Whole Systems Integrated Care Pioneer Programme

1. North West London Whole Systems Integrated CareMeeting with New Zealand Health Economies4th April 2014

2. Whole Systems Integrated Care Pioneer Programme Our shared vision of whole systems integrated care… • “ … supported by 3 key principles • 1 • 2 • 3 • We want to improve the quality of care for individuals, carers and families, empowering and supporting people to maintain independence and to lead full lives as active participants in their community • People will be empowered to direct their care and support and to receive the care they need in their homes or local community. • GPs will be at the centre of organising and coordinating people’s care. • Our systems will enable and not hinder the provision of integrated care. • ”

3. Our track record of working together to design and implement joined up care NW London Integrated Care Pilots Tri-borough Whole Place Community Budget Pilot We have a strong history of genuine partnerships between health, social care, third sector and patient and user-led organisations across 8 boroughs. • Providers working together & with patients • Involves community, primary, secondary and social care, mental health, community pharmacy, specialist nursing and third sector (eg. Age UK and Diabetes UK) • Providers come together to co-create integrated, proactive and personalised care plans • Monthly multi-disciplinary groups with aim to improve the care of individuals with complex needs • Active involvement of patients, service users, carers • Commissioners working together with providers to change the commissioning framework and delivery model • Working in partnership with national partners and across Tri-borough • Business case identified steps to achieving integrated care, such as aligned financial incentives, integrated provider networks, shared information and joint accountability • Tri-borough and West London Alliance continue to work with Public Service Transformation Network • Outcomes • Evaluation by Imperial College and the Nuffield Trust of the initial stage showed : • 69% of patients felt they had increased involvement in decision making; • 77% of GPs felt MDGs had improved their knowledge of patient care • Outcomes • Estimated potential net acute savings of £38m a year by Yr 5.  • This is primarily driven by a reduction in acute hospital activity, through investment in community and social care services.

4. Next steps - what is whole systems integrated care? • Joined up health and social care • Organise around people’s needs not historic organisational structures • There is one set of records shared across organisations • Care is coordinated around the individual • More investment in primary and community care • Social care and mental health needs considered holistically with physical health and care needs • Less spending on acute hospital based care • Care is provided • in the most appropriate setting • Multidisciplinary home care teams • Fewer people are treated in hospital, and those that are leave sooner • More specialist support for management of people in the community • Funding flows to where it is needed

5. How will we get there – our ten step plan for North West London

6. How we get from where we are today to where we want to be in 2015/16 • 1 • 2 • 3 • 4 • Whole Systems integrated care business as usual • Co-design framework centrally once • Expressions of interest in being early adopters and plan locally • All NWL prepares for implementation and learns from early adopters • Roll out Whole Systems approach • Apr 2015 – • Apr 2014 – • Mar 2015 • Jan 2014 – • Apr 2014 • Oct 2013 – • Jan 2014 TODAY

7. Co-design phase – October 2013 to January 2014 This has not been a typical programme! • 31 partners support our transition towards whole systems integrated care • Over 150 people engaged in developing and discussing the content • The programme is organised across five module working groups which collectively have met over 30 times

8. Embedding Partnerships: Co-design with people and partners as our guiding principle “Co-production means delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and neighbours… both services and neighbourhoods become far more effective agents of change.” Nesta & new economics foundation Our commitment to working co-productively in North West London means: Commitment to agreed ways of working – everyone is valued as equal partners, we will capitalise on lived experience as well as professional learning Supporting development and learning Fostering a supportive environment – developing collective resilience and acknowledging that mistakes will be made along the journey Working towards shared goals – promoting local voice and enabling people to be involved in the delivery of their care and support

9. We have been working together within the working groups below to tackle the tough questions for integrated care framed around the ten step plan Embedding Partnerships Population and outcomes GP networks Provider networks Commissioningand finance Informatics • Instead of organisations or diseases, which groups of people should we organise care around? • What are the opportunities to improve care for these people? • What goals do people in these groups want to achieve? • What services could groups of practices provide better for people if they work together? • How can these GP groups work with other care providers to deliver better services? • What services could groups of providers provide better for people if they work together? • How can incentives for providers make the right thing to do the easy thing to do? • How do different providers of care decide to spend money in new ways without damaging existing care? • How can people get better care by not having different organisations paying for care with separate budgets? • If there were one pot of money how do different commissioners make sure that people are getting the care they want? • What information is needed to provide better services to people? • What information do commissioners need to make sure people are getting the care they need? • What do we have and what is missing today?

