NHS Bromley Clinical Commissioning Group 24 May 2018 ENCLOSURE 6 - - PDF document

A meeting of the Governing Body of NHS Bromley Clinical Commissioning Group 24 May 2018

ENCLOSURE 6 BROMLEY INTEGRATED CARE SYSTEMS UPDATE - PRESENTATION SUMMARY: This presentation provides the Governing Body with a progress update on Integrated Care Systems in Bromley. It sets out some of the achievements to date, the current status of the system and details of some of the key programmes in the coming year. This includes key enablers required to support the development of Integrated Care across Bromley. KEY ISSUES: Background: The Bromley Integrated Care System is comprised of the signatories to the Bromley Alliance, which was signed in October 2017. This was a continuation of the Bromley Out of Hospital Strategy and the previous Bromley System Memorandum of Understanding signed in April 2016. The signatories to the Alliance Agreement are:

• NHS Bromley Clinical Commissioning Group
• London Borough of Bromley
• King's College Hospital NHS Foundation Trust
• Oxleas NHS Foundation Trust
• Bromley Healthcare Community Interest Company
• Bromley GP Alliance
• St Christopher’s Hospice
• Bromley Third Sector Enterprise

The Alliance agreement set out the following principles:

• 1. work towards a shared vision of integrated service provision;
• 2. commit to delivery of system outcomes in terms of clinical matters, Service User

experience and financial matters;

• 3. commit to common processes, protocols and other system inputs;

Clinical Chair: Dr Andrew Parson Accountable Officer: Andrew Bland Managing Director: Dr Angela Bhan

• 4. commit to work together and to make system decisions on a Best for Service basis;
• 5. risk reward scheme where We all share in savings generated by reduction in acute

activity.

• 6. take responsibility to make unanimous decisions on a Best for Service basis;
• 7. always demonstrate the Service Users’ best interests are at the heart of Our activities;
• 8. adopt an uncompromising commitment to trust, honesty, collaboration, innovation and

mutual support;

• 9. establish an integrated collaborative team environment to encourage open, honest

and efficient sharing of information, subject to competition law compliance; 10. adopt collective ownership of risk and reward, including identifying, managing and mitigating all risks in performing our respective obligations in this Agreement; and 11. co-produce with others, especially service users, families and carers, in designing and delivering the Service The development of Integrated Care is a key part of the delivery of the Five Year Forward View – next steps and the development of the Bromley Integrated Care System follows through that agenda, through collaborative working across London and as part of the South East London STP. Work Programme The previous Memorandum of Understanding set out two initial pathways to developed under the integrated care model:

• Pro-active care pathway
• Frailty pathway

Both pathways are operational and currently being reviewed. They are delivered through the Integrated Care Networks by an alliance of providers, all inputting into the pathway. Through a series of events and meetings with stakeholders, and as set out in the CCG Operating Plan and Commissioning Intentions, the following priority areas for ICS development have been set for 2018/19.

• Proactive Care
• Urgent Care
• End of Life Care
• Diabetes
• Mental Health
• Children and Young People

These workstream do not represent the full scale of the work of the CCG, but have been selected as areas where various principles of Integrated Care could be applied.

Clinical Chair: Dr Andrew Parson Accountable Officer: Andrew Bland Managing Director: Dr Angela Bhan

The presentation provides more detail about the individual programmes and also the work on enablers to the system Governance A Governance Structure has been developed in Bromley to support the development of ICS in Bromley. This is led by the Integrated Care Systems Board, supported by a more Operational Executive. The development of the Governance Structure to give more responsibility to providers to commission quality services on behalf of the population through the use of enablers such as Population Health Management and data analytics. Systems will need to change with workstreams around finance and contracting which will explore how budgets and opportunities can be given to the Alliance partners. As further integrated commissioning plans are developed with the London Borough of Bromley, governance and commissioning systems across the Integrated Commissioning system will also need to be developed to match the opportunities that will be provided under new models of care. This will entail more formal contractual arrangements around budget and potential risk sharing. PROFESSIONAL INVOLVEMENT

• Senior Managers and clinicians across the Bromley Integrated Care System

Organisations COMMITTEE INVOLVEMENT:

• Integrated Commissioning Board and Executive
• CCG Clinical Executive

PUBLIC AND USER INVOLVEMENT:

• Public and user involvement takes place through the individual workstream.
• An over-arching engagement strategy will be required going forward.

