Daloni Carlisle looks at two pioneering health communities where integrated care is putting the needs of patients centre stage


BR7TAH A man directing traffic


Trafford CCG: a revolutionary programme

Trafford Clinical Commissioning Group is aiming to revolutionise the way its local residents are cared for by embarking on an ambitious integrated care project.

Its working title – the Patient Care Coordination Centre (PCCC) – does little to convey the notion behind this venture between the CCG and consulting and IT services company CSC. This ambition takes a bit of explaining.

‘The more things we introduced, the harder it was to navigate around the system’

Gina Lawrence, chief operating officer of Trafford CCG, starts at the beginning. Trafford, she says, is a financially constrained health economy and for the last few years has been developing community services that could deliver better outcomes for patients and better value for money.

“We developed a whole series of community integrated services that work very well,” she says. “But we found that the more things we introduced, the harder it was to navigate around the system. People were becoming confused about what was where.”

So Trafford CCG came up with the concept of a service that would operate like an air traffic control system, tracking patients as they move through the system and guiding them to different services.

With no preconceived ideas of what such a service might look like practically or how it might be achieved, the CCG started a dialogue with providers. This conversation generated a great deal of interest and resulted in the appointment of CSC as the partner in creating and operating the PCCC, under a five year contract worth approximately £12m.

The vision for the innovative centre is to provide a single point of contact, both for patients and their families and for clinicians. Each patient’s journey will begin with their GP making a referral by phone.

A discussion with clinicians will result in the patient’s onward journey being mapped out on a patient pathway. Pathways will be based on the Map of Medicine – a clinical tool that enables clinicians to plan care according to the best available evidence.

‘We will know where everybody is in the system and can coordinate care around them’

Once the patient is assigned to a particular care pathway, their ongoing management will be overseen by a care coordinator who makes the practical arrangements such as booking outpatient appointments and X-rays or arranging transport or social care support.

Each care coordinator has a whole host of interfaces with different service providers available to them.

The model envisages patients being flagged up in the system as they move along patient pathways, enabling the PCCC to proactively coordinate discharge plans, for example.

“We will know where everybody is in the system and can coordinate care around them,” says Ms Lawrence.

Number one

In this model, there is no need for individual GPs to have information about the plethora of services available to their patients or how to contact these services. There is no need for patients or their relatives to know which number to call as there is just the one number.

The data sharing and information technology are clearly going to be crucial to the project’s success. With most GPs on the EMIS system, there is a potential for creating a shared care record held within the PCCC.

‘This has never been tried before so there are risks’

This is the foundation of care coordination, with individual patient data forming that air traffic control view.

The PCCC vision is now close to becoming a reality with a full go live planned for September 2015. For CSC, the development has been more than just another project.

“We recognised from our initial dialogue with Trafford that this would be a unique, first of type service and that we wanted to be their partners,” says Kevin McMonagle, CSC’s coordinated care lead.

“We are making significant investment as we see this model as being entirely replicable elsewhere.”

He envisages a series of ways in which patients, clinicians and care coordinators will view and interact with information.

CSC is building in health analytics that allow functions such as patient risk stratification. These tools could, in future, allow the CCG to carry out health population management. It could put the CCG in a position where it can meaningfully support patient held budgets.

Partners’ progress

CSC is working with Orion to build portals and will use Microsoft’s CRM (client relationship manager) to track patients.

Colin Henderson, Orion’s general manager in UK and Ireland, says: “This is patient experience focused. How do we set this up so that the right services are made available to patients at the right time?

“That means setting up around the person and sharing information.”

‘How do we set this up so that the right services are made available to patients at the right time?’

Another crucial part of this project will be finding the right people with the right skills to work in the PCCC. Here the partner is Care UK, which will recruit the clinical staff.

“From our perspective we see a connection between high quality care and value for money,” says Care UK deputy managing director for secondary care John O’Brien.

“One of the central tenets is tailoring services to individuals. That way you do not build in resources to pathways that are not needed by individuals.” This is a key element of what the Trafford PCCC is all about, he adds.

“We have a long history of working with clinicians in Manchester.”

Caveat emptor

It is easy to get swept along by the ambition and vision of people involved in this project. But all partners are wary of overselling it, and admit that there are risks and challenges.

For example, is this really just another complicating organisational layer? It is a question that Mr McMonagle acknowledges must arise ahead of the go live date.

‘We see a connection between high quality care and value for money’

“This has never been tried before so there are risks,” he says. “But it is an attempt to break out of the existing model of care by bringing silos together to improve patient care and outcomes, and move integration forward.”

Back at Trafford CCG, Ms Lawrence and Paul Hulme, head of implementation for the PCCC, agree that yes, there are risks, but none so great as doing nothing.

“One of our biggest challenges has been keeping people on board, with them saying this is taking too long or we should start with something smaller,” says Mr Hulme.

“But this is a system approach and must be for it to work.”

They are clear what success will look like and will be benchmarking against other CCGs, particularly on patient experience measures.

There is a way to go yet – and in many ways it is unusual for a CCG and its partners to be this open about such an ambitious project so early. In Trafford, it is all systems go in order to get the system ready for autumn.

Watch this space.

Sheffield: foundations for integration

Another example of integrated care being built firmly around the needs of patients is developing in Sheffield. Three foundation trusts (the teaching hospital, children’s hospital and mental health trust) along with the city council, the Sheffield-wide CCG and all 400 GPs in 87 practices now work collaboratively.

The overall aim is to help vulnerable people live independently. The starting point was risk stratifying patients to identify those most at risk of losing that independence – all 16,000-18,000 of them – and developing care plans and care coordinators for them.

GPs have coalesced into 16 associations so they can work at scale and pace more effectively. Meanwhile, community health services have aligned with local authority short term intervention teams under the management of the acute trust. Health and social care have pooled £260m in a better care fund.

‘It has been a massive organisational development programme where we have to retrain and change behaviours’

These structural changes have supported more fundamental shifts in the way people are cared for, with the aim of avoiding unnecessary admission and assisting safe discharge.

For example, vulnerable patients are no longer assessed for discharge in the hospital but at home.

“The bed stays open but the discharge processes happen at home,” says Sir Andrew Cash, chief executive of Sheffield Teaching Hospitals Foundation Trust.

GPs no longer simply admit patients into the hospital but call an assessment service that visits the patient and looks for alternatives.

The next phase will be setting up three new out of hours hubs that will extend access in primary care. Like Trafford, this is part clinical services wrapped around patients and part IT with a shared patient record at its heart.

‘The bed stays open but the discharge processes happen at home’

This is just a snapshot of Sheffield’s work, which Sir Andrew describes as “light years” ahead of much of the NHS. Even so, he says Sheffield is still “in the foothills” of integration.

“We have good partnership and we are innovative, but it is risky,” he says. “It has been a massive organisational development programme where we have to train and retrain and change behaviours.”

Yes, the results are starting to show. Yes, there is a long way to go. But always, this is about putting the patient at the centre.