Posts Tagged ‘Integrated care’

11 health areas to receive help with planning

By Mike Broad - 17th February 2014 1:21 pm

Eleven financially-challenged health economies in England are to receive expert help with strategic planning in order to secure sustainable quality services for their local patients.

Monitor, NHS England and the NHS Trust Development Authority have agreed to fund a series of projects to help groups of commissioners and providers work together to develop integrated five-year plans that effectively address the particular local challenges they face.

As part of the annual planning round, all NHS organisations are being urged to plan over a five-year period in future as part of a concerted effort to tackle the long-term financial and operational challenges facing the system.

The eleven areas have been chosen on the basis that they will most benefit from external support in the first few weeks of the new financial year, and potential suppliers are now being invited to tender for the work.

Responsibility for delivering strategic plans remains with the individual commissioners and providers. The appointed supplier will act as a critical friend, seeking to bring together all partners in the health economy  and testing whether the organisations are undertaking their long term strategic planning in the most effective way.

Suppliers will be appointed at the end of March and will begin a programme of work lasting around 10 weeks across four work streams;

- A diagnosis of supply and demand;

- Solutions development and options analysis,

- Plan development;

- Implementation.

NHS England’s Chief Financial Officer Paul Baumann said: “We are investing resources now to help organisations across these health economies to plan effectively. The health economies identified are those where we believe that this immediate support will have the greatest long-term impact, providing significant positive benefits to patients and taxpayers in the future.”

The 11 health economies are:

1.            South West London

2.            North East London

3.            Cumbria

4.            Eastern Cheshire

5.            Staffordshire

6.            Mid Essex

7.            Cambridge & Peterborough

8.            Leicestershire

9.            Northamptonshire

10.          East Sussex

11.          Devon

Taking out the barriers to integrated care

By Dr Leonid Shapiro and Dr Michelle Tempest - 5th December 2013 10:54 am

Commissioners, whether at NHS England, Clinical Commissioning Group (CCG), or local authority level, are increasingly looking to integrate care across hospital and community as well as health and social care.

It’s the only way for the system to gain enough efficiencies to be able to deal with the massive growth in demand from an aging population increasingly living with long term co-morbidities. This has resulted in the fundamental shift from giving contracts to the local incumbent NHS provider of a specific (‘silo-ed’) service to any lead provider (NHS or private) providing care to an entire population.

This has a number of implications. First, is the idea that private organisations can compete on a level playing field to NHS incumbents. Section 75 rulings, which require CCGs to tender out all services to all providers rather than automatically giving them to the local NHS provider, is a fundamental driver of this. Even heavily pro-NHS CCGs are now being forced to consider if private providers can offer a better deal for the population they are responsible to look after.

Second, payments for care are shifting from activity based, per-procedure for example, to capitated population base (fixed amount of money for looking after all care needs of over 65 year olds, for example). This puts the onus onto the provider and changes the incentives, not to just deliver an increased number of procedures, but to better maintain the health of the population so that they don’t need to do so many procedures, completely changing the way providers view the world and their purpose.

Third, it is impractical for one provider to deliver all care under an integrated care contract and increasingly providers are either partnering (including partnerships between NHS and private providers) or subcontracting some services. The concept of prime contractor has surfaced whereby a main provider contracts with the CCG and then subcontracts other providers (some of whom may have unsuccessfully bid one the same contract tender) to deliver the care.

Alliance contracting, common in the construction industry for complex projects, has become popular now in healthcare. Under alliance contracting, the prime contractor creates a special contract with the subcontractors where payment is not based on individual subcontractor performance, but on the performance the service overall - linking every member’s success in the contract to one another. This creates incentives for subcontractors to help out each other and ‘pull in the same direction’ as they are ‘in the same boat’. It also reduces the complexity of contracts between the providers and litigation.

As a result of this doctors and multidisciplinary teams will have to work with care coordinators, perhaps employed by lead providers, perhaps from the private sector, to look after patients. This shift from a purely clinical, doctor-led approach to care to a more managed full patient pathway approach should start linking up clinical pathways, rather than encouraging the status quo of ‘silo-ed’ service delivery, and integrating care using fact backed evidence.

Data will also become more important. Currently, patient clinical data is only available to the organisation that delivers the care direct to the patient. For example, the CCG does not have visibility over how money has been spent by acute providers and even less visibility over how block community and mental health provision has been allocated.

