Posts Tagged ‘Integrated care’

Personal budgets expanded for NHS patients

By Mike Broad - 9th July 2014 7:51 pm

Personal budgets are to be expanded and cover both the health and social care needs of vulnerable people, the new chief executive of NHS England has announced.

Simon Stevens wants to see the frail elderly, people with disabilities and those with serious mental health problems given joint budgets from the NHS and council-run social care services to spend as they see fit.

The hope is that five million people will be offered them by 2018.

Patients will be given a nominal budget - at least £1,000 - which they can then decide to spend on whatever care and services they want, as part of a drive to give patients more power.

GP and emergency care is not included, and they can use these the same as anyone else.

Nearly 650,000 people currently have a social care personal budget. Under 2,500 patients have them in the NHS.

Speaking at the annual conference of the Local Government Association in Bournemouth, Stevens set out the plans for a new Integrated Personal Commissioning (IPC) programme.

Four groups of high-need individuals are to be included in the first wave from next April 2015, although councils, voluntary organisations, and NHS clinical commissioning groups may also propose others.

These include people with long term conditions, including frail elderly people at risk of care home admission; children with complex needs; people with learning disabilities; and, people with severe and enduring mental health problems.

This will blend funds contributed from local authorities and NHS commissioners (CCGs and NHS England). Individuals enrolled in the programme will be able to decide how much personal control to assume over how services are commissioned and arranged on their behalf.

NHS England will now work with partners in local government, CCGs, patient groups and the voluntary sector to develop an IPC Prospectus which will be published at the end of July. This will formally invite local expressions of interest in jointly developing and participating in the IPC programme from April 2015.

NHS England will provide technical support to develop projects, and fund independent evaluation. Wider scale rollout of successful projects is envisaged from 2016/17.

Experience with pilots have shown that this approach has the potential to join-up services and funding at the level of the individual, for people who often need multiple services.

Stevens said: “We need to stop treating people as a collection of health problems or treatments. We need to treat them as individuals whose needs and preferences should be seen in the round and whose choices shape services, not the other way round.

“That’s the big offer the NHS increasingly has to make to our fellow citizens, to local authorities, and to voluntary organisations.”

£2bn extra health and social care integration fund call

The Guardian - 18th June 2014 10:59 am

Councils and the NHS need an extra £2bn “transformation fund” to help integrate services, says the chairman of the Local Government Association.

Sir Merrick Cockell said the additional funding was needed on top of the Better Care Fund, the £3.8bn project to bring together health and social care services. He also called for the fund to become a five-year commitment, rather than the year it is officially scheduled to last.

Speaking at conference organised by the King’s Fund thinktank in London, Cockell said a transformation fund would “ease the short term disruption to residents and to patients”, and that it would have to be a “significant” amount of extra money towards the £2bn mark.

However, Cockell’s general attitude towards the Better Care Fund seemed to be one of confidence, calling it “our best answer to the questions asked of us in these testing times”.

The Better Care Fund relies on pooled funding from local authorities and the NHS, with the intention of reducing pressure on hospitals by providing more care and support in people’s homes.

Read more in The Guardian.

Integrated care model holds key to solvency

By Jonathan Fagge, CEO of NHS Norwich CCG - 16th May 2014 8:58 am

A week in the life of a CCG chief executive

If winter is the season of pressures, spring is the season of workshops. I’ve attended four this week covering collaborative commissioning, 5 year plans, integrated care for Norwich, and Strategic Workforce Planning.

Regular attenders of these might sometimes substitute ‘talk’ for ‘work’ when they describe them, and for an outsider we must look at times like the Committee of the People’s Front of Judea, but system workshops endure because we have not yet found a better way to bring everybody together to tackle the problems none of us can solve on our own.

