Health and Social Care integration: where should HIV services fit?

Gordon Scott

Chalmers Centre

Edinburgh

Why is Health and Social Care Integration (HSCI) happening?

The simple answer is the changing demographic– Increasingly ageing population

The unsaid answer is the lower and lower threshold for seeking services

The awkward answer is the fractured nature of public services, their centralist/silo tendencies and their struggle to be locally responsive

Why am I talking on this subject?

In addition to working in an integrated Sexual Health Centre…

GUM – STI management

Contraception HIV treatment and care Medical Termination of

Pregnancy – Half of Lothian’s TOPs

All young people’s sexual health services

Psychosexual services Medical Gynaecology Menopause clinics

Colposcopy Sexual assault Vasectomy Clinical Psychology Gender Reassignment Genital dermatology Premenstrual syndrome

clinic Training clinics

– Both specialist and general

I have this wonderful title

Vice Chair of the Professional Advisory Committee (PAC) to the Integrated Joint Board (IJB) of the Edinburgh Health and Social Care Partnership (HSCP)

The HSCP is mainly a mixture of Edinburgh City Councillors and Senior NHS Lothian reps

– Plus a range of Practitioners/Managers who represent the views of the shop floor

Whilst almost everyone else is obsessed with structures, and responsibility for various bits of financial governance etc, our role is to look at individual patients and how to improve care pathways

Try not to get overwhelmed by the new “structures”

This is about individual patients My concept of what we are trying to achieve

through HSCI is– The right professional sitting down with the right

patient/client/service user in the right place at the right time to sort out the issue(s) that most affect their health and/or the public health

Other crucial buzz words to get your head around are

Localities Anticipatory care

What are the steps?

Identify where there is most to gain from avoiding an adverse outcome

Identify individuals/groups more likely to have an adverse outcome

Identify the actions that frontline staff can do to reduce the likelihood of an adverse outcome

Support them to implement those actions

An example might be the Care Home Liaison Service

The right professional sitting down with the right patient in the right place at the right time to sort out the issue(s) that most affect their health and/or the public health

Medicine of the Elderly Consultant (facilitated by the liaison nurse)

Frail elderly person at high risk of hospital admission

Home visit Improved care package

to prevent admission

The steps in this example

Identify where there is most to gain from avoiding an adverse outcome

Identify individuals/groups more likely to have an adverse outcome

Identify the actions that frontline staff can do to reduce the likelihood of an adverse outcome

Support them to implement those actions

Reduce hospital admission

Elderly patients in care homes

Care Home staff alert the liaison nurse about particularly frail patients

Send out a consultant who will optimise the package of care in the community

Remember the buzzwords

Localities– This is an intervention firmly embedded in the

local community

Anticipatory care– You know from previous experience what type of

patient is most likely to end up in hospital, so don’t sit and wait for it to happen

What about HIV and H&SC Integration?

Certainly in Edinburgh in the 1980’s, HIV services led the way

An epidemic driven by intravenous drug use requires multiple, responsive, integrated, community-based services

At strategic level we had the Lothian Regional AIDS team with any number of sub-groups beneath that

Today we still have integrated strategic planning, with a specialist BBV social care team and good links to third sector

What do you do if you only have generic services?

At strategic level

Your H&SC Partnership(s) should be writing a strategic plan based on some kind of needs assessment (JSNA)

This may be driven very much by the Frail Elderly agenda

You need to find out if HIV/BBV/Sexual Health is included in your JSNA

And if it’s not, get it in there

HIV ticks a lot of boxes

Anticipatory care (prevention)

– Prevention of new infections

– Fewer late diagnoses– Reduction in ill-health

(and use of services)

Localities– Are where people with

HIV live, often in clusters – Are where transmissions

happen, so prevention initiatives should be established there

Don’t forget co-morbidities

Mental health Including addictions

– Don’t forget New Psychoactive Substances (NPS) Obvious health issues But can also include multiple Social Care strands eg

drug recovery, C&F, Criminal Justice HCV can be added here

Everyone bangs on about HIV and ageing

In the grand scheme of things, I’m not convinced it will cut much ice

Multiple co-morbidities and issues with polypharmacy/interactions are par for the course across the whole “ageing” sector

The biggest problem I see is demented patients not taking their ART, becoming detectable, thus creating issues with personal care

– Of concern, but still a relatively small risk of resultant harm

Key considerations when arguing your case

Bad outcome x costs a lot money It is more common in y subset of my patient group Investing z in a service development (considerably

less than x) is therefore a good plan

And in time, may well require a comparison with the relative value of investment in, for example, Frail Elderly

Conclusions

Health and Social Care Integration is about individuals

It begins close to home “anticipatory care” means intervening as far back in

the pathway as possible “localities” means services within communities Get to know the key Locality Managers/Practitioners

in the parts of your patch where HIV is most prevalent

Patients, carers and Third Sector all have a voice/role too, so don’t forget to include them