Transcript Integration Health and Social Care

Integration Health and Social Care
Jennifer McGovern – Assistant Director, Integrated Commissioning
GM Heath & Social Care Reform
GM Public Service Reform programme
Aging Population
Skills and
Worklessness
Reducing demand for
generations
Transforming
Justice
Early Years
X
Turning off the
dependency tap at
source
Reducing demand today
and tomorrow
Reducing demand
today
Troubled Families
Health & Social
Care
Better outcomes, lower
cost
Better outcomes, lower
cost
SAVINGS
Re-investment of resources across partners
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Salford’s Integrated Care Programme
Promote independence for
older people, delivering:
1. Better health and social
care outcomes
2. Improved experience for
services users and carers
3. Reduced health and social
care costs
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High demand and rising
34,541
people aged
65+, 28%
projected
increase
Growth in
limiting
long-term
illness
1: 14 have
dementia and
over-represented
in acute beds
Growth in people living alone:
12,542 in 2011 to 15,998 in 2030
Disability-free life
expectancy
2,130 falls
related A&E
attendances
Population Stratification
Salford’s Integrated Care Programme
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1
Local community assets
enable older people to remain
independent, with greater
confidence to manage their
own care
Promoting independence
for older people
2
 Better health and social
care outcomes
 Improved experience for
services users and carers
 Reduced health and
social care costs
Centre of Contact
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acts as an central health and 2
social care hub, supporting
Multi Disciplinary Groups,
helping people to navigate
services and support
mechanisms, and coordinating
telecare monitoring
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Multi Disciplinary Groups
provide targeted support to
older people who are most at
risk and have a population
focus on screening, primary
prevention and signposting to
community support
2020 targets – what and why?
Emergency admissions and readmissions
• 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn)
• Reduce readmissions from baseline
• Cash-ability will be effected by a variety of factors
Permanent admissions to residential and nursing care
• 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn)
• Savings directly cashable but need to be offset by cost of alternative care (especially
increased domiciliary care)
Quality of Life, Managing own Condition, Satisfaction
• Maintain or improve position in upper quartile for global measures
• Use of a variety of individual reported outcome measures
Flu vaccine uptake for Older People
• Increase flu uptake rate to 85% (from baseline of 77.2%)
Proportion of Older People that are able to die at home
• Increase to 50% (from baseline of 41%)
Cost reductions (work-in-progress)
Forecast spend ~£100m+ on care for older people of which c. 50% (£48.3m) from SRFT
Need to account for primary care/GP practice expenditure
65+ population projected to grow by 24% by 2030
Significant cost reductions already required by each partner
26% reduction in
permanent care
home admissions
• 84 admissions
avoided
• £1.57m value
(cashable)
Reduction in
care home
admissions
Reduction in
hospital
admissions
19.7% reduction in
emergency hospital
admissions
• 2071 admissions
avoided
• £8.63m value
(part cashable)*
* Only a subset of this will be releasable due to the fixed and semi-fixed costs within the hospital.
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Financial context and implications
Current spend: ~£100m on care for older people (£48.3m from SRFT)
65+ population projected to grow by 24% by 2030
Significant cost reductions required by all partners
• Status quo is unaffordable and
unsustainable
• Economic risks and benefits not
equitably shared by partners
1
• Integrated care solutions are more
cost-effective than the status quo
• Three categories of £ benefit
– Reduction in admissions (hospital, care homes)
– Removal of duplication and fragmentation
– Reducing future demand
2
• £ benefits need be set against
– Cost of new delivery models
– Growth in population and associated demand
– Existing savings plans
3
• Integrated care is likely to create
costs before it generates savings
• Not a quick fix but the most credible
and sustainable solution
• Support and mitigate adverse
consequence of cost reductions 4
• New contractual and financial arrangements will be required
5
(section 75 / Alliance Agreement / JV)
• Modelling assumptions to be refined and tested through pilot work
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Risk and benefit sharing
“Provider income reductions … should be based on an ability to
reduce costs … the rate and pace of income reduction should …
be equal to the realisable reduction in marginal and fixed costs”
Some costs will remain fixed
during the duration of the
Programme and there is likely to
be a time-lag between change
and cost reduction.
“All parties are required to demonstrate ‘best endeavours’ to
deliver the agreed cost reductions … If resolution cannot be
agreed by the Board or the resolution is not actioned … then
standing contractual arrangements … will apply after 12 months
notice of the deadline passing”
BUT not an excuse to maintain
the status quo
“Some parties within the Partnership have separate contractual
arrangements with third parties which are governed by
separate commercial arrangements.”
And some costs can be extracted
at the same rate that demand is
reduced
“Cost reduction, income loss and any reinvestment will need to
be reconciled … cashable savings will be reinvested in care for
this population. If savings exceed the predicted growth in
demand, the Integrated Care Board will agree appropriate
benefit sharing arrangements.”
