When it comes to integration and working as a system, we have examples of strong innovation and some fantastic work across a range of services. We have two sub-systems within the ICS – developing integrated health and care models which work for their local populations bound by a common purpose and determination to better meet the health and wellbeing needs of our rapidly changing population, and stretching the public purse as far as we can.
Joining up data and information
One of our key enablers of change has been driven by the local digital roadmap initiative, which predates STPs. Connected Nottinghamshire is perhaps one of the most advanced of these initiatives in the country and reflects extraordinary work on integrating information systems across health and social care. We have a data warehouse, a GP repository for clinical care (GPRCC), which has half a billion patient/citizen records. Each day, a million records are updated. 100% of GPs signed up to the data sharing protocols and can provide not only integrated records, but also pseudonymised data. As a result:
- The portal is now used to access records 4,300 times a month and is increasing month on month across NUH. Approximately 20% of ED patients GP records are now checked, with imminent plans for mental health data to go live.
- Urgent and emergency organisations from 111 and ambulance to GP federations and out-of-hours providers are now using record sharing every day, with around 33,000 records accessed every month.
- GPRCC continues to grow every day – 5,000 patients a month are now benefiting from more proactive care (identifying to the care coordinators where interventions need to occur). This is constantly evolving and may help to play a part in the development of the national algorithms for social care risk stratification.
- Requests for assessment are now semi-automated, bringing the time taken from four hours to approximately 30 seconds. This happens 365 days a year, without the loss of time over weekends and holidays.
Of course, you need to make the system proportionate and relevant. There has been some particularly innovative work at two of our hospital trusts, which means the end of paper transfers, so all data can be shared in real time.
We can extend this to our care home pilots, and across the whole sector.
Primary care integration
Secondly, we have a range of multidisciplinary teams in primary care. People think integrated care is in some way new. It has been happening in pockets, but it’s not been applied systematically either to the cohort of our population as a whole, or in the community of primary care.
We should focus on the population who are at most risk of needing hospital or residential care and develop a co-ordinated approach to provide support and manage risks.
Integration can save money – if the model is right
We received Local Government Association funding to research multidisciplinary work. Looking at what had been published previously, we found next to no evidence that integration really saves money.
The research we have done locally suggests that, if you get the model right, integration does save money as well as improve the experience and outcomes for the population. That’s quite exciting.
We worked on three broad multidisciplinary models for primary care in Nottinghamshire. The research found that two of these have been improving outcomes for citizens and saving money for health and social care. It provides effective person-centred coordinated support and enhanced choice and control. It can help to give those people needing care the best help we can. We are building on this through the integrated personal commissioning pilot, where in 18 months we have gone from 85 personal health budgets to nearly 2000, 500 of which have been integrated health and care budgets, putting people with long-term conditions in control.
The research we have done locally suggests that, if you get the model right, integration does save money as well as improve the experience and outcomes for the population. That’s quite exciting.Deputy Chief Executive
There is some evidence that, in fact, if you don't get care integration and co-ordination right, it certainly costs social care money and if you don't have the right health intervention, it increases social care costs. Looking at fall prevention as an example, historically, 40% of people who have a fractured hip end up in a residential care home.
The fact that one of the models of multidisciplinary working didn’t realise the benefits is important. The model of integration matters – it’s more than just putting people from different disciplines into the same room around a pooled budget.
Previous national policy was based on the idea that pooled budgets and integrated structures would make the difference. That proves not to be true: the integration model matters most.
It seems to be the case that when social care staff are working to a clear social care model and are properly integrated with the NHS, the staff can influence the NHS model to promote different interventions. These staff then better understand the NHS model to refer people to services that can keep them independent and out of acute settings or a care home for as long as possible.
In mid-Nottinghamshire, the local integrated care teams also based their approach around this, with other interventions and shared set of outcomes across health and social care. This is critical.
