Snapshot of integrated working 2013

ADASS and NHS Confederation survey of local authority and NHS

commissioners

About the survey• Targeted Directors of Adult Social Services and Clinical

Commissioning Group (CCG) leaders• 69 respondents: 58 Local authority (84%); 9 CCG (13%)

– Some people responded on behalf of their whole locality (e.g. one Director of Social Services told us they consulted three local CCGs before responding on behalf of the area)

– Two respondents did not specify (likely to be joint appointments)

• Fieldwork: 25/03/2013– 30/04/2013. Designed to take a snapshot of progress at the ‘go live’ date for the new NHS architecture, but this timing will have been difficult for new CCG leaders and impacted on response rates.

• Builds on earlier (2010) survey of DASSs and PCT Chief Executives. Some tracker questions included.

• Will follow up findings through interviews and roundtable discussion

Local leaders report that integration can save money and benefit service users, patients

and carers

The benefits of integrated care: efficiency and value

• Respondents reported that where integrated care was achieved, it had reduced pressures on services in their localities in the following ways:– 57% saw reduction in delayed discharges from hospitals– 42% saw reduction in unplanned emergency admissions– 41% saw reduction in the number of interventions across health

and social care– 41% saw an increase in the proportion of older people still at home

91 days after being discharged from hospital into rehabilitation

– 55% saw more effective sign-posting to low level interventions (including information advice and guidance)

• Alongside this, 48% reported quantifiable financial savings made, with 29% seeing cashable savings.

The benefits of integrated care: patient experience and quality of life

• 46% reported that where they had developed integrated care, it had improved quality of life for people with long term conditions; 42% saw improved quality of life evidenced through patient/ user surveys

• 45% saw improved patient/service-user satisfaction

• 39% saw improved carer satisfaction

• 45% saw more patient centred care

What is helping and what is hindering? What support is

required?

What has helped integrate care?• Leaders matter. 84% said leadership helps; 81% identified

commitment from the top as a factor helping the delivery of integrated care.

• Both factors were among the most important in 2010, though ‘friendly relationships’ was the top factor then (cited by 36% in 2010)

• Joint planning /strategy (71%), collaborative working between commissioners and providers (70%) and joint vision (68%) also very often helpful

• In comparison with 2010, frontline staff commitment and joint commissioning are comparatively more helpful

• Some low-scoring factors (health and wellbeing boards, personal budgets) are at an early stage of development – they may be more helpful in future

What has helped integrate care?

0%

10%

20%

30%

40%

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60%

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84%81%71%70%68%67%

55%54%49%43%42%38%

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20102013

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NB 2010 data is from analysis of free text responses whereas in 2013 respondents were given options to tick based on the factors identified in 2010 and others identified by policy analysts

What hinders integration of care?

• Data and IT systems were most often cited as a hindrance – by almost two thirds of respondents.

• Since 2010, organisational complexity and changing leadership are much more often seen as barriers - perhaps reflecting recent reforms?

• Half of respondents saw different cultures as a hindrance – and this has become comparatively more important since 2010.

• Payment mechanisms and financial pressures are another key area.

• Performance regimes was the most frequently cited factor holding integration back in 2010. This has been overtaken by other issues.

What has hindered integrated care?

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10%

20%

30%

40%

50%

60%

70%

64%57%

51% 51% 51% 49%43%

38%

25% 23% 23%17% 16% 13% 13%

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Data and IT, culture, organisational complexity and changing leadership have risen up the agenda

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20102013

NB 2010 data is from analysis of free text responses whereas in 2013 respondents were given options to tick based on the factors identified in 2010 and others identified by policy analysts

What would assist in increasing the scale, and accelerating the pace, of integration? Themes

• Share examples of good practice (9 mentions)• Shift financial resources / address financial incentives

(7 mentions)• Evidence of what works (6 mentions)• IT / information sharing solutions (5 mentions)• Organisational stability / no more restructuring (4

mentions)

National bodies should focus on sharing good practice and evidence, rather than more central guidance. Practical policy solutions will be required to address IT / information sharing and financial incentives.

Impact of NHS reform

Working arrangements change over time

0%5%

10%15%20%25%30%35%40%45%50%

2010 responses At present Expected in April 2015

2010 -13 shift away from ‘enhanced partnership’ may have reflected disruption during NHS reform.

However, over time respondents expect a shift towards ‘enhanced partnerships’ and more structural integration.

Progress in much CCG-local authority joint working, despite disruption of NHS reform

Asked about joint working between NHS and local authority commissioners:

• 8 cited effective joint working between local authority and CCG

• 3 referred to challenges from commissioning reform: complexity in the system, a challenge to established integration of health and social care, and development needs within CCGs

The immediate impact of the NHS transition process has been mixed:

• “the CCG authorisation process and the closedown of PCTs has diverted staff time away from this agenda. We have still made progress due to the tenacity of a few individuals”

• “a change of leadership within the PCT/CCG moved integration on quickly”

• “[relationships] are generally positive here in [county] (i.e. Between the Council and the CCGs) [...] CCGs are particularly pressed in terms of time/capacity.”

Health and social care leaders are optimistic

1: not s

upportive 2 3 4 5 6 7 8 9

10: very

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‘I believe that my local health andwellbeing board will drive

integrated care locally’

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‘I believe that we will be able tocontinue to integrate care under

the new system reforms’

What practical characteristics of integration are in place – and

which of them make a difference?

