sara shaw: the trafford integration story

THE TRAFFORD INTEGRATION STORY

Progress to date and future challengesg

SARA SHAWSenior Fellow, Nuffield Trust

t: 0207 631 8450e: [email protected]

www.nuffieldtrust.org.uk

OVERVIEWOVERVIEW

• Nuffield work with Trafford– 15 months– In‐depth case study– ‘Critical friend’

• Tracking and telling ‘the story’– Work in progress– Three phases– Key challenges for Trafford to respond to



DRIVERS FOR INTEGRATION • History of financial problemsproblems

• Rise in acute admissions and GP workloadand GP workload

• Managing long term conditionsconditions

• 2008: new PCT strategy

• Integration = way forwardIntegration = way forward

• End of ‘invest to save’



PHASE ONE: PLANNINGPHASE ONE: PLANNINGJanuary 2008 to March 2010

SHAPING INTEGRATED CARE• September 2008

First (of five) Clinical Congress events– First (of five) Clinical Congress events

– Mandate for developing new integrated approach

– Development of ‘office medicine’Development of office medicine

• Evidence + international models of care– Kaiser, Inter Mountain, GeisingerKaiser, Inter Mountain, Geisinger

• Strategic context (SHA, DH, TCS)

• Communication and engagement (ongoing)Communication and engagement (ongoing)



SIX FOUNDING PRINCIPLES1. ‘Nothing about me, without me’

2 General practice should be ‘locus of integrated2. General practice should be locus of integrated services’

3. Consultant opinion is an essential component of3. Consultant opinion is an essential component of effective integrated services

4. The delivery of integrated services will primarily rest on extended roles for nurses and AHPs

5. Integrated services must incorporate social care

6. Future integrated services should bring together the full range of primary care



MEDICINE AND SURGERY ARE DIFFERENT

ACUTE

HORIZONTAL

INTEGRATION

HORIZONTAL

INTEGRATIONACUTE SURGERY

Increased use of TGH site for NHS activity

l d hi h Enabled throughACUTE

MEDICINE

presently done at high cost in the private sector and potentially through service‐level

Enabled through the creation of a new organisation and full

OFFICE MEDICINE

gmergers engagement with

primary care producing a shift in activity

FAMILY MEDICINE

VERTICAL

INTEGRATION

VERTICAL

INTEGRATION

in activity

MEDICINE INTEGRATION

• February 2009 PCT B d i ff i t t d t t– PCT Board sign‐off integrated care strategy

– Funding for development of a business case

d l ‘ h l ’– Agreement to deliver ‘whole economy’ CIPs

• November 2009– SHA supports the concept of ‘integrated care’

– Rethink required in terms of funding and pace of implementation



• April 2010– ‘Proof of concept’ year beginsp y g

– Reworked plans, guided by founding principles

– Supporting eight work streamspp g g

– Over one year (and beyond?)

– £2m funding from PCT

• Shifting language/approach– Integrated Care Organisationg g

– Integrated Care System



Integrated Care1. Data sharing, population risk

managementIntegrated Care System

management2. Clinical panels and compacts3. Medical services redesigng4. Surgical Redesign5. Patient experience and

coordination6. Leadership and quality

ImprovementIntegrated

Care

Improvement7. Programme support and

evaluationCare Organisation

e a uat o

PLUS

8. Vertical integration

PHASE TWO: IMPLEMENTATIONApril 2010 to March 2011

PROGRESSING INTEGRATIONPROGRESSING INTEGRATION• April 2010 onwards

– Continue to develop ICO and supporting systems

– Develop governance structures

– Engage stakeholders, in Trafford and on the borders

– Develop ICO business plan• for submission to NHS North West under Transforming C it S iCommunity Services