MANAGEMENT OF CONFLICTS OF INTEREST

• The Bromley GP Alliance is a signatory to the Bromley Alliance agreement and

provide services to some of the existing workstreams

• As set out in the declared conflict of interest register, some GPs are members of

practices who are members of the GP Alliance

• This paper is provided for information only

Clinical Chair: Dr Andrew Parson Accountable Officer: Andrew Bland Managing Director: Dr Angela Bhan

IMPACT ASSESSMENT: These are completed for each individual workstream project RECOMMENDATIONS: The Governing Body is asked

• To receive and note the presentation
• Provide any comments on the direction of travel

ACRONYMS BTSE – Bromley Third Sector Alliance ICS – Integrated Care System STP – Sustainability and Transformation Fund AUTHOR CONTACT: Name: Mark Cheung Position: Programme Director – Bromley Integrated Care Systems E-Mail: BROCCG.ContactUs@nhs.net DIRECTOR CONTACT: Name: Mark Cheung Position: Programme Director – Bromley Integrated Care Systems E-Mail: BROCCG.ContactUs@nhs.net GP CLINICAL LEAD: Name: Andrew Parson Position: CCG Clinical Chair E-Mail: BROCCG.ContactUs@nhs.net

Clinical Chair: Dr Andrew Parson Accountable Officer: Andrew Bland Managing Director: Dr Angela Bhan

Bromley Integrated Care System Governing Body Update 24th May 2018

STP Shadow ICS Full ICS Mature ICS

STP development programme

Criteria to become a shadow ICS is met Criteria to become a full ICS is met

Shadow ICS development programme ICS development programme

Leaders from across different

• rganisations are

working together to improve the way care is delivered. There is a single STP leader. A full ICS has taken on greater responsibilities and has greater freedoms. Operationalising integrated ways of working. Partnership working is embedded at all levels of the

• system. Public

engage with health and care services is done in a demonstrably different way. System forms structures around its ICS. Care is being designed in a different way and there is a dedicated team to support the ICS development.

The diagram below illustrates the roadmap to become an ICS, including the two “gateways” to become a “shadow” and “full” ICS.

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National Integrated Systems Development

2

• Primary Care
• Mental Health

Accelerating service improvement in priority clinical areas

• Improvements in clinical priority areas
• Cancer
• Urgent and Emergency Care

System finance reform

• Shared system control totals
• Payment models
• Capital and transformation funding
• System-wide efficiencies

Leadership and international learning

• Leadership development
• Governance

Future regulatory and commissioning models

• Commissioning
• Streamlining oversight

Population health management

• Public health
• Data analytics and external partnerships
• Care model design

Communicating and campaigning for change

• Local
• Regional
• National

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Support from National Workstreams

3

4

5

6

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BROMLEY INTEGRATED CARE SYSTEM

• We have three integrated care

networks (ICN’s) in Bromley, each covering around a third of the population.

• ICN’s brings together a range of

health and care services to provide more joined up care for patients

Integrated Care Networks

Core ICN Providers

• GP Alliance
• Bromley Healthcare
• Kings College Hospital NHS

Foundation Trust

• Oxleas NHS Foundation Trust
• Bromley Third Sector

Enterprise

• St Christopher’s Hospice

Bromley Third Sector Enterprise

New venture for the sector Part of the new Integrated Care Network initiative Open to voluntary

• rganisations

involved in health and wellbeing to join as Associate Members

Existing Proactive Care & Frailty Pathway

1 2 3 4 5 6

ACCESS TO SOCIAL PRESCRIBING AND SELF MANAGEMENT via an IT portal managed by third sector

• 1. Patient Identified for Proactive Care Pathway - referral managed

by MDT liaison 2 & 3. Initial holistic assessment and creation of care plan by community matron and Care Navigator (when required)

• 4. Care plan assessed and ratified by MDT. MDT 4 hours duration

(70% of patients will require discussion at a 2nd MDT)

• 5. Appropriate clinician identified as clinical lead for patient. Care

Navigator established as point of contact for patient

• 6. Implementation of care plan - overseen by clinical lead and

coordinated by the care navigator with support from MDT liaison. This may include signposting to social prescribing

