Integrated Care A Service Provider s Perspective

Transcription

1 Integrated Care A Service Provider s Perspective Tony Garthwaite Senior Fellow, Welsh Institute for Health and Social Care UNISON Wales Integrated Care Seminar Tuesday 3 rd September2013

2 Integrated Care - Conclusions There is enough evidence to lend support for integration but local circumstances must be taken into account. Integration can mean different things to different people. It is a means not an end. Achieving integration is not easy and depends on many factors.

3 Why integrate? Don t start with the wrong questions! What s in it for me? Will it save me money? Will it cost me money? Will I lose control? Will it distract me from my day job? Will my elected Members (or Board) like it? Will it upset the staff? Must I do it because the Minister said so?

4 Why integrate? Some better questions! Will integration improve the outcomes for users of the service? Will integration make the service more efficient and effective? Will integration make the service more accessible and acceptable? How can I find the right answers to 3 basic questions: Why integration? What kind of integration is appropriate? How do I achieve successful integration?

5 The Why? Question: The Case for Integrated Care Ageing populations and higher levels of frailty, dementia and chronic conditions require a much more integrated approach to care Demand is increasing We live in an unprecedented state of austerity Collaboration between different organisations and professionals is needed to overcome fragmentation Integrated services give people a stronger voice and control of their lives Integrated services are more sustainable Collaboration is a buffer against increased competition Therefore, there is a Burning Platform and we need to be realising a compelling vision of care

6 The Why? Question: The Case for Integrated Care IT S A COMPLEX ISSUE The evidence base underpinning joint and integrated working remains less than compelling. It largely consists of small-scale evaluations of local initiatives which are often of poor quality and poorly reported. No evaluation studied for the purpose of this briefing included an analysis of cost-effectiveness. There is an urgent need to develop high-quality, large-scale research studies that can test the underpinning assumptions of joint and integrated working in a more robust manner and assess the process from the perspective of service users and carers as well as from an economic perspective. Social Care Institute for Excellence Briefing Paper 41 (2012)

7 The Why? Question: The Case for Integrated Care Some studies suggest improvements in: HOWEVER Clinical Outcomes quality of life, health and well-being Avoiding inappropriate admission to acute or residential care e.g. because of intermediate care Service provision e.g. via increased flexibility and responsiveness and a single point of access Service organisation, staff satisfaction and stress factors improve but not immediately Social Care Institute for Excellence Briefing Paper 41 (2012)

8 The Why? Question: The Case for Integrated Care AND NOTE The organisation of a service does not appear to improve the likelihood of service users being able to live in the community; rather, need and access to support at home are key factors. Social Care Institute for Excellence Briefing Paper 41 (2012)

9 The Why? Question: The Case for Integrated Care Reviews by The King s Fund and the Nuffield Trust of the research evidence conclude that significant benefits can arise from the integration of services where these are targeted at those client groups for whom care is currently poorly co-ordinated. King s Fund and Nuffield Trust report to the Department of Health and the NHS Future Forum (2012)

10 The Why? Question: The Case for Integrated Care Examples of Evidence of Integrated Approaches: Torbay: Reduction in the daily average number of occupied, emergency bed day use for over 65s lowest in the region, negligible delayed transfers of care; fewer people aged over 65 in residential and nursing homes, with a corresponding increase in home care services targeted at prevention and lowlevel support. Bolton Diabetes Integrated Care Centre: High patient and staff satisfaction levels; lowest number of hospital bed days in the area. Pan London Stroke Care Pathway: Improved access; reduced length of hospital stay. Wales Chronic Care Management Demonstrators: Reduction in bed days for emergency admissions. King s Fund and Nuffield Trust report to the Department of Health and the NHS Future Forum (2012)

11 The What? Question: What kind of integration? Pitching the scale right Macro (whole population), meso (specific care groupings), micro (individual users)? Avoiding the wrong kind of integration: small scale; too focused on diseases and not populations; not providing high quality and accessible care Seeing integration as a means not an end Not rushing to organisational integration Understanding the merits of virtual integration Concentrating on clinical and service integration?

