I t ti i C b iI t ti i C b iIntegration in CumbriaIntegration in Cumbria

Sue PageSue PageggJohn HowarthJohn HowarthHugh ReeveHugh ReeveRos FallonRos FallonNHS CumbriaNHS Cumbria

Welcome to CumbriaWelcome to CumbriaWelcome to CumbriaWelcome to Cumbria

HCH

Cumbria profile

2,500 sq miles

Cumbria profile

2,500 sq miles

HCH CH

500,000 people

73 people per km2

500,000 people

73 people per km2H CHCH

CHCH

CH

p p p

Urban/rural split

Wide health variations

p p p

Urban/rural split

Wide health variationsH Wide health variations

Huge travel times

Wide health variations

Huge travel timesH

H

CH

The way we were…The way we were…H lth b t £36 7 hi t i d bt Health economy was bust – £36.7m historic debt -£100m deficit projected over 5 years

People marching on the streets

Effi i i d d i t t Efficiencies needed in acute sector

Community services fragmentedCo u y se ces ag e ed

Standards of care inconsistent – systematic approach neededneeded

Wh ?Wh ?Where are we now?Where are we now? Debt solved (although pressures still exist!) Debt solved (although pressures still exist!)

Highest score in North West for WCC

Closer to Home strategy

Clinicians in charge in all 6 localities

Devolution of power to ICOs Devolution of power to ICOs

This is plan A there is no plan BThis is plan A there is no plan BThis is plan A, there is no plan BThis is plan A, there is no plan B

Where does integration take place?Where does integration take place?Business Support Services

Copeland

South

Allerdale

d

CumbriaCentral

Furness

South Lakelan

d

CarlisleEden

Integrated Care relationshipsIntegrated Care relationshipsSub locality Sub locality

Locality Locality Locality Locality Locality Locality

Clinical Senate(Clinical Executive Group)

Support Headquarters

• Developing evidence based clinical pathways and service models• Peer support to localities to improve performance• Collaborating for commissioning and contracting• Working with key public sector partners

Business functions

HR, Contracting, Finance,Intelligence, Pathway design etc

PCT (System Manager)

g , y g

PCT (System Manager)

Ensures public health is protectedContracts with HQ to improve health outcomesIntervenes in the event of whole system failure

£800m from DH

Welcome to South LakelandWelcome to South Lakeland

DGHDGH

DGHDGH

W t l d P i C C ll b tiW t l d P i C C ll b tiWestmorland Primary Care CollaborativeWestmorland Primary Care Collaborative

WPCC is 21 practices (list size 600 – 16,000) and all WPCC is 21 practices (list size 600 16,000) and all PCT community health services

“Make or Buy” for 110,000 population Key priorities for next 5 years:

Integrating services for older peopleL t diti (i l di t d lf ) Long term conditions (including supported self mx)

High quality primary care Access to appropriate urgent care services Access to appropriate urgent care services Efficient and effective use of elective care services Working with others to promote healthy individuals g p y

and communities

PPProgressProgress Agreement to form a social enterprise, from April1st, to

both commission and in future provide services Company limited by shares, holding APMS contract with

PCT – important for NHS pensions etcp p Leadership from GPs, nurses and therapists across all of

primary care Taking on increasing proportion of the PCT budget Taking on increasing proportion of the PCT budget –

approx 50% this coming year A Board including lay members – bringing expertise not

token representation Approach to public engagement building on existing

structures (mainly non-health)( y )

Th “ i t l” it h it lTh “ i t l” it h it lThe “virtual” community hospitalThe “virtual” community hospital Step-up step-down unit in Kendal (51 beds)p p p ( )

Nearly 50% of admissions are step up Acute to a community focus - culture challenge Moving to nurse led with doctor support

STINT serviceM i d l t d di h Manage crises and early supported discharge

Health and social care input (joint funding) Nursing home support team Nursing home support team

Day Hospital Moving to co-location with wardsg Coordination of physical and mental health services

Early discharge and rehabilitationEarly discharge and rehabilitation

The “virtual” community hospital:The “virtual” community hospital: Team responsible for individuals undergoing a p g g

crisis – cared for at home, stepping down to a community bed or supported early discharge

