This document summarizes a presentation on integrated care and support given by representatives from NHS England and ADASS. It discusses the context of integration between health and social care services, identifies three "wicked issues" challenges to integration, and outlines next steps. Graphs and figures are included showing relationships between long-term conditions, costs of care, and the potential impact and cost savings of integrated models of care. The presentation addresses definitions of integration, evidence challenges, barriers such as information governance, and emphasizes the importance of person-centered coordinated care and building the capacity of patients to engage in self-management.

1. Integrated Care and Support
Martin McShane & Damian Riley – NHS England
David Pearson - ADASS
NHS Medical Leaders Conference
11 February 2014

2. Content
•
•
•
•
Context – “follow the money”
Integration – is it possible?
Three ‘wicked’ issues?
Next steps

3. Morbidity (number of ETGs) by age band
100%
90%
80%
Number of
conditions
70%
0
60%
1
2
50%
)
%
(
s
n
e
i
t
a
P
3
4
40%
5
6
30%
7+
20%
10%
0%
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Age band (Years)
3

4. £2000/head of
population
Gearing of investment across the system
Primary Care
£200
Comm/MH
£500
Public Health
Social Care
(H&WB Board)
Specialised
£300
NHS
England
Acute
£1000
CCGs
4

5. Gearing in activity into acute care
NHS Expo Seminar Domain 2
5

6. Year of Care Costs
6

7. Relationship between number of long-term conditions
and cost
LTC Year of Care Programme

8. Risk stratification versus no. of LTCs – do they select
the same patients?
LTC Year of Care Programme

9. Do Integrated Care teams change
service delivery?
LTC Year of Care Programme

10. 1990
2014
CARE GAP
GP
Specialist Specialist
Complexity
10

11. Integration is the answer to all our problems!
INTEGRATED CARE
Locality teams
Self-management
100%
Risk profiling
Third sector
provision
Long Term Condition
Management incl Cancer
Primary
Care
COMPLEX
CARE
PRACTICE
SHIFT
LEFT
Quality
of life
COMMUNITY CARE
Consultant-led
services
ACUTE CARE
Specialty Clinic
Specialist teams
???
Planned procedures
ICU
0%
£1
£10
Cost of Care per Day
£100
£1,000
£5,000
11

12. Problems for integration
•
Lack of common definitions and boundaries. For example: integrated,
coordinated or collaborative care, case management, continuity of care etc. The
Kings Fund (2010) found 165 definitions of integration.
•
Vertical and/or horizontal integration
•
Patchy evidence and lack of focus on patients
•Some evidence that certain integration models work but not clear whether
this is a consequence of applying the model as a whole, or whether the
same benefits can be achieved using only some of the components.
•Inconclusive evidence that collaboration between health and social care
improved service outputs and/or user outcomes.
•Difficult to prove causal link between various components of collaboration
and its effects.
•No national picture on integration but lots of case studies
•
Clinicians and commissioners convinced? When asked whether integration had
the potential to produce desirable outcomes, respondents to a BMA survey (2011)
answered as follows:
•Nearly half said ‘yes’ (47%)
•Nearly half said ‘don’t know’ (45%)
•The remainder said ‘no’ (8%)

13. A definition of integration
My
goals/outcomes
Communication
Person centred
coordinated care
Emergencies
“My care is planned with people who
work together to understand me and
my carer(s), put me in control, coordinate and deliver services to achieve
my best outcomes”
Information
Transitions
Care planning
Decision-making
13

14. The House of Care
Organisational
Organisational
& clinical processes
& clinical processes
Plan
Engaged, informed
Engaged, informed
individuals & carers
individuals & carers
Do
Health & care
Health & care
professionals
professionals
committed to
committed to
partnership working
partnership working
Person-centred,
Person-centred,
coordinated care
coordinated care
Study
Act
Commissioning
Commissioning

15. The House supports:
– Informational continuity: by which people and their
families/carers have access to information about their
conditions and how to access services; health and social
care professionals will have the right information and
records needed to provide the right care at the right time.
– Management continuity: a coherent approach to the
management of person’s condition(s) and care which
spans different services, achieved through people and
providers collaborating in drawing up collaborative care
plans.
– Relational continuity: having a consistent relationship
between a person, family, and carers and one or more
providers over time (and providers having consistent
relationships with each other), so that people are able to
turn to known individuals to coordinate their care.
15