Agreeing the outcomes across health and social care that matter, not just within each sector’s silo, with meaningful measures of a good integrated system enables the sharing of objectives and a common purpose. It made a major difference in mid-Nottinghamshire to how people see admissions to residential and nursing homes, which we subsequently reduced by over 20%.
Agreeing the outcomes across health and social care that matter, not just within each sector’s silo, with meaningful measures of a good integrated system enables the sharing of objectives and a common purpose.Deputy Chief Executive
Start small and scale up
The STP process acknowledges that much more prevention is needed through the NHS itself, and that the public is generally not sufficiently involved. Public health does get involved in the STP processes, but I’m disappointed that the funding is not there to implement what is needed. So much more could be done to improve efforts around prevention, be it primary, secondary or tertiary. For example with alcohol related harm, we have strong evidence on the benefits of alcohol liaison teams and targeted, focused efforts in acute and community settings, but unfortunately rather than scaling these up, they’re being cut back. That’s shortsighted.
As for smoking, I think every patient with a smoking related illness should have access to a brief intervention and support to stop smoking: that should be standard across the NHS, as should encouraging healthier habits in physical activity and diet.
And we have to work with patients and communities to improve people’s understanding of their risk factors and what they can do to improve their own health and wellbeing. We need to empower them.
Fourthly, we have benefited and learned from scaling up smaller scale pilots, including our involvement in the vanguard programmes. Last year we saw a 23% reduction in hospital admissions from relevant care homes within the vanguard area.
Through our ICS, we have been spreading that approach across the city and county and we implemented it in Mid Nottinghamshire, where care homes have seen a 13% reduction in emergency admissions from care homes so far.
Another example would be the potential to improve outcomes and efficiency through joint commissioning. Our community equipment contract is with a third sector provider – this issue illustrates how hard it is to do integrated commissioning, but how valuable to get it right using a pooled budget and common contract across seven CCGs and two councils.
The STP process acknowledges that much more prevention is needed through the NHS itself, and that the public is generally not sufficiently involved.Deputy Chief Executive
Practice around use of community equipment was very different between health and social care and the reutilisation of equipment was extremely inefficient.
Some areas took a more a proactive approach and did more on collection and recycling. Gradually, everyone has moved and developed a more robust and consistent approach to understanding what intervention makes a difference, reducing variation.
There has been a 10% rise year-on-year in the need for equipment since 2004. The budget for the service has remained at £7.3m for the last five years, but we have saved £1.1m on our budget spend. Due to the service model and efficiencies, the service actually handles between £25-30m of equipment each year, with 95% of equipment being recycled back into use.
This is not rationing, it is simple efficiency and recycling, and we have case study evidence.
This exemplar shows that despite this being hard work and involving tough discussions, and changing change cultures, if you monitor money and spend, and work with external providers, as well as motivating staff to get kit back for repair and renovation, the impact is huge.
Looking to the future
If STPs and ICSs prove to be successful, in five to ten years’ time the population will have benefited from the different strengths of the NHS and local government working together. The NHS has, for the past 70 years, been good at keeping us well and helping us live longer. Social care, when properly funded and working well, delivers person-centred, co-ordinated care with and for people with long term conditions or disability. We need to join this with other public services and interventions in the local place. Housing is crucial but so are other public services and the community and voluntary sector.
If STPs and ICSs prove to be successful, in five to ten years’ time the population will have benefited from the different strengths of the NHS and local government working together.Deputy Chief Executive
It will mean person-centred, coordinated care, and living well independently with long-term conditions. It will mean a system that aims to prevent illness, from primary to tertiary prevention, from childhood obesity to end of life care. It will mean a system that addresses the needs of informal carers, who are worth £120-139bn to the UK’s health and care economy.
The enablers and system design will have interdependencies around financial outcomes, performance and quality, so we’ will be looking at a whole system in a local place. And there must be a better balance between local and national bodies, supporting and enabling local responsibility, as well as accountability.
We need a clearer, longer-term plan for direction and funding, so we’re not lurching from spending review to spending review – we need the longer-term view on how this is to be paid for, operated locally. That is a huge issue for social care right now.