PROACTIVE CARE PATHWAY

Core MDT members GP Chair Community Matron Interface geriatrician Mental Health Professional Care Navigator MDT Liaison Other professionals as required

various 10

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BROMLEY INTEGRATED CARE SYSTEM

WORK IN PROGRESS 2017/18

Alliance Agreement for Virtual MCPs

PROACTIVE CARE PATHWAY FRAILTY PATHWAY JOINT CARE HOMES PROGRAMME END OF LIFE / IV THERAPIES PROJECT INTEGRATED HEART FAILURE PROJECT INTEGRATED THERAPY SERVICES PROJECT BROMLEY AND ORPINGTON HUBS

Bromley Joint Strategic Needs Assessment

Bromley Integrated Care System Development Areas 2018/19

Proactive Care Urgent Care End of Life care Diabetes Mental Health Children and Young People

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Proactive Care Pathway

• Background: The Pro-active pathway has enabled the active identification of patients with

complex and long term conditions that need extra support to keep well and reduce the number of crisis episodes. The ICN is a model used to bring together a range of health and care services to work together using an MDT approach. Integrated Case Management (ICM) is the collaborative process of assessment and care coordination for options and services to meet individual’s and family’s comprehensive health needs.

• Programme: The early HIN evaluation indicates a positive start has been made with the

implementation of the ICN and Proactive care pathway. The pathway has been in operation for 18 months providing an opportunity to review and refine the current service model focusing on: – Understanding performance and outcomes including demand and capacity across the system – Improving the MDT and management processes – Identifying how the pathway can be streamlined ensuring the right patients are benefiting from an integrated MDT approach – Refinements to the proactive pathway are to be identified, agreed and implemented during summer 2018.

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Proactive Care Pathway

• Outcomes:

– Greater partnership working using the MDT approach to improve patient outcomes – Improved access to service provision across the health & social care system – Proactively supporting the health and wellbeing of patients and carers through better co-ordinated care – Reduction in emergency admissions, DTOC and ED attendances

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Urgent Care

• Background: Currently there are a range of emergency and urgent care pathways and

provision in Bromley to support admission attendance and avoidance. Individually each pathway works well, however attendance at the PRUH and pressure on hospital based care has continued to rise. Following the review of winter, it was identified that there was a need to bring all existing services together into an integrated Urgent Care Pathway, with an increased focus on community based care, in order to support the increasing complex and co-morbid population that are presenting at the PRUH.

• Programme: The aim of the project is to create a more integrated, community based system

that prevents the need for hospital attendance and admission. This will: – Integrate existing resources (e.g. EOL, Rapid Response, Acute/community therapies, Geriatrician, Primary Care, VCS and social care) into a single community based admission avoidance service – Provide reactive care in the community for patients that would otherwise require hospital based case – Undertake assessment, care planning and treatment of acute and urgent care needs (up to 5 days) with ongoing support provided from existing community based care pathways

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Urgent Care

• Outcomes:

– Reducing inappropriate acute admission and attendance with a long term view of reducing number of acute beds in the system (consideration for capitated budget) – Improve Emergency Care performance through reduced attendance and decongestion – Reduced Delayed Transfers of Care (DToC) – Increase acute interventions in the community to reduce the need for hospital based care – Increase numbers of acute interventions for proactive care planning in the community – Improved integrated working across acute, community and primary care services that provides holistic, wrap around care and support that meets the needs of individuals – Better quality of care delivered in the community for frail and older people reducing risks associated with hospital attendance and admissions.

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Mental Health

• Background: Case for change in Bromley:

– The Five Year Forward View (5YFV) for Mental Health identifies a number of imperatives for action to deliver improvements to outcomes and access to high quality services. – Parity of esteem is the principle by which mental health must be given equal priority to physical health (enshrined in the Health and Social Care Act 2012) – The current fragmentation of commissioning and service provision is not sustainable across health and social care – There is a need to shift care and resources to more preventative

• Programme: The aim of the project is to create a more integrated, community based system

that prevents the need for hospital attendance and admission. This will: – Integrate existing resources (e.g. EOL, Rapid Response, Acute/community therapies, Geriatrician, Primary Care, VCS and social care) into a single community based admission avoidance service – Provide reactive care in the community for patients that would otherwise require hospital based case – Undertake assessment, care planning and treatment of acute and urgent care needs (up to 5 days) with ongoing support provided from existing community based care pathways

