2. OVERVIEW
• Nuffield work with Trafford
– 15 months
– In‐depth case study
– ‘Critical friend’
• Tracking and telling ‘the story’
– Work in progress
– Three phases
– Key challenges for Trafford to respond to
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
3. DRIVERS FOR INTEGRATION
• History of financial
problems
• Rise in acute admissions
and GP workload
and GP workload
• Managing long term
conditions
• 2008: new PCT strategy
• Integration = way forward
= way forward
• End of ‘invest to save’
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
5. SHAPING INTEGRATED CARE
• September 2008
– First (of five) Clinical Congress events
First (of five) Clinical Congress events
– Mandate for developing new integrated approach
– Development of ‘office medicine’
Development of office medicine
• Evidence + international models of care
– Kaiser, Inter Mountain, Geisinger
Kaiser, Inter Mountain, Geisinger
• Strategic context (SHA, DH, TCS)
• Communication and engagement (ongoing)
Communication and engagement (ongoing)
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
6. SIX FOUNDING PRINCIPLES
1. ‘Nothing about me, without me’
2.
2 General practice should be locus of integrated
General practice should be ‘locus of integrated
services’
3. Consultant opinion is an essential component of
Consultant opinion is an essential component of
effective integrated services
4. The delivery of integrated services will primarily rest
on extended roles for nurses and AHPs
5. Integrated services must incorporate social care
6. Future integrated services should bring together the
full range of primary care
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
7. MEDICINE AND SURGERY ARE DIFFERENT
HORIZONTAL HORIZONTAL
INTEGRATION ACUTE
ACUTE INTEGRATION
SURGERY
Increased use of TGH
site for NHS activity
presently done at high
l d hi h Enabled through
Enabled through
cost in the private sector ACUTE the creation of a
and potentially MEDICINE new organisation
through service‐level
g and full
mergers engagement with
OFFICE primary care
MEDICINE producing a shift
in activity
in activity
VERTICAL VERTICAL
FAMILY
INTEGRATION INTEGRATION
MEDICINE
MEDICINE
8. • February 2009
– PCT B d i
PCT Board sign‐off integrated care strategy
ff i t t d t t
– Funding for development of a business case
– Agreement to deliver ‘whole economy’ CIPs
d l ‘ h l ’
• November 2009
– SHA supports the concept of ‘integrated care’
– Rethink required in terms of funding and pace of
implementation
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
9. • April 2010
– ‘Proof of concept’ year begins
p y g
– Reworked plans, guided by founding principles
– Supporting eight work streams
pp g g
– Over one year (and beyond?)
– £2m funding from PCT
• Shifting language/approach
– Integrated Care Organisation
g g
– Integrated Care System
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
10. 1. Data sharing, population risk
Integrated Care
Integrated Care management
System 2. Clinical panels and compacts
g
3. Medical services redesign
4. Surgical Redesign
5. Patient experience and
coordination
6. Leadership and quality
Improvement
Integrated 7. Programme support and
Care
Care e a uat o
evaluation
Organisation
PLUS
8. Vertical integration
12. PROGRESSING INTEGRATION
PROGRESSING INTEGRATION
• April 2010 onwards
– Continue to develop ICO and supporting systems
– Develop governance structures
– Engage stakeholders, in Trafford and on the
borders
– Develop ICO business plan
• for submission to NHS North West under Transforming
Community Services
C it S i
• for NHS Competition and Cooperation Panel
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
14. GOVERNANCE
ICS MANAGEMENT BOARD
Chair, Chief Executive NHS Trafford
Formal decision‐making group
REDESIGN GROUP CLINICAL BOARD
Chair, GP/PBC Lead Chair, PCT Medical Director
Focused on detailed
Focused on detailed Overseeing clinical panels,
Overseeing clinical panels
local system development Advisory clinical governance,
and the disposition education & training, quality
of surgical services
g improvement and patient
p p
across Trusts empowerment
STAKEHOLDER BOARD
STAKEHOLDER BOARD
Chaired by PCT Chair
Underpinning partnership forum
15. CLINICAL BOARD
the most powerful body in the ICS... linking the panels directly
the most powerful body in the ICS linking the panels directly
with the whole group incentive scheme, or professional dividend
Orthopedics
Multi‐disciplinary
team panels General surgery
with resource
with resource Urology
Diabetes
allocation powers
ENT and standards Gynecology
End of Life Care
End of Life Care authority – Colorectal
overseeing the
Mental Health Cardiology
move from
Unscheduled Care ‘outpatients’ to Cancer Care
office medicine, Pediatrics
Respiratory
and offering
collegiate process Ophthalmology
control
t l Rheumatology
Six panels in ‘proof of concept’ year ....... another 18 to follow
16. Example – End of Life Care
• Four work streams centred on lung cancer and COPD
• Aim: to reduce deaths in hospital by 10% by April 2012
– Develop operating manual for appropriate delivery of EoL care
assessment and intervention across Trafford.
