Agenda Item No.11 CASTLE POINT & ROCHFORD CLINICAL COMMISSIONING GROUP DISCUSSION PAPER: FUTURE INTEGRATED COMMUNITY SERVICES MODEL Submitted by: Prepared by: Status: Kevin McKenny / Helen Taylor Kevin McKenny / Amanda Swift (ECC) For Discussion & Approval Purpose The discussion paper outlines the unique health and social care challenges facing our adult population in Castle Point and Rochford and starts to explore possible solutions, based upon the principle of integrating community services currently commissioned separately by the NHS and Essex County Council, to deliver population- based outcomes and system sustainability. The purpose of this paper is threefold: 1. We ask the Governing Body to acknowledge and agree that we will face increasing demand on acute services linked to our ageing population and rise in complex long term conditions. 2. We ask the Governing Body to acknowledge that potential integrated solutions exist that could help manage this demand, and 3. We ask that the Governing Body approve the development of a full business case for an integrated solution to be presented at the CCG Board in Q4 2015/16. 1. The Problem 1.1 Context Castle Point and Rochford CCG serves a population of approximately 182,000 which is projected to increase to around 192,000 by 2015. Over 65s currently make up approximately 22-24% of the population and over 75s just over 9%. This is older population is projected to increase to between 29 and 32% by 2035. CPR CCG, together with neighbouring CCGs and Essex County Council are already facing unprecedented demand upon its health and social care services at a time when funding levels are reducing. These challenges will intensify over the coming years as the older population increases and the number of residents with multiple and complex health and care needs grow. It is estimated that 45% of GP referrals relate to older people, approximately half of our over 60s have a chronic illness and almost two thirds of all emergency hospital admissions in 2013/14 were for over 75s which equates to 46,298 bed days.
As a CCG we have successfully turned around our financial deficit however health inequalities are still increasing and in light of the projected future demand for services, it is vital that we continue to identify and explore options for improving quality, safety, outcomes and patient experience whilst offering best possible value for money and future sustainability. As a result our operational plan focuses on the need for transformation and change across acute, community and primary care services and workforce, with the aim of developing services that are needs led rather than system led. It is therefore our intention to work closely with our partner organisations across health, social care and the third sector and our patients and families/carers over the next two years to undertake radical transformation of services. The aim will be to provide integrated, holistic care that is wrapped around the patient and their GP and delivered in their local community. This will not only improve outcomes but also support a shift away from high cost and unsustainable hospital based care and towards prevention and supported self-management, ensuring patients are in control of their own care and able to live long and healthy lives 1.2 Current System Challenges Community services have evolved to meet the needs of the system rather than the patient, resulting in numerous individual services operating in silos structural and organisational constraints. It is widely accepted that current fragmented services fail to meet the needs of the population and that greater integration can improve the patient experience and the outcomes and efficiency of care (Ham & Walsh, March 2013). The key issues currently affecting the wider health and social care system are as follows: Workforce Lack of capacity and flexibility (7 day working across the system) Lack of multi-skilling Lack of volunteers and use of voluntary community services Culture Organisational, professional and specialist barriers Historical, ingrained working practice with a focus on the needs of system/workforce rather than the patient Patient Experience Confusion, frustration, poor access and gaps in support, due to: o Fragmented services o Multiple access points o Lack of continuity of service o Poor care co-ordination and information giving Incentives Providers paid by activities not outcomes Perverse incentive to keep patients in services Information Sharing Barriers to sharing patient records Multiple IS systems Inability to link data across providers 2
Partner Relationships Lack of robust networks, communication and joint working processes across acute, community and primary providers Duplication of services, processes and effort 1.3 Case for Integration The unprecedented financial and service pressures facing health and social care cannot be tackled by making incremental adjustments to existing services and ways of working. A step-change is needed and Integration is a necessity (NHS Confederation, 2012) (Ham & Walsh, March 2013) (Edwards, February 2014) The current health and social care system is complicated and pathways are siloed and rarely holistic. Patients have several care plans and services are often inconsistently delivered resulting in multiple hand offs for patients, inequitable provision and needless duplication. Acute and community care are often in black alert with an over reliance on agency staff to cover gaps in staffing means that patients are not guaranteed continuity of care. Knowledge of services is patchy compounded by complicated systems for front line staff and patients/carers to navigate. Both the CCG and ECC manage multiple provider contracts which are process based and not driven by patient outcomes. In addition, there is little to no incentive for providers to focus on outcomes and no single payment mechanism to support consistent provision and performance As a result patients are not supported via consistent reliable and timely transitions between services and levels of support which inevitably means that both they and the costs are shunted around the system with each organisation blaming the other for the failures. Integration of services is needed to provide joined-up care for patients at best value and given the huge cultural challenges associated with introducing new ways of working this will involve large scale, radical transformation.. We must therefore work in real partnership with commissioners, providers, patients, carers and local communities to explore the evidence, develop innovative solutions and drive change if the system is not to fail. 2. Potential Solutions 2.1 Organisational Overview As set out in strategy documents, NHS Castle Point and Rochford CCG envisages a radically different health care system across our localities over the next 5 years time, emerging through a focus and commitment to transformation in the following key areas: 1. A focus on Transforming the care of the vulnerable elderly 2. Recognition that the home, and not the hospital, is the main location where healthcare takes place and having appropriate models to deliver this 3. A focus on preventative healthcare models to minimise the impact of long term condition development such as diabetes. 2.2 National Drivers: 3
