Ensuring success for new models of care

Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated Care

Ensuring success for new models of care: recent experience and evidence

Lessons from SLIC

Nuffield Trust – November 2016

Mark KewleyDirector of Transformation, NHS Southwark CCG


Contents

3. How

5. Lessons

6. Nextsteps

4. When

2. What

1. Who


St Thomas’s Hospital

King’s College Hospital SLaM

Guy’s Hospital

• Two diverse inner city London boroughs covering 600,000 people

• Some world class medical institutions and research power

• Significant health inequalities and worse than average outcomes and deprivation

• Three FTs covering acute and community services for physical and mental health

• >90 GP practices including chains, merged practices and single handers

Local CCGs and LAs LAs, GPs and FTs AHSC

Southwark and Lambeth Integrated Care

Independent assets

Citizens’ Board &

Citizens’ Forum

Who

Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated CareWhat

• A quite familiar integrated care programme

• Focused on Older People (>65s)

• Emphasis on reducing unplanned hospital admissions and care home admissions

Case finding/risk stratification, holistic assessment and care management

Community MDT approach

Admission avoidance team and Hospital-at-Home team (@home)

Redesign of some more proactive pathways for high prevalence admissions (falls, UTI, dementia, malnutrition)

N.B. a more detailed pathway description is provided in the appendix


• The SLIC OPP was one of a variety of transformation projects being undertaken by the partners in the partnership

• Some great innovations happening alongside: 3D4D, DMI, Lambeth Living Well, SAIL

• The Programme team did not oversee all of these inter-dependent strands of work

• The programme was therefore trying to harness the existing capacity for innovation, and to bring some coordination to this as a whole system

What

Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated CareHow

Phase 1

Integrated CarePilot (ICP)

Business caseto GST Charity

Implementwork streams

Agree shiftin resources

Owned by PMOcentral team

• A relatively linear approach to pathway redesign and implementation: deliberate strategy

• Resource shifts allowed investment and new incentives within community services and in the primary care contracts; these were activity related

• Programme governance in place; emphasis on ‘delivery’ and implementation rather than an overall culture change and shift in accountability


Phase 2

Build wholesystem approach

Leadershipdevelopment focus

Focus more onchanging mindsets

Agree alignmentof accountability

Owned by teamssupported by PMO

• A more emergent / adaptive approach

• Needed to build a collective recognition about a collective problem that can only be solved by formal collaboration and joint accountability

• Had to invest in leadership development, and encourage federations in general practice (coincident with PM Challenge Fund)

• Had to go beyond piece-rate incentives towards more joint-incentive schemes, but using the pre-existing and disparate contractual forms

How

Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated CareWhen

CCGsestablished

BCFintroduced

FYFVlaunched

GPFVlaunched

AUA DESlaunched

Routine CQCinspections

Vanguardapplications

PMChallenge Fund

MCPframework

AHSNsdesignated

2011 2012 2013 2014 2015 2016

LaunchedICP

Launched SLICOPP

ERR / @homecommissioned

Strategy

Plan

Resources

Phase 1

Adapt &Adopt

‘Whole system’business case

Falls servicecommissioned

Activity paymentsin LES contracts

GP EmergingLeaders Prog

Phase 2

Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated CareLessons

Changingpeople’s

individualcare

Changingsystem

measures

Clinicians in general practice and our local hospitals have unanimously been singing [the LCR’s] praises and saying what a huge difference it has made to their working lives and the safety, quality and experience of patients.

ChangingIT!!

EHI Award for 'Best use of IT to support integrated care’


“Some of us formed really strong networks. Having headspace outside of the practice was really helpful, and being challenged in different ways was really useful, it allowed me to do things on a bigger scale.”

Changingleadership

capacity

Changinginvolvement

andparticipation

“Citizens’ involvement in SLIC is something to be proud of. Working on an equal footing with professionals to co-design projects and being represented at every level of governance meant we could play an important role in improving care for local people.”


Local Care Record Conditions for success

• Agreement about the problem, and a commitment to co-design the solution

• Clear description of the resources required, non-recurrently and recurrently

• Dedicated operational teams owned the task, supported by a coordinating PMO

• Clear lines of accountability

• Service innovations were linked to funding changes in routine contracts

GP Emerging Leaders Programme


• Co-create a vision that is meaningful to all –burning ambition as well as burning platform

• Produce a strong business case – know what are your relative priorities and timescales

• Create the conditions for change – invest in people’s time to think and work together

• Identify interventions and system enablers

• Facilitate and encourage co-design

• Identify programme support – and be explicit about expectations and mandate

• Use available expertise

• Develop lateral leadership and change skills

• Use measurement – and think about how to capture ‘intangibles’

• Evaluate continuously –this is an adaptive process not an RCT

• Learn and adapt as you go – prototype, test, fail fast and improve

• Have strong governance – be explicit about accountability

These are the formal ‘lessons’, but most of these would have been recognised as important at the start. The big unanswered question remains: why is this so hard to do in practice?