They also do not have access to clinical data held by providers, making it impossible to review outcomes, identify patients getting dis-coordinated care, and create an integrated care strategy on a whole system basis. This has to change. If commissioners, lead providers, and subcontractors are to deliver integrated care, to improve patient care, patient experience, and reduce cost inefficiencies, they must be able to analyse and leverage big data sets from all stakeholders.

Current legislation prevents this from happening and much work is needed to clear the road to data sharing in this brave new world.

Dr Leonid Shapiro is managing partner and Dr Michelle Tempest, a partner, at Candesic, a strategic consultancy serving the NHS, private operators, and investors.

14 pilots announced as integrated care leaders

Social Care Worker - 4th November 2013 7:19 pm

Fourteen areas are leading the way on integrating health and care, the care minister says, and he wants their learning to spread across the country.

The pioneers have been selected by a renowned panel of experts, including international experts drawing together global expertise and experience of how good joined up care works in practice.

The aim is to make health and social care services work together to provide better support at home and earlier treatment in the community to prevent people needing emergency care in hospital or care homes.

Read more at SocialCareWorker.

NHS can learn from NZ’s integrated care story

By Francesca Robinson - 1st November 2013 11:07 am

A joined-up approach to healthcare which has transformed care in New Zealand could have important lessons for the UK government as it seeks to integrate health and social care.

Since 2007 Canterbury District Health Board (DHB) has embarked on a major investment in community services which enable more people to be cared for in their own homes.

This has relieved pressure on hospital services, reduced inappropriate admissions, ensured timely discharge of patients and reduced readmissions.

The Board has moved from a position where its main hospital in Christchurch, struggling with unsustainable demand, regularly entered gridlock with patients backing up in its emergency department and facing long waits as the hospital ran out of beds – to one where that rarely happens.

In the last three years, despite the upheaval of the earthquake in 2011, patients have been saved 1.5 million days of waiting for treatment and almost 25,000 patients cared for in community settings have avoided a hospital stay altogether.

The goal has been to build capability in general practice giving GPs good access to services such home nursing care and meals on wheels and secondary care support and advice, making them a single point of continuity.

GPs have also been provided with direct access to a range of diagnostic tests. This has enabled increasing numbers of patients to arrive for outpatient appointments already “worked up” with their need to see a specialist already established.

A range of conditions that once were treated purely or mainly in hospital are now provided in general practice – for example, the removal of skin lesions in a country with a high incidence of skin cancer, and treatment for heavy menstrual bleeding.

A shared patient record, a well-resourced out of hours service and a triage tool which enables ambulance officers to ring the general practice team, all help to keep people needing emergency care out of hospital.

Carolyn Gullery, DHB general manager for planning and funding, says their mantra is “one system one budget” and the ethos is that everybody works for the one service – the Canterbury health system.

“Also we are really good at using information to drive service change. Our vision is one of a connected health system, centred around people where data is the major driver of change.

“We work with a UK organisation called Lightfoot and we use them to make information available and live to the system. Because it is live we can interrogate the data and see what’s really going on. Also it enables us to figure out what next bit going to improve.”

She says lessons the UK could learn are:

- If you are going to integrate services develop a shared vision: everyone needs to be seeing the ultimate outcome as the right outcome.

- Remove financial incentives from contracts. Design the way the system needs to work then figure out how to fund it.

- Join up the data: that way you can see solutions that may otherwise be hidden.

- When aspiring towards an ED target of under 4 hours look carefully at what is happening in primary care.

- Make sure out of hours services are well resourced and make sure only the right people are brought into hospital from primary care.

- The whole system, primary, secondary and social care, all need to work together.

“The key behavioural change for us was based on developing trust between primary and secondary care and with the whole system. It is important that everybody comes to work each day expecting to do a good job and are going to make the system work.

“We have created a virtuous cycle. People get faster access, care is provided at home and people stay out of hospitals. Integration is more of a journey than a destination. We have proved to ourselves that it is a journey worth taking,” she says.

In a report on New Zealand’s quest for integrated health and social care the King’s Fund said recently that “Canterbury’s story deserves careful study and adaptation if the commitment to integrated care is to be translated into practice.”

