Introduction to Community Fit February Community Fit

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Hilary Skinner
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1 Introduction to Community Fit February 2016 Community Fit

2 Community Fit Purpose of this session Phase 1 of Community Fit To update attendees on the findings from phase one of Community Fit. To inform the shape and priorities of Community Fit: Phase two. Sets out the current position for community services, some of the challenges it faces and the opportunities for greater integration Does not address a comprehensive strategy for the development of community based services.

3 Phase 1 Outputs By April 2016: 1. Describe Current Activity Levels A description of activity currently taking place in primary care, community services, mental health and social care across Shropshire and Telford and Wrekin. 2. Impact of Demographic Change An agreed estimate the impact of demographic change on activity levels within these sectors. 3. Describe Patients Service Use across Health and Social Care A linked health and social care dataset, identifying patients receiving care from two or more sectors and describing they care they receive. 4. Classify Patients by Patterns of Service Use An agreed taxonomy (classification) of care packages delivered by each of these sectors. 5. Describe the Acute>Community Transfer Challenge from Future Fit A description of the activity that the Future Fit 1 models anticipate will move out of the acute setting and therefore may have an impact on primary care, community services, mental health and social care services.

practices) Subject to Future Fit programme board

4 Where are we starting from? Detailed description of current activity levels in; Community health services Mental health services Social care (state funded) Primary care (4 pilot practices) Subject to Future Fit programme board approval, these will be available from Future Fit website following May board meeting

5 How will demographic change affect activity levels? We modelled three aspects of demographic shift to predict the future use of primary care; Will the population of Shropshire and Telford grow or shrink by 2019? Population Size Will there be more or fewer older people by 2019? Will older people be more of less healthy in 2019? How will this effect demand for community services by 2019? Population Age Profile Age Specific Health Status

6 Note : Demography is not the only driver of activity growth 350,000, ,000, ,000,000 Estimated Number of GP Practice Consultations in England 1 Growth 3.2% per annum 200,000, ,000, ,000,000 50,000,000 0 Current RCGP estimate 370m consultations per annum 2 What is behind these increases? Changes in demography Changes in clinical standards and guidelines Changes in patient expectations

7 350, , ,000 Population size Population growth Shropshire and Telford and Wrekin 316, , % Shropshire 200, , , % 178,600 Telford and Wrekin* 100,000 50, * Telford & Wrekin population projections have been adjusted locally to account for major residential build plans. Shropshire projections are taken directly from ONS published figures

8 Change in population age/gender profile: 2014 to 2019 Shropshire 90 and over ,000 2, ,000 4,000 Females 2015 Males 2015 Males 2020 Females plus 80 to to to to to to to to to to to to to to to 14 5 to 9 0 to 4 Telford & Wrekin 10,000 5, ,000 10,000 Females 2015 Males 2015 Males 2020 Females 2020 Sources: ONS Subnational Population Projections (2012 based) and Telford & Wrekin Local Authority

9 Projections of life expectancy and scenarios for disability free life expectancy at age 65 years, England 24

10 Impact of Demographic Change Pessimistic Scenario Optimistic Scenario Community Services Mental Health Social Care Primary Care Nursing contacts Specialist Nursing contacts Podiatry contacts Therapy contacts MIU/OP Intermediate Care Common MH problems contacts Non-psychotic disorders (moderate) contacts Non-psychotic disorders (severe) contacts Non-psychotic disorders (chaotic / Psychosis (first episode) contacts Psychosis (mild/moderate) contacts Psychosis (crisis) contacts Psychosis (severe depression) contacts Psychosis and affective disorder contacts Cognitive Impairment & dementia contacts Eating disorder contacts IAPT sessions MH Inpatient bed days Learning disability contacts PICU bed days RAID contacts Assessments Homecare hours Daycare Hours Direct payment costs Reablement days Residential and Nursing care days GP Surgery Consultations Home Visits Prescriptions -1.0% -1.6% 10.8% 6.9% 9.4% 5.1% 6.2% 11.4% 6.2% 3.2% 2.7% 0.5% 1.9% 3.6% 7.6% 2.4% 12.1% 1.5% 5.6% 1.0% 1.9% 6.8% 8.8% 6.3% 1.7% 0.7% 9.2% 9.1% 6.9% 12.0% 8.9% -7.0% -2.2% -3.5% -0.6% -1.8% -7.8% -1.3% -7.2% -0.1% -0.4% -1.4% -3.2% -4.9% -3.1% -0.4% -4.1% -6.2% -1.0% -7.9% -2.5% 0.4% 0.7% 1.3% 0.6% 0.8% 1.1% 0.8% 1.2% 1.1% 0.6% 0.3%