The Care Act (2014) has a clear focus on wellbeing, preventing, reducing and delaying people s needs from developing. The Care Act sets out the integration agenda between local authorities and the NHS by making it a default position for the design and delivery of services. The Five Year Forward View (2014) set out a clear direction for the NHS and how future services could be configured, including outcomes based commissioning. There is an expectation that when people do need health services, patients will gain far greater control of their own care. 2.3 Success Regime On 3 June, the NHS Chief Executive announced that Essex (including Southend and Thurrock) is part of the first ever NHS Success Regime. The aim of the Success Regime is to provide increased support and direction to the most challenged systems in order to secure improvement in three main areas: 1. Short-term improvement against agreed quality, performance or financial metrics; 2. Medium and longer-term transformation, including the application of new care models where applicable; 3. Developing leadership capacity and capability across the health system. Unlike under previous interventions, this success regime will look at the whole health and care economy: providers, such as hospital trusts, service commissioners, clinical commissioning groups and local authorities will be central to the discussions. 2.4 Local Drivers: Within Essex, a Joint Strategic Commissioning Board, of which we are members, has been established to consider commissioning frameworks, capitated budgets and local design principles as follows: A single commissioner With a single budget (eventually) With a population focus Handling a single portfolio of contracts Aim to improve outcomes for a population: Reduce inequalities Good quality of experience Ensure sustainability of the Essex health and care economy 2.5 Local Integration Developments Our vision is to improve quality of care and outcomes by overcoming the fragmentation associated with multiple providers through commissioning outcomes based integrated service model to manage our most vulnerable applying the following design principles: The model (depicted in diagram below) will combine core primary medical care services with wider community-based NHS services and social care. For example, district nursing and pharmacy, dentistry, step-down beds, re-ablement and domiciliary care services. It may well provide mental health and preventative services It will incorporate, through employment or partnership, some acute specialists e.g. consultant geriatricians and psychiatrists, to provide integrated specialist services in the community. Integrated into the model will be increased partnership working with the voluntary sector, mobilising communities to support and maintain the independence of the vulnerable elderly 4
Additional recognition and support will be provided for carers, acknowledging the vital role carers undertake, and ensuring services are available to support carers to look after their own health and well-being. In partnership with Essex County Council, we have commenced a transformation programme to establish a more person-centric, integrated and outcomes focused model of care, this includes the following new service developments: 1. Four locality hubs and coordinating centres 2. Care co-ordination pilot (incorporating community services, primary care, community pharmacy and 3 rd sector (Age UK) commencing in September 2015 3. Community Geriatrician for CP&R patients 4. Remodelling of all community nursing services to provide more holistic care and reducing silos within current care delivery. 5
5. The introduction of a pilot social prescribing project in targeted areas of the CCG.- co -commissioned with ECC 6. The alignment of Essex County Council social workers to the care co-ordination service (from September 2015. 7. Workforce led innovation to reduce unplanned admissions, through 100 Day Challenge Teams (started in June 2015) 8. Developing discharge to assess principles across health and social care (By October 2015) 9. Joint commissioning of Reablement services to improve client independence and offer system financial benefits (procurement starts August 2015, new service start April 2016. Option to novate contract Whilst this represents a major step towards the transformation of care, these schemes in isolation are unlikely to provide the large scale transformation that is required to ensure long term financial stability. They do however provide a solid foundation on which to build the more radical change required to address the challenges outlined earlier 2.6 Five Year Forward View - Models of Care The Five Year Forward View (2014) outlines 7 potential models of care working on the basis that not one size fits all due to population and current health services. These are summarised in Appendix A The organisation and service models include: multi-speciality community provider; primary and acute care; urgent and emergency care; care homes; smaller hospitals; maternity services, and; specialised care. In all cases, one of the most important changes is to expand and strengthen primary and out of hospital care. Lessons from international experience shows us that the success of care models is dependent on a number of enabling factors including capitated budgets, long term contracts, flexible employment and workforce models as well as the ability to attract investment. In respect to the demand challenge set out earlier in this paper we can exclude the following potential models as integrated solutions for CPR