Flexible roles – some staff who can work either on the wards or in the community – so can “flex” with

i th tpressures in the system Co-location of all + common electronic clinical

recordrecord

Integrated primary care informationIntegrated primary care informationIntegrated primary care informationIntegrated primary care informationEMIS webEMIS web

“allows primary secondary and community healthcare“allows primary, secondary and community healthcare practitioners to view and contribute to a patient's cradle to grave healthcare record”

In last 12 months: Installation of superfast local network connecting all health bases

across the localityacross the locality 20 of 21 practices now using EMIS (21st on the way!) All community nursing teams moving to EMIS by mid 2010 and

i bil b db d / tb kusing mobile broadband / netbooks Specialist community teams – transfer almost completed GP OOHs, PCAS and step-up/step-down Unit have access to

summary information from the GP record

Pharmacy

Radiology PCAS, GP led wards and GP OOHsHospital

EMIS Web 

Hospital InfoRadiologyReport

EHREMIS Data

EHREHREHR

EHR

RReports

PatientInfo PatientLab

Results

RadiologyReport

ReferralData RepositoryPath Lab

Specialist Teams and clinics

Data

RxRxReports

Guidelines

InfoResults

EMIS Web 

PatientInfo ReportsData Streaming

GP and Community Teams

Central Support Team

Info epo ts

Guidelines

ReferralData Streaming

between local centres and central repository

Long Term ConditionsLong Term ConditionsLong Term ConditionsLong Term Conditions

Cumbria DiabetesCumbria DiabetesCumbria DiabetesCumbria Diabetes

The needThe need

Increasing prevalence of diabetes Evidence for high quality care in Cumbria

HCC and QoF But... Poor patient education and high drug

costs BUT variations in both quality and patient

i C b iexperience across Cumbria Fragmented and non aligned specialist service

The Cumbria Diabetes Model of Healthcare:

P i

Primary care

Primary care (core)

Primary care setting Secondary and Tertiary care setting

y(enhanced)

Specialist support for Primary Care Complex care

Description of servicesRegisterDelivers holistic annual review (care planning)

P i

( g)for patients with Type 2 diabetesComplete QoF measuresAdheres to agreed guidelinesRefers to DESMONDPartnership with Cumbria diabetesW k t d i i lit

Primary care

Primary care (core)

Primary care settingSecondary and

Work towards improving quality

y(enhanced)

Specialist support for Primary Care Complex care

tertiary care setting

Description of services

P i

Provides core care Named clinical lead

Primary care

Primary care (core)

Primary care settingSecondary and

Identify high risk/ use tools and interventionsStepped approach to glucose loweringCare planning and on going

t i ti ty

(enhanced)

Specialist support for Primary Care Complex care

tertiary care settingmanagement in patients with Type 1 diabetes Insulin initiation / on going support in Type 2Address learning needs with spec support teamwith spec support teamRegisters of housebound / high riskCare for house bound / vulnerable groupsSpecific needs of women of child bearing ageWork to max’n QOF points

Description of services

P i

Primary care

Primary care (core)

Primary care settingSecondary and y

(enhanced)

Specialist support for Primary Care Complex care

tertiary care setting

Reviews newly diagnosed Type 1 before referring to Enhance CareProvides a structured Type 1 support serviceProvides a structured Type 1 support serviceProvides staff training both formally and informallyCoordinates/provides patient education and Type 1 post education supportAd hoc specialist advice to other professionalsLocality based individual case discussion with specialist teamContributes to developing clinical guidelinesp g gSupports development with Core Primary Care Practices to become enhanced practicesProvides enhanced services to core practicesCo ordinates the specialist support services for Primary Care eg nutrition, psychology, retinal screening

Description of services Provides care to individual patients with complex needs

P i

Provide/coordinates multi specialty services eg Pregnancy, renal, eyes, vascular, heart and feetProvides transition and young adult servicesProvides inpatient care

Primary care

Primary care (core)

Primary care settingSecondary and y

(enhanced)

Specialist support for Primary Care Complex care

tertiary care setting

Financial resource(Health)

Local authority resource

PersonalisedPrimary care is the HUB through

commissioning, facilitating, understanding and providing

Biomedical

Personalised individual care

The population(healthy, high risk and

undiagnosed)

