Islington Integrated Networks

Islington Integrated Networks

Inner London borough: Islington Population 249,000 registered population/33 GP practices Most densely populated borough in England 24 th most deprived borough in England (down from 11 th in 2014), however Islington ranks third nationally on the income deprivation indicator for children, and fourth for income deprivation affecting older people. High levels of smoking, obesity, child poverty, etc. Poor health outcomes 38,000 living with at least one LTC Extremely high prevalence of psychosis Young population students and young professionals High population churn (20/25%)

Strategic Case for Change Five Year Forward View & GP Forward View - growing demand against a backdrop of reduced resource - urged to explore new collaborative ways of working - reducing the divide between physical & mental health and social care Better Care Fund - aimed at supporting local health and care economies to work more effectively together Significant reduction in funding across the system Sustainability & Transformation Plan - Drive towards greater patient empowerment self care/self management: Care Closer to Home Building on basic infrastructure of teleconference MDTs

What we aimed to change

Anticipated Outcomes The hypothesis: Integrated working leads to better outcomes for patients improved staff satisfaction a system that is more financially efficient Measurable outcomes: Reduction in non-elective admissions to hospital Reduction in A&E attendances Reduction in referrals to secondary mental health services Reduction in recorded risk scores Reduction in long term placements into care homes Assessing the impact on primary care usage Improved patient satisfaction Improved staff satisfaction

Network goals Improved Outcomes Patients: Local I Statements, developed with Islington Patients based on the National Voices I statements I want to be listened to and heard I want to be treated as a whole person and for you to recognise how disempowering being ill is I want my care to be co-ordinated and to have the same appointment system across services I want to have longer appointments with someone who is well prepared so that I do not have to tell my story again I want to feel supported by my community and get the most out of services available locally I want you to put a greater focus on my mental well being I want to feel respected and to feel safe Professionals: Not a new service a different way of working based on development of strong cross organisational relationships Working smarter, not harder offering holistic approach Being part of a team and able to access support and input easily parity of esteem Clear about roles, responsibilities and procedures Redirecting activity to the most appropriate person Removing non-clinical tasks from clinicians Patients identified by systems, not professionals

Test and Learn process Expressions of Interest from primary care Two models allowed autonomy & flexibility to experiment and develop Funding to guarantee buy-in (BCF) GP representation from 7 practices Community Matrons x 2 Social Services x 2 Mental Health x 2 Age UK Health Navigator x 1 Top 2% Highest Risk Patients Project management support Monthly review meetings & quarterly Test and Learn combined team reflection events EVALUATION based on cohort of 123 patients Reduction in A&E attendances - Pilot patients saw a faster decline in A&E attendances post-mdt compared to controls. The difference in the rate of change in A&E attendances (compared to 6 months and 12 months prior to MDT) is statistically significant when comparing pilot and control patients Reduction in non-elective admissions no significant rate of change

Delivery flexible roll out Weekly / fortnightly / hybrid - Venue: fixed / alternating Face to Face GP membership: same GP / rotating representation contracted through LCS Operational management: INC service with honorary contracts Patient cohort: discharge planning/admission avoidance - highly chaotic & complex patients. Referral based mainly on clinical judgement (risk score) Referral source equal value placed on each organisation s selection IT: Wi-Fi, hardware, access to each organisation s systems, GP IT support, EMIS template linking directly to patient record Workforce high level of seniority Parity of esteem Navigator service 6 dedicated Navigators/1 Manager Community nursing 4 INC Matrons Full roll out Jan 2016 Social Services 2 senior practitioners (blended role with housing) Mental Health Primary Care Mental Health service (not yet full coverage) Integrated Network Coordination (INC) Service admin team (4 x band 3 / 2 x band 6 / 1 x operational manager band 8a) Implementing strong admin systems for scheduling, managing actions & arranging follow up. Provided by Whittington Health

12 Networks (31/33 practices) All practices engaged 370 patients discussed per month (Oct 2017) 180 new patients 34 meetings 526 patient discussions 2 practices yet to join logistic issues

Quantitative data: CSU matching data PPL - statistical significance (admissions and attendances) Nuffield Trust input Qualitative data: HealthWatch undertaking patient interviews Social Kinetic (change consultants Pioneer) measured perceived energy for and resilience to change. Staff Survey External evaluators (PPL Consulting) to deliver recommendations & reassurances: Correct patient cohorts Optimum number of Networks Size of Network Locality spread Alignment to STP Evaluation 2016/17

