Elaine Mead, Chief Executive, NHS Highland and Dr Adrian Baker, a GP in NHS Highland provide the background as to why they integrated health and social care services in their area and why they concluded that a radical structural reform was the way forward. They also explain some of the pre-work that they tested, the experience they gained from elsewhere, and where they are now. They also share some of the challenges that they faced and how they dealt with those things that they did not quite anticipate. See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources

1. Integrating Care in the
Highlands:
our story so far

2. Intro Film Clip

3. Integrating care in the Highlands
our story so far
Adrian Baker, GP
Elaine Mead, Chief Executive

4. Integrating care in the Highlands:
About a journey from 2005

6. NHS HIGHLAND (Highland Council and Argyll & Bute Council Areas)
Actual and projected number of people aged over 75: 1981 to 2031
Source: General Register Office for Scotland
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000

7. Why did we need to integrate care?
• High level of delayed discharges
• Early (young) admissions to care homes
• Lack of alternatives to hospital admission
• Unnecessary and avoidable admissions
• Limited care at home access
• Lack of ‘joined-up’ services

8. New admissions to care home
75.4
75.9
75.7 75.8
76.3
72.5
73.2
73.7
73
73.4
70
71
72
73
74
75
76
77
2008 2009 2010 2011 2012
Average age at admission
Scotland
Highland

9. What do people want?
• Maintain good health
• Maintain independence
• Prevent unnecessary hospital admissions
• Support carers to care
• Stay in their own homes for as long as
possible

10. Cost and quality of experience
Independent
Supported self care
Care at Home
Hospital at Home
Community Hospital
Residential Care
Acute Hospital Care
BetterExperience
IncreasingCosts

11. Journey of dependence
• Home Care £6K / pt /year
• NHS 24 = NHS Direct £36.67 / call
• OOH contact £68.00
• GP in hours contact £30.00
• District nurse £40.89
• A&E £92.50
• Admission (Ave 10 days) £2,784
• Long stay care £20K to £40K+

12. Integrating – what?
Acute
Health
3rd Sector,
voluntary
People
Community
resilience
Health &
Social

13. Integrating health & social care
2005 2011-12 2020

14. Integrating health
2005 2011-12 2020
Unscheduled Care
Anticipatory
Polypharmacy

15. Whole system flow

17. A&E waits
• A&E waits compromised when no flow
• Medical admissions redirected through
A&E
• Trauma space compromised
• Patients waiting on trolleys
• Long minor patients waits

18. Actions in hospital
• Acute physician
• AMAU (assessment not admission)
• Nurse call triage
• Focus on planned date of discharge
• Reduce bed stays for tests
• Reduce medical outliers
• Maximise community hospitals

19. Percentage Compliance with the Four Hour Target: July 2007 to March 2013
NHS Highland and NHS Scotland
NHS Scotland
NHS Highland
88%
90%
92%
94%
96%
98%
100%
Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan-12 Jul-12 Jan-13
Month
Percentageofpatientsspendinglessthanfour
hoursinA&E

20. Nairn Town and County

21. The Gatekeeper and the Wizard: a fairy tale.
(Br Med J 1989;298:172-3)
“The wizard asked the Minister for bigger and better
crystal balls and more powerful magic potions. But it
was no good….”

22. Healthy Aging

23. Lots happening
• SPARRA
• Casefinding
• Anticipatory Care
• Polypharmacy
• Hospital at Home
• Community Hospitals
• Virtual Ward
• Unscheduled Care – Flow 5!

24. Nairn Case Finder
2006/07 Nairn Cumulative Emergency Bed days
5%=44%
List
BedDays
100%
100%

25. Anticipating

26. The Anticipatory Care Plan (ACP)
• Carer or Cared for status, what happens ?
• Acute medical problem
• Acute surgical problem
• Discussion of condition by professional
• Preferred Place of Care
• Resuscitation status

27. Homework
• Power of Attorney
– Welfare – who do you want to decide on this?
– Finance – who do you want to have control of
your financial affairs?
• Will – do you have a will?
• Do you have a Living Will and if so who
knows?

