1. Integration in Cumbria
I t ti i C bi
Sue Page
g
John Howarth
Hugh Reeve
Ros Fallon
NHS Cumbria

2. Welcome to Cumbria
CH
H Cumbria profile
CH CH
 2,500 sq miles
CH
CH
CH CH
 500,000 people
CH
H
 73 people p km2
p p per
 Urban/rural split
H  Wide health variations
CH  Huge travel times
H

3. The way we were…
 Health
H lth economy was b t – £36 7 hi t i d bt -
bust £36.7m historic debt
£100m deficit projected over 5 years
 People marching on the streets
 Efficiencies needed i acute sector
Effi i i d d in t t
 Co
Community se ces fragmented
u y services ag e ed
 Standards of care inconsistent – systematic approach
needed

4. Where are we now?
Wh ?
 Debt solved (although pressures still exist!)
 Highest score in North West for WCC
 Closer to Home strategy
 Clinicians in charge in all 6 localities
 Devolution of power to ICOs
This is plan A, there is no plan B
A

5. Where does integration take place?
Business Support Services
Copelan
d
Allerdal
e
South
Lakelan
Furness Cumbria d
Central
Carlisle
Eden

6. Sub locality Sub locality Integrated Care relationships
Locality Locality Locality Locality Locality Locality
Support Headquarters
Clinical Senate
(Clinical Executive Group)
• Developing evidence based clinical pathways and service models
• Peer support to localities to improve performance
• Collaborating for commissioning and contracting
• Working with key public sector partners
Business functions
HR, Contracting, Finance,
Intelligence, Pathway design etc
g , y g
PCT (System Manager)
£800m from
DH Ensures public health is protected
Contracts with HQ to improve health outcomes
Intervenes in the event of whole system failure

7. Welcome to South Lakeland

8. DGH
DGH

10. Westmorland P i
W t l d Primary C
Care C ll b ti
Collaborative
 WPCC is 21 practices (list size 600 – 16,000) and all
PCT community health services
 “Make or Buy” for 110,000 population
 Key priorities for next 5 years:
 Integrating services for older people
 L
Long t term conditions (i l di supported self mx)
diti (including t d lf )
 High quality primary care
 Access to appropriate urgent care services
 Efficient and effective use of elective care services
 Working with others to p
g promote healthy individuals
y
and communities

11. Progress
Progress
 Agreement to form a social enterprise, from April1st, to
both commission and in future provide services
 Company limited by shares, holding APMS contract with
PCT – important for NHS p
p pensions etc
 Leadership from GPs, nurses and therapists across all of
primary care
 Taking on increasing proportion of the PCT budget –
approx 50% this coming year
 A Board including lay members – bringing expertise not
token representation
 Approach to public engagement building on existing
structures (mainly non-health)
( y )

12. The “ i t l” community h
Th “virtual” it hospital
it l
 Step-up step-down unit in Kendal (51 beds)
p p p ( )
 Nearly 50% of admissions are step up
 Acute to a community focus - culture challenge
 Moving to nurse led with doctor support
 STINT service
 M
Manage crises and early supported di h
i d l t d discharge
 Health and social care input (joint funding)
 Nursing home support team
 Day Hospital
 Moving to co-location with wards
g
 Coordination of physical and mental health services

13. Early discharge and rehabilitation
The “virtual” community hospital:
 Team responsible for individuals undergoing a
p g g
crisis – cared for at home, stepping down to a
community bed or supported early discharge
 Flexible roles – some staff who can work either on
the wards or in the community – so can “flex” with
pressures i th system
in the t
 Co-location of all + common electronic clinical
record

15. Integrated primary care information
EMIS web
“allows primary secondary and community healthcare
primary,
practitioners to view and contribute to a patient's cradle to
grave healthcare record”
In last 12 months:
 Installation of superfast local network connecting all health bases
across the locality
 20 of 21 practices now using EMIS (21st on the way!)
 All community nursing teams moving to EMIS by mid 2010 and
using mobile b db d / netbooks
i bil broadband tb k
 Specialist community teams – transfer almost completed
 GP OOHs, PCAS and step-up/step-down Unit have access to
summary information from the GP record

16. Pharmacy
H
os
pi
ta
Radiology Radiology
PCAS, GP led wards
lI
nf
o
Report
EMIS Web Hospital and GP OOHs
EHR
Radiology EHR
Report EHR
Lab
EMIS EHR EHR
Patient
Info Patient
Results DataReferral
Data R
Reports
Rx InfoRx
Path Lab
Repository
Guide Specialist Teams
linesData and clinics
EMIS Web
Patient
Info Data Streaming
Data Streaming Reports
epo ts
Referral
between local centres
GP and Community Teams Guide
and central repository lines
Central Support Team

17. Long Term Conditions
Cumbria Diabetes

18. The need
 Increasing prevalence of diabetes
 Evidence for high quality care in Cumbria
 HCC and QoF
 But... Poor patient education and high drug
costs
 BUT variations in both quality and patient
experience across C b i
i Cumbria
 Fragmented and non aligned specialist service

19. The Cumbria Diabetes Model of Healthcare:
Primary care
Pi
(core)
Primary care setting Secondary and
Tertiary care setting
Primary care
y
(enhanced)
Specialist support
for Primary Care Complex care

20. Description of services Register
Delivers holistic annual review (care planning)
( g)
for patients with Type 2 diabetes
Complete QoF measures
Adheres to agreed guidelines
Refers to DESMOND
Partnership with Cumbria diabetes
Primary care
Pi Work t
W k towards improving quality
d i i lit
(core)
Primary care setting
Primary care
y Secondary and
(enhanced) tertiary care setting
Specialist support
for Primary Care Complex care

