Hounslow Integrated Care

16th July 2018

Hounslow Position

� Hounslow is facing the same issues as much of the health service across the country.

Changes expected to take place over the next five years mean that work is needed to

make sure that the system has the right capacity and capability

• Population expected to increase by 6.3% 1 over

the next 5 years

• 30,416 older people (10% of the population) in

2016 – rising to 35,481 in 2022 2 (12% of the

population) – a 16.7% increase

• Black and minority ethnic population expected to

increase to 155,310 by 2022 (an 11.3%

increase) 2. Ethnic groups have different health

and care needs and population changes can

magnify these

• Men in more economically deprived areas die up

to 4.1 years earlier than men in less

economically deprived areas; for women this is

3.4 years 1

• Significantly more people die from heart disease

and stroke in Hounslow than the England average 1

• 23.5% increase in dementia diagnosed between

2012 and 2020 3

• 3.6% increase expected in population of younger

adults with learning disabilities 3

• 17,500 people with diabetes (increasing 3%

annually)

• High numbers of children who are overweight or

obese, and particularly high rates of tooth decay

in 5 year olds (closely linked with eating habits)

• High rates of self harm in young people pointing

to factors affecting mental health and wellbeing 1

• Analysis suggests over 30% of NWL hospital

inpatients could be treated elsewhere 3

• The 2% of people in Hounslow with the most

complex conditions require support costing over

17% of the CCG’s budget 4

• The way services are planned and provided can

be improved – with more patient and carer

perspective, greater clinical expertise and even

stronger evidence. This should improve health

and care outcomes, while achieving

performance targets

• £40m of savings are needed by 2021 to bring the

Hounslow system into financial balance 3

• Potential to save £3.7m / annum in non elective

admissions through matching performance of peer

CCGs; and a further £1.4m / annum in elective

admissions 4

• 24% increase in costs of supporting people with

common complex conditions (physical disability,

severe and enduring mental illness, learning

disability, cancer, dementia, long term conditions)

(per the WSIC toolkit 1)

• Total cost for children’s continuing healthcare

services has increased over 3 ½ times in 4 years

3The 2022 Hounslow health system

9

Integrated Care in Hounslow

Theme Example Aim

Varied and

Fragmented Care

People often have to repeat their story

multiple times to different providers, which

makes accessing care a frustrating

experience

Organisations working together to deliver

coordinated, proactive and planned care for

patients

Duplication of

servicesMultiple providers entering patients home

Multi-disciplinary health care professionals

working together to make decisions regarding

recommended care of individual patients.

Variation GP practices providing different care form

Consistent primary care health offer from

primary care ensure patients receive the same

service wherever they live in the borough

Misaligned

Incentives

Mixture of PBR and Block contract across

providers

Single contract for the delivery of services

within Hounslow

WorkforceGPs and Nursing reaching retirement age,

not seen as an attractive career choice

Opportunity for career development across all

providers, opportunities for staff to work in

different places and increase skill base

Financial Pressures NWL significant financial challengesFocus on preventative care to reduce the need

for expensive hospital activity

� Integrated care provides an opportunity to address some of the problems faced within

the current system

Essential Elements

� Any commissioned service or integrated model will be based on the following

essential elements

1 AccessProviding a personalised, responsive, timely and accessible

service.

2 Self-Empowerment and EducationSupporting and improving the health and wellbeing of the

population in a way that works for them.

3 Multi-disciplinary Teams

Health care professionals working together to make

decisions regarding recommended care of individual

patients.

4 Care co-ordinationProviding patient centred, coordinated care across health

and social care.

5 Individualised Care PlansDelivering coordinated, proactive and planned care for

patients

What is integration?

� Integrated care takes on many forms, all models though aim to address the

fragmentation of care common across health systems, to improve the health

outcomes of people living longer with increasingly complex health concerns

� Integrated care can be defined at five different levels.

1. Systemic: Coordinating and aligning policies, rules and regulatory frameworks.

2. Normative: Developing shared values, culture and vision across organisations,

professional groups and individuals.

3. Organisational: Coordinating structures, governance systems and relationships

across organisations.

4. Administrative: Aligning back-office functions, budgets and financial systems.

5. Clinical: Coordinating information and services and integrating patient care

within a single process.

� International examples are focussed around improving patient care planning,

population health management, better use of technology, Multi-specialty health

groups and aligned financial incentives across providers.

www.nuffieldtrust.org.uk/files/2017-01/what-is-integrated-care-report-web-final.pdf

Integration

� Benefits of better integration has been shown to:

− Improve outcomes for clinical networks

− Improve health outcomes for patients with long terms conditions

− Increase the use of good practice across providers, reducing variation

− Reductions in hospital activity.

