Developing an Integrated Care Organisation / Accountable Care System in Salford 15 December 2015 Jack Sharp Executive Director of Service Strategy & Development Salford Royal NHS Foundation Trust

2 Salford Together Partnership Four high performing partners £112m Pooled Budget for 65+ Governed by Alliance Contract Underpinned by Service and Financial plan (inc. BCF) Formal structured programme management approach Enabler to Healthier Together and fully aligned with GM Devolution Salford care economy Urban area in Greater Manchester Population of circa 234,000 Area of significant deprivation and health inequalities Largely co-terminus -Salford CGG -Salford Royal -Salford City Council -Greater Manchester West Long history of successful partnership working

Status quo is unaffordable and unsustainable Economic risks and benefits not equitably shared by partners £ benefits need be set against – Cost of new delivery models – Growth in population and associated demand – Existing savings plans Integrated care creates costs before it generates savings Integrated care solutions are more cost-effective than the status quo Integrating care is essential to improving the health and wellbeing of the population Three categories of £ benefit – Reduction in admissions (hospital, care homes) – Removal of duplication and fragmentation – Reducing future demand Shift focus from institutional settings 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 (section 75 / Alliance Agreement / Prime provider) Effective integration of services and systems Highest quality, safest, most productive care system 5 3 Why change?

ICO population scope 4 All Adult population 185,000 Long Term Conditions Older people 35,000 Issues and solutions are not unique to older people Significant growth in long term conditions – worst decile for related outcomes Greater scale required to deliver system-wide impact Upstream focus to secure population health benefit

Multi Disciplinary Groups provide targeted support to people who are most at risk and have a population focus on screening, primary prevention and signposting to community support 3 Local community assets enable people to remain independent, with greater confidence to manage their own care 1 Centre of Contact acts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring 2 1 Promoting independence for adults and older people Better health and social care outcomes Improved experience for services users and carers Reduced health and social care costs 3 2 New model of care 5

Population risk stratification & integrated care standards Measureable joint outcomes Alliance Contract £112m pooled budget Service & financial plan Academic Longitudinal evaluation POPULATION RISK STRATIFICATION Shared Care PlansIntegrated Care Standards Integrated care enablers 6

NHS Five Year Forward View – New Care Models National Vanguard Status (PACS) GM Devolution: Salford Locality Plan and Life Course model Partnership commitment to create an Integrated Care Organisation (MoU, SOC and OBC; FBC in progress) SRFT as prime provider – system integrator Community health and medical services Adult social care (transfer) District mental health services (supply chain) General Practice – part of single system of governance Three stage approach to transformation Integrated care system 7

MDGs Community Assets Centre of Contact Care Homes standards Extend care model to adultsLong term conditions redesign Enhance adult strategies – mental health, carers Fully embedded locality model Pilot locality model Alliance Agreement and Pooled Budget Extend Alliance Agreement Service Coverage and Pooled Budget to Adults General Practice Provider Leadership and Engagement Provider Workforce Planning & Redesign Integrated Care OrganisationEstates Capitation modelling IM&T, Capacity for Change, Evaluation CORE COMPONENTS KEY ENABLERS 3. Integrated Neighbourhood Model 3. Integrated Neighbourhood Model 2. ICP Plus 1. ICP for Older People 8 Three-stage approach

Geographical communities of 30-50,000 people Community-based care delivered on a neighbourhood basis Groups of GP Practices operating on a networked basis GPs, specialists, community staff, social workers and mental health practitioners working together as a ‘partnership of equals’ Significant shift in care from hospital to the community Much greater focus on person- centred care, application of standards and pathways Clear accountability through multidisciplinary Locality Boards Neighbourhood accountability, with delegated budgets 9 Neighbourhood model

System design features

11 Procurement considerations Two stage option appraisal undertaken -Selection of prime provider as the organisational form -Determination of SRFT as the preferred prime provider Most credible form No rationale for full mergers Most credible provider Full consensus Commissioner determination as to the range of services to be incorporated Objective assessment regarding strategic fit Safeguards relating to patient choice, competition and referral practice Existing safeguards No loss of competition (vertical not horizontal integration) Commissioners specifications shape the supply chain Commissioner reserves the right to shape the market

Pooled Budget SRFT Salford CCG Salford City Council NHS England Other CCGs Adult Social Care Providers GM West – Mental Health Services Other providers e.g. Well-Being Services Local Primary Care Primary Care Enhanced Services ICO Services commissioned from Pooled Budget, including Adult Social Care direct provision Strategic Partners KEY Contract Other Providers commissioned from pooled budget Commissioner Prime Provider Prime Provider Supply Chain Commissioner and ICO relationships with other providers and Primary Care to be determined Integrated care system and ICO 12

BENEFITS Full range of services within a single management arrangement – more effective, efficient and coordinated care Collaborative environment without the need for new organisational forms 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 CCG, SCC, SRFT, GMW Health, social care & wellbeing for 65+ population (extending to adults) £112m pooled budget (rising to £246+m) 4 year investment/disinvestment plan (refresh as part of GM Devolution Plan) 13 Integrated care system and ICO Lead Commissioner ICO Prime Provider P P P P P

Contracting & payment systems 14 S75 Pooled budget and Alliance Agreement in place for 2014/15 for older people, with local Gain / Loss mechanism Full range of adults and older people services within ICO Acute and community health services £135m Adult social care £82m Adult and older peoples’ district mental health services £29m Planned extension of S75 Pooled budget to the adult population Longer term aim to move towards capitation formula for population health needs Key enabler to integrated care Requires stage management, regulatory support Careful analysis of risks and benefits at each stage

15 Integration accountability Integration of services, care and pathways is a means not an end in itself – focus on triple aim Moving to an ACO model requires a radical shift From a reactive to a proactive system From episodic to holistic and long term care From providing treatment to enabling care (incl. self care) Increased responsibility for population health and wellbeing, as part of a new accountable care system Requires significant changes – organisational, cultural and behavioural – as well as a changes in incentives and levers

16 “At the centre of our renewed ambition is a clear vision for population health improvement, reaching beyond ‘out of hospital care’ to a single system of governance for health, care and wellbeing in Salford. The benefits will come with the shift of care from institutional settings towards the empowerment of citizens and communities to be independent, for longer” Outline Business Case Salford Together, November 2015

StrategicProtective Population Health Improved health & wellbeing – wider societal benefits Renewed focus on primary prevention Greater community resilience Reduce demand faster than marginal revenue decreases System Consolidated & agile governance – greater allocative efficiency Care delivered where needed, not where infrastructure happens to be – person centred System interoperability (workforce, IM&T, Estates) – Technical efficiency Move knowledge to the patient, not patient to the knowledge Workforce Job role flexibility to match system flexibility Job satisfaction – retention of scarce staff Quantified Benefits (by 2020/21) ~£25m recurrent savings (14/15 baseline on £246M annual commissioning budget) From 13/14 baseline 20% reduction in emergency admissions 25% reduction in permanent admissions to residential care homes Increase Flu vaccine uptake to 85% 50% of older people able to die at home Upper quartile position in self- reported Quality of life Ability to manage own condition Patient experience Integrated care benefits

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