“Canterbury DHB could provide some of the solutions the NHS so badly needs,” it concluded.

Labour: CCGs would lose commissioning role

By Francesca Robinson - 27th June 2013 8:47 am

Battle lines were drawn by politicians over who should commission care after the next election in key debates at Health+Care Conference 2013.

Norman Lamb, Minister for Care and Support declared that he was passionate about integrated care and said he was absolutely determined to use his time in government to encourage health and social care professionals to work collaboratively to achieve ‘real and positive’ change.

But Shadow Health Secretary Andy Burnham said if Labour won the next election he planned to take responsibility for commissioning services away from CCGs and hand it to local authorities which he believed were better qualified to develop integrated care services.

Lamb said a tranche of integrated care pioneers would be announced in September and would be given expert help and advice from a central unit. “Our starting place will be to say yes and try to help rather than coming up with new ways of saying no or getting in the way,” he said.

Too often patients became trapped in hospital for months unable to be discharged because there was no connection between primary, social and community care. “This is poor care, it feels too often like a dysfunctional system designed for a past age.”

“Introducing integrated care means squeezing every last penny of value for the money that we spend and using the money we have got available to us much more effectively than we do now,” said Lamb.

Some parts of the country were showing how services could be integrated, he said, citing examples of integrated care systems in Leeds, Northumbria and Cumbria. But he said even in those places which had made good progress none had yet developed a fully integrated system of care.

Expanding on his ideas for developing integrated care, Andy Burnham said CCGs would be downgraded to an advisory role and local authorities through health and wellbeing boards would take over commissioning ‘whole person care’.

“The big paradigm shift we have got to make is from a medical model of commissioning to a social model of commissioning. That is why we have to have local government in the lead, as difficult as that is to hear for some people in the NHS.

“We are not going to meet the challenge of 21st century around mental health, lifestyle and ageing if we don’t make the link between health and housing, health and planning, health and education and health and leisure. I see CCGs as advisory bodies only because commissioning is a broader job – it’s about meeting all the population’s needs. GPs only see a subset of population whereas local government has better understand of all of the needs of the population.”

When questioned, Mr Burnham admitted labour would not commit any extra money to health and social care but he said more money from the overall budget would be spent on adult social services.

But he did promise there would be no further structural reorganisation of health services under a Labour Government.

He said an independent commission has already been set up by Labour under Sir John Oldham, former national clinical lead, quality and productivity at the Department of Health, to examine how health and social care could be integrated.

“The right things will follow if the whole person is at the centre of our thoughts,” said Mr Burnham.

Sir Robert Naylor, Chief Executive University College London NHS Foundation Trust, said he did not agree with Labour’s idea of transferring commissioning budgets to local authorities. ‘I’m proud to be part of the NHS and if we are going to keep the ‘N’ in the NHS then we need to be very, very careful about what we do with the money,’ he cautioned.

During a debate at the end of the conference more than 80 per cent of the audience said they thought it was unlikely that CCGs would avoid major re-organisation in three years’ time.

CSR threatens automatic pay rises in NHS

By Mike Broad - 26th June 2013 5:21 pm

Public sector workers are set to lose automatic annual pay increases as part of £11.5bn in cuts unveiled by Chancellor George Osborne.

As part of the comprehensive spending review, Osborne announced that annual incremental pay increases in the civil service would be axed in 2015 and a fresh push made to remove automatic pay rises for time served in NHS, prisons and police. The armed forces will be excluded from the changes.

He told MPs: “Progression pay can at best be described as antiquated; at worst, it’s deeply unfair to other parts of the public sector who don’t get it and to the private sector who have to pay for it.”

There will also be a 1% cap on public sector pay rises.

On a more positive note, the NHS, schools in England and foreign aid, will continue to be protected from budget cuts. Local government will take the biggest hit with cuts at the Department for Communities and Local Government of 10%.

The cuts package will cover a single financial year - 2015/16.

The chancellor also announced the introduction of a pooled budget for health and social care services to help older and disabled people. Almost £4bn from the NHS budget will be poured into integrated care to help older and disabled people in 2015-16.

The new integrated care fund, worth £3.8bn, is at least £2bn higher than the current level of annual NHS resource allocated to social care, and is designed to provide support for older and disabled people to stay out of hospital and reduce hospital stays.