– Provide clear guidance on content of intervention, training
requirements for staff, patient and family information, documentation
and information sharing
• Identified cohorts via vanguard practices
• Testing with patients (home, hospital, care homes) from
January 2011
• Mix of qual/quant measures: admissions/cost, shared
Mix of qual/quant measures: admissions/cost, shared
information, administrative time
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
17. VANGUARD PRACTICES
• 9 practices
• 90,000 population
• Laboratory for ‘testing’
integrated approach
• Wrap around
community‐based
community based
teams
• Identifying cohorts
Identifying cohorts
of ‘high risk’ patients
18. SUPPORTING OFFICE MEDICINE
• 4 neighbourhood teams
• 4
4 community hospitals
i h i l
• 10 community physician
sessions
sessions
• 7 days p.w. telephone advice
• 5 Community matrons
• 2 Advanced Nurse
Practitioners
• 1 practice / 60 telehealth
1 ti / 60 t l h lth
units
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
19. • May 2010
– First cohort: Advanced Training Programme
First cohort: Advanced Training Programme
focused on leadership and quality improvement
– Set up ‘patient experience’ monitoring
Set up patient experience monitoring
• October 2010
– Second ATP cohort
Second ATP cohort
• January 2011
– Begin reviewing outcomes
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
21. CONCLUSIONS SO FAR
• A great deal has been achieved through strong clinical
engagement and leadership development
• ICS provides robust foundations that appear to
ICS id b tf d ti th t t
accommodate changes
• Reinforced through a programme of quality improvement
and service redesign
d d
• Significant issues persist around QIPP/financial balance
• Progress with proof of concept has been slower than
Progress with ‘proof of concept’ has been slower than
anticipated but is speeding up.
• Plans for ICO ‘on hold’, awaiting SHA decision
• To deliver transformation, a more consistent policy
T d li t f ti i t t li
framework is needed to encourage integration and
provide clarity and direction
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
22. 5 PRACTICAL CHALLENGES
5 PRACTICAL CHALLENGES
1. What goes in shapes what comes out: how can Trafford
ensure good data quality / pop’n management?
g q y/p p g
2. What shifts in utilisation and finances are expected in
Trafford as a direct result of integration? Will
integration deliver QIPP agenda?
3. How/when will the system roll out across Trafford? (e.g.
all practices; all generalists and specialists)
ll ti ll li t d i li t )
4. What are the opportunities and threats to integrated
care from the emerging GP Consortium?
care from the emerging GP Consortium?
5. Is there a Plan B?
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
23. 5 POLICY CHALLENGES
1. How is it possible to deliver a new relationship between
GPs and physicians in the present choice environment?
GPs and physicians in the present ‘choice’ environment?
2. What is the ‘best’ means of delivering population‐based
services? (PbR vs capitated budgets)
i ? (PbR it t d b d t )
3. What are the implications of a new GP contract?
4. Accountability vs Authority – what is going on?
4 A t bilit A th it h ti i ?
5. What is the impact of:
– New role for local authorities
New role for local authorities
– Coalition government/politics
t: 020 7631 8450
e: info@nuffieldtrust.org.uk
www.nuffieldtrust.org.uk