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Mental Health

• Outcomes:

– Greater partnership working and collaboration across health, social care, third sector, service users and carers – Improve integrated working and collaboration across the health and social care system – Improve co-ordination of care with a greater focus on prevention, early intervention and recovery. – Less variation in care – Mental health will be given equal status to that of physical health – The provision of community based services will be enhanced

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Children & Young People Co-production

• Background: Co-production is a key theme in ‘Future in Mind’ (2015) and in ‘Implementing the Five

Year Forward View for Mental Health (2016). – Co-production takes the principles of engagement further and allows for jointly developed

• utcomes against which commissioners can procure services

– Progress to date: – Surveys undertaken (1896 received) – Focus groups (8 groups took place) – Stakeholder events (120 interests expressed)

• Emerging themes from co-production:

– Core to the process was facilitating conversations and distilling the key themes that emerged. – Jointly owned outcomes and principles would form the foundation for future co- commissioning

• 6 principles of co-production:

– See people as assets – Building on our capabilities – Developing mutuality & reciprocity – Blur distinctions between producers and consumers – Grow people’s networks – Facilitating not delivering

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Children & Young People Co-production

• Programme: Next Steps:

– New system delivery from Dec 2019 – 18 month period of remodelling and transformation – Use of all the data and intelligence – Strengthen the emerging network – Combine collaboration with competitive procurement – Collaboration with the third sector, community organisations and young people. – Agree the outcomes and service principles across the new sector – Alliance contract with those who agree to the values and principles – Learning, reflection and prototyping – Moving from Co-Design to Co-Production

• Outcomes –

– In development

Bromley CYP Outcomes Framework for MH services External Factors Good functioning Personal Resources Supportive friends and peers Relatedness peers and adults Empathy Confidential services Autonomy Self esteem Community belonging Choice Patience Close family Emotional intelligence Accepting emotions Wellbeing focused schools Community connectedness Directing emotions

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End of Life

• Background: Following the implementation of the Proactive Care pathway and increased

work with primary and acute care to identify people in the last 12 months of life, there has been a significant increase in the identification and demand for service provision for end of life patients.

• Currently St Christopher’s provide a range of end of life services in Bromley. In addition

wider provision and care is also provided from a range of community health and social care

• rganisations. The current infrastructure is not aligned in the most efficient and effective

way to support the changing needs of this vulnerable population group. There are gaps and duplications in commissioning and service provision in the system.

• Programme: Further develop End of Life integrated care pathways in the community building
• n the Proactive Care pathway and bringing together exiting End of Life health and social care

services into a single integrated offer.

• The core principle will be bringing together St Christopher’s Care Co-ordination Centre and

Bromley Health Care’s nursing element of Care Co-ordination Centre to provide a more integrated reactive and proactive response to end of life patients. This will be further enhanced by the integration of voluntary and community sector resource and wider end of life provision.

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End of Life

• Outcomes:

– A sustainable end of life infrastructure that meets presenting need within the existing financial framework – Greater partnership working to improve quality of care for end of life patients – Reduced commissioning and operational duplication and addressing gaps in the system – More people supported to die in their chosen place of death – Less people identified as being end of life requiring hospital based interventions – More people identified as end of life from the community – Further build on identification of non-cancer end of life patients – Improved single oversight and reactive care for EOL patients across the system

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Diabetes

• Background: Following the implementation of the Proactive Care pathway and increased

work with primary and acute care to identify people in the last 12 months of life, there has been a significant increase in the identification and demand for service provision for end of life patients.

• Currently St Christopher’s provide a range of end of life services in Bromley. In addition

wider provision and care is also provided from a range of community health and social care

• rganisations. The current infrastructure is not aligned in the most efficient and effective

way to support the changing needs of this vulnerable population group. There are gaps and duplications in commissioning and service provision in the system.

• Programme: Further develop End of Life integrated care pathways in the community building
• n the Proactive Care pathway and bringing together exiting End of Life health and social care

services into a single integrated offer.

• The core principle will be bringing together St Christopher’s Care Co-ordination Centre and

Bromley Health Care’s nursing element of Care Co-ordination Centre to provide a more integrated reactive and proactive response to end of life patients. This will be further enhanced by the integration of voluntary and community sector resource and wider end of life provision.