However, local government budgets are set to fall by 2.3% in real terms from 2014-15 to 2015-16, suggesting more pain for adults’ and children’s social care, both of which are facing rising demand.

Responding to the review, chair of the BMA council, Mark Porter, said: “Although the NHS budget in England has been protected this does not allow for keeping pace with new treatments, an ageing population and rising demand. All too often short term cuts are being made to meet soaring financial pressures often without the involvement of clinicians. Only by putting resources in the right place and working with doctors can the government strive to meet the challenges the NHS faces.

“We support the government’s commitment to the care of older people and we hope that the allocated funding is indeed used to genuinely meet the needs of patients and help alleviate the current pressures on emergency departments. However, we are concerned that the Chancellor’s decision to cut the local government budget by 10% will seriously undermine the government’s commitment to vulnerable people because of the impact on social care, and wider public health needs.”

Mike Farrar, chief executive of the NHS Confederation, said: “Social care budgets have really been squeezed over the past three years and this has had a big impact on the numbers of people we are seeing admitted to hospital as emergencies because the right support outside hospital is not available to them.

“This allocation should help address the need to join up services and provide the right care for people, allowing them stay in their own homes. But NHS organisations will want to have strong assurances that the money going to social care does the job it is meant to do. Rather than see local health and social care budgets as separate, we need to support integrated care by bringing together providers and commissioners to look at how we can spend our money to the best effect.

“To make a real improvement to the care people receive, we have to change the way we do things in the future, and ensure the NHS is able to provide care at the right time, in the right places. This settlement means NHS organisations will have less money available in real terms for front line services, so the need to change services is now more pressing than ever.”

On pay progression, the BMA said it needed to see further detail regarding the government’s intentions. Porter commented: “Doctors pay progression is already based on satisfactory completion of their duties and other criteria. There are currently exploratory talks taking place on junior doctor and consultants contracts and they will need to consider any potential changes.”

The BMA also welcomed the government’s decision not to transfer funds for medical training and research from the Department for Business, Innovation and Skills.

Government’s framework for health and care integration

By Mike Broad - 25th May 2013 12:54 pm

Delegates attending the Health+Care show will be among the first to hear details of a new cross government partnership framework for integration being developed by the Department of Health (DH).

Damon Palmer, policy lead for Health and Social Care Integration, at the DH, who is speaking at the conference, will be explaining how the framework will be used to encourage and promote enthusiasm for integration among those who are leading the way.

“The framework will be a key vehicle for alerting and signposting people to the work that we are involved in. It will be a springboard for our ambitions,” he says.

There are already a number of sources of inspiration and good practice beginning to emerge from some of the early pioneers of integrated care.

Examples of the numerous changes that need to take effect across an entire locality can be found among the Community Budget pilots. Community Budgets are designed to allow providers of public services to share budgets, improve outcomes for local people and reduce duplication and waste. Further information can be found on the local government association website.

Mr Palmer points to one particularly successful project - the tri-borough Community Budget pilot where three central London councils, Hammersmith and Fulham, Kensington and Chelsea and City of Westminster, have joined forces to protect front-line services by combining funding streams from across their patch. They are now starting to show very promising early signs that services can be improved and savings made. Initial findings showcased in a report in published in June last year demonstrate that change is possible, savings can be made and services improved.

These three local authorities are now looking to further integrate care across their clinical commissioning groups, providers and community services to improve patient and user health outcomes and experience.

Mr Palmer points out that the DH, and its partners, are committed to encouraging local experimentation: “We want to encourage and support those who are working together locally to build innovative models of care, tailored to local needs and circumstances. We know there are still barriers and complexities at national level, so through the national collaboration (between the DH, Monitor, Commissioning Board, Local Government Association, Association of Directors of Adult Social Services) we are considering how best to support local innovation and share learning without getting in the way of innovative service development.”

Announcing the pilots at the end of last year, care services minister Norman Lamb said the DH was keen to enable local ‘experimentation’ rather than dictate how integration should be done.

The King’s Fund and the Nuffield Trust have also been doing a considerable amount of research into integration and Mr Palmer says the DH will be keen to highlight the evidence that these organisations reveal including their pilot work with a series of English integrated sites.