Benefits and risks need to be
shared, recognising that
underlying demand may limit
cashable savings
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As-is (traditional contracting)
DIFFICULTIES FOR INTEGRATED CARE
• Changes difficult to enact; multiple parallel
negotiations between commissioners and
providers
Commissioner(s)
• Focus on individual institutions rather than
the continuum of care
P
P
P
P
P
P
• Payment systems are different in different
sectors; no mutual incentives to work
together
• Limited mechanisms to move resources
between services / providers
• Providers primarily rewarded for treating
service users not improving outcomes
• Short term contracts provide limited
incentives to invest in longer term outcomes
Contracting models
• As-is (do nothing option)
• Informal network - profit/risk
sharing
• Accountable Care Organisation
• Integrated Care Hubs
• Prime contactor and
subcontracting model
• Single Integrated Care
Organisation
• Joint Venture with Joint
Management Board of providers
• Alliance Agreement
Prime
Contractor
 The commissioner(s) hold one contract with
one provider which has full accountability for
the care model
 The prime contractor subcontracts some
provision to other provider organisations
 The Prime Contractor determines any risk and
benefit sharing arrangements with
subcontractors
Joint
Venture
 Collaborative approach between providers,
promoting joint ownership of outcomes and
accountability, and shared risk
Alliance
Agreement
 Variant to the traditional Joint Venture
 Collaborative approach with all organisations
(commissioners and providers) sharing
contractual responsibility and risk
 The emphasis and focus is on the joint
ownership and responsibility for agreed
outcomes
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Alliance Agreement
Lead Commissioner
 Collaborative environment without the
need for new organisational forms
P
P
P
P
BENEFITS
 Full range of services within a single
management arrangement – more
effective, efficient and coordinated care
P
P
• CCG, City Council, SRFT, GMW
• Health, social care & wellbeing for 65+
(may excl. specialist & elective surgical services)
• Some services subcontracted or directly
contracted by commissioners
• General Practice or other parties could
be incorporated
• Phased introduction from 2014/15
 Aligns interests of commissioners and
providers, removing organisational and
professional ‘silos’ that contribute to
fragmented and sub-optimal care
 Collective ownership of opportunities
and responsibilities; any ‘gain’ or ‘pain’
is linked to performance overall
 Supports a focus on outcomes and
incentivises better management of
population demand
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Alliance Agreement
SCOPE OF THE AGREEMENT
• Population / client focus
• Proposed strategic partners
• Service content
• Aims and improvement measures
• Decision-making principles
• Management arrangements
• Payment options
• Commercial terms
• Pace of change
1 Management  How should services within the Alliance be
arrangements
managed and governed?
2 Payment
 What payment mechanisms should be
considered?
options
 How should income be distributed between
providers?
3 Commercial
 What duration should be considered for the
contract?
terms
 How should financial risks and benefits be
distributed between parties?
4 Pace of
 Do you support the proposed commencement
of the Alliance Agreement in 2014/15?
change
 What elements should be implemented from
the outset and which should be introduced on a
phased basis (and over what time period)?
Better Care Fund (1)
• £3.8 billion national funding to deliver closer integration between
health and social care (est. £20m for Salford)
• “Single pooled budget for health and social care … based on a plan
agreed between NHS and local authorities”
– Transform health and social care
– Deal with demographic pressures in adult social care
– Support significant expansion of care in community settings
• Funding subject to national conditions and an element will be
performance-related (est. £5m for Salford)
• Each locality to submit an investment plan by 4th April 2014, setting
out plans for 2014/15 and 2015/16
Better Care Fund (2)
• Proposed that the BCF forms part of the Alliance ‘pool’, so that
BCF investment supports PSR and integrated care plans
• Aligned to priorities in the Joint H&WB Strategy
• BCF (and pooled budget) to fund:
–
–
–
–
costs associated with the new integrated care model
capacity in community services and to ‘protect’ social care
implementation and change management costs
cost pressures and savings targets
• Plan was developed in partnership with SRFT and GMW
• Plan needs to be approved by the CCG and Council and endorsed
by the Health & Wellbeing Board
Better Care Fund (3)
• Plan Assurance – High Ambition, Low Risk
• High Ambition?
 Fully integrated partnership of Health and Social Care
Commissioners and Providers
 Scale and scope of service integration
 Alliance provides strong financial, governance and contractual
framework
 Is it easy?
 Is it worthwhile
• Low risk - Careful, stepped progression
Future direction of travel
• In principle decision to the further integration of commissioning
across Salford CCG, Salford City Council and, if possible, others
• Absolute commitment to the further integration of adult health
and social care for the benefit of the population
• Strong role for providers in the delivery of integrated care,
building on the track record of partnership working
• Ambition to progress Salford’s Integrated Care Programme at
greater scale
Conclusions
• Significant progress is being made through the Integrated Care
Programme – a Salford focus, but part of a wider GM programme
• The new model will be rolled-out, city-wide, from April 2015, with a
focus on enabling older people to retain their independence
• A key element is the use and expansion of local community assets
• It will be underpinned by an Alliance Agreement and a pooled budget,
incorporating the Better Care Fund (AA = £98m, BCF = £20m)
• This work is being done in partnership with the Health & Wellbeing
Board, which will have responsibility for endorsing the BCF plan
• The direction of travel is for further integration of both commissioning
and provision