Hounslow Integrated Care 16 th July 2018 Hounslow Position Hounslow - - PowerPoint PPT Presentation

Hounslow Integrated Care

16th July 2018

Hounslow Position

• Hounslow is facing the same issues as much of the health service across the country.

Changes expected to take place over the next five years mean that work is needed to make sure that the system has the right capacity and capability

• Population expected to increase by 6.3% 1 over

the next 5 years

• 30,416 older people (10% of the population) in

2016 – rising to 35,481 in 2022 2 (12% of the population) – a 16.7% increase

• Black and minority ethnic population expected to

increase to 155,310 by 2022 (an 11.3% increase) 2. Ethnic groups have different health and care needs and population changes can magnify these

• Men in more economically deprived areas die up

to 4.1 years earlier than men in less economically deprived areas; for women this is 3.4 years 1

• Significantly more people die from heart disease

and stroke in Hounslow than the England average

1

• 23.5% increase in dementia diagnosed between

2012 and 2020 3

• 3.6% increase expected in population of younger

adults with learning disabilities 3

• 17,500 people with diabetes (increasing 3%

annually)

• High numbers of children who are overweight or
• bese, and particularly high rates of tooth decay

in 5 year olds (closely linked with eating habits)

• High rates of self harm in young people pointing

to factors affecting mental health and wellbeing 1

• Analysis suggests over 30% of NWL hospital

inpatients could be treated elsewhere 3

• The 2% of people in Hounslow with the most

complex conditions require support costing over 17% of the CCG’s budget 4

• The way services are planned and provided can

be improved – with more patient and carer perspective, greater clinical expertise and even stronger evidence. This should improve health and care outcomes, while achieving performance targets

• £40m of savings are needed by 2021 to bring the

Hounslow system into financial balance 3

• Potential to save £3.7m / annum in non elective

admissions through matching performance of peer CCGs; and a further £1.4m / annum in elective admissions 4

• 24% increase in costs of supporting people with

common complex conditions (physical disability, severe and enduring mental illness, learning disability, cancer, dementia, long term conditions) (per the WSIC toolkit 1)

• Total cost for children’s continuing healthcare

services has increased over 3 ½ times in 4 years

3 The 2022 Hounslow health system 9

Integrated Care in Hounslow

Theme Example Aim Varied and Fragmented Care People often have to repeat their story multiple times to different providers, which makes accessing care a frustrating experience Organisations working together to deliver coordinated, proactive and planned care for patients Duplication of services Multiple providers entering patients home Multi-disciplinary health care professionals working together to make decisions regarding recommended care of individual patients. Variation GP practices providing different care form Consistent primary care health offer from primary care ensure patients receive the same service wherever they live in the borough Misaligned Incentives Mixture of PBR and Block contract across providers Single contract for the delivery of services within Hounslow Workforce GPs and Nursing reaching retirement age, not seen as an attractive career choice Opportunity for career development across all providers, opportunities for staff to work in different places and increase skill base Financial Pressures NWL significant financial challenges Focus on preventative care to reduce the need for expensive hospital activity

• Integrated care provides an opportunity to address some of the problems faced within

the current system

Essential Elements

• Any commissioned service or integrated model will be based on the following

essential elements 1

Access Providing a personalised, responsive, timely and accessible service. 2 Self-Empowerment and Education Supporting and improving the health and wellbeing of the population in a way that works for them. 3 Multi-disciplinary Teams Health care professionals working together to make decisions regarding recommended care of individual patients. 4 Care co-ordination Providing patient centred, coordinated care across health and social care. 5 Individualised Care Plans Delivering coordinated, proactive and planned care for patients

What is integration?

• Integrated care takes on many forms, all models though aim to address the

fragmentation of care common across health systems, to improve the health

• utcomes of people living longer with increasingly complex health concerns
• Integrated care can be defined at five different levels.

1.

Systemic: Coordinating and aligning policies, rules and regulatory frameworks.

2.

Normative: Developing shared values, culture and vision across organisations, professional groups and individuals.

3.

Organisational: Coordinating structures, governance systems and relationships across organisations.

4.

Administrative: Aligning back-office functions, budgets and financial systems.

5.

Clinical: Coordinating information and services and integrating patient care within a single process.

• International examples are focussed around improving patient care planning,

population health management, better use of technology, Multi-specialty health groups and aligned financial incentives across providers.

www.nuffieldtrust.org.uk/files/2017-01/what-is-integrated-care-report-web-final.pdf

Integration

• Benefits of better integration has been shown to:

−

Improve outcomes for clinical networks

−

Improve health outcomes for patients with long terms conditions

−

Increase the use of good practice across providers, reducing variation

−

Reductions in hospital activity.