Findings: Based on the preliminary data analysis there is a significant decrease in acute activity for patients who have been through the MDT Data analysis Data has been provided via the CSU - outpatient, accident & emergency and inpatient activity for patients who have been seen by a network between April 2016 to March 2017. The data included activity 12 months before and 12 months after their first MDT encounter. Outpatient, A&E and inpatient activity have been extracted and may have omitted entries due to coding and matching process with significantly fewer records post their first MDT which could indicate low data quality ASC data was provided fully for 16/17, however only summary figures for 15/16 which contain gaps that could indicate low data quality Acute There appears to be a sizeable decrease in outpatient, A&E and inpatient activity and costs for patients who have attended the network MDT Adult social care: ASC costs have increased for patients in the network, mostly for Physical Support needs for Personal Care Evidence of reduced safeguarding alerts Risk Scores There appears to be slight increase in risk scores after the first couple of months after MDT 1600 1400 1200 1000 800 600 400 200 0 Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT MDT Central - Central 1 Central 2 Central 3 Central 4 North 1 North 2 North 3 Not in South East South East South South South East Network 1 2 West 1 West 2 1 OP IP A&E

Challenges, Risks, Issues IT only partially overcome issues remain with speedy access to electronic systems Maintaining GP buy-in One practice yet to join a Network due to capacity/logistics Inefficient use of resources - network with one practice Consistent Mental Health input Conflict between services (INC matrons, etc.) Wider organisational understanding of the programme Cross Border issues: managing Islington registered patients living outside the borough (social services, nursing, etc.) patients linked to non-islington trusts - Homerton, RFH, North Mid etc. Sustainability and Transformation Plan

Care Closer to Home Integrated Networks Sustainability and Transformation Plan North London Partners (NCL) Care Closer to Home Integrated Networks - CHINs Move towards developing an Accountable Care Organisation Population based approach 50,000 to 80,000 patients Pro-active/Preventative approach Clinically and data led Improve patient experience and reduce variation between practices Two pilots long term conditions and low to medium frailty Quality Improvement Support Teams - QIST

WORKSHOP

MDTs Why are we bothering? What are the reasons for implementation of your project? What is the driving force - rationale Who is the driving force - leadership What are the differences? Are they actually different? Where are the similarities?

MDTs How are we doing them? Operationally: What approach have you taken or do you intend to take? What are the common themes? What are the challenges and where are they the same across all projects? How are they being resolved?

MDTs Where are they going? Sustainability - short, medium or long term? Are they delivering (or will they) deliver the Why? What are the overall expectations How can they continue and be self supporting? How do you factor in development/expansion? Is continuity possible (contingency plans) in the face of ever more shiny new NHS changes?

Why are we bothering? How are we doing them? Where are they going? MDT Projects What would your three recommendations be to someone about to embark on setting up a similar project? Three things about which you are most proud The three things you have learned today (and maybe already knew) that are essential to be able to get projects like these off the ground and make them sustainable

West London CCG and My Care My Way Henry Leak and George Katsunde Wednesday 6th December 2017

West London and NWL STP West London CCG was established in April 2013 under the Health and Social Care Act 2012. It is made up of 45 GP member practices that in 2016/17 served an estimated registered patient population of 245,315 (QOF 2016/17) and is responsible for planning and buying (commissioning) health services for the people living in the Royal Borough of Kensington and Chelsea and the Queen s Park and Paddington area of Westminster. Clinical Commissioning Groups do not provide any health services directly, but buy these services for our residents from providers such as NHS hospitals, GPs and the voluntary sector. We are committed to improving the care provided to our residents, reducing health inequalities and raising the quality and standards of services within our allocated budget. Our vision is that everyone living, working and visiting West London should have the opportunity to be well and live well to be able to enjoy being part of our capital city and the cultural and economic benefits it offers. Sustainability and Transformation Plan In 2016 West London CCG joined with Kensington & Chelsea Council, Westminster City Council and other local partners to look at what we wanted to do to make positive change happen, and feed this into the wider NW London Sustainability and Transformation Plan (STP). The STP, which covers the eight boroughs in NW London, takes its starting point from the national NHS Five Year Forward View strategy and translates it for our local situation The STP is driven by a strong case for change across NW London. Only half of our population is physically active Half of over-65s live alone and over 60 per cent of adult social care users want more social contact Many people are living in poverty People with serious long-term mental health needs live 20 years less than those without.