10. Co-design used three ways to group the population of North West London around similar needs Health and social care commissioners, clinicians, public health experts, the ASHN and lay partners have collaborated to provide professional judgement, statistical data analysis and a review of other models globally. 1 2 3 • Judgement of multiple professionals and lay partners • In-depth analysis of integrated health and social care data set • Review of internationally applied segmentation models

11. Whole Systems approach to population grouping for people with similar needs • Serious and enduring mental illness • Advanced stageorganic brain disorders • Defined episode of care • Severe physical disability • Socially excluded groups • Single • LTC • Mostly healthy • Multiple LTC • Learning disability Age • Cancer 0-15 Children • The programme is currently not focused on integrated care for children 16-74 • 1 • 3 • 5 • 6 • 7 • 8 • 9 • 10 • Adults and elderly people with SEMI • Adults and elderly people advanced stage organic disorders • Adults and elderly people with learning disabilities • Adults and elderly people with severe physical • disabilities • Mostly healthy adults • Adults with one or more long term conditions • Adults and elderly people with cancer • Homeless people, alcohol and drug depende-ncies 75+ • 2 • 4 • Mostly healthy elderly people • Elderly people with one or more long term conditions • Only primary need shown, other needs are also treated • A group has broadly similar needs but care is tailored further • Some services common to all, some unique to group 1 Severe and enduring mental illness 2 For example, the homeless, people with alcohol and drug dependencies Source: Whole Systems Integrated Care module working group

12. Four interventions are based on strong evidence and widely tested • Number of reviews showing positive evidence • Intervention • Additional insight from evidence base • Average impact1 • Hospitalisations reduced by 25-30% (inter-quartile range) • 83% (20 of 24 reviews) assessed patient support for self-care and found a positive impact • Supported self-management has the strongest effect on clinical outcomes of all IC components when estimated at component-level • Tsai et al, Am J Manag Care, 2005 (August), 11(8), 478-88 (Table 4) • 1. Self- empowerment and education • Intervention inclusion criteria • All reviews have concluded that specialised follow up of patients by a multidisciplinary team can reduce hospitalisation • Holland et al, Heart, 2005, 91, 899-906 • Hospitalisations reduced by 15-30% (inter-quartile range) • 2. Multi-disciplinary teams • 81% (13 of 16 reviews) assessed MDTs and found a positive impact • Strong, consistent published evidence of efficacy • Also used in the overwhelming majority of the 13 case studies looked at • Hospitalisations reduced by ~37% (pooled estimate only reported in 2 relevant reviews) • Interventions involving case management reduce HbA1c [in patients with diabetes] by 22% more than interventions without case management. • Shojana et al, JAMA, 2006, 296(4), 427-440 • 57% (8 of 13 reviews) assessed care coordination and found a positive impact • 3. Care coordination • Personalised approaches using tailored information influence health behaviour more than uniform approaches • Graffy et al, Primary Health Care Research & Development, 2009, 10(3), 210-222 • Hospitalisations reduced by ~23% (pooled estimate only reported in 2 relevant reviews) • 64% (7 of 11) reviews) assessed care plans and found a positive impact • 4. Individualised care plans2 1 Impact measured from systematic reviews, including relevant interventions and containing meta-analyses of hospitalisation rate 2 Cochrane review of the evidence for personalised care planning (Coulter et al.) currently in process Source: Richardson, Dorling – Global Integrated Care Case Compendium (McKinsey)

13. We are now moving into the implementation phase for all of NWL and early adopters • Pioneer principles • Who will complete this 1 • People will be empowered to direct their care and support and to receive the care they need in their homes or local community. • A • A. ALL OF NWL 2 • GPs will be at the centre of organising and coordinating people’s care. 3 • Our systems will enable and not hinder the provision of integrated care.Our providers will assume joint accountability for achieving a person’s outcomes and goals and will be required to show how this delivers efficiencies across the system • B • B. EARLY ADOPTERS

14. Early adopters will move further and faster and share learning across NWL and must plan to implement the following criteria for Whole Systems • Criteria for Whole Systems and “Early Adopters” • Embedding Partnerships Use co-production to develop plans Commitment to move to personalisation, self care and use of community capital • Putting people at the centre of care • Commissioning governance & finance Pool health and social care budgets Operate shadow capitated budgets Generate significant savings to system Agree binding performance management Organise care models around people with similar needs • Population and Outcomes Identify outcomes to be delivered Establish governance for networks, bringing together different types of providers around a GP registered population • Provider networks Reallocate money across a care pathway to fund innovative models of care regardless of setting Agree binding performance management Ensure the flow of information to support care delivery, performance management and payment • Information Information governance to support this across all providers

