When service redesign meets sustainability
A London partnership’s service redesigns aim to offer better care, while reducing bed occupancy and being sustainable, as Jennifer Taylor explains
Southwark and Lambeth Integrated Care has come up with a unique approach of placing equal focus on redesigning models of care and systems, in which even social care has been involved from the outset.
‘We started the programme for and with older people as we could see how together we could make a real difference to their lives’
Deputy director Maggie Kemmner says: “Our vision is to fundamentally change the way care is provided, driven by and centred on local people. We are working with them to design care that is coordinated, proactive, engaging and improves their experiences and wellbeing.
“However, we realised early on that this wasn’t enough. We needed to work across our local organisations to make sure the system was able to support sustainable change for people.”
Also unique is that social care has been involved from the outset. There are three co-chairs on the programme board: Jo Cleary, executive director of adults’ and community services at Lambeth council, Dr Femi Osunuga, GP lead for integrated care in Southwark, and Sir Ron Kerr, chief executive of Guy’s and St Thomas’ Foundation Trust.
Sir Ron says: “Southwark and Lambeth Integrated Care is helping us to work with partners to improve and integrate social and health care across the boroughs. This is a large scale programme, but it isn’t ‘the system’ designing for the public − involving local people and patients is at the heart of our approach.”
Work to redesign models of care started with older patients (over 65s) and this year will expand to all adults with long-term conditions. The aims are to give people a far better experience of care, and have a healthier population, resulting in reduced bed occupancy and admissions to care homes.
Ms Cleary says: “We started the programme for and with older people as we could see how together we could make a real difference to their lives, as well as making efficiencies. Older people deserve better outcomes. We all know that there is less public money to achieve these better outcomes so it follows that we all have to work differently – that we need to put the person at the heart of everything we do.
“For us as leaders across all the organisations involved in delivering integrated care, it requires us to lead differently, demonstrating our collective responsibility to achieving our vision.’
Six community multidisciplinary teams across Lambeth and Southwark coordinate the care of higher-risk patients with complex needs. Professionals from primary, secondary, mental health and social care discuss patients at fortnightly meetings and a plan of action is made, helping timely shared decision making.
The new model of care includes holistic health assessment which identifies people who are becoming frail. Physical, mental health and social care risks for older people are assessed such as falls and mobility, skin integrity and dementia.
Patients may be referred for a single intervention – for example a local exercise programme if they are at risk of falls – or tracked into case management if they have more complex needs that require support from different organisations.
Rapid response teams
A number of changes have also been made to the urgent care pathway. GPs have 24/7 telephone access to consultant geriatrician advice. This is backed up on the same or next day assessment by geriatricians in an outpatient setting near A&E with access to x-rays, scans and blood tests.
‘Most people prefer the fact that they are treated at home if they can be’
Dr Dan Wilson, the programme’s clinical lead for frail older people at King’s College Hospital Foundation Trust, says: “People can have a very quick diagnostic work-up and then we make decisions about how safe it is to treat them at home.”
People avoid admissions or get home earlier through rapid response community teams for nursing, therapy and social care rehabilitation. Nurse-led home wards provide oxygen, nebulisers or intravenous therapy.
Dr Wilson adds: “Most people prefer the fact that they are treated at home if they can be.”
There are five strands to the systems redesign. The first is governance – a range of joint equal partnership boards govern the programme; and the potential for different organisational forms, such as a joint venture or alliance contract, may be considered.
Second is a cross-sector reporting system which helps the partners hold each other to account and will help prioritise future areas for integrated care.
Third is joining up IT systems across partners to enable real-time sharing of information about patients. Workforce is a fourth area. So far the focus has been training people to deliver the new model of care but this year they will plan future needs for a more integrated workforce.
And the final strand is the money. The three-year business case involves each of the health and social care partners making savings but the current intention is to be cost-neutral while getting better value and managing rising demand.
The costs of integrated care
The total cost of changes to the model of care for older people in Lambeth and Southwark is £6.5m per year for three years, of which £4.5m of start-up funding has come from the Guy’s and St Thomas’ Charity.
One-off infrastructure and development costs total a further £2.5m per annum over the three years. This includes a significant investment in IT.
Every year, money is being reinvested:
- £1.1m in primary care.
- £2.2m in social care.
- £2.8m in community services.
- £500,000 in mental health.
- £220,000 into the charitable sector.
This arrangement will operate from 2012-13 to 2014-15 and probably beyond. The balance of contribution from different organisations changes over the three years because of the initial funding from the charity.
Recouped costs are predicted to be 50 per cent in 2013-14, 80 per cent in 2014-15 and 100 per cent in 2015-16 (ie: the net investment will be zero at that point).
Additional system savings of £7m each year – including additional savings to commissioners and social care, and saved opportunity costs in the acute sector – are set to start from 2015-16.
Predictions are that by the end of year three, hospital bed days will fall by 15,400 (14 per cent) and residential care placements by 118 (18 per cent).
Economic modelling with provider data revealed that income from admissions for older people was much lower than the cost of providing care. The acute trusts agreed to put in significant investment every year to fund activity that will prevent admissions, and hence improve their own economic situation.
‘Another hurdle stems from the fact that the NHS operating framework is re-released every year’
Ms Kemmner says: “For acute trusts there’s an incentive to pay money to keep activity out of the hospital because emergency care for older people is an absolute loss maker and inhibits the trusts’ ability to deliver elective or tertiary care.”
The partnership is using existing contracting models including payment by results, with a claw-back. It has two pieces of work investigating alternative funding mechanisms. One is the Department of Health’s year of care funding project which is developing a tariff for people cared for by the Consortium for Medical Device Technologies. The other is a broad piece of work investigating potential to introduce capitated budgets.
Some aspects of the service models are delivered jointly – rapid response services, for example – while others are done by one type of provider, such as holistic health checks in primary care and geriatrician assessments in acute care.
General practice is fundamental to integrated care since it holds the registered list and communicating with the 95 local practices required a lot of leg work.
Inner-city London has recruitment and retention issues and the original vision of a nurse-led model of case management was changed to include social workers.
IT and information governance are an ongoing challenge, with continual efforts being made to join up systems so that patient data can be shared across sectors.
Another remaining hurdle stems from the fact that the NHS operating framework is re-released every year. “This is an inherent instability and we have to renegotiate every year,” says Ms Kemmner.
The four-part external evaluation looks at user experience; reductions in hospital bed days and admissions to residential care homes using control data; economic costs and savings of the new model; and the process of change including governance and leadership.
“We are actively monitoring and will improve and extend the model of care if we need to as we go,” says Ms Kemmner.
The new chief officer of Southwark and Lambeth Integrated Care, Merav Dover, says: “Our vision is of a bold transformation. We will develop relationships that empower people to improve their health and well being. Driven by this strong health and social care partnership, together with local citizens and communities, care will look and feel different over time.”
Tips for successful integrated care
- Get all health and social care partners around the table from the outset.
- Look at the real costs of providing services, not just what commissioners pay for them.
- Co-design the model of care with patients and professionals and draw on local experience.