12 The What? Question: What kind of integration? Meso (specific care groupings) level ingredients Partnership boards Case-managed multidisciplinary teams Co-located workers Organised provider networks (not necessarily fully integrated organisations) Single Access Points Financial incentives (single or pooled budgets that can be used flexibly)

13 The What? Question: What kind of integration? Micro (individual care) level ingredients Case management Virtual wards in the community Personal health budgets Electronic patient care record Telecare or Telehealth

14 The What? Question: What kind of integration? Macro level Warnings You can integrate all of the services for some of the people, some of the services for all of the people, but you can t integrate all of the services for all of the people. Leutz W (1999) Five laws for integrating medical and social services: lessons from the United States and the United Kingdom

15 The What? Question: What kind of integration? Macro level Warnings Don t start by integrating organisations. Integration that focuses mainly on bringing organisations together is unlikely to create improvements in care for patients. Ramsey et al (2009) The evidence base for vertical integration in health care

16 The What? Question: What kind of integration? Integration can happen effectively when staff from different health and social care organisations are able to do their jobs well Tony Garthwaite 2013 based on a personal experience

17 The How? Question: How to successfully integrate? Coherent policies are needed to support integrated care eg. Single outcomes framework for LAs and Community Planning Partnerships in Scotland, Welsh Government Framework The impact on individual democratic and public accountability must be taken into account. Net benefit (to the wider public service the collective good ) must be considered alongside potential individual losses and benefits

18 Making Integration Happen at Scale and Pace - King s Fund 16 point plan 1. Find common cause with partners and be prepared to share sovereignty 2. Develop a shared narrative to explain why integrated care matters 3. Develop a persuasive vision to describe what integrated care will achieve 4. Establish shared leadership 5. Create time and space to develop understanding and new ways of working 6. Identify services and user groups where the potential benefits from integrated care are greatest 7. Build integrated care from the bottom up as well as the top down 8. Pool resources to enable commissioners and integrated teams to use resources flexibly

19 Making Integration Happen at Scale and Pace - King s Fund 16 point plan 9. Innovate in the use of commissioning, contracting and payment mechanisms and use of the independent sector 10.Recognise that there is no best way of integrating care 11. Support and empower users to take more control over their health and wellbeing 12. Share information about users with the support of appropriate information governance 13.Use the workforce effectively and be open to innovations in skill mix and staff substitution 14.Set specific objectives and measure and evaluate progress towards these objectives 15.Be realistic about the costs of integrated care 16.Act on all these lessons together as part of a coherent strategy

20 A Local Authority Perspective To commit to integration with the NHS there must be: Political understanding, leadership and commitment Consistent political aspirations and intentions No power battles No feeling of takeover No loss of ultimate control and sovereignty An appropriate balance of costs, risks and benefits No evidence of obstructive, defensive and/or parochial attitudes Evidence of: A rationale for integrating service improvement and user benefits A clear business case for integration, evidencing benefits and costs An appraisal of options choosing the right integration model A common vision clarifying the collaborative gain, aims, goals and objectives Good budget modelling Appropriate sharing of financial risk Who pays?/who gains? ALL ARE CHALLENGING BUT ACHIEVABLE

21 Summary Why integrate? Rationale for doing so is sound Sufficient evidence base Users and carers deserve an integrated service Welsh Government policy supports it BUT, be clear about different objectives - To produce savings (NO!) or to gain service improvement (YES!)?

22 Summary What kind of integration? Organisational integration is neither necessary nor always sufficient Structural integration brings few benefits unless accompanied by other changes Start by integrating from the bottom up the lesson of Torbay Keep a focus on integration around the needs of patients and service users Mrs Smith, Wyn etc. It s a means not an end

23 Summary How to Integrate? Learn from research and experience e.g. King s Fund 16 point plan Implement a robust change programme Leadership at all levels and a shared vision is critical in making it happen Appreciate it will probably not save money but may produce added efficiency Understand that it isn t easy but can be done turn the barriers into enablers

24 Concluding thoughts... The path to integration is full of potholes You aren t the first learn from research; use the guidance! Do it for the right reasons Don t confuse means and ends Under promise: over achieve Tony Garthwaite Senior Fellow Welsh Institute for Health and Social Care University of South Wales Lower Glyntaf Campus CF37 1DL tony.garthwaite@btinternet.com It is achievable and if it s worth doing, do it! University of Glamorgan