Next


“The [PMO] team was expected to ‘step into the gulf’ because of a lack of agreement between partners, only to be criticised for the lack of agreement”

Create a dedicated ‘engine room’ to drive and manage the local transformation programme, with adequate dedicated resources and capabilities. This is not just a programme management office and it needs your best people

PMO provides capacity and skills but cannot assume an

operational mandate

Operational teams need to see themselves as leaders

across a wider system

Best of both: A mandated operational ‘engine room’

supported by a PMO

Next


Thank you & Questions


Appendix

Ensuring success for new models of care: Lessons from Southwark and Lambeth Integrated CareWhat


No of Conditions per person

Base: People registered at practices that allow PHMCC accessSource: LTCs from acute inpatient data (11/12) & PHMCC

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

pe

op

le (

%)

Age band (Years)

Morbidity (number of LTCs) by age band

0

1

2

3

4

5

6

7

8+

What

Over time we have moved away from an age-based and ‘PARR-type’ risk-

stratification and towards a model based on complexity of need for people with a high burden of planned and unplanned care. This includes medicines, OP appts, GP appts (i.e. not just NEL admissions)


Rank Practice / Intervention Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Total % of total

1 CMDTs X X X X X X 6 13%

2 Holistic Health Assessment of need X X X X X 5 11%

2 KCH Volunteering X X X X X 5 11%

2 Community + Social care have universal access to each others records X X X X X 5 11%

5 Rotations of nursing staff to community nursing service X X X X 4 9%

5 Community geriatricians X X X X 4 9%

5 Connect + Care X X X X 4 9%

8 Care co-ordinator roles such as Integrated Care Manager X X X 3 7%

9 Red Cross X X 2 4%

9 My Health Locker X X 2 4%

9 Local availability of investigation results X X 2 4%

12 Home share X 1 2%

12 Wheel of wellbeing X 1 2%

12 Every pound counts X 1 2%

15 Extension of access to specialist advice through 24 hour TALK hotlines 0 0%

Total 8 9 8 7 6 7 45

6

5

5

5

4

4

4

3

2

2

2

1

1

1

0

CMDTs

Holistic Health Assessment of need

KCH Volunteering

Community + Social care have universal…

Rotations of nursing staff to community…

Community geriatricians

Connect + Care

Care co-ordinator roles such as…

Red Cross

My Health Locker

Local availability of investigation results

Home share

Wheel of wellbeing

Every pound counts

Extension of access to specialist advice…

Count of 'votes' for each practice

Discuss long list from ICAN #1 Initial short list Detailed appraisalA B C

• At the ICAN#1 workshop a host of approaches were identified and discussed, with each considered in terms of its readiness for adoption based on defined criteria

• Five categories of intervention were identified

• Within which 15 interventions/practices were listed for discussion within the ICAN#2 workshop

• At the ICAN#2 workshop six mixed tables discussed the long list of interventions/approaches. There was an opportunity to amend or add at that stage.

• In discussions the tables selected a small subset of interventions using a set of criteria: — Suitability, Feasibility, Viability, Inter-

dependence• Following the workshop the core team counted

the frequency with which each practices was selected, and ranked the practices

• For the top half of the ranked list (7 interventions) the core team have subsequently collated more detailed analysis of the models

• These summaries were used to inform discussion within the provider group about which practices should be priorities for adaptation and adoption across the boroughs


Agree the ‘package’ of 3-4 practices

Work collaboratively to codify the characteristics of each practice

Work on detailed local blueprints to adopt and adapt at scale

D E F

• Representing a large proportion of the provider interests in the local system, the Provider Group has identified interventions that offer the most suitable, feasible, viable and complementary package to enable integrated care

• For each practice selected the Provider Group will oversee a cross-borough working group to define/codify the most important characteristics of the practice

• Alongside this the workgroups will consider what factors need to be considered to support effective adoption at local level

• At local level (where applicable) neighbourhood teams will be supported to undertake detailed planning to successfully adopt and adapt the chosen practices within and between their organisations.

• This involves operational leaders working together to create their own ‘blueprint’ for service delivery, supported by PMO-type staff

• Case finding• Named person• Care planning• Self-mgmt.• MDT working

Healthcare

Ensuring success for new models of care