Initiative(s) focusing on specific population group(s) across all health and social care services e.g. learning disability, children with disabilities, frail elderly

Service specifications which include jointly agreed integrated care outcomes

An atmosphere of trust and collaboration in service development and delivery

Formal agreements between organisations (e.g. Shared guidelines, protocols)

An ethos of shared values between organisations

Pooled budgets

Joint contracts

Care processes and pathways which have been developed to cover multiple organisations

Provision of clinical services through multidisciplinary teams

0% 10% 20% 30% 40% 50% 60% 70% 80%

What can we see happening in most localities?

Some characteristics only in a minority of localities

All patients/service users with complex needs have an agreed care plan

Coherent rules and policies in place between organisations

Formally merged organisations or joint senior appointments

All patients/service users with complex needs have a named case manager responsible for coordinating their care

Integrated clinical services in a single organisation

Aligned information technologies (eg electronic patient records)

Other

These rules and policies are consistent at all levels throughout our organisations

Integrated back office functions

0% 5% 10% 15% 20% 25% 30% 35% 40%

Making a difference to patients/service users

• Respondents had the greatest confidence in arrangements which have been key features of recent integrated care pilots:– Initiative(s) focusing on specific population group(s) across all

health and social care services e.g. learning disability, children with disabilities, frail elderly

– Providing clinical services through multidisciplinary teams – Service specifications which include jointly agreed integrated

care outcomes

• ‘An ethos of shared values between organisations’ and ‘an atmosphere of trust and collaboration’ also scored highly.

• Pathways that cross organisational boundaries and formal agreements such as shared guidelines are believed by most to be making a difference, as are care planning and case managers (though these are only fully in place in a minority of localities).

A majority were confident the following things make a difference

Initiative(s) focusing on specific population group(s) across all health and social care services e.g. learning disability, children

with disabilities, frail elderly

An ethos of shared values between organisations

Provision of clinical services through multidisciplinary teams

An atmosphere of trust and collaboration in service devel-opment and delivery

Service specifications which include jointly agreed integrated care outcomes

All patients/service users with complex needs have an agreed care plan

All patients/service users with complex needs have a named case manager responsible for coordinating their care

Care processes and pathways which have been developed to cover multiple organisations

Formal agreements between organisations (e.g. shared guide-lines, protocols)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

% rating these arrangements 4 or 5 for their contribution contribute more in-tegrated care for patients and service users where 1 = not confident and 5=

very confident

Scepticism that structural solutions help patients and service users

Three types of arrangement were rated poorly by 10% or more of respondents:• Integrated back office functions (28% rated 1 or 2)• Integrated clinical services in a single organisation (17%

rated 1 or 2)• Formally merged organisations or joint senior

appointments (10% rated 1 or 2)

These were all only present in a minority of organisations.

Respondents were asked how confident they felt that specific arrangements contribute towards more integrated care for patients and service users. 1 = not confident, 5= very confident. The above aggregates scores of 1 or 2.

Where are efforts focused?

Whose care is prioritised for integration?

• All the groups we asked about (older people, learning disabilities, mental health, children, physical and sensory impairment and carers) received a significant degree of priority.

• Older people, learning disabilities and mental health are most often given a high priority; older people are most often given maximum priority.

• Leaders less often scored the benefit all these groups were receiving from integrated care as substantial.

Integrating care for older people

Commissioning: prioritised

Commissioning: deliver real benefit

Provision: prioritised

Provision: deliver real benefit

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1 (minimum) 2 3 4 5 (maximum / substantial)

% respondents selecting each rating

Older people are most often given maximum priority for integrated care. But the benefits seen do not yet match leaders’ aspirations.

This group has risen up the agenda in the last couple of years, so perhaps there has not yet been time for extra efforts to have an impact. The benefits from integration reported in this survey are typically seen in older people’s services.

Reported real benefit more closely reflects prioritisation for people with learning disabilities

Commissioning: prioritised

Commissioning: deliver real benefit

Provision: prioritised

Provision: deliver real benefit

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1 (minimum) 23 45 (maximum priority / substantial benefit)

% respondents selecting each rating

Integrated care has been a national focus for this group for a longer time.

Integration across all relevant services

• Efforts should cover a wide range of other services. Some

priority was given to all areas we asked about (housing,

learning, leisure, environment, police and criminal justice, local

businesses).

• Housing most often seen as top priority, followed by police and criminal justice. These are also where most benefit is reported – though responses overall showed some ambivalence with many rating 2 or 3 on a scale from 1 (min. priority) to 5 (max. priority).

• Some benefit reported from integration with each service – but people more often reported lower levels of benefit from working with environment and local businesses.

What might the future hold?

Aspirations for integrated working in April 2015

Delivery of integrated care through Integrated Care

Organisations with collaborative

commissioning arrangements with the CCG

With a strategic integrated care plan for [our city] being implemented in our 3 health and care localities, overseen and governed by our HWB. Implementing on the ground

changes to our services, workforce, estates and

financial models to deliver integrated care services for

the 20% most high need citizens in [our city].

Our “default” is “why wouldn't we do this

jointly?”

Aspirations for integrated working in April 2015 (contd.)

Robust pooled budgets for certain service areas, joint contracting/commissioning approaches and integrated teams (service delivery).

Realistically, this will not be achievable across all

service areas, probably just a few to begin with.

Strong equal partners with shared objectives

cooperating – avoiding risks of mergers and takeovers

A single health and social care organisation with one governance structure and

a single budget