Outline What is the Whole Systems Integrated Care Programme? - PowerPoint PPT Presentation

Outline • What is the Whole Systems Integrated Care Programme? • Progress to date • Next Steps

What is the Whole Systems Integrated Care Programme? • Hounslow is part of the North West London Whole Systems programme: 1 of 14 national pioneers (“Early Adopters”) for joined up care • A vision to deliver better integrated care • If we can get it right, we know it will transform the daily lives of many of our residents • Builds on what’s being achieved

A vision to deliver better integrated care • Our vision for whole system integrated care is based on what patients and carers tell us is most important to them: • a seamless service to patients and carers • delivering person-centred care.

A vision to deliver better integrated care • Joined up health and Care is social care coordinated • Organise around around the people’s needs not individual historic • More investment organisational in primary and structures community care • There is one set of • Social care and records shared mental health across organisations needs Care is considered Funding provided holistically with flows to • Multidisciplinary in the most physical health where it is appropriate home care teams and care needs needed • Fewer people are setting • Less spending treated in hospital, on acute hospital and those that are based care leave sooner • More specialist support for management of people in the community

Transforming people’s daily lives What are our population groups? • Adults 16-74 years with one or more long-term conditions (47,687) • Adults 75+ with one or more long-term conditions (9,865) • Adults and elderly people with advanced organic brain disorders (839)

Transforming people’s daily lives Physical disabilities - About 35,000 people • have a long term illness or disability. About 12,000 report they are in “bad or very bad” health. (2011 Census) Carers – 8% of the adult population provide • unpaid care in the borough and only about 1% of adults are receiving a carer’s allowance. Dementia now affects one in six of people over • 80 and this will continue to grow. Diabetes - The recorded diabetes rate is • significantly higher (6.1%) compared to the national rate (5.8%). There are an estimated 5,000 undiagnosed cases of diabetes. 285,500 patients registered with Hounslow CCG GPs. • Cardiovascular disease - emergency admission 24,000 patients registered to Hounslow GPs were • • residents of Ealing, 8,500 were residents of Richmond, rates for chronic heart disease are significantly and 5,500 in other locations outside Hounslow (tot.38,000) higher than the national rates (237 in Hounslow, 198 in England) The number of households has grown 13% since 2001. • • Population growth is expected to rise between 2012 and • 2020 by 12% . Falls - Every year around one in three over-65s • living in the community and one in two people The growth rate of elderly population (over 65s) will be • over 85 will have at least one fall. above 18% between 2012 and 2020.

Builds on what’s being achieved • Hounslow commissioners and providers have been developing an integrated care model since 2012 and now has in place strategies and programmes delivering integrated care to its residents.

Builds on what’s being achieved • Strategies include… • the Out of Hospital Delivery Strategy (May 2012) • Hounslow CCG Integrated Commissioning Plan (September 2012) • Integrated Care Organisation (Feasibility study February 2013; Final Business Case July 2013) (with the Council and Hounslow and Richmond Community Healthcare Trust); • the London Borough of Hounslow’s Adult Social Care ‘Change and Deliver’ Adult Transformation Programme • The Better Care Fund (BCF) Submission April 2014 (Hounslow CCG and the London Borough of Hounslow).

Builds on what’s being achieved • Programmes include… • Better Care Fund programme • ICRS / CRS / Prevention • Integrated Care Pilot – multi-disciplinary teams in GP localities • Locality Working – social workers, care navigators • Prime Ministers Challenge Fund • Partner programmes – eg Hounslow & Richmond Community Healthcare services, the Ambulatory Emergency Care programme at WMUH etc

Progress to date • Overview of the programme • Delivering the Outline Business Case • Expert Panel Review

Overview of the programme

Delivering the Outline Business Case

Delivering the Outline Business Case Co-production: four co-design sessions Who was there What we covered • Patients and Carers biggest Session 1 What is Whole Systems • group in all sessions Co-production • Outcomes wanted by patients, carers and social/voluntary groups • • Hounslow CCG Carers Strategy • Dementia Strategy • • Whole Systems Lay Advisor Session 2 • West Middlesex University What is Whole Systems • Co-production • Hospital Outcomes wanted by all participants • Developing the Model of Care: • • Borough of Hounslow • The Multi-Disciplinary Team • Three case studies from the Better Care Fund • Voluntary / social organisations Session 3 • GPs Developing the Model of Care: • The Multi-Disciplinary Team • • Hounslow & Richmond Two case studies from the Integrated Care Pilot • Community Healthcare Trust Session 4 • West London Mental Health Developing the Model of Care • The Multi-Disciplinary Team • Trust • Self empowerment • Care coordination • Care Planning Implementing Whole Systems •

Delivering the Outline Business Case Outcomes • “Be as independent and well as possible for as long as possible” • Get a ‘seamless service’ that delivers care around the person, not around different systems • “Best clinical practice for my condition” • “One person I can talk to, who helps coordinate care and who is accountable”

Delivering the Outline Business Case Developing a Model of Care

Expert Panel Review – 12 th June 2014 • Department of Health : Ed Scully (Deputy Director, Integrate Care) • Monitor : Catherine Pollard (Director of Pricing Strategy and Integrated Care) • NHS England : Ben Dyson (Director, Primary Care) • National Association of Primary Care : James Kingsland (President) • Lay Partner : Angeleca Silversides (West London) • Kaiser-Permanente : Hal Wolf, (Ex COO) • McKinsey : Tim Ward (Principal) • Chen Med : Craig Tanio (Chief Medical Officer)

Next Steps • To deliver Whose Systems integrated care will mean significant change across the whole of our current health and care provider landscape, and perhaps for voluntary and social organisations too. • Whole Systems is the catalyst and enabler for this change. We must take this opportunity. We are working to a Full Business Case that will describe in detail how this can be done.

Next Steps How we will continue to implement • Strong governance framework and partnerships: H&WBB, Joint Commissioning • Turning the Integrated Care Pilot in the five GP localities into business as usual • Support the capacity and capability of Practices (PMCF & access to General Practice 8am-8pm (Mon-Fri) and 6hrs / day weekends) • Using the Out of Hospital contract mechanism • Underpin services available to patients existing Model of Care; co-design with providers • Progress and develop joint locality working and develop the role of care coordinators • Integrate work on Carers & Dementia , including dementia advisors at locality level

Next Steps “Wicked Problems” • Timescales • Contracts (incl. double running costs, TDA approval for Joint Venture arrangements; providers ) • Getting people to work in a new way • Enablers: IT and Estates (having the community infrastructure in place) • Scale and pace – but safe (particularly SaHF) • Geography - impacts on Hounslow, Richmond and Ealing, e.g., • Patients registered to Hounslow GPs are residents of Ealing, Richmond and elsewhere. Also impacts e.g. on West Middlesex University Hospital • Providers need to respond to their commissioners in all three Boroughs - would want to see WSIC helping them manage this response • Impacts on hospital social workers (eg discharge, patient flow with ICRS, variable by borough)