Aspirations for integration and the workforce

challenges Guy Daly

and David Holmes

Introduction

• Context/drive for integration• Evidence• Projects

– Older adults workforce integration– HEE LET B transformational theme

• Lessons learned• Challenges and opportunities

Context and Drivers• £ challenges

– Health inflation (c4%)– Current efficiencies (0.5-1%)– Most acute Trusts in deficit

• FYFV– Need £30M– Got £10bn - CHECK

• Local government – 46% austerity reductions• Need/demand/demographic challenges

‘Crisis’ in health and social care

• NHS – funding & budgets– workforce– challenges: mid-staffs/Francis– expectations

• Social care funding (means and need)• Workforce challenges in both health and

social care

Yet health care (and public health) a great success

• Commonwealth Fund 2014 research• improvements in mortality and morbidity • BUT inequalities in health persist

– Service area– Geographically– Demographically

• Age• Ethnicity• Class

Social care less so …?

• increasingly only the most needy • Winterbourne View• Market failure – Southern Cross• 10 fold difference in use of residential care

across UK • no residential care in London because no

one can afford it • See Professor John Bolton

… social care less so?• LA social care – 1/3rd of LAs have seen increases,

1/3rd a cut • even with 2% c tax increase (if all local authorities

increased by 2% over next 4years, still £4bn short;• residential care for older people (nursing and res

care) – many / most die within 0.5-2 years;– 0.25 recover and leave the nursing home to go

home– so, getting it wrong for 0.75??

Health and Social Care Policy

• 1946 NHS Act & 1948 National Assistance Act

• Crisis of funding in the 1980s– ‘perverse incentives’

• 1990 NHS and Community Care Act – empowering community care users 

Health and Social Care – the Coalition and Conservative Governments

Health and Social Care Act 2012 CCGs and AWP

Continued roll out of IBs, PBs, DPs in social care

Crisis of funding Dilnott Review (2011-12)

Commission on Funding on Care and Support

• White Paper (HMG, 2012) - Caring for our future: reforming care and support and Care Act 2014– promote independence & wellbeing– greater national consistency in access to care– provide better information to help choices – more control– improve support for carers– improve the quality of care and support– improve integration

• Care Act 2014• Postponement to 2020• Cap on individuals’ expenditure• Overall (individual and LA) expenditure

capped at £72,000 – subject to inflationary increases

• Better Care Fund• 2% Council Tax for social care• 5YFV, Vanguards,

State of Social Care now (1)

social care markets mixed economy of providers has occurred substantial shift to independent sector little LA/public sector provision

shift to home care numbers of LA funded users decreases year on year only those most in need receive LA funded support

paradoxically, these individuals have received more hours of care and more bespoke care

Non publically funded users increasingly resorting to self funding

The solutions?

• Integration• Social movements & asset based

approaches • Choice and personalisation• Socially insured health and social care

Integration the answer? • Very complicated health and

social care system currently• Tackle bedblocking• Various examples - NI, Torbay,

etc.

…integration the answer?

• Work of Jon Glasby• Unhelpful disruption of reorganisizations• Have to deal with health and social care

divide – the 1944/46/48 legislation• More efficient, effective, efficacious?• It certainly would help….• Governance

– role for local authorities or combined authorities

Integration – the answer?

• FYFV• Care Act 2014• Framework 15 – HEE Strategic Framework

2014 - 2029• New Care Models - Better Care Fund,

Vanguards, STPs• Devolution

Integrated care map: examples of new models of care in practice

• See Kings Fund• http://www.kingsfund.org.uk/topics/integ

rated-care/integrated-care-map

• England – 34• Europe – 4• Rest of World - 11

Defining Integration

• Mix or join• Combine• Desegregate

Integrated Care - DefinitionsIntegrated care is person centred co-ordinated care: “I can plan my care with people who work together to understand me and my carer(s), allow me control and bring together services to achieve the outcomes important to me.” (TLAP/National Voices, 2013)

“Care which is intended to improve the quality of care for individual patients, service users and carers by ensuring that services are well co-ordinated around their needs”. (Kings Fund)

Varieties of Integration

• Health and social care• Primary and secondary• Patient/care pathways

Examples from the West Midlands

• Older adults workforce integration• HEE LET B Integrated Care

Transformation Theme

Learning from the Older Adults Workforce Integration (OAWIP)

Programme

David HolmesHR Director

Context• Increasing numbers of

older adults/increased longevity

• Increasing numbers with complex co-morbidities / LTCs

• Need to reduce emergency admissions, length of stay and facilitate effective discharge from hospital

• Improving the experience of people who use services

• Develop a fit for purpose workforce delivering appropriate care in the right setting

• NHS Five Year Forward View • Care Act 2014• Framework 15 – HEE Strategic

Framework 2014 - 2029• New Care Models - Better Care Fund,

System Transformation Plans, Vanguards

Delivering Integrated Care

From an approach based on: To an approach based on:

Patients Population health management

NHS workforce Health and social care workforce - statutory, private and voluntary sectors ….and wider!