The workshop season has been particularly febrile this year; in part because of the very complex and ambitious planning guidance that requires us to plan five years ahead and pool health money with social care; but also because as problems go, we are having to face up to some big ones. Amongst them stride two colossi:

Balancing the budget

This financial challenge is expressed in a variety of ways - the cash, the demographics, the growing burden of disease, even the 24-hour society - but it all relates to the last six years of budget growth below wage growth and inflation, combined with increasing levels of demand for healthcare.

Each year it gets harder for commissioners to balance the overall budget for their system, and providers have to find efficiency savings of 4-5%. They’ve all done the easy stuff, and now have to find ways of cutting into the wage bill without reducing the quality of care.

Our mental health and community providers  got less than a 1% uplift this year, but they have to treat more people, pay a small wage increase of 1-2%, and face higher costs on equipment and consumables. Our mental health provider produced a five year plan that added these 4% challenges all together and described a 20% cost pressure over 5 years. It has been unhelpfully translated by the newspapers into a ‘20% budget cut for mental health’.

These headlines are technically wrong - Norwich CCG for example has increased its spend on Mental Health in 2014/15, and ring fenced at least that level of spend in 15/16 - but there is a truth at their heart.

We cannot pay any of our providers enough to continue with their existing models of care, there is little slack in the system to fund change, and so it becomes increasingly difficult for them to balance the books, and for us to get signatures on contracts.

We have a plan for Norwich that we hope will meet this challenge, and are excited about working with the Kings Fund for the next three years. We will create a whole system model of integrated health and social care for the City - improving  outcomes, reducing costs, and keeping people well, independent, and at home for as long as possible.

I believe this is represents our best chance of emerging from this period of austerity with the quality of care protected and our health system intact and solvent, but it will not be easy and we will need to work together to make it happen. And if an occasional workshop brings us together, reminds us of the mission, and creates a space for us to iron out the tensions, then I will happily sit cabaret style with a mug of coffee and some flip chart paper and give it my undivided attention.

The retirement challenge

The workforce challenge has had less coverage than the money, and yet in some ways it is of greater concern.

In Norfolk and Suffolk, 17% of the health workforce are over the age of 55, and are expected to retire within the next five years. I am told by the Local Medical Committee that almost half of all surgeries in Norfolk have at least one GP vacancy. We expect to be 2,000 nurses short of requirements in Norfolk and Suffolk by 2019. We already need 400 more paramedics for the East of England. And many hospital departments - especially A&E, Stroke, Medicine for the Elderly - report increasing difficulty in recruiting consultants.

Unlike the money problem, government cannot simply turn the tap back on. It takes between two and ten years to train people into these various careers; double the number of nursing commissions at Universities tomorrow and they will begin to join the wards, surgeries, and patients’ homes in the summer of 2018.

Do the same for doctors and it will be later than 2020. The paradox is that although we are training fewer than we need, we are training as many as we can afford.

Health Education England is responding to this challenge -  looking for efficiency savings that will enable them to increase the number of commissions they can afford. Even more importantly they are investing in the training, support, qualifications, and greater recognition for the health support workforce, known internally as ‘Bands 1-4′.

If we can standardise the training and produce a nationally recognised qualification we could quickly create a large skilled and transferable workforce able to perform a variety of health support tasks, and freeing up the time of doctors and nurses.

I have taught on HCA courses in the past (from new to ready to go can take as little as three months), watched them provide care, and talked to both doctors and nurses about the opportunities for sharing their workload with trained assistants. I believe there is huge scope for reducing the costs of care without reducing quality, and this initiative should be a major part of the puzzle to the workforce challenge we face.

I asked a senior clinician that worked on our Urgent Care Unit trial this winter about what had made it so successful. He talked about the developing relationship between community and hospital staff, the proximity of the unit to A&E, and the speed of treatment and discharge.

But top of the list was the Healthcare Assistant that drove frail patients home, settled them in, and made sure they were comfortable and safe. Each journey almost certainly prevented a patient being admitted. This wasn’t nursing on the cheap; it was professional and appropriate assistance that made nursing care on a ward unnecessary.

So, money is tight and workforce is ageing? All hail Bands 1-4!

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.