Describing Patients Service Use across Health and Social Care Acute Inpatient Services Mental Health Services Acute Outpatient Services Community Healthcare Services Acute A&E

11 Describing Patients Service Use across Health and Social Care Acute Inpatient Services Mental Health Services Acute Outpatient Services Community Healthcare Services Acute A&E Services Social Care Services 999, 111 & ambulance services GP services & prescribing GP Out-of-hours Continuing Healthcare Pharmacy, dentistry, opticians etc Voluntary Sector

12 Approach to Data Linkage and Matching Results Data supplied by partner NHS and social care organisations for all adults aged 18 and over. 380,000 - population of Shropshire, Telford and Wrekin All data pseudonymised at source. Patient identifiable details are replaced by a common pseudonym before being transferred to the CSU. CSU can link data for patients but is not able to identify patients. The approach is fully complaint with Information Governance legislation and guidelines. 210,000 patients receiving at least one of the following services; Acute Community Mental health Social care (state funded) 170,000 patient unmatched because; None of the services above NHS number / age not available

13 Cost of service users The total cost incurred was 408,147,156 which covered 210,859 service users across Health and Social Care services. Large proportion of costs were incurred by a relatively small proportion of service users. The highest costing 2% of service users cost 132,910,335; 80% of service users cost less than this at 77,218, ,000,000 90,000,000 Cost Profile of Service Users in Shropshire & Telford 14/15 133m = 4.2k Service Users 80,000,000 70,000,000 60,000,000 Cost 50,000,000 40,000,000 30,000,000 20,000,000 10,000, m = 168.7k Service Users Percentile

14 The service users have been grouped into 4 cost groups based on overall costs Service User Cost Bands they consume. These are: Very High (Top 2% of all costs), High (Top 3-10% of all costs), Medium (Top 11-50% of all costs), Low (Bottom 50% of all costs). Cost band Service Users / % of Population Total Cost / % of Total Cost Average Cost Very High 16, ,956 4,218 1% 132,910,335 33% 31,510 High 4,497-16,472 16,872 4% 135,320,968 33% 8,020 Medium 395-4,498 84,360 22% 122,143,127 30% 1,448 Low up to ,409 28% 17,772,726 4% 169

15 The mekko chart below illustrates the proportion of spend on each service by cost band. The size of the shaded area represents proportional spend. Cost of Services by Cost Bands 100% A&E Amb ComOP MHOP MHCon MHIP IP OP SCA SCP ComCon 80% Proportion Split by Cost Band 60% 40% Very High High Medium Low 20% 0% 0% 20% 40% 60% 80% 100% Proportion of Spend on Services

16 Geographic Distribution of Very High Cost Users Rate per 1,000 population

17 Interactions between High Level Services across Health and Social Care There are 15 different combinations between the 4 services. There were a total of 2,608 service users. MH (*) SC (0) Not possible to determine without Primary Care data SC&MH (*) SC&Com (21) Com (19) AC (232) AC&MH (118) SC&AC&MH (96) SC&Com&MH (31) SC&AC Com&MH (924) Com&MH (16) SC&AC(72) SC&AC & Com (309) AC&Com& MH (448) Key: AC Acute Services Com Community Services MH Mental Health Services SC Social Care Services Ac&Com (315) *Numbers below have been suppressed to avoid unintentional identification

18 Incorporating Primary Care from Pilot Practices 20 By incorporating primary care data we can; Improve data coverage Understand a further dimension of patients healthcare utilisation Gain insights into patients long term conditions 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Very High High Medium Low PC Surgery Consultations Telephone Consultations Home Visits Very High High Medium Low Primary Care Only Prescriptions Average 20 0 Very High High Medium Low Primary Care Only

Long Term Conditions Methodology Comparison The chart below compares the 2 methods of calculating Long Term Conditions (SUS data and Primary Care data) and shows the percentage overlap and the

The CHD and CKD Registers were not calculated from the Primary Care data and the Epilepsy, Rheumatoid Arthritis and Peripheral Arterial Disease Registers were not calculated from the SUS data so have