Organisations Places

Workforce plans primarily focused on the NHS workforce

Integrated system-wide workforce planning

Programme Board – bringing partners together

Acute Trusts

Patient & Practitioner reference groups

Community Health Trust

Local Authorities

(Social Care)

Mental Health Trust

Better Care

Boards

CCGs

Crucial role of care co-ordinator

Consider the wider workforce, including: independent sector

providers, social care, informal carers

ICT is an enabler but don’t over rely on it - process and interpersonal communication are more important

BEST PRACTICE

RESEARCH Multi-disciplinary teams should be built around models of continuous learningTake care with

recruitment to new roles – use value based approaches and ensure buy-in from the team

Knowledge of local population and services is very important

Service redesign and workforce development need to go hand in hand

Co-location helpful - more important for team members to align their goals and work together

Patient engagement is important to sustain integrated services, that are responsive

Learning about Integrated Working

Older Adults Workforce Integration Programme - Pilots

Project Theme Lead Organisation

Integrated Care Model Pathfinder Healthcare Developments CIC

Falls and Fractures - Care Homes University Hospitals Birmingham NHSFT

Falls Prevention – Health and Social Care

Walsall Council

Complete Care Programme (community)

Birmingham Community Healthcare NHS Trust

Integrated Care and Support (GPs) Solihull CCG

Competency Based Education and Training Programme – Care Homes

Shropshire CCG

HEE LET B Integrated Care Transformation Theme (ICTT)

Aims• implement workforce development interventions that

enable new models of care to be delivered• vehicle for expanding and applying work previously

undertaken on integrated working, including from OAWIP

• scale and spread products and tools already developed – Identifying best practice and pilot projects, – e.g. principles and framework for integrated working,

care coordination and development of care home workforce and volunteers

Acute Care

Diagnostics

Self Care

Specialist Treatment

Primary Care

More Investment In Workforce Here

Prin

cipl

es A

nd F

ram

ewor

ks F

or In

tegr

ated

Wor

king

(Wor

kstre

am 3

)

Workforce C

ompetencies And D

evelopment Program

mes

(Workstream

4)

Support Self Care And Digital Innovations (Workstream 1)

Kais

er P

yram

id M

odel

Mindset And Culture ShiftINTEGRAT

ED CARE THEME

Long Term System Vision And Workforce Profile (Workstream

2)

Integrated Care Transformation Theme: Workstreams and Relationship with other

Transformation Themes

Lead

ersh

ip T

hem

e

Mental Health Theme

Acute, Urgent &

Emergency Care Theme

Primary & Communit

y Care Theme

ICTT

1. Development of education packages for carers, volunteers and to support self-care 2. Delivery of a shared longterm system vision with clear workforce recommendations and multi-organisation signup (tested in Birmingham & Solihull) 3. Production of a directory of principles and best practice to support integrated care 4. Produce an agreed shared competency framework for key roles in delivering integrated care.5. Develop and deliver education to support healthy ageing 6. Development of Data Sets for Evaluation

Learning from elsewhere

• Skills for Care• Skills for Health

Skills for Care – Creating new roles

• Care Navigators/Co-ordinators • Physician Associates supporting doctors in

the diagnosis and management of patients • Associate Nurses (Nursing Associates)

widening access to the profession and supporting the requirements for nurses within Social Care settings

• Joint Health and Social Care Apprentices

Skills for Health’s Six Steps Methodology to Integrated Workforce

Planning

1. Defining the plan2. Mapping service change3. Defining the workfoce requres4. Understanding workforce availability5. Developing and action plan6. Implement, monitor and refresh

Overall key Messages1. Alignment of leadership and OD with workforce development initiatives2. The definition of the workforce3. The need for integrated system workforce planning4. Workforce redesign – roles and competencies5. Approaches to learning and development

1. Leadership and OD

• Workforce development in isolation?• The importance of OD and systems

leadership in promoting integrated working

• Sustaining integrated working• Experience of pilot projects• The “Leading Integrated Workforce

Solutions” Programme

2. Defining the WorkforceEveryone, including paid and unpaid/informal carers, working in health and social care settings, including people’s own homes.

Workforce integration v integrated working • Relationships• Understanding each others perspectives• Good communications• Trust

3. Integrated System Workforce Planning

• Across health and social care economies• To reflect new models of care• HEE North Central and East London• Aligned with local commissioning priorities

and plans• The offer: helping commissioners to identify

and address workforce implications• HEE North West – Devolution, Workforce

Planning and development of tools

Integrated System Workforce Planning Challenges

• Definitions: the system, the workforce, the plan?

• Timescales• System leadership• Intelligence gathering –

demographics/long term conditions, trends and projections,

• Workforce intelligence: health, social care, PIV

Integrated System Workforce Planning Challenges

• Definitions: the system, the workforce, the plan?

• Timescales• System leadership• Intelligence gathering –

demographics/long term conditions, trends and projections,

• Workforce intelligence: health, social care, PIV

4. Workforce Redesign Options

New (alternative) worker

New work

Old worker

Old work

increasing the numbers of nurses, doctors, and other health professionals

expanding the job descriptions of existing workers, such as community matrons, to include work previously not done by anyone

handing off existing tasks to other workers, such as nurse practitioners and general practitioners with specialist interests

creating new jobs for work previously not done by anyone, such as genetic counselors, and lay providers to support self-care

Redistribution Creation

Capacity expansion Retraining

Source: Bohmer, Imison. Health Affairs 2013

Skills, Competencies, Roles• Common principles, values, behaviours

based on outcomes for patients/service users

• Competencies, skills and knowledge for the wider team

• Care Co-ordination and Navigation • Supporting workforce transition, eg

acute to community settings• Apprenticeships

5. Learning and Development

• Emphasis on learning together, training, networking, job rotation

• Expand Multi Professional Learning opportunities

• Common foundation and part of CPD• Role of HEIs and other training

providers

Conclusion

• HR Practitioners • HR Business

Partners• Learning and

Development Specialists

• Terms and Conditions?• New Organisational Structures?• Changing the way we work √• Change management/OD √• Systems Leadership √• Integrated workforce planning √• Creating shared opportunities for

learning √

ConclusionsChallenges and opportunities

• Challenges– Funding– Workforce demography– Levels of education and training of social

care workforce– Changes to funding of NMAHP pre-

registration education

• Opportunities– Integrate(!) into the STPs– Devolution/Combined Authorities

Discussion

• Thoughts from other experiences• Other examples• Key challenges• Key opportunities