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Diabetes

• Outcomes:

– Integrated approach to enable more support to manage diabetes in primary and community care (consideration for a pooled or capitated budget) – Improved patients experience across different healthcare provision – Reduction in emergency admissions & attendances at A&E (including episodes of diabetic ketoacidosis, hypoglycaemia and hyperosmolar non-ketotic state) – Reducing the use of inpatient services for patients with a primary diagnosis of diabetes – Reductions in complications

Patient and Networks

Data , Information and Population Health Management Workforce Estates Finance and contracts Organisations and Culture Information Technology

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Supporting Enablers and Infrastructure

Population health Management

Population health is defined by The Institute of Healthcare Management as; ‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group.’

Population Health is heavily influenced by healthcare and the quality of services to patients. However it is important to note, that population health is also influenced by a number of factors. The following should also be considered by Integrated Care Systems in the management of population health. Education

• Work
• Living and working conditions
• Unemployment
• Housing

What are the influencers on population health according to the Kings Fund

Population health Management

According to The Good Governance Institute, population health management is baselined, monitored and improved according to 6 areas that should be driven by data

• Prevention & Public health
• Big Data & Population Analytics
• Digital Health and AI
• Case management & Self Care of LTCs
• Patient Engagement & Empowerment
• Healthcare Delivery

Population health management brings together an understanding of population need through big-data, patient engagement and healthcare delivery Population health management, should be seen as the initiative that facilitates the delivery of the Healthcare Triple Aim

• Improving the patient experience of care (including quality

and satisfaction);

• Improving the health of populations; and
• Reducing the per capita cost of health care

Good Governance Institute Dimension of Population health Management Figure 3 – IHMs Triple Aim

Education, Housing, Employment, Criminal Status Age, Ethnicity, Gender, Sexual orientation, Location

Population Health management Acute Data Mental Health Data Primary Care Data Community Data Public Health Data Social Care Data

Wider Socio-economic influencing factors Demographic Influencers Initial system data

Data and Information Sources within Population Health Management

Misaligned / perverse incentives

• Block contracts
• National Tariff /

cost and volume

• Risk share
• Packages of care

Aligned objectives and payment mechanism

• Whole Population

Budgets

• Improvement

payment based on

• utcomes
• Gain / Loss share

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Financial and Contractual Framework

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Local Estates Forum

• Attended by all local Alliance organisations, both NHS Property companies,

SEL STP, CCG commissioners and the London Borough of Bromley

• Strategic and Operational oversight of estates issues in Bromley
• Working alongside the STP on South East London wide strategies
• Development of three hub sites in Bromley

– Beckenham Beacon – Orpington Health and Well Being Centre – Bromley Health and well Being Centre

• Support co-ordination across organisations of changes to Bromley Estate
• Ensuring best use of estate in Bromley

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Bromley Digital Board

• Partnership working across Bromley attended by and working with all

Stakeholders

• Delivery of the local Digital Road Map
• Aligning with the wider STP digital programme
• Consider IT developments across area ensuring interoperability across

systems

• Monitor the implementation of systems and digital workstreams across

Bromley including – Local Care Record – GP systems – Improving IT infrastructure in primary care – Implementing National programmes such as E-referrals and Patient on line

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INTEGRATED COMMISSIONING

Integrated Commissioning Board Health and Wellbeing Board Joint Commissioning Strategies Joint Leadership Roles Joint Work Programmes

Integrated Care Systems Governance

SUPPORT FUNCTION

Bus Int & IT Estates Finance Workforce OD

ICS Development

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Corporate Infrastructure

• Shared Financial Reporting, Business

Intelligence, Executive Responsibility

Working Groups

• Executive Sponsorship
• Organisational Development

Shared Teams

• Efficiency and Effectiveness

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BROMLEY INTEGRATED CARE SYSTEM CHALLENGES

MANAGING CHANGE RISK EXISTING PERFORMANCE MANAGEMENT REGIMES CHALLENGED HEALTH AND SOCIAL CARE ECONOMY TRANSITIONING GOVERNANCE AND ASSURANCE EFFECTIVE PATIENT AND PUBLIC ENGAGEMENT