Biomedical intervention

s

Policy determinant

s

S lf t

Community engagement to

maximise local assetsSelf management

Relevant information

Care planning

Risk factors

Awareness raising

Maintaining registers

Routine reviewp g

Linking with community and

support services

Social marketing

Reducing inequalities

Personalised care planning

Contact point to NHS

Healthy cities, schools, stadia etc

Helping to build resourceful individuals

Helping to build resourceful communities

ProgressProgressProgressProgress Challenges of identifying lead providerg y g p Now sitting with Primary CareWPCCWPCCAll staff (incl consultant lead) moving to

primary care Cumbria wide educationDaphne, Desmond and Walking away from p g y

Diabetes Other long term conditions following Incl paediatrics, elderly care

CockermouthCockermouth FloodsFloodsCockermouthCockermouth Floods Floods 20092009

Cockermouth FloodsCockermouth FloodsCockermouth Floods Cockermouth Floods 1717thth November 2009November 2009

November 2009 was the wettest on record in the UK ( 8 i h i th th)UK (over 8 inches in the month)

Over 12 inches fell in 24 hours on the fells above CockermouthCockermouth

10 out of 11 bridges damaged or destroyed880 h d 190 b i fl d d 880 houses and 190 businesses flooded

Our health model in action!

CockermouthCockermouth Town CentreTown Centre

Cockermouth Main StreetCockermouth Main Street

Collapsed Bridge Workington Collapsed Bridge Workington PC Bill Barker diedPC Bill Barker diedPC Bill Barker diedPC Bill Barker died

13 whole team meetings to co13 whole team meetings to co--ordinate the ordinate the d i kd i krecovery and manage riskrecovery and manage risk

Priorities for the health services:Priorities for the health services:Priorities for the health services:Priorities for the health services:

To avoid excess mortality and morbidityTo avoid excess mortality and morbidityy yy y

Measures to avoid diarrhoeal diseaseM t t i t ill Measures to prevent severe respiratory illness (crowding in church halls and reception centres)Re establishment of normal health services for Re-establishment of normal health services for long term conditions asap especially the re-establishment of pharmacy services andestablishment of pharmacy services and systems

Boosting psychological support g p y g pp

Reducing risk:Reducing risk:Id tifi d ll t i k l bl ti t d ti l Identified all at risk vulnerable patients and proactively contacted them e.g. Severe COPD, palliative care, frail elderly.

Established heightened surveillance for diarrhoea cases – every case was investigated by the seconded infection control nurse

Gave public health information/lectures to rescue workers and all staff and displaced at the reception centres on hand hygiene and diarrhoea preventioncentres on hand hygiene and diarrhoea prevention.

Vaccinated 1000+ at risk in reception centres and 350 rescue workers against swine flu and seasonal flu in the first weekfirst week

Reducing risk:Reducing risk:R idl b ilt GP t l h d IT t Rapidly rebuilt GP telephone and IT systems (within 24 hours)

Re-established pharmacy services (within 24 p y (hours)

Provided extended GP opening 24 hours for first day then 8am-8pm every day for the next 2day then 8am-8pm every day for the next 2 weeks including weekends

Rapidly established additional counselling i i l di d i iservices including drop in services

Dug the foundations for a 26 room temporary building within 5 days of the floodsg y

Longer Term:Longer Term:

Adolescent Health Programme with school and pupilspupils

Centre for the Third Age – co-locating third sector, health, social care, memory clinics, d i idementia expertise etc

Harnessing the whole community response to health cheer up teas street angels etchealth – cheer up teas, street angels etc

Doing more with lessDoing more with less

C k th H it l 300% i i Cockermouth Hospital - 300% increase in throughput 2006-9Length of Stay down from 36 days to 11 days Length of Stay down from 36 days to 11 days

£250,000 reduction in annual nurse costs from 2006 to present2006 to present

Nurse wte reduced from 23.4 to 13Cost per admission reduced by more than half Cost per admission reduced by more than half

19% reduction in non elective bed days spent in Acute Trust in 2008 9Acute Trust in 2008-9

P li IPolicy Issues Practice based commissioning has been central Practice based commissioning has been central

to our approach Based on building relationships with GPs more than

th li it lfthe policy itself Trusting clinicians and handing over real

responsibility (+accountability) has been crucial Transforming Community Services - vertical

integration v horizontal integrationS i l i d i i Social enterprises and pension issues

PBR and Foundation Trusts