In common with other health and social care systems, Lambeth and Southwark face mounting pressure and costs as people live longer and their health and social care needs grow more complex.

When we started work on our integrated care model 18 months ago we knew that, although the quality of care was often good, it was fragmented and patients found it hard to navigate the system. We felt we could have much better impact on people’s health, independence and experiences of care if we worked together to identify and respond to people’s needs earlier, and coordinate care across our organisations.

Aligning incentives

The key aim of our programme is to improve outcomes for local people, within the funding we have got. So we started redesigning pathways from the start, to impact on patient care as soon as possible. This has given a focus for conversations with local people and professionals, and allowed us to build trust and demonstrate words being put into action.

This has been important, not only for individuals’ outcomes, but also for commissioners and providers. Partners from across primary, acute, community, mental health services and social care worked together with a group of local people to develop ways of keeping the 50,000 older residents of Lambeth and Southwark healthier and more independent. The fact that social care has participated in our programme from the start has been critical to our improvements for local people and also to our business case. The new elderly care model is explained later in this article.

However we also knew we needed to work on aligning how we worked together as organisations, to make our new pathways sustainable. Too often in the NHS, schemes fold when the enthusiasts move on. We therefore have significant areas of work covering joint governance, IT, finance and workforce, with the aim of making it easier for the system to work together and support redesign.

The new system is based on cross-sector boards, with members participating as equals and holding each other to account in terms of delivering change and outcomes. The model is not about creating an entire new organisation but getting agreements between existing organisations and permission from them to move money around the system.

We have looked at the real cost of patient care across the health and social care pathway (not just costs to commissioners) and agreed to move money around to achieve better outcomes. The total cost of changes to our pathway for older people is £6.8 million per annum, totalling nearly £21 million over three years, of which £4.5 million pump-priming funding has come from the Guy’s and St Thomas’ charity. But the business model is such that, in three years’ time, changes will be self-sustaining, with annual savings of up to £13.9 million across the health and social care systems as fewer hospital beds and residential placements are needed. Funding arrangements transfer spend from acute and long-term social care, reflecting reduced acute activity and care home placements in years two and three.

In the longer term, we aim to align the financial incentives for all providers more closely. The way care is contracted separately with different providers, under block contracts or payment by results, does not incentivise us to work together. Providers are not encouraged to plan together to improve quality of care along the pathway or change investment to achieve this. That’s why we are currently doing early research work to look at how we could introduce a capitated budget for our local population.

New IT

We are looking to spend £2.77 million on IT over three years, to create ways of joining up our information on local people. We are trying not to go too big and are being pragmatic in finding a solution for the medium term. It will be a system that will join the existing IT systems together but will not be a ‘big bang’ single patient record. It will mean that people involved in an individual’s care – GPs, social workers, A&E clinicians  – will be able to view certain records from each others’ systems at any time.

We are talking to companies that have already achieved this kind of functionality in other places and getting as much engagement as possible from the people who are going to be using the software.

CCGs and GPs as providers

Of course since the boards’ inception CCGs have been introduced but this has been relatively easy for us as the CCG chairs have been involved with the project from the start. It’s been really important to us to
have all GPs on board from the beginning, as commissioners but also as providers, as we design and introduce new community pathways. We have made a lot of effort to go out and talk to individual practices as well as inviting them to meetings and early design workshops, and communicating regularly through the CCGs.

The new elderly care model

Design workshops were held to determine a new pathway for elderly patients. The discussions of 40 health professionals were shaped by the advice of a user group, put together and facilitated by Age UK.

The model covers prevention through to hospital discharge and reablement. The emphasis is on preventative interventions in the community to reduce the reliance on residential and hospital care. By the end of the third year of implementation, we aim to reduce emergency hospital bed days by 15,400 (14 per cent) and residential care placements by 118 (18 per cent).

Prevention

A significant part of the pathway is a £1.2 million local enhanced service for 99 GP practices to provide health checks for half of over-65s and to designate a member of their team – often practice nurses – to be case managers called ‘integrated care managers’.

We wanted these new posts to be held within general practice, so practices feel they are really part of their team, and to support practice leadership in the system. These will join new community multidisciplinary (CMDT) teams that include community matrons, social workers, community mental health representatives and geriatricians. The integrated care manager holds the relationship with the patient and represents their views and needs in CMDT meetings.

The CMDT reviews high-risk patients using risk-stratification software and identifies other patients using information from the integrated care managers or community matrons.Home care workers from social services, already seeing dependent people in their own homes, will be trained to spot deterioration and report this to practices.

Alternative urgent response

To reduce inappropriate admission to hospitals, we have created a number of alternative acute responses.

A patient can be referred to a ‘hot outpatient clinic’ at the hospital where a geriatrician will assess them on the same or next day. They can be referred there by their GP or from A&E. Patients needing help with IV antibiotics, catheter care, subcutaneous hydration can be cared for by community services.

To reduce long-term placements in care homes we have greatly expanded reablement. This is a rehabilitative type of home care, free for up to six weeks. Home care workers work with therapists so that people are supported to re-learn the skills to look after themselves at home.

Next steps

We are at the stage where we have defined what can work and what this means for local people and individual organisations. We have started to monitor outcomes and costs for the new older people pathway so we can start to make ongoing improvements. The overall integrated care model is being evaluated by Picker, RAND Europe, HSMC Birmingham, the LSE and the King’s Fund.

We can see trust being built up, and discussions are taking place about how the system can work better for patients. We are now starting on our next pathway, for adults with long-term conditions, which will have a particular focus on supporting people with co-morbidities. Improving outcomes for and with
local people is at the heart of what we are doing
and we believe we’re creating a better system to achieve this.

60-second summary

⦁ Initiative An integrated care model that pulls together existing organisations to improve outcomes for local people. Cross-organisation boards including acute, acute & community and mental health trusts, community services, primary care and social services have been established that agree pathways for patients and hold each other to account in terms of outcomes and delivery. The first pathway agreed on is for older people’s care, which involves a £1.2 million LES to health check 25,000 patients, introduce care managers in primary care and set up community multi-disciplinary teams.

⦁ Costs The integrated care model for older people will cost £6.8 million per annum, totalling nearly £21 million over three years, of which £4.5 million pump-priming funding has come from the Guy’s and St Thomas’ charity. 

In three years’ time objective is for model to be self-sustaining, as annual savings will be some £13.9 million.

The project is being evaluated by Picker, RAND Europe, HSMC Birmingham, the LSE and the King’s Fund.

⦁ Savings By the end of the third year of implementation, hospital bed days should have fallen by 15,400 (14 per cent) and residential care placements by 118 (18 per cent).

⦁ Contactwww.integrated careprogramme.org