Hugh ReeveWestmorland Primary Care CollaborativeNHS Cumbriahugh.reeve@cumbriapct.nhs.uk

Developing clinician-led integrated services

The NHS in Cumbria circa 2006

A health community at war A series of unhappy mergers that failed to address

fundamental issues Clinicians (and in particular doctors) completely

disengaged Community services fragmented, with proposals to

close community hospitals Finance and activity out of control – £36.7m

historic debt – £100m deficit projected over 5 years

Another merger created NHS Cumbria

Growing clinical leaders

Growing clinical leaders

Primarily all about culture change

Getting the right people on board Nurturing them Learning together – on the job, on study

trips, and in tackling wicked issues together Building trust across the team and earning

autonomy

A medical degree isn’t a leadership qualification

GPs leading in partnership with senior managers

PCT Board

Clinical Senate(6 GP Locality Leads, 2 Medical Directors, DPH, 5 Executive Directors)

Six Localities

Allerdale Carlisle Copeland Eden Furness South Lakeland(Each locality has developed a slightly different structure and approach to

suit local circumstances)

Localities are responsible for 60% of commissioning (97% from April 2011) and provide leadership for general practice and all community services.

Clinical Senate

CarlisleEden

FurnessSouth

Lakeland

Allerdale

Copeland

Business Support Services

Integration across primary care

Welcome to South Lakeland

DGH

DGH

600 square miles population of 110,000

Westmorland Primary Care CollaborativeDoing the right thing for our patients

Commissioning Group of 21 practices and community teams – national ICO pilot

Integrated primary care information systemEMIS webAllows bi-directional sharing of clinical record across the local health community 20 of 21 practices using EMIS (21st by Jan 2011) All community nursing teams Specialist community teams (including Macmillan nursing) Community wards Read only access to GP summaries by GP out-of-hours, and in

PCAS and two local A&E departments

Integrating care for older people – the journey so far

Well elderly

Vulnerable/At risk

Crisis

End of Life

Generally healthy, many with at least one long term condition. All living either

totally or fairly independently at home.

Significant physical and/or mental health problems. Living

at home, or NH/RH

Sudden, significant deterioration in health status. At home, NH or hospital.

Palliative & terminal care. Home, hospice, hospital.

Multi-disciplinary end of life care

Short -term interventions –acute care and rehab.

Wherever possible at home.

Proactive interventions to reduce risk and promote independence.

GP care, specialist community teams, day hospital, respite care.

Multi-agency interventions to maintain health and

independence. Normal GP care and wider health-promoting

initiatives.

Our model of integrated care for older people

Integration of care for frail older people First challenge – get a grip on a system out of

control: develop alternatives to acute hospital caremake it easy for clinicians to do the right thing actively manage the interface with acute care.

The medium term – develop services and programmes aimed at keeping people well and independent for as long as possible.

Partnerships between primary care, specialist health care (physical and mental health), social care, third sector, district council and other public services.

Getting a grip …

In three years we’ve gone from

GP referral

999 Ambulance

DGH

DGH

DGH

Care homes

Urgent Care Pathway before April 2008

Four options

Walk in

DGH

999 Ambulance

Short-term intervention service

(nursing/therapy/SW)

GP/other clinicianreferral

Community IVantibiotic service

Community respiratory team

Short-term urgenthome care

Communityurgent care

hub

Step-up Step-down

beds

Single point of access

Care homes

DGH

DGH

Liaisonnurse

Liaisonnurse

Primary care assessment service

Urgent Care Pathway Autumn 2010

Walk in

All Cat C, others diverted after discussion with PCAS

DGH

999 Ambulance

Short-term intervention service

(nursing/therapy/SW)

GP/other clinicianreferral

Community IVantibiotic service

Community respiratory team

Short-term urgenthome care

Communityurgent care

hub

Step-up Step-down

beds

Single point of access

Care homes

DGH

DGH

Liaisonnurse

Liaisonnurse

Primary care assessment service

Urgent Care Pathway Autumn 2010

Walk in

All Cat C, others diverted after discussion with PCAS

One option

WPCC – the financials To deliver this we needed to release resources

£83m ‘hard’ budget for current year (60% of total PCT budget), with accountability devolved by chief executive to locality level

September 2010PBR expenditure in Sept 2010 £613k less than in

Sept 2009Prescribing: forecast year end under spend £538k

(-3.2%) on a prescribing budget of £17m (that was reduced by 1% on 09/10 budget)

Community services budget in balance

600

650

700

750

800

850

900

950

1000

1050

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

2008/09 2009/10 2010/11

SOUTH LAKES TOTAL PBR NON-ELECTIVE INPATIENT SPELLS

Actual Trend

4.6% reduction over 2 years

SOUTH LAKES TOTAL PBR NON-ELECTIVE EXCESS BED DAYS

0

200

400

600

800

1000

1200

1400

1600

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

2008/09 2009/10 2010/11

Actual Trend

26.5% reduction compared to last year

200

250

300

350

400

450

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

2008/09 2009/10 2010/11

SOUTH LAKES TOTAL PBR ELECTIVE INPATIENT SPELLS

Actual Trend

No growth last 18 months

600

650

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800

850

900

950

1000

1050

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

2008/09 2009/10 2010/11

SOUTH LAKES TOTAL PBR DAY CASE SPELLS

Actual Trend

4% increase over 2 years

1500

1700

1900

2100

2300

2500

2700

2900

3100

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

2008/09 2009/10 2010/11

SOUTH LAKES TOTAL PBR OUTPATIENT FIRST ATTENDANCES

Actual Trend

30% reduction over 2 years, 16% last year

(only 6.7% growth over last 12m in OP procedures)

3000

3500

4000

4500

5000

5500

6000

1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112

2008/09 2009/10 2010/11

SOUTH LAKES TOTAL PBR OUTPATIENT FOLLOW UP ATTENDANCES

Actual Trend

26.2% reduction over 2 years

Prescribing costs per prescribing unit 2008-2010

-26.1% -22.8%

Reflections Short-termism, over-analysis and procrastination

Last three years about getting a grip … the next five about delivering great healthcare consistently

Clinically-led integration: primary care and specialty clinicians in partnership clinical leaders (not clinical managers) who

understand the system, data and financial flows while staying in touch with patients

support and partnership of high-quality managers who believe in clinical leadership.

Integration v competition Complex care needs full integration across the

system, working within a single programme budget Competition risks duplication, inefficiency, added

expense, and leaving gaps in pathways of care

Getting the incentives right Patients are not ‘products’ that generate a profit PBR leads to hospitals and clinical teams being seen

as profit centres Incentives for all clinicians and teams – equalise the

incentives across the system

Keeping control by letting go

Thank You

hugh.reeve@cumbriapct.nhs.uk