1. Beyond the Legislation: Investing in Sustainable Transformation
Anne Hendry
Clinical Lead for Integrated Care

2. Delivery Context Population 5.4 million @ £13 billion budget
14 NHS Health Boards
Universal coverage
No co-payments
38 Hospitals
1020 General practices
Integrated delivery system
Unique patient identifier
32 Local Authorities
Free personal care for 65+

3. Context for Public Services
a majority government
All parties had integrated health and social care in manifestos.
“effective services must be designed with and for people and communities – not delivered top down”
Report of the Christie Commission on the future delivery of public services

4. Reshaping Care Programme
‘Bottom Up’ Change and Innovation
£ 300 million Change Fund
20% of funds to be invested in direct or indirect support for carers

5. Kotters 8 Steps for Transformational Change Leading Change, Kotter J,(1996); The Heart Of Change, Kotter J & Cohen D, (2002

6. Public Bodies(Joint Working) (Scotland) Act ) Act 2014
People are supported to live well at home or in the community for as much time as they can and have a positive experience of health and social care when they need it
All adult care groups +/- children’s services & criminal justice
Principles for integrated health and social care
Integrated governance : body corporate or lead agency
Integrated budgets for health and social care
Chief accountable officer has integrated oversight of delivery
Nine national outcomes for health and wellbeing
Strategic and locality planning based on population needs

7. A Framework for Locality Integrated Care
Collaboratively orientated healthcare professional
Governance and Accountability for Population Health
Strategic Plan and Integrated Budget
Health & care professionals committed to partnership working
INFORMAL AND FORMAL SOURCES OF SUPPORT AND CARE
sustained by the responsive allocation of resources
Engaged, Informed, Empowered and Enabled People and Populations
Collaborative Leadership
Interdisciplinary Workforce Education and Development
Realistic Medicine Outcomes based
Care and Support
Conversations and Commissioning
Technology Enabled Care
Information sharing and analysis
Quality contracts and performance improvement

9. New Scottish GP Contract from 2017
Builds on 2016/17 agreement (removal of QOF)
GP as expert-generalist in complex care
Primary care led person centred integrated system
Quicker access to other professionals working at ‘top of licence’
eg Transforming Nursing Roles; Community Connectors
Each GP Practice has a Practice Quality Lead (PQL)
Cluster working on quality across a group of GP practices
Each Cluster agrees a Cluster Quality Lead (CQL)
Improving Together Framework for leadership development and shared learning

10. Role of the GP Cluster Intrinsic Extrinsic
Learning network, local solutions, peer support
Consider clinical priorities for collective population
Transparent use of data, techniques and tools to drive quality improvement
Improve wellbeing, health and reduce health inequalities
Extrinsic
Collaboration with MDT and third sector partners
Influence priorities and strategic plans
Clinical advice to aid oversight of managed services
Ensure relentless focus on improving clinical outcomes and addressing health inequalities

11. Local Leadership for Integration
Tradition and hierarchy in large public bodies is a significant factor affecting the ability of locality teams to change their part of the wider system.
Readiness of locality teams varies as they develop at a different pace across Scotland
Integrating learning with doing is critical to developing inquiry habits and spotting whole system issues or themes
Collaborative Leadership in Practice: Rolling programme of group coaching and action inquiry

12. MSc Leading People Centred Integrated Care Helen. Rainey@uws. ac
MSc Leading People Centred Integrated Care Online from January 2018
Year 1 (Post graduate Certificate)
Creating the Conditions for Integrated Care (20 credits)
People and Communities (20 credits)
Leading and Transforming Together (20 credits)
Year 2 (Post Graduate Diploma)
Value, for People, Services & Organisations (20 credits)
Research for Health & Social Care (20 credits)
Option module (20 credits)
Year 3 (MSc)
Research and Enquiry Dissertation (60 credits)

13. £ Integrated Data CHI Partnership Access Via secure platform
Linked Health and Social care file at an individual service user level (Aggregated Activity & Costs)
Intermediate Care
SIMD
Outpatients
A&E
Deaths
Inpatients
Community
Hospitals @
Home
Day cases
SPARRA
Social Care
Prescribing
Housing and Homeless
Age/gender
Partnership
Access
Via secure
platform
Linked File 13

14. Example of an individual pathway
Social Care Notes £1200
Social Care Assessment (1)
By locality team
Reablement
Community alarm
£600
Social Care Assessment (2)
Crisis care home package
73 days
Cost £3,400
May
June
July
August
September
October
Hospital Admission
Emergency admission – hosp X - general medicine
Abdominal swelling requiring minor intervention
Discharge to own home
4 days
£1,200
Outpatient
GP referral
Palliative medicine consultant
Visit at home
Cost £160
Death
In the care home
Liver cancer
GP Prescribing
£500

15. Support to Use Data
apping

16. LIST support for GP clusters
Identifying people for Anticipatory Care Planning and Case management
Redesign of appointments, prescribing, improving pharmaceutical care
Benchmarking and variation of practice
Chronic Pain Management
Demand and Capacity
Target interventions – eg diabetes care; screening
• Chronic Pain Management

17. Technology Enabled Care Programme - Year One 2015/16
25,000 citizens benefit
2700 people using HMHM
11,600 ALISS searches per month
12,000 new LiU registrations
9000 new Telecare users

18. Change Fund

20. IN RATE OF 75+ EMERGENCY BEDDAYS
39%
CHANGE FUND
SPEND 2014/15
SUPPORTED
CARERS
2.8
Million
MORE DAYS
IN OWN HOME
THAN ‘EXPECTED’
17%
FEWER
OLDER PEOPLE
CONVEYED
to HOSPITAL
after a fall
(non-injured)
10%
REDUCTION
IN RATE OF 75+ EMERGENCY BEDDAYS
OVER 5 YEARS
1600
PER DAY
FEWER PEOPLE
AGED 65+ IN HOSPITAL BEDS
IN RECEIPT OF
FORMAL CARE AT
HOME
HAVE TELECARE
6000
IN CARE HOMES
19%
PEOPLE DELAYED
IN HOSPITAL
OVER 2 WEEKS

21. Is this now radical change from which there is no going back?
Health Foundation definition for transformational change:
‘’a deliberate, planned process that sets out a high aspiration to make dramatic and irreversible changes to how care is delivered, what staff do (and how they behave) and the role of patients, that results in substantial, measurable improvement in outcomes, patient and staff satisfaction and financial sustainability.’’