for following reasons: Urgent and Emergency Care - A programme of work already exists via the local System Resilience Group which will dovetail into local integrated solutions Care Homes Work is currently being carried out separately on a potential primary medical care solution for care homes. Smaller Hospitals Felt not to be a viable short term option for CPR Maternity Services and Specialised Care Both focus on specialist services not linked to problem and challenge set out in this paper The two models capable of delivering the scale of the transformational change required in Castle Point and Rochford are the following: Multi-speciality Community Provider (MCP) With primary care in the UK under pressure and recognition that the current approach to general practice has reached its limits, the announcement of the MCP model has received positive attention Under this new care model, a lead provider, under primary care leadership, will bring together nurses and community health services, hospital specialists and social care staff in a much more coordinated way to provide comprehensive integrated out-of-hospital care. Taking a population health mind-set, shifting the 6
focus to wellness and prevention and achieving better outcomes for patients and populations is at the heart of this sense of purpose. This service model would transfer the majority of outpatient consultations and ambulatory care to out-ofhospital settings, and work to fundamentally transform care and bring it closer to home. Primary and Acute Care System (PACS) Under this new care model, primary and acute care systems (PACS) would provide list-based GP and hospital services, together with mental health and community care, in a single NHS organisation. One option would be for PACS to be established as virtual organisation rather than as single merged organisation. Under some circumstances, PACS could become accountable for the whole health needs of a registered list of patients. 3. Business Case and Scope Based on our knowledge as described above and potential solutions, we recommend the development of a full business case based on a proposed population scope, service scope and outcomes as set out below. 3.1 Proposed Population The proposed population scope is based on the premise that a critical issue in the current way that care is commissioned and provided within Castle Point & Rochford, is that insufficient focus in placed on primary, secondary or tertiary prevention interventions. In order to secure a good outcome, a broader population scope would be beneficial to promote better long term outcomes and the ability for any new provider to invest in such prevention interventions: Therefore whilst it is envisaged that the central focus will be on patients with multiple and complex needs, the proposed population scope will be continue to be broad as follows: For the NHS, any individual aged 18 or over who is registered with an NHS Castle Point & Rochford CCG practice, or is unregistered but lives within an NHS Castle Point & Rochford CCG postcode. For Essex County Council social care, any individual who is aged 65 or over. Therefore the population exclusions for this service are as follows: Maternity, Children, Family and Young People Services within the NHS and Essex County Council social care, including Child and Adolescent Mental Health Services. People who require a specialist service, including (but further definition required): o Learning Disability Services within the NHS and Essex County Council Social Care. o Statutory mental health sectioning for Essex County Council Social Care. o People who receive, or who may receive social care support in relation to sensory impairment, HIV or community equipment services. 3.2 Services Services in scope will be worked through as part of the business case however, it is likely to include and build upon the services currently within the Better Care Fund. The list is not exhaustive as it is likely to be expanded dependent upon the chosen model. 3.3 Expected High Level Outcomes 7
The service will improve the experience of patients through: Reduced number of people admitted into acute and inappropriate residential care settings, helping them to retain their independence for as long as possible Promote prevention and early intervention to enable a shift to lower cost, community-based services, helping people stay safe and well in their homes Improved quality of life for people with long term conditions Identify people at risk and work with partners to avert crises and the need for acute services Reduced demand and financial pressures on the health and care systems. Improve quality of services Improve public health services The full evaluation methodology, incorporating the elements above, will be finalised during the development of the full business case, in order to ensure full recording and reporting is in place to enable robust evaluation of the service 3.4 Key Business Case Objectives The key objectives which will be explored and validated in the development of the full business case are as follows: Refinement of locality hub model of integrated care Scoping of services and options appraisal to include emerging best practice, supporting evidence base and local audit Identify how integrated commissioning, pooled budgets and multi-disciplinary teams working around primary care will be implemented. Identify clear governance mechanisms with the appropriate level of devolved budgetary and organisational authority Propose budget/risk share arrangements, which may include the development and adoption of capitated budget arrangements A key decision paper will be presented to the CCG Board in November outlining commissioning and procurement options, to include implementation timelines 4. Conclusion In conclusion, the paper has attempted to set out the case for the development of a more comprehensive business case that provides fully appraised options and recommendation for Governing Body consideration later this financial year. The Governing Body is therefore asked to: 1. Acknowledge and agree that we will face increasing demand on acute services linked to our increasing ageing population and rise in complex long term conditions. 2. Acknowledge that potential integrated solutions exist that could help manage this demand, and 3. Approve the development of a full business case to be presented at the CCG Board in Q4 2015/16. 8
Appendix A Models of Care Overview