The DH is also currently working to put as much material about integrated care as it can on to the Local Government Association’s website called the Knowledge Hub, a professional social network which helps people in local government and across the NHS connect and share online in a secure environment.

Mr Palmer says they are keen to support continuous learning and innovation: “We want to work in partnership with localities to understand what the problems are and what we can do to support them in terms of helping them to overcome any barriers or obstacles and challenges.

“What we don’t want is for there to be just isolated pilots while other localities stand by and watch from a distance. We want to enable all localities to embark upon more innovative and integrated working.

“I hope that delegates coming to the Health+Care conference will find they have the opportunity to take back to their offices  different ideas and will be inspired to ask themselves why they are or are not doing different things. Our message is that there is no one model of integrated care, there is no one-size-fits-all blueprint.  To some extent it’s about localities finding and developing and implementing the solutions that best meet their local needs.”

Attend the Health+Care Conference on integration for free. Click here.

Pledge to integrate health and social care

By Francesca Robinson - 14th May 2013 3:52 pm

Plans to make joined up health and social care the norm by 2018 have been announced by the government.

The aim is to put an end to people being “passed round the system” and “falling through the cracks” of uncoordinated care.

Better integrated care between hospital and social care staff could relieve pressure on A&E services by preventing emergency readmissions and could also help to reduce the £370 million a year cost of long waits for discharge from hospital. It should also ensure that people get the support they need with the appropriate information and notes being shared by different parts of the system, argues the government.

“Unless we change the way we work the NHS and care system is heading for a crisis,” said care and support minister Norman Lamb.

The government has set out plans for pilot areas from September to pioneer the practical approaches that are needed to achieve change as quickly as possible.

New measures of people’s experience of joined up care and support will be introduced by the end of this year to monitor whether people are feeling the benefits of the change.

The government has also published a Shared Commitment document which sets out how the national leaders of the health and care system have come together to help local areas make integration happen.

It sets out how local areas should use existing structures like Health and Wellbeing Boards to bring together local authorities, the NHS, social care providers, education, housing services, public health and others to bring about better integration of local services.

But the government has not committed any additional money to the proposals. Instead it is suggesting that clinical commissioning groups should set aside two per cent of their annual funding for non-recurrent expenditure to support innovative approaches to integrated care.

Michelle Mitchell, director general of Age UK , said that for the government’s vision for integrated care to become a reality, there needed to be good social care provision in place with sufficient funding. Since the government came to power, £710 million in real terms had been cut from social care budgets mostly through reduced local authority funding. She called for an emergency injection of funds to “shore up the current system”.

Chris Ham, chief executive of The King’s Fund, warned that feedback from their work with local health and social care leaders indicated that some aspects of current policy and regulation were acting as barriers to delivering co-ordinated care. “This should be addressed by giving pioneer areas freedoms and flexibilities to overcome these restrictions when they are rolled out from September,” he said.

Nuffield Trust chief executive Dr Jennifer Dixon also cautioned that it would be important to learn carefully from new initiatives and not over claim their benefits. “There have been attempts to develop integrated care for at least 20 years, but with mixed results. The will is there but the policy context can often work against hard won efforts. Today’s announcement recognises this by attempting to align a number of policies to speed progress,” she said.

Professor Andrew Kerslake, associate director of the Institute of Public Care, said: “Health and social services can be integrated managerially but the important question is are services integrated at the point of delivery – in other words does the person in the community experience an integrated service that could prevent them from being admitted to hospital?

“People want to experience integrated care because they don’t want to be constantly referred from one service to another and that’s something the government is hoping to achieve but integrated care on its own won’t deliver what NHS and social care needs which is a reduction in demand.

“Also I worry that integration actually hides issues around performance because studies by the Royal College of Physicians have shown that the health service is simply not performing well enough on some of the areas concerning older people such as dementia, falls, strokes, continence etc. Integration will help but it is not necessarily the solution.”

Professor Andrew Kerslake is speaking at on 12 June. Visit the website to register for a free ticket.

Labour launches commission on care integration

By Mike Broad - 23rd April 2013 11:02 am

Labour leader Ed Miliband has called for the swift integration of health and care services so that the NHS can be made financially sustainable.

He cited figures from the Nuffield Trust which show, unless we improve the way services are delivered, growing care needs will leave a shortfall of up to £29 billion a year by 2020 in NHS funding. And claimed that there’s growing evidence that the coalition government’s reform programme is stifling the real change the health service needs and threatening its sustainability.