15. GP Networks are essential as part of an integrated care system GP practice GP practice Major hospital Hubs & GP networks Home Care plan 111 • … • … service user 999 Electivehospital Local hospital Care home Community

16. Primary care in the UK is under significant strain…

17. … and is unable to meet increasing pressures Risingpatientexpectations ITdevelopments Competition andprocurementlaw New medicaltechnologies Constrainedfundinggrowth Primary care Undertaking clinicalcommi- ssioning Workforcepressures Risingprevalenceof chronicdisease SOURCE: The Kings Fund

18. These challenges are affecting patient experience of primary care services in London • ‘…significant variation in quality and outcomes’ • Particular challenges in London Access to care Continuity of care 1 2 3 4 Patient engagement and involve-ment Overall patient experience SOURCE: GP Patient Survey 2011-12

19. There are many benefits of GPs working in networks • Improved Care Offering • Focus on population health across a geographic region will enable inequalities in health to be addressed • Able to offer extended range of services including new forms of care for groups with the highest need (e.g., elderly with multi-morbidity) and seven day working • Freeing up time spent on administration for direct patient care • Economies of Scale • Allows for efficiency gains from sufficient scale such as access to: • Specialist skills (e.g., diabetes nurse, consultant geriatrician) • Specialist resources (e.g., diagnostic equipment, information systems) • Capacity and capability building (e.g. contract bidding) • Shared investments (e.g., IT) or joint premises • Coordination with other partners • Build collaborative relationships with wide range of partners (e.g., local government agencies, schools, and charities) • Serve as basis to coordinate with other providers: • Acute sector (e.g., for consultants to work in community) • Community health and social care services (e.g., for coordination of field-deployed staff) • Opportunities to spread learning e.g., through peer review and joint education activities

20. Organisational options for GP networks • Description • Contracting options • Service or case example No formal contracting • GPs do not have formal contracts or organisational structures but agree to cooperate when there are benefits for their population 1 • Collaboration • Nearby GPs opening at different times • GPs come together as equals, and have a contract that sets out how they will work together 2 • Formal cooperation agreements • Referring patients between practices to specialist GPs Horizontal governance: Federated (and Integrated) • GPs set up new and separate organisation, that then provides services to all the member practices 3 • Shared services • Network funds shared services such as case conferences or diagnostics One organi-sation: Integrated only • GP Practices merge to create larger scale organisations 4 • Practice merger • Practices merge completely and co-locate their services • A single organisation is commissioned to provide all services, and employs GPs on a salary basis 5 • Fully integrated primary care company • ChenMed

21. New networks must think about their purpose, size and membership when deciding on an organisational structure • Things to consider 1 Purpose • E.g., networks for education, audit and governance purposes will require a simpler (informal) structure than networks aiming to bid for extended services, out of hours etc. which will require formal legal models e.g. limited company, partnership 2 Size • Larger networks will require more complex operating models to manage things such as governance, service delivery, risk, communication, accountability, decision making, engagement, involvement etc. 3 Membership • The differing characteristics of individual member practices and there location will affect form – how much discretion, autonomy and choice is required, how much standardisation is possible?

22. How can GPs legally collaborate and enter into contracts to provide out of hospital services? (1/2) • GP practices are legally independent entities • Key question • GP practices in England are usually set up as sole traders, partnerships or companies limited by guarantee or shares • They are independent of the NHS, but are subject to certain eligibility criteria that they must fulfill to hold GMS, PMS or APMS list based primary care contracts • The eligibility criteria differs between the different types of contract, but in broad terms, GP practices are independent organisations with differing legal structures • They are not "NHS bodies" and therefore, unlike NHS provider trusts and Foundation Trusts, are not established by statute or subject to the constraints on their powers of being a statutory body. They are of course subject to external regulation. • What is the contract form that is used to commission out of hospital services, as if the GPs are collaborat-ingto provide services, they will need to ensure that the form of collaboration is one that is eligible to enter into the relevant contract?

23. How can GPs legally collaborate and enter into contracts to provide out of hospital services? (2/2) • There are three main options for organising contracts between GP practices 1 2 3 • Contractual joint ventures • This could be as simple as a light touch agreement between the parties setting out how they will work together to provide certain services (e.g. including sharing premises and staff) • It could also be a more detailed (and more robust) arrangement with details of how the parties will collaborate to provide services, how financial liabilities will be shared and how decisions will be taken by the collaboration • It is possible for GP practices to agree that one GP practice will be the lead provider of certain services, and other GP practices will essentially be sub contractors of the lead provider. The detail of how this lead provider GP network would operate practically could be set out within a contract • Practice Mergers • GP practices could seek to formally merge with each other in order to create larger scale organisations • This would include full operational and management merging, as well as possible co-location of services • Would include merged support staff • Corporate joint ventures • GP practices could seek to set up a new corporate entity that they are all responsible for (either by way of shareholding or membership, for example). • There are a number of different legal forms that this new corporate entity could take, with suitability of the form largely depending on the function and purpose of the new entity. • Any of these forms would enable the GP collaboration to tender collectively for out of hospital services. In each case, the governing documents for the joint venture would set out how the participating practices could refer patients between themselves.

