1. Integrated Care in Somerset Linking Big Data with a Right Care Approach Kevin Hudson Head of Business Solutions & Innovation SaWCS LPF Bid Director Kevin.hudson@swcsu.nhs.uk 07717 530 220

2. Context in Somerset  Somerset’s imperatives for integrated care o Understanding those patients who would benefit o A person-centred approach o A radical ambition for commissioning change  Our understanding of national Right Care principles (particularly in relation to data) o Where to look? (understanding what matters?) o What to change? (undertaking a deep-dive) o How to change? (equipping the commissioning tool-kit)  Through this work we have discovered that local priorities and national initiatives can be one and the same 2

3. Telling the story through data – BIG DATA  Most data analysis (and commissioning) is ‘episodic’ - Episodes of care, amalgamated over time and categorised by provider  We built a Holistic data model – where the patient is the ‘base unit’, not the episode  577,000 Somerset patients – activity mapped and costed -All their encounters with all aspects of Health & Social Care - £676M of health and social care spending -Cross-cut against all their diagnostic conditions (mapped from 400 Episode Treatment Groups recorded through Primary and Secondary Care Coding)  Purpose of the model is to: – Help set the scope of Outcomes Based Commissioning – Help set the focus within any agreed scope – Help develop an evaluation methodology to measure change  Biggest Challenge: Not how to build it but how to understand it

4. Where to look? Cost by age….?

5. Where to look? …or by condition?

6. Regression variables Age Number of conditions Age, Number of conditions Variation explained 3.36%18.76%19.30% What drives cost – age or conditions?

7. 7 What matters? (it’s not all about data) The Symphony Project wanted to get ideas and thoughts from people with lived experience and from current frontline staff. April Strategy were engaged to help do this and they undertook a series of activities in Autumn 2013. They: Reviewed national and local publications (often based on patient and staff engagement) Held one-to-one interviews with people with long term conditions Facilitated a large event with people, carers and frontline staff. Insights were gathered about what works well now, what people hope to see more of and what they want to see less of in the future. People and carers’ shared hopes: Staff’s shared hopes:

8. Deep-Dive What might you change? Patients on Pathways? Patient with Condition? If so, which conditions?

9. Starting point: Different conditions / characteristics

10. Starting point: Multi-morbidity and Cost

11. But not all follow this pattern…

12. For multi-morbidity, number ≈ type

15. What to change? Multi-morbidity, not disease type

16. How to change? (Equipping the Commissioning Tool-kit) Year of Care Budgets Patient Mapping / Social Factors Person-Centred Outcomes Personalised Care Planning

19. Number of Patients And for the LIG’s (Local Implementation Groups) we map where the patient’s are…

20. Cost of Patients …their cost…

21. Cost of Patients …and the setting of care (‘at home’ or ‘in a home’)

22. Mosaic Social Indicators can help inform scope and engagement: Type M56 – Older people living on social housing estates with limited budgets Key Features: State pensioners Low use of credit Enjoy reading Small housing Basic education Shop locally Traditional Lifelong council tenants Face to face contact Communication Preferences: Access Information Local Papers and Face to Face Not Internet, Telephone, Magazines, SMS Text Service Channels Face to Face Not Internet, Mobile Phone or Telephone 2% Population, 8% of full cohort, 12% of high cost patients

23. The insights were used to create a mandate to guide the design work and formulate the outcome set 23 FocusMe and my carer (s), taking account of all my conditions and our physical, mental, social and emotional needs OutcomeI am helped to manage my conditions and live in the way I want to the best of my ability Features ACTIVE INVOLVEMENT I am listened to and involved in planning and making choices about my care in a way that suits me. POSITIVE RELATIONSHIPS I have one key person who takes ownership for coordinating all aspects of my care. They make me aware of all the options and keep me informed about what’s happening. They understand me and I trust them. EASY ACCESS I can contact my care coordinator when I need to. I am given access to information, education, advice and expertise to help manage my condition. Support and services are available as close to my home as possible and I know there is a 24/ 7 response available if I need it. SEAMLESS COORDINATION I receive seamless timely, coordinated care with easy, efficient transitions from one service to another. Professionals across all services have access to an up-to-date shared record of my condition, needs history and services and treatments I am receiving. Enablers Caring, compassionate, competent and knowledgeable staff work in multi-disciplinary teams across organisational boundaries with up-to-date, shared records, facilitated and supported by organisations and systems. Patients and carers are asked for feedback on services and see improvements happen as a result. What matters – designing a outcome set

24. Outcomes Hierarchy

25. 25 Personalised Care Planning Training Personalised Care Planning and Support Training Courses 2014/15: “It has been really interesting to see how the medical model is driven by tests, tasks and numbers, rather than by the individual. I am really positive about the opportunities Care Planning presents for partnership working and to get the voluntary sector and other services involved in healthcare.” Regional Lead, Age UK “The Care and Support Planning training gave me a ‘light bulb’ moment about preparing patients for their annual reviews. It acted as a useful reminder in these busy times, that putting a bit of time into empowering the patient can have positive rewards in terms of subsequent use of services as well as clinical outcomes” GP “Self-reflection of my consultation skills. I have realised that patients may not always hear what I think I am saying. I will also try to dig deeper to find their real story and agenda, rather than just doing what I think it is.” Practice Nurse

26. National Coverage Symphony data analysis was covered on the front page of HSJ – April 2014 Professor Andrew Street also recorded a video: http://www.youtube.com/ watch?v=Cr7aevRGBqM (or search Youtube for ‘integrated care in Somerset’) Published in International Journal of Integrated Care – January 2015 (after academic peer review)