Miliband announced the launch of an Independent Commission which is being asked to find ways of integrating health and social care so that both of these key public services are affordable in an era when there is less money around than there was in the past.

Ed Miliband said: “The NHS is facing the biggest challenge in its history. The toughest financial pressures for 50 years are colliding with our rising need for care as society gets older and we see more people with chronic illnesses like cancer, diabetes and dementia.

“The NHS will always be a priority for expenditure under a Labour government but we must make every pound we spend go further at a time when our NHS faces the risk of being overwhelmed by a crisis in funding because of care needs by the end of this decade.”

He said that even in tough times there should be an expectation to provide a better service for patients. “The changes we propose will ensure that - but they do something else too. They will save billions of pounds which can be better spent elsewhere in the NHS. These reforms are necessary if we are going to ensure that the high quality effective NHS, which the British people expect, is affordable in the decades to come,” he added.

He described how the growing number of older people and those with chronic illnesses is fundamentally challenging current models of care, where different problems are handled separately in different services. Instead, he argued that the future demands ‘whole-person care’ – an agenda that would bring together physical health, mental health and social care into a single service to meet all of a person’s care needs.

By ensuring the commissioning of health and care services at local level are joined up better, both services can be planned more effectively and affordably.

He said: “In the 21st Century, the challenge is to organise services around the needs of patients, rather than patients around the needs of services. That means teams of doctors, nurses, social workers and therapists all working together. It means care being arranged by a single person who you know – ending the frustration of families being passed around between different organisations and having to repeat the same information over and over again. It means a greater focus on preventing people getting ill and more care being provided directly in people’s homes so they avoid unnecessary hospital visits.”

Labour’s Independent Commission on Whole-Person Care will be led by former Department of Health specialist Sir John Oldham. The Commission will produce recommendations on achieving Labour’s vision of ‘whole-person care’, without another top-down reorganisation and within existing resources.

Sir John Oldham commented: “I am very pleased to undertake this important task. 70% of activity and cost in the care system is for people with multiple chronic diseases, which includes a rising number of older people. Their care crosses organisational boundaries, and is fragmented. Those patients say: I want you to treat the whole of me, and act as one team, which also leads to better outcomes and greater efficiency for the whole system. We need to bring that about.

“If we don’t change, the crisis of need approaching rapidly will make the NHS and care system unsustainable, and reduce the competitiveness of our economy driving a spiral of decline. It is that significant.”

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Integration could trigger hospital reconfiguration

By Francesca Robinson - 31st January 2013 10:25 am

An increasing focus on integrating health services by clinical commissioning groups (CCGs) could destabilise acute trusts and drive hospital reconfigurations, says a leading GP.

The integration of primary and secondary care to address the fragmentation of patient services and achieve greater efficiency and value for money means that services will be designed to more effectively prevent illness and keep patients out of hospital.

Dr Charles Alessi, chair of NHS Clinical Commissioners, says a current obstacle to integration is the payment by results system which rewards secondary care for increasing activity.

But commissioners will have to work with limited budgets and prioritise care which means that if one provider gets more money, another will get less.

“We are very conscious of the fact that we have too many acute trusts and distribution of services is not ideal so integration of health services could be one of factors that drive reconfiguration.

“The payment by results system that we currently have is a product of a different age when we were expanding the NHS. In future acute trusts will need to understand that they live within the local health economy. Integrated care is based on the premise that we need to use the resource that we have for health care as efficiently as possible. Let’s sit down and have a discussion about how we are going to do that clinically,” said Alessi.

There were likely to be heated discussions in CCG meetings which must be held in public because people need to understand the need for prioritising care.

“Integration is going to have to be driven by all sides. It’s in everybody’s interest that we get commissioning input into the process from our colleagues in secondary care. We know there is going to be a whole series of reconfigurations over the next three to four years because of the financial situation we are in. Integrating services gives us the potential to think differently around the way we deliver services,” said Alessi.

Dr Alessi will be speaking at Health+Care Conference (June 12& 13 at London’s Excel) on the potential for integrating primary and secondary care health services.

Integrating care is high on the agenda following the Labour Party’s move last week to place it centrally within their new health policy.