16. The House of Care - Person centred, coordinated
care at three levels:
National:
What can national
organisations and policy
makers can do to enable
construction of the House
of Care at the next two
levels.
Local:
How local health
economies ensure that the
House of Care involves a
whole system approach,
including ‘more than
medicine’ offers
Personal:
How the House of Care
gives professionals on the
front line a framework for
what they need to do for
patients and ask local
commissioners to secure for
them

17. The House of Care in pounds p.a.
c.£5.5bn:
£0.4-0.6bn:
Avoidance of drug errors
Incentivised wellness
e.g. through electronic
programmes in healthy pop
records/e-prescribing (7)
& early stage LTCs inc.
smoking cessation, salt ↓,
exercise ↑(6)
Empower people in
supportive selfmanagement (4)
Shift activity to cost
effective settings
e.g. pharmacy minor
ailments (5)
Avoid ambulatory care
sensitive admissions
though e.g. following
NICE guidelines (1)
£2bn:
Reduction of hospital
admissions for common
LTCs through integrated care
esp frailty, cormorbid (2)
£0.2-0.4bn:
£1-1.6bn:
£1.2bn:
£0.8-1.2bn:
Reduce use of low value drugs,
devices and elective procedures
using commissioning analytics
and clinician education (3)

18. Long Term Conditions
18

19. A collaborative approach
•
14 national organisations* published ‘Integrated Care and
Support: Our Shared Commitment’ in May 2013, and
committed to:
 tackling barriers;
 encouraging innovation and experimentation; and
 enabling localities to make person-centred coordinated care
the norm
• 14 pioneers are helping to test the way
• Developing the evidence base and case for change
* NHSE, DH, LGA, Monitor, ADASS, ADCS, PHE, SCIE, TLAP, NV, NICE, CQC, NHSIQ, HEE

20. Information Sharing
• What are the real and perceived barriers to
information sharing?
– Information governance
– Patient owned records
– Integrated digital health record
– Care planning

21. Changing the nature of the conversation….the biggest
challenge?
21

22. The soft stuff…is the hard stuff
What we see
and attempt
to address
Individual
behaviours
Spe
t h e n d t im
poli profe e on
ss
tics
a n d io n s ,
pub
l ic
Mindsets
and beliefs
What we don’t
see and don’t
know how to
address
Values
Needs
(met or unmet)
SOURCE: Scott Keller and Colin Price, ‘Performance and Health: An evidence-based approach to transforming
your organisation’, 2010.

23. Investing in the capacity of patients
• Current model medical staff, tech and drugs create
value. QIPP 1 model was pay and provider efficiency.
• More of the same model will mean unsustainable
demands on staff.
• QIPP 2 – New model must build capacity of patients
to add value into the health system.
• Increasing contribution of 53m patients. All other
industries look do this (e.g. banks, supermarkets).
• Contribution of 3m volunteers in health and care
• Self management is key – increasing effectiveness of
patients 5800 waking hours vs few hours with NHS

24. Does the NHS measure what matters to patients?
Classic NHS measure
Outcomes that matter to patients
Quality of life
Finance
Process measures/waiting times
Being supported to stay well
Being treated with dignity and respect
Clinical information
Seamless and coordinated care
Patient safety data
Being supported to make decisions
Services that listen to feedback and
improve
24

25. Measuring Integration
• Patient/user experience of integrated care has been
a placeholder indicators in both the NHS and Adult
Social Care Outcomes Frameworks
• Balance between national comparability and
responsiveness to local populations
• Areas for indicators
– Transformation of individual outcomes and experience
– Transformation of local health, care and support systems
– Change in process including effective engagement of
housing and other services in local authority sector and
third sector

26. Panel Q&A
•
•
•
•
Where do you see the opportunities?
What do you see as the barriers?
What could we do to overcome these?
Who could we engage?
m.mcshane@nhs.net