• Integrated Care will have the following features which will drive shared accountability

for improving health:

−

Pooled budgets between organisations covering a defined population’s needs

−

A contract that is focused on outcomes e.g. the providers will be required to demonstrate that their activities have had a demonstrable impact on health

−

Use of technology to pre-emptively work with patients so that their health and care needs do not needlessly deteriorate

−

An ability to respond nimbly to changing opportunities which is not hampered by an over-specific contract

−

Use of information and intelligence to support patients

−

Integrated care can take many different forms at a variety of different levels, from small internal team working better together to large organisations working in partnership.

Outcomes

• Under the CCG’s plans for Future Proofing Health in Hounslow we are aiming to create

a health system which provided the following outcomes for patients and professionals

Residents

• I am confident that I receive support designed to

deliver the best health and social care outcome for me

• I receive safe, appropriate care at the right times

– preventing my needs becoming more complicated where possible

• I am supported by a great team that work well

together and enjoy their work

• I know how and can make use of voluntary and

community services that offer support I need in addition to the health and care services I receive

• I know that technology is used to innovate and

improve the support I receive – including providing the tools and information I need to help me live a healthier, independent life

• I am confident that available resources are used

in the most effective way to provide my care Care professionals

• I am confident that I provide safe, effective

services that deliver the same quality outcomes as my professional peers

• I am able to work with partners – without

barriers or constraints - to improve the availability and quality of services available

• I love my work in Hounslow and I’m motivated

to contribute to make the system even better

• I feel like have influence and control over my

workload and the way that services work around me and Hounslow residents

• I can direct people to make use of a range of

voluntary and community services – improving wellbeing while reducing my workload

• I can use new and innovative technology and

tools to make my work easier while improving patient care

Outcomes

• As part of the development of Integrated Care Business Case the working group has

expanding these ‘I Statements’ to three areas, Patients, Professionals and Carers.

Carers

• My dependant receives safe and

appropriate care at the right time, preventing my needs becoming more complicated where possible.

• I am confident that I received support that

enables me to deliver the best health and social care outcomes my dependant.

• I am supported by health and social care

professionals who enjoy their work

• I know how and can make use of voluntary

and community services that offer support I need in addition to the health and care services I receive

• I know that technology is used to innovate

and improve the support I receive – including providing the tools and information I need to help my dependant live a healthier, independent life

• I am confident that available resources are

used in the most effective way to provide my care. I feel I am valued as an individual person as well as a carer Patients

• I receive safe and appropriate care at the

right time, preventing my needs becoming more complicated where possible.

• I am confident that I received support

designed to deliver the best health and social care outcome for me

• I am supported by a great team that work

well together and enjoy their work

• I know how and can make use of voluntary

and community services that offer support I need in addition to the health and care services I receive

• I know that technology is used to innovate

and improve the support I receive – including providing the tools and information I need to help me live a healthier, independent life

• I’m confident that available resources are

used in the most effective way to provide my care Professionals

• I am confident that I provide safe, effective

services that deliver the same quality

• utcomes as my professional peers
• I am able to work with partners – without

barriers or constraints - to improve the availability and quality of services available

• I love my work in Hounslow and I’m

motivated to contribute to make the system even better

• I feel like have influence and control over

my workload and the way that services work around me and Hounslow residents

• I can direct people to make use of a range
• f voluntary and community services –

improving wellbeing while reducing my workload

• I can use new and innovative technology

and tools to make my work easier while improving patient care

• The outcomes framework has been provided as a supporting document to this paper.

Business Case

• There are a number of requirements that the Business Case will need to contain to

support the decisions of the CCG and Hounslow Borough Council. It is the intention

• f the CCG to also have this independently reviewed as it is such a significant step to

ensure we do place undue risk on the local system, both clinically and financially.

• The detailed content of this business case will be set out in a five case model

according to HM Treasury guidance. The five cases, and their key purposes, are:

1.

The Strategic Case: This explains what changes are required within the health economy and why they cannot be delivered without Integration.

2.

The Economic Case: This sets out the value for money case of the proposed approach, through a structured comparison of the costs and the benefits, including both the quantifiable and non-quantifiable financial and health benefits of the work.

3.

The Financial Case: This assesses the affordability of the proposed solution for both the CCG and Hounslow Borough Council .

4.

The Commercial Case: This demonstrates that the preferred option will result in a viable procurement and well-structured deal.

5.

The Management Case: This demonstrates that the preferred option is capable

• f being delivered successfully, in accordance with recognised best practice.