19 Long Term Conditions Methodology Comparison The chart below compares the 2 methods of calculating Long Term Conditions (SUS data and Primary Care data) and shows the percentage overlap and the percentage of each Long Term Condition that was identified by each method individually. The CHD and CKD Registers were not calculated from the Primary Care data and the Epilepsy, Rheumatoid Arthritis and Peripheral Arterial Disease Registers were not calculated from the SUS data so have not been compared. Atrial Fibrillation, COPD and Diabetes have the highest proportion identified in both dataset although this was 50% or lower for all of them. The largest difference is for people identified in the Primary Care dataset but not in the SUS dataset and in particular there is a high proportion of people on the Dementia and Depression Primary Care registers that were not identified from SUS. Heart Failure, Atrial Fibrillation and Diabetes show a high proportion of people identified from the SUS data who were not on a Primary Care Register. This may be an issue with the conversion of READ Codes to ICD10 codes or could be under diagnosis of these diseases on the QOF Registers.

20 Patient Classifications The linked dataset provides a fresh opportunity to understand how patients use services across health and social care. But patterns of service usage are complex and highly variable between patients and so using this information for planning purposes can be difficult. Cluster analysis is used to identify common grouping of service usage patterns and provide some useful classification of the ways in which patients use healthcare services. Initial high level classifications are supplied as handouts. Further work will take place to provide more granular classifications for final report in May.

21 Baseline Acute Activity Future Fit Models Pre-requisites of change Demographics Community or Primary Care Alternative (e.g. step-down) Take activity out of the acute sector Handle remaining activity more effectively efficiently Public health / preventative intervention (e.g. smoking cessation) Policies and Thresholds (e.g. procedures of limited clinical value) Future Acute Activity

22 Important notes for presenter : continues to be provided acute does not mean stays unchanged will be subject to changes in process to improve efficiency comm / primary alternative = 3 admissions and 30 bed days per practice per month on average but not direct substitution The challenge from Future Fit Continues to be provided by Acute Trust 95.1% Inpatient Spells Community and/or primary care alternative 1.6% Public Health / Prevention 2.3% Policies and Thresholds 1.0% Continues to be provided by Acute Trust 81.1% Inpatient Beddays Community and/or primary care alternative 9.2% Public Health / Prevention 7.9% Policies and Thresholds 1.8% Outpatient Attendances A&E Attendances Continues to be provided by Acute Trust 92.5% Policies and Thresholds 7.5% ED / urban/rural urgent care centres split to be decided 99.0% Community and/or primary care alternative 0.4% Public Health / Prevention 0.5%

23 Shropshire VCSA State of the Sector Survey 2014/15 Survey being updated for 2016/17 and exploring possibility of combining approach to include Telford & Wrekin as well. Survey results are intended to inform VCSE organisations, public sector partners and stakeholders of how this sector is coping in the current climate and how they are surviving against factors such as public sector cuts, lack of funding for services, growing numbers of service users. Survey has run since 2009 and the relatively low response rate has increased year on year.

24 Highlights 2014/15 survey

25 Independent Care Sector Funding Survey Survey undertaken with Care providers across Shropshire and Telford and Wrekin in June 2015 by Shropshire Partners in Care. The results will be representative of the current situation in Spring Completion Rate: (Care Homes) The Survey was sent to 171 CQC Registered Residential & Nursing Homes in Shropshire/Telford & Wrekin. The Survey covers a total of 4076 registered beds(3146 Shropshire & 930 Telford & Wrekin) out of a total of 5089 (3869 Shropshire & 1220 Telford & Wrekin) according to CQC across Shropshire, Telford & Wrekin. Domiciliary data Shropshire Responses 104 Sent to: 124 Return 84% Telford & Wrekin Responses 40 Sent to: 47 Return 85% Care home data Shropshire Responses 31 Sent to: 48 Return 65% Telford & Wrekin Responses 15 Sent to: 28 Return 54%

26 Rural urgent care services The rural urgent care sub-group is finalising a report that will go to the Future Fit programme board in May. Some of the developments can be achieved within existing resource, for otherswe are seeking support from the STP transformation fund It is likely to include a recommendation to rapidly prototype an approach to rural urgent care provision which will include: Integrated locality based community teams able to offer a wider range of service e.g. UTIs, falls, IV antibiotics, transfusions, chemotherapy More community based therapists Co-location of community teams with GP out of hours Mental health service offer Point of care testing Extended x-ray offer at the 4 MIUs Advice and guidance from SATH consultants

27 Questions for table discussions What are the themes of Health and Social Care in the community that we should consider in a programme of design? Your views will inform the Steering Group s report from Phase One of Community Fit to go to STP programme board in late May.

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