� Integrated Care will have the following features which will drive shared accountability

for improving health:

− Pooled budgets between organisations covering a defined population’s needs

− A contract that is focused on outcomes e.g. the providers will be required to

demonstrate that their activities have had a demonstrable impact on health

− Use of technology to pre-emptively work with patients so that their health and

care needs do not needlessly deteriorate

− An ability to respond nimbly to changing opportunities which is not hampered by

an over-specific contract

− Use of information and intelligence to support patients

− Integrated care can take many different forms at a variety of different levels, from

small internal team working better together to large organisations working in

partnership.

Outcomes

� Under the CCG’s plans for Future Proofing Health in Hounslow we are aiming to create

a health system which provided the following outcomes for patients and professionals

Residents

• I am confident that I receive support designed to

deliver the best health and social care outcome

for me

• I receive safe, appropriate care at the right times

– preventing my needs becoming more

complicated where possible

• I am supported by a great team that work well

together and enjoy their work

• I know how and can make use of voluntary and

community services that offer support I need in

addition to the health and care services I receive

• I know that technology is used to innovate and

improve the support I receive – including

providing the tools and information I need to

help me live a healthier, independent life

• I am confident that available resources are used

in the most effective way to provide my care

Care professionals

• I am confident that I provide safe, effective

services that deliver the same quality outcomes

as my professional peers

• I am able to work with partners – without

barriers or constraints - to improve the

availability and quality of services available

• I love my work in Hounslow and I’m motivated

to contribute to make the system even better

• I feel like have influence and control over my

workload and the way that services work around

me and Hounslow residents

• I can direct people to make use of a range of

voluntary and community services – improving

wellbeing while reducing my workload

• I can use new and innovative technology and

tools to make my work easier while improving

patient care

Outcomes

� As part of the development of Integrated Care Business Case the working group has

expanding these ‘I Statements’ to three areas, Patients, Professionals and Carers.

Carers

• My dependant receives safe and

appropriate care at the right time,

preventing my needs becoming more

complicated where possible.

• I am confident that I received support that

enables me to deliver the best health and

social care outcomes my dependant.

• I am supported by health and social care

professionals who enjoy their work

• I know how and can make use of voluntary

and community services that offer support

I need in addition to the health and care

services I receive

• I know that technology is used to innovate

and improve the support I receive –

including providing the tools and

information I need to help my dependant

live a healthier, independent life

• I am confident that available resources are

used in the most effective way to provide

my care. I feel I am valued as an individual

person as well as a carer

Patients

• I receive safe and appropriate care at the

right time, preventing my needs becoming

more complicated where possible.

• I am confident that I received support

designed to deliver the best health and

social care outcome for me

• I am supported by a great team that work

well together and enjoy their work

• I know how and can make use of voluntary

and community services that offer support

I need in addition to the health and care

services I receive

• I know that technology is used to innovate

and improve the support I receive –

including providing the tools and

information I need to help me live a

healthier, independent life

• I’m confident that available resources are

used in the most effective way to provide

my care

Professionals

• I am confident that I provide safe, effective

services that deliver the same quality

outcomes as my professional peers

• I am able to work with partners – without

barriers or constraints - to improve the

availability and quality of services available

• I love my work in Hounslow and I’m

motivated to contribute to make the

system even better

• I feel like have influence and control over

my workload and the way that services

work around me and Hounslow residents

• I can direct people to make use of a range

of voluntary and community services –

improving wellbeing while reducing my

workload

• I can use new and innovative technology

and tools to make my work easier while

improving patient care

� The outcomes framework has been provided as a supporting document to this paper.

Business Case

� There are a number of requirements that the Business Case will need to contain to

support the decisions of the CCG and Hounslow Borough Council. It is the intention

of the CCG to also have this independently reviewed as it is such a significant step to

ensure we do place undue risk on the local system, both clinically and financially.

� The detailed content of this business case will be set out in a five case model

according to HM Treasury guidance. The five cases, and their key purposes, are:

1. The Strategic Case: This explains what changes are required within the health

economy and why they cannot be delivered without Integration.

2. The Economic Case: This sets out the value for money case of the proposed

approach, through a structured comparison of the costs and the benefits,

including both the quantifiable and non-quantifiable financial and health

benefits of the work.

3. The Financial Case: This assesses the affordability of the proposed solution for

both the CCG and Hounslow Borough Council .

4. The Commercial Case: This demonstrates that the preferred option will result

in a viable procurement and well-structured deal.

5. The Management Case: This demonstrates that the preferred option is capable

of being delivered successfully, in accordance with recognised best practice.