• for NHS Competition and Cooperation Panel



OVERVIEW

GOVERNANCE

ICS MANAGEMENT BOARDChair, Chief Executive NHS Trafford

Formal decision‐making group

REDESIGN GROUPChair, GP/PBC LeadFocused on detailed

CLINICAL BOARDChair, PCT Medical DirectorOverseeing clinical panelsFocused on detailed

local system development and the disposition of surgical services

Overseeing clinical panels, clinical governance,

education & training, quality improvement and patient

Advisory

STAKEHOLDER BOARD

gacross Trusts

p pempowerment

STAKEHOLDER BOARDChaired by PCT Chair

Underpinning partnership forum

CLINICAL BOARDthe most powerful body in the ICS linking the panels directlythe most powerful body in the ICS... linking the panels directly

with the whole group incentive scheme, or professional dividend

Multi‐disciplinary team panels with resource

General surgery

Orthopedics

Urologywith resource allocation powers and standards authority –

Diabetes Urology

Gynecology

Colorectal

ENT

End of Life Careoverseeing the move from

‘outpatients’ to Unscheduled Care

Mental Health

End of Life Care

Cardiology

Cancer Careoffice medicine, and offering

collegiate process t l

Respiratory Pediatrics

Ophthalmology

control Rheumatology

Six panels in ‘proof of concept’ year ....... another 18 to follow

Example – End of Life Care• Four work streams centred on lung cancer and COPD • Aim: to reduce deaths in hospital by 10% by April 2012

– Develop operating manual for appropriate delivery of EoL care assessment and intervention across Trafford.

– Provide clear guidance on content of intervention, training requirements for staff, patient and family information, documentation and information sharing

• Identified cohorts via vanguard practices • Testing with patients (home, hospital, care homes) from

January 2011• Mix of qual/quant measures: admissions/cost, sharedMix of qual/quant measures: admissions/cost, shared

information, administrative time



VANGUARD PRACTICES

• 9 practices

• 90,000 population

• Laboratory for ‘testing’ integrated approach

• Wrap around community basedcommunity‐based teams

• Identifying cohortsIdentifying cohorts of ‘high risk’ patients

SUPPORTING OFFICE MEDICINE

• 4 neighbourhood teams4 i h i l• 4 community hospitals

• 10 community physician sessionssessions

• 7 days p.w. telephone advice• 5 Community matrons• 2 Advanced Nurse

Practitioners• 1 ti / 60 t l h lth• 1 practice / 60 telehealth

units



• May 2010– First cohort: Advanced Training ProgrammeFirst cohort: Advanced Training Programme focused on leadership and quality improvement

– Set up ‘patient experience’ monitoringSet up patient experience monitoring

• October 2010Second ATP cohort– Second ATP cohort

• January 2011– Begin reviewing outcomes



FUTURE CHALLENGES

CONCLUSIONS SO FAR• A great deal has been achieved through strong clinical

engagement and leadership development• ICS id b t f d ti th t t• ICS provides robust foundations that appear to

accommodate changes• Reinforced through a programme of quality improvement

d dand service redesign• Significant issues persist around QIPP/financial balance• Progress with ‘proof of concept’ has been slower thanProgress with proof of concept has been slower than

anticipated but is speeding up.• Plans for ICO ‘on hold’, awaiting SHA decision• T d li t f ti i t t li• To deliver transformation, a more consistent policy

framework is needed to encourage integration and provide clarity and direction



5 PRACTICAL CHALLENGES5 PRACTICAL CHALLENGES1. What goes in shapes what comes out: how can Trafford

ensure good data quality / pop’n management? g q y / p p g

2. What shifts in utilisation and finances are expected in Trafford as a direct result of integration? Will integration deliver QIPP agenda?

3. How/when will the system roll out across Trafford? (e.g. ll ti ll li t d i li t )all practices; all generalists and specialists)

4. What are the opportunities and threats to integrated care from the emerging GP Consortium?care from the emerging GP Consortium?

5. Is there a Plan B?



5 POLICY CHALLENGES1. How is it possible to deliver a new relationship between

GPs and physicians in the present ‘choice’ environment?GPs and physicians in the present choice environment?

2. What is the ‘best’ means of delivering population‐based

i ? (PbR it t d b d t )services? (PbR vs capitated budgets)

3. What are the implications of a new GP contract?

4 A t bilit A th it h t i i ?4. Accountability vs Authority – what is going on?

5. What is the impact of:New role for local authorities– New role for local authorities

– Coalition government/politics



www nuffieldtrust org ukwww.nuffieldtrust.org.uk


sara shaw: the trafford integration story

Health & Medicine