24. Evolution of a model in practice Current Model New Model • Select patient • Initiate care plan • Review at MDG Continuous Patient Improvement Key New Features 3

25. Updated Structure 1. Patient Registry Integrated Management Board (IMB) Regional Strategy 2. Risk Stratification • >1 Million Harrow Integrated Management Group (IMG) Brent Integrated Management Group (IMG) Hillingdon Integrated Management Group (IMG) Ealing Integrated Management Group (IMG) CCG Delivery 3. Care Pathways • >300,000 4. Work Planning 6 Provider Networks Based MDGs • Total Number • 348,000 • Community Ward • 6,960 4 Provider Networks Based MDGs 4-6Provider Networks Based MDGs 4-7 Provider Networks Based MDGs • Per Network • MDG plans • 1740 • Per Month • 145 • Per Network • MDG annual • 174 • Per Month • 15 Locality Delivery 5. Care Delivery • 50,000 6. Case Conferencing High Risk Population    Practice Delivery Patient Care Plans 7.Performance Review • 2,000 – 20,000 Updated Structure 4

26. Patient Registry and Risk Stratification Patient 3 Axis Stratification Current Model New Model Patient Registry Risk Stratification • Practice self-selected by pathway only • Frequent flyer information sent to practices • No risk stratification tool • Single one off care plan • MDG meetings twice a month Very High Risk (0.5%) High risk (0.5-5%) Moderate risk (5-20%) Low risk (20-50%) Very low risk (50-100%) • Practice defined populations (≈2-3%) • 3 axis triangulation: BIRT2, Practice and Provider • Audit those whom they can have an impact on • Set up a community ward (practice & MDG profile) • Monitor delivery against agreed patients throughout the year Very High Risk (0.5%) Community Ward Evaluation • >1 LTCs • MH • Dementia • LD • >75 • Cancer • …. High risk (0.5-5%) Moderate risk (5-20%) Low risk (20-50%) Very low risk (50-100%) • There is a defined list of who the patients are • From the list, patients are segmented based on need (and history/predicted utilization) Specific changes 5

27. Care Pathways and Work Planning Current Model New Model 3. Care Pathways Work Planning • Pathway specific care plan • Relies on clinician prioritization of pathway • No direct interaction with other services • Care plan accessible only to patient • No regular review and in-hours access only 111 • Risk based care plan • Updated at least 4 times a year • Incorporates multi-morbidity • Increase use of SPNs/CMC for 111 • Accessible electronically out of surgery hours Care Plan Patient Medical Information Sharing: include Unscheduled Access …. …. Patient records: GP Hospital Community • An agreed care pathway across multiple professionals based on best evidence • A care plan can be agreed with the patient for targeted support Specific changes 6

28. Care plan Action 1 Action 2 Action 3 Care Delivery and Case Conferencing Current Model New Model 5. Care Delivery 6. Case Conferencing • Pathway specific delivery of care • Relies mainly on the practice and GP • MDGs happen up to 2 times a month • Unclear about impact on complex patients • Minutes noting review and updates only Patient Clinician/Provider MDG • Risk based delivery of care based on GP network • Relies on all providers • MDGs as Community Ward reviews once a month: trigger use of coordinators • Impact on Ward patients monitored • Health and Social Care Coordinators supporting patient delivery provide updates to MDGs Care Plan Integrated Patient Care Planning Health & Social Care Coordinators Patient Clinician/Provider …. …. Action: Review by falls service • The defined care delivery providers in the community, e.g. GP and other providers • A means of seeking advice and support for complex patients amongst this cohort Action status: Completed Community Ward MDG Specific changes 7

29. Performance Review Current Model New Model 7. Performance Review • Metrics from SUS • Borough based data • Data input based solely on care planning • Reviewed at IMG and CCG only GP PRACTICE HUBS AND GP NETWORKS • Metrics from BIRT2, Practice and other sources • Practice, MDG and Borough based • Data on actions from H&SC coordinators • Reviewed at Community Ward levels BOROUGH BOROUGH    • Review of the process looking at standard outcome measures Specific changes 8