Strategic Timeline

April 2018

April 2019

April 2020

Operational Timeline

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2018 2019

Final Business CaseFinancial Modelling

Evaluation Methodology

Governance Strategy

Procurement Timetable

Communications Plan

Contract NoticeCall for competition

ISAP MeetingNHS England Assurance

Draft ContractDevelopment of

contract – Specialist

support required

Invitation

to Tender

Final Contract

Mobilisation

Contract Start

Contract Award

Key Dates Event

10th July Governing Body

18th July Council of Members

14th August Governing Body Seminar

5th September Adult Scrutiny Committee

11th September Governing Body

30th September Commissioning intentions letters

to providers

Procurement Considerations

� Hounslow has been working with its procurement advisors to put together a road map

for tendering the future vision

Procurement: Factors to consider

� Clear vision and case for change

− Existing provision - current opportunities and challenges to address

− Local authority alignment - local position on essential or otherwise

− Clinical and financial outcomes

� Scope and phasing

− Priorities

− The total could be unmanageable and unsustainable - provider experience

currently?

− Consideration of existing contracts and scope of the ICS - novation, re-procure,

legal risks

� Cultural shift

− Existing provider relationships – ability and desire to collaborate

− Step-change with contractual complexity v incremental change with simpler

(legal) variances

− Recognition that change takes time - long term transformation

− Small and achievable priorities can underpin a greater ambition

− New mutually dependent relationships

− Removing the ‘them’ and ‘us’

Regulatory Requirements

� Public Contracts Regulations 2015 (PCR 2015)

− Advertise contract opportunities in OJEU and Contracts Finders valued at

£589,148 or above

− Run a process compliant with principles of transparency and equal treatment

� NHS (Procurement, Patinet Choice and Competition) (No.2) Regulations 2013

(PPCCR)

− Advertise in Contracts Finder (Same advert as above)

− No minimum value for advertisement requirement

− Run a process compliant with principles of transparency and equal treatment and

non discrimination

− PPCCR include objectives to be considers by the commissioner for the

procurement

� Both sets of regulations must be complied with

Road Map

Contract Options

� There are several options available for the procurement and management of a new

contract

� Option 1: A lead provider model

Contract Options

� Option 2: Single Organisational Entity

� This would involve the creation of a new non-NHS entity which would present legal

and financial issues

Contract Options

� Option 3:Working with system providers to achieve the optimum integrated solution

Provider Network Development

� Hounslow has a STP Implementation Group in place to holds the strategic

responsibility for bringing all the involved organisations together to review progress

towards Integrated Care.

� Alongside the business case development there is extensive work needed to form the

relationships between providers that will enable new ways of working to be

embedded within Hounslow. These programmes are supporting the development of

both strategic and operational partnerships and shared approaches to work across a

number of organisations.

− Enhanced Primary Care Contract− Feltham - reduction in variation and improved outcomes− Transforming Care through system leadership and the redesign of community

nursing− Intrapreneur Programme and the review of urgent care pathways.− Primary Care Patient Coordinator Care redesign work

Risks and Issues

� Below is summary of the risks and issues associated with this work, the full risk log is

provided as a supporting document to this paper.

Summary of Risks Actions RAG

AssuranceNHS England require additional assurance and adult scrutiny are

not satisfied within best interests for Hounslow residents

CCG will follow ISAP process for NHS England and proactively engage with

Adult scrutiny

CommissioningProject will not be completed within the planned timeframes and

CCG does not have the personnel to support the workProject planning, and dedicated staff time allocated

CommunicationPublic/Media negativity about work and outcomes are not what

patients want

Communications and engagement plan to be agreed and implemented to

manage all stakeholders

Financial

Finance and activity modelling is not completed within timescales

or does not realise the system and financial benefits needed in

order to deliver the transformation

ICHP have commenced work, review of differential models of costing -

capitation, bottom up and affordability assessments to be completed as part

of the business case.

LegalLegal framework unclear and potential for procurement

challengeProcurement roadmap and expert advice from SBS

Partner

LBH and CCG do not agree on priorities and approach to

integrate care, Difficulty incorporating LBH charging model with

CCG finance model

Senior discussions held between LBH and CCG and joint working group

developing business case

Provider

System not mature enough to support outcomes based

contracts, providers not used to working together and

insufficiently mature GP federation

STP Implementation group in place to support providers working better

together, GP consortium development programme underway as part of the

Primary Care contract

Quality Quality and safety is negatively impactedImpact assessment requires as part of business case moving to a more

detailed assessment when service areas identified for integration

Strategic

Central programme not moving at sufficient speed leading to

difference of approach, potential for NWL work to changes

elements of local integrated care in order to get consistency

across boroughs

Hounslow continuing with local timeframes for delivery while working a apart

of the NWL virtual team and feeding into developments across STP

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