Strategic Timeline

April 2018 April 2019 April 2020

Operational Timeline

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2018 2019 Final Business Case

Financial Modelling Evaluation Methodology Governance Strategy Procurement Timetable Communications Plan

Contract Notice

Call for competition

ISAP Meeting

NHS England Assurance

Draft Contract

Development of contract – Specialist support required

Invitation to Tender Final Contract Mobilisation Contract Start Contract Award

Key Dates Event 10th July Governing Body 18th July Council of Members 14th August Governing Body Seminar 5th September Adult Scrutiny Committee 11th September Governing Body 30th September Commissioning intentions letters to providers

Procurement Considerations

• Hounslow has been working with its procurement advisors to put together a road map

for tendering the future vision

Procurement: Factors to consider

• Clear vision and case for change

−

Existing provision - current opportunities and challenges to address

−

Local authority alignment - local position on essential or otherwise

−

Clinical and financial outcomes

• Scope and phasing

−

Priorities

−

The total could be unmanageable and unsustainable - provider experience currently?

−

Consideration of existing contracts and scope of the ICS - novation, re-procure, legal risks

• Cultural shift

−

Existing provider relationships – ability and desire to collaborate

−

Step-change with contractual complexity v incremental change with simpler (legal) variances

−

Recognition that change takes time - long term transformation

−

Small and achievable priorities can underpin a greater ambition

−

New mutually dependent relationships

−

Removing the ‘them’ and ‘us’

Regulatory Requirements

• Public Contracts Regulations 2015 (PCR 2015)

−

Advertise contract opportunities in OJEU and Contracts Finders valued at £589,148 or above

−

Run a process compliant with principles of transparency and equal treatment

• NHS (Procurement, Patinet Choice and Competition) (No.2) Regulations 2013

(PPCCR)

−

Advertise in Contracts Finder (Same advert as above)

−

No minimum value for advertisement requirement

−

Run a process compliant with principles of transparency and equal treatment and non discrimination

−

PPCCR include objectives to be considers by the commissioner for the procurement

• Both sets of regulations must be complied with

Road Map

Contract Options

• There are several options available for the procurement and management of a new

contract

• Option 1: A lead provider model

Contract Options

• Option 2: Single Organisational Entity
• This would involve the creation of a new non-NHS entity which would present legal

and financial issues

Contract Options

• Option 3: Working with system providers to achieve the optimum integrated solution

Provider Network Development

• Hounslow has a STP Implementation Group in place to holds the strategic

responsibility for bringing all the involved organisations together to review progress towards Integrated Care.

• Alongside the business case development there is extensive work needed to form the

relationships between providers that will enable new ways of working to be embedded within Hounslow. These programmes are supporting the development of both strategic and operational partnerships and shared approaches to work across a number of organisations.

−

Enhanced Primary Care Contract

−

Feltham - reduction in variation and improved outcomes

−

Transforming Care through system leadership and the redesign of community nursing

−

Intrapreneur Programme and the review of urgent care pathways.

−

Primary Care Patient Coordinator Care redesign work

Risks and Issues

• Below is summary of the risks and issues associated with this work, the full risk log is

provided as a supporting document to this paper.

Summary of Risks Actions RAG Assurance NHS England require additional assurance and adult scrutiny are not satisfied within best interests for Hounslow residents CCG will follow ISAP process for NHS England and proactively engage with Adult scrutiny Commissioning Project will not be completed within the planned timeframes and CCG does not have the personnel to support the work Project planning, and dedicated staff time allocated Communication Public/Media negativity about work and outcomes are not what patients want Communications and engagement plan to be agreed and implemented to manage all stakeholders Financial Finance and activity modelling is not completed within timescales

• r does not realise the system and financial benefits needed in
• rder to deliver the transformation

ICHP have commenced work, review of differential models of costing - capitation, bottom up and affordability assessments to be completed as part

• f the business case.

Legal Legal framework unclear and potential for procurement challenge Procurement roadmap and expert advice from SBS Partner LBH and CCG do not agree on priorities and approach to integrate care, Difficulty incorporating LBH charging model with CCG finance model Senior discussions held between LBH and CCG and joint working group developing business case Provider System not mature enough to support outcomes based contracts, providers not used to working together and insufficiently mature GP federation STP Implementation group in place to support providers working better together, GP consortium development programme underway as part of the Primary Care contract Quality Quality and safety is negatively impacted Impact assessment requires as part of business case moving to a more detailed assessment when service areas identified for integration Strategic Central programme not moving at sufficient speed leading to difference of approach, potential for NWL work to changes elements of local integrated care in order to get consistency across boroughs Hounslow continuing with local timeframes for delivery while working a apart

• f the NWL virtual team and feeding into developments across STP