and to make it work
• How to integrate mental health, secondary care services in primary
and community services.
• Joint KPIs and performance management
• Client feedback and surveys, co-production to inform delivery
• Workforce: joint induction, training and development and
opportunities to share good practice and innovate.
• Information governance and consent protocols
• Joint workplaces , IT and patient/client record systems
Challenges