Elements present at hub 1 Care plan for health and social needs Equally involved Carers and Family Involved in making decisions for care 2 Tier 0: Mostly healthy over 65s Tier 1: Over 65s with 1 well managed LTC Service Users Tier 2: Over 65s with 2 or more LTC and mental, health/social care needs Tier 3: Over 65s with 3 or more LTC and mental, health/social care needs Increasing health and social care needs 3 Users & carers empowered for self-care HSCAs GP with clinical responsibility and named accountability Case Managers CIS teams Tailored increase in resources for self-care, carer involvement and primary care for over 65s e.g., longer appointments, 24x7 GP cover (through OOH provider) Home GP practice North / South hub 4 Psycho-Geri.. Diagnostics Allied Pharmacy health services Social Existing Worker Specialists Voluntary services sector Geriatrician OT Mental Health Physio Frontline admin Hub Staff Clinical Lead Mgmt Out of Hours care Lead New/ OOH services expanding roles Diagnostics CIS (urgent care) GPs Case Managers HSCAs Supports a fixed number of practices 5 Voluntary Services Housing & Benefits Advanced Diagnostics Pharmacy North & South hubs 999, CIS, OOH Acute NEL 6 Cultural and people integration: of locally based staff moving towards a single organisation Financial integration: Capitated budgets, aligned financial incentives in the long terms Systems and operational integration: Shared IT and systems supported with robust legal and governance arrangements Long-term aspirations

Refining the Model of Care Worked with multidisciplinary teams based in nine practices to rapidly develop and improve the service model. Each team worked on a different challenge, on behalf of the wider system. Teams met weekly over six weeks to develop and test ideas to improve their challenge area. Over 70 people involved including representatives from District Nursing, Rapid Response, Adult Social Care, Older Adults Community Mental Health Team, Community Living Well, Memory Clinic and Kensington and Chelsea Social Council.

Areas for refinement Practice Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 Practice 6 Practice 7 Practice 8 Practice 9 Challenge Developing a one team approach to primary care Improving the interface between MCMW and Mental Health services Getting the most out of hub sessions Improving joint working with Adult Social Care (Westminster City Council) Reducing avoidable admissions Improving joint working with Adult Social Care (RBKC) Improving self care and social prescribing Reducing avoidable admissions Improving the interface between Geriatricians and MCMW

Reducing variation Clarifying and codifying the model in: A Quick Guide to MCMW A service blueprint Updated standard operating procedures

Integration Challenges Multi-skilled workforce. Cultural shift for all Partners. Differing KPI s. Recruitment and retention. Dealing with duplication (MCMW, DN, CIS, ASC, Mental Health ) and inefficiencies (throughput) to develop a revised model of care and business case for the Multi-speciality Community Provider.

PHASED OVER 18/19 & 19/20 Strategy overview: Developing our MCP components MCMW 24 x MCMW GP Contracts (Wave 1 & 2) 20 x MCMW GP Contracts (Wave 3) CIS 2017/18 2018/19 2019/20 COMMISSIONER & CONTRACT HOLDER Staffing Orgs x 2 Self Care (VCS) Transport Governance Org. Geriatrician (CW & ICHT) Falls District Nursing Community Living Well Rapid Response Rehabilitation In Reach Reablement Intermediate Care beds OPMH (incl. MAS) Primary Care elements Adult Social Care Palliative Services COMMISSIONER & CONTRACT HOLDER 1 ENHANCED WHOLE SYSTEMS TEAM Enhanced MCMW (65+) mobilised from April 1 st 2018 Alliance agreement/ Virtual MCP Single management team Single shadow budget Single Outcomes Framework Single set of Outcomes KPIs Harmonised Output KPIs Teams tailored to PCH pilots need Enhanced MCMW absorbing an increasing number of care functions as services and contracts mature Older adults, transitioning to complex adults where possible HIGH LEVEL TIMELINE Q1 18/19 Q2 Q3 Q4 CONTRACT DIAGNOSTICS & IMPROVEMENT REPORTS (Sept/ Oct 2017) INTEGRATED CARE STRATEGY (Nov 2017) WS Model of Care BC MCP Market engagement ICT Model of Care BC Prioritising the development of an Integrated Community Team shared across practices with a particular focus on Grenfell - to meet the needs of the whole population including children and young people. Enhanced Whole Systems team mobilised Commissioning Framework LOCAL COMMISSIONING ROLE PRIMARY CARE HOME PILOT LOCAL COMMISSIONING ROLE PRIMARY CARE HOME PILOT Q1 19/20 Partial MCP Single contract Whole population coverage Pooled budget for agreed MCP elements Fully operational Integrated Community Team Integrated Community Team delivered through MCP PCHs delivery units of MCP (five in this example) Each PCH defines requirements of their ICT team to meet local need Mobilisation: ICT Mobilisation: MCP 26