21. Description of services
Provides core care
Named clinical lead
Identify high risk/ use tools Primary care
Pi
and interventions (core)
Stepped approach to Primary care setting
glucose lowering
Care planning and on going Primary care
y Secondary and
management in patients
ti ti t tertiary care setting
with Type 1 diabetes
(enhanced)
Insulin initiation / on going Specialist support
support in Type 2 for Primary Care Complex care
Address learning needs
with spec support team
Registers of housebound /
high risk
Care for house bound /
vulnerable groups
Specific needs of women of
child bearing age
Work to max’n QOF points

22. Description of services
Primary care
Pi
(core)
Primary care setting
Primary care
y Secondary and
(enhanced) tertiary care setting
Specialist support
for Primary Care Complex care
Reviews newly diagnosed Type 1 before referring to Enhance Care
Provides a structured Type 1 support service
Provides staff training both formally and informally
Coordinates/provides patient education and Type 1 post education support
Ad hoc specialist advice to other professionals
Locality based individual case discussion with specialist team
Contributes to developing clinical g
p g guidelines
Supports development with Core Primary Care Practices to become enhanced practices
Provides enhanced services to core practices
Co ordinates the specialist support services for Primary Care eg nutrition, psychology, retinal
screening

23. Description of services Provides care to individual patients with complex
needs
Provide/coordinates multi specialty services eg
Pregnancy, renal, eyes, vascular, heart and feet
Provides transition and young adult services
Provides inpatient care
Primary care
Pi
(core)
Primary care setting
Primary care
y Secondary and
(enhanced) tertiary care setting
Specialist support
for Primary Care Complex care

24. Financial resource Local authority
(Health) resource
Personalised The population
individual care Primary care is the HUB through (healthy, high risk and
commissioning, facilitating, undiagnosed)
understanding and providing
Biomedical Policy
intervention determinant
s Community s
engagement to
maximise local assets
Self
S lf management
t
Maintaining registers
Risk factors
Relevant information
Routine review
Awareness raising
Care planning
p g
Personalised care
Social marketing
Linking with planning
community and
Reducing inequalities
support services Contact point to NHS
Healthy cities,
schools, stadia etc
Helping to build resourceful Helping to build resourceful
individuals communities

25. Progress
 Challenges of identifying lead p
g y g provider
 Now sitting with Primary Care
 WPCC
 Allstaff (incl consultant lead) moving to
primary care
 Cumbria wide education
 Daphne,
p Desmond and Walking away from
g y
Diabetes
 Other long term conditions following
 Incl paediatrics, elderly care

26. Cockermouth Floods
2009

27. Cockermouth Floods
17th November 2009
 November 2009 was the wettest on record in the
UK (over 8 inches i th month)
( i h in the th)
 Over 12 inches fell in 24 hours on the fells above
Cockermouth
 10 out of 11 bridges damaged or destroyed
 880 h
houses and 190 b i
d businesses fl d d
flooded
 Our health model in action!

28. Cockermouth Town Centre

29. Cockermouth Main Street

30. Collapsed Bridge Workington
PC Bill Barker died

31. 13 whole team meetings to co-ordinate the
co-
recovery and manage risk
d i k

32. Priorities for the health services:
To avoid excess mortality and morbidity
y y
 Measures to avoid diarrhoeal disease
 Measures to prevent severe respiratory illness
M t t i t ill
(crowding in church halls and reception centres)
 Re-establishment
Re establishment of normal health services for
long term conditions asap especially the re-
establishment of pharmacy services and
systems
 Boosting p y
g psychological support
g pp

33. Reducing risk:
 Identified ll t i k l
Id tifi d all at risk vulnerable patients and proactively
bl ti t d ti l
contacted them e.g. Severe COPD, palliative care, frail
elderly.
 Established heightened surveillance for diarrhoea cases
– every case was investigated by the seconded infection
control nurse
 Gave public health information/lectures to rescue
workers and all staff and displaced at the reception
centres on hand hygiene and diarrhoea prevention
prevention.
 Vaccinated 1000+ at risk in reception centres and 350
rescue workers against swine flu and seasonal flu in the
first week

34. Reducing risk:
 Rapidly b ilt
R idl rebuilt GP t l h
telephone and IT systems
d t
(within 24 hours)
 Re-established pharmacy services (
p y (within 24
hours)
 Provided extended GP opening 24 hours for first
day then 8am-8pm every day for the next 2
weeks including weekends
 Rapidly established additional counselling
services i l di d
i including drop i services
in i
 Dug the foundations for a 26 room temporary
building within 5 days of the floods
g y

35. Longer Term:
 Adolescent Health Programme with school and
pupils
 Centre for the Third Age – co-locating third
sector, health, social care, memory clinics,
dementia expertise etc
d i i
 Harnessing the whole community response to
health – cheer up teas street angels etc
teas,

36. Doing more with less
 Cockermouth H
C k th Hospital - 300% i
it l increase i
in
throughput 2006-9
 Length of Stay down from 36 days to 11 days
 £250,000 reduction in annual nurse costs from
2006 to present
 Nurse wte reduced from 23.4 to 13
 Cost per admission reduced by more than half
 19% reduction in non elective bed days spent in
Acute Trust in 2008-9
2008 9

37. Policy Issues
P li I
 Practice based commissioning has been central
to our approach
 Based on building relationships with GPs more than
the li itself
th policy it lf
 Trusting clinicians and handing over real
responsibility (+accountability) has been crucial
 Transforming Community Services - vertical
integration v horizontal integration
 Social
S i l enterprises and pension i
i d i issues
 PBR and Foundation Trusts