Integrated Health and Wellbeing- The Plymouth JourneyThe view from Craig…

The Vision for Our City

Local Challenges

Our Local Vision for Health and Wellbeing

The Health and Wellbeing Board set the level of ambition and timeline for our system integration The Board set the strategic ambition but stayed out of the operational detail, taking a System Leadership approach Vision of Improving Population-Based Wellbeing through Integration:

➢ Integrated Commissioning ➢ Integrated Health and Social Care ➢ Integrated System of Health and Wellbeing

Delivered through the Integrated Health and Wellbeing Programme, the aims of this are:

➢ To improve health & wellbeing outcomes for the local population; ➢ To reduce inequalities in health & wellbeing of the local population; ➢ To improve people’s experience of care; and ➢ To improve the sustainability of our health & wellbeing system.

Integrating Health and Wellbeing

Integrated Commissioning

• Co-location of commissioners

• Integrated Governance Arrangements

Integrated Health and Care

• 2005- Residential Care to Independent Living

• 2011 - Transformation of ASC-

Children and Young People

• Early Help Gateway

• The Hub • Children’s

Social Care- End to End Review

• Family

Integrated System of Health and Wellbeing

Thrive Plymouth Development of Life Centre Focus on preventative Services Information and advice OFFER/POD Befriending Timebanking

Integrated Commissioning• Co-location critical • Teams split to drive cross pollination • Desks mingled – but IT still not completely shared! • Share all resources – each other’s buildings, spaces, people,

expertise • Joint social events…. • Organisational Development • Integrated governance arrangements

– Integrated Commissioning Board – Integrated Director – SLT

• Four Commissioning Strategies

COMMISSIONING STRATEGIES

Supporting healthy and happy communities by encouraging and utilising social networks, increasing investment in public health and putting health and wellbeing at the heart of everything we do. A system that consists of quality specialist health and care services that promote choice, independence, dignity and respect.

Our ambition is for every child to have the best start to life by ensuring they can access education, health care and are safeguarded from harm.

This strategy targets services for people who need support in the short term to recover from a crisis or short term need.

Needs Assessments/Annual Plans/Performance Scorecard/SDGs

Integrated Fund- Overview

Plymouth Integrated FundThe net total of the Pooled and Aligned Fund

£462mNet Pooled Fund

“Any pooled fund established and maintained by the Parties as a pooled

fund in accordance with the regulations”

£241m

Net Aligned Fund“Budgets for commissioning prescribed services that the

Regulations specify shall not be pooled, but which will be managed

alongside the Pooled Fund”

£221m

• Section 75 agreement between NEW Devon CCG and Plymouth City Council. Integrated funds £638 million gross (£462 million net)

• Cradle to Grave Fund• Risk share and financial framework

Risk Management & Risk Share

The partners have agreed a risk share mechanism, with a specified ceiling, which will operate as a “backstop” to the agreement:

• Maximum value of risk to share is set as 0.5% of the Applicable Value (circa £460m and £2.3m)

• Maximum risk share due to each partner is proportional to the defined contribution to the Applicable Value (circa CCG 75%, PCC 25%)

• Overspend for risk share is calculated as net of planned overspends (i.e. unplanned overspends)

• Overspend for risk share is adjusted for agreed service developments with differential impacts on the partners

• Risk share works both ways – i.e. is also benefit share

Support and Engagement

Integration journey underpinned by extensive engagement and organisational development Patient and Families

• “Plymouth Sofa” • Series of TCS Roadshows • Development of “I” Statements

Strong Political and Clinical Engagement • Active Scrutiny Panel: Pre- decision scrutiny which made

recommendation to support to Cabinet • Political and Clinical Development Sessions • Enduring political consensus

Staff and Stakeholder Collaboration • Leadership development and staff engagement – workshops, events

and regular briefings • Providers, VCSE and System Design Groups

Current ChallengesDemographics and Complexity of Need • High levels of deprivation and ageing population • Rising demand and increasing acuity Financial Sustainability and Equity • Rising cost of care and challenging cost improvement programmes • The 10% equity challenge Fragility of Primary Care • GP Practice contract hand-backs • Number of GP vacancies across the city and an ageing workforce System Flow

• Multiple system reviews have highlighted interface issues that inhibit patient flow in different parts of the system

Workforce and Market Sufficiency • Significant workforce gaps in certain areas • At times of surge, specialist care home places are stretched

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CQC Local Area Review• The review found strength and commitment amongst system leaders to deliver

a fully integrated system in order to meet the needs of the residents of Plymouth. This process had already begun with integration between the CCG and local authority, with innovative risk sharing agreements and a significant shared budget.

• However, the city faced significant pressures in relation to finance and flow of people through the system. In order for this to succeed moving forward key challenges need to be addressed including, primary care capacity, continuing healthcare and organisational budgets.

• At the time of the review, people’s experiences of health and social care services in Plymouth were varied. More people were attending A&E, being admitted and staying longer than necessary. Recent work undertaken by the system had led to some improvements, However, Derriford Hospital remained under pressure.

• While there was a compelling strategic vision for the future, system leaders need to ensure that the key challenges including primary care capacity continuing healthcare and patient flow were addressed

CQC Local Area Review• Professor Steve Field, Chief Inspector of Primary Care

Services, said: • “The review of Plymouth's services - and how the system works

together – has found some shining examples of shared approaches. The system leaders had a clearly articulated, long-established vision of integration which translated well into local commissioning strategies. Leaders were consistent in their commitment to the vision with whole system buy-in.

• “I would encourage system leaders in Plymouth to drive this forward to ensure there is a more community, home-based focus. System leaders also need to ensure that as the system moves towards further integration, work is undertaken to ensure that staff are fully engaged, from the outset and led by a collaborative leadership.”

Strategic Ambition - Future Plans

• Shared System aim of improving outcomes and reducing inequalities. • Strong self awareness around system issues, but commitment to integration remains. • Further and faster towards System Integration - Priorities 2017- 20: • Integrated Care System and Local Care Partnerships • Strategic Commissioning and Integrated Commissioning at place Commissioning

Intentions: o Development of Integrated Care Organisation

– Integration of Acute and Community – No health without mental health

o Integration of Primary Care and Community Services o Primary Care Joint Commissioning o Integrated Children and Young People Services o Integration of Wellbeing Services around network of hubs o Enhanced Care and Support o Making Every Adult Matter- Alliance Approach

Lessons and Reflections

• Integration takes time • Integration is complex • Integration is a journey • Integration is not a panacea • Integration is the right thing to do!- people are what

matter not organisations or artificial boundaries • Integration is about people, behaviours, culture,

relationships and trust