28. The Numbers
• Initial study 2005-8 100 patients and 100 controls
• 15-16% mortality rate in the year.
• Survivors, 42% fewer admissions (P = 0.002)
• 52% fewer bed days (P = 0.020)
• The cost of hosptialisation of the study population was
reduced by 50%. (P = 0.029)
• The control population had 11 patients die in hospital,
the study population had 3 deaths in hospital (P = 0.007)

29. At scale for >5,000 patients
• By 31st March 2011, 5,329 patients who had received
ACPs, demonstrated:
– 29% reduction in emergency new admissions, and
– 47% reduction in occupied bed days.
• Patients with a SPARRA score of ≥ 50% but no ACPA in
place showed:
– 59% increase in emergency new admissions,
– 63% increase in occupied bed days

30. Impact
• For end of life care there is more chance of
dying at home rather than in hospital if a ACP is
in place.
• In the practice, there are less chaotic home
visits, more structured and organised times with
families and less work regarding crisis
guardianship cases.

31. Lillian – Our Highland Esther

32. Small tests of change
Gaining 2 beds for £3K a month
DD days in Hospital and Community, Nairn, 2007 - 11
0
20
40
60
80
100
120
140
160
180
200
Apr-07
Aug-07
D
ec-07
Apr-08
Aug-08
D
ec-08
Apr-09Aug-09
D
ec-09
Apr-10
Aug-10
D
ec-10
Apr-11
Aug-11
Date
DD'spermonth
DD's in Hospital
Ave LOS pre 70h
Ave LOS post 70h
DD days in the community

33. Frailty / Dementia Trajectory
Function
Decline in ADL’s &
Memory
Death
First Acute
Problem
TIME 3-10 years
Unable to
self care
High
Low

34. A Highland Huddle

35. Dementia Film Clip

36. Carers

37. Percentage of last 6 months of life spent at home or in a community setting
2 3 4 5 6
NHS Highland
SCOTLAND
89.0
89.5
90.0
90.5
91.0
91.5
92.0
92.5
93.0
93.5
2006/07 2007/08 2008/09 2009/10 2010/11
% of last six months of life spent at
home or in a community setting

38. Trend in care home places for older people, 1999/00 to 2011/12
1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11
NHS Highland
SCOTLAND
0%
20%
40%
60%
80%
100%
120%
1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12
Care Home Places for Older People

39. Trend in bed days by type of admission,
Highland residents 2001 -2012

40. Changing Landscape

41. • These things had and continue to have an
impact…
BUT
It won’t be enough

42. to make it better for the
people of the Highlands
Commitment

43. Integration of Services
“Banish the artificial divide between health
and social care and involve charities,
social enterprises and community groups
more closely in service provision.”
Scottish Older Peoples Assembly, 2010

44. Ambition to devolve decision making to
integrated front line teams
Single management and single budget for
ALL health & social care in a locality

45. Lead Agency approach
• NHS Board and the Highland Council moved to
explore the benefits of a lead agency model
• NHS Highland - Older adults
• The Highland Council - Children’s services
• CEOs committed to STOP if any identified
detriment to adults and children as a result
• Agreement made in December 2010 with plan to
go live April 2012

46. Statement of Intent
“We will improve the quality and reduce
the cost of service through the creation of
new, more simple organisational
arrangements that are designed to
maximise outcomes.”
The Highland Council & NHS Highland
16 December 2010

47. Scale of change: some numbers
• Social care staff to NHS Highland = 1,500
• Budget to NHS Highland = £90m
• Health staff to Highland Council = 250
• Budget to Highland Council = £8m
• Buildings occupied under licence to NHSH
• Partnership Agreement = 400 pages

48. March 2012
Partnership Agreement signed

49. “Merger not a take over”

50. NHS Highland now delivers care:
• In hospitals
• In care homes
• In the communities, and
• At home
For patients and clients across the north of
Highland

51. Working closely with Argyll and Bute Council
to develop a model to support integration
of adult care in this area

52. But our journey continues
• Working to change culture & attitudes
• Developing shared language and
approaches
• Working across boundaries ……

53. Lots of opportunities
• RNI Community
Hospital
• Mackenzie Centre
• York Day Hospital
(Inverness)

54. Film clip

56. Working with the third
and voluntary sector

57. Maximise
use of
technology

58. Building community resilience

59. Integration, integration, integration
2005 2011-12 2020
StructuralChange
Re-designWork ……………………
Re-designWork
Re-designWork
Third and voluntary sector
Community resilience
Partners in care
IntegratingHealth

61. Family &Friends
Care Home
Day Services
Acute
Hospital
Neighbours
Home
Carers
Respite
Care
Physio
GP
Day
Services
Consultants
Residential
Care
Social
Workers
Pharmacy
District
Nurse
OT
Voluntary
Community
Hospital
Care Co-
ordinator
Communities
3rd Sector
A new model
for care and
caring

63. Film clip

64. And our last message ?
It is not hard!

65. It is really hard …

66. But it is worth it

67. Thank you