Almost every health and social care economy is looking at how it can better deliver joined up and integrated care. In some areas of Greater Manchester re-designed integrated health and care services are being delivered and are already improving the experience and outcomes for people.
Pennine Acute Hospitals Trust chief executive Gillian Fairfield has no doubt about the challenges facing her and other organisations. ‘It is becoming increasingly difficult to deliver quality healthcare in the health systems we work in. How we are currently organised creates artificial boundaries and we need to think very differently to remove these barriers. Integrating health and social care is key and we need to move at pace.
‘Both Healthier Together (the Greater Manchester-wide reconfiguration of certain services) and GM Devo give us excellent opportunities to work differently and shape our future. We are confident that as a trust we will work with our partners to create new and exciting models of care that benefit the populations we serve.’
Due to its large footprint, the trust has been able to work innovatively with a wide range of partners to design and deliver innovative approaches whilst remaining flexible and responsive to local circumstances. The trust has a transformation map which sets out its vision for the next five years led by Dr Fairfield.
This was developed in the spring of 2014 following 27,000 individual contributions from staff and also involving local clinical commissioning groups. ‘Our transformation map clearly sets out that we will finalise our clinical services strategy, finalise service reviews consistent with Healthier Together and roll out new models of care for a range of services. We have committed to actively participate in GM Devo and in the further integration of health and social care across Greater Manchester,’ says Steve Taylor, divisional director for integrated and community services.
The trust is experienced in delivering integrated and community care and has delivered community services in the north part of Manchester since they transferred to the trust in 2011 as part of the national Transforming Community Services programme.The trust began its integration transformation journey in 2013 focusing on hospital discharge.
Working with local authorities and voluntary sector providers, the trust developed an integrated discharge service. This saw approximately 30 staff who were employed by a number of different organisations working together. Mr Taylor says: ‘We agreed to jointly fund a small capital upgrade of an empty ward to co-locate the staff. The new team had a single lead/line manager and they were all tasked with redesigning what was a fragmented approach to planning and supporting discharge of patients from hospital which ultimately led to a poorer patient experience and longer stays in hospital’.
Some of the positive results arose from staff no longer having to fax requests to distant offices – being co-located meant they could discuss and plan supportive discharge arrangements with their health or social care colleagues in a more timely way. Wards and departments had dedicated discharge planning staff in the new team who visited at least daily and this together with streamlined documentation and processes meant planning for discharge was significantly quicker and resulted in a better experience for people and families.
‘We made some significant inroads on our length of stay,’ says Mr Taylor. ‘The figures for the North Manchester Hospital were the worst of our four hospitals when we started.’ Average length of stay came down dramatically – the number of patients who were in hospital for 15 days or longer reduced by 55 per cent and those who stayed for a very long time – with over 100 days in a hospital bed – reduced by 83 per cent.
The site is now the best in our trust for length of stay,’ says Mr Taylor. ‘And a lot of that is down to the integrated team working.
Other indicators have also improved – fewer cases of clostridium difficile, for example, and enhanced patient satisfaction. In 2014-15 the A&E department at North Manchester also achieved the national target set for emergency care access standard. The North Manchester area also has integrated neighbourhood care teams, which involve trust staff, social workers, GPs and mental health workers working in four geographical neighbourhoods. A risk stratification tool is used to assess patients’ risks
of being admitted to hospital. The multi-disciplinary team can then offer care and support to those at greatest risk with the aim of co-ordinating care and preventing admissions. Integrated plans of care that are personalised around the goals set by patients themselves are in place for 1,607 people across 36 GP practices.
This has contributed to a 16 per cent reduction in A&E attendances for those people being cared for by the integrated neighbourhood care teams. In addition, a 26 per cent reduction in non-elective admissions, an 11 per cent reduction in outpatient appointments and a six per cent reduction in follow up appointments has been achieved. This has been done with the support of the CCG which included funding additional community based staff, project management support and an incentive scheme to encourage GPs to be active members of the integrated neighbourhood way of working.
‘This approach is central to the CCG’s commissioning intentions for integrated health and care,’ says Mr Taylor and ‘we have worked in partnership with the CCG on this development.’ This is aligned with the national strategy for more out of hospital integrated and community care. The North Manchester area has also been designing and delivering a community based assessment and support service which went live in September. The service includes; intermediate care either in bedded facilities or their own homes, and crisis response for short term health and care crises. The newly integrated service brings together both trust staff and the local authority’s reablement team in a 150 strong unit.
This approach has enabled them to reduce overlaps and duplicated assessments for people by adoption of single assessments, co-located teams and shared information systems. For example, assessments carried out and plans put in place by one member of staff – whether trust, community health, or social care staff employed by the local authority – can be trusted and followed by all members of the team. For those receiving care this overcomes the common situation elsewhere where people have their care needs repeatedly assessed because teams and organisations does not accept or trust each other’s assessments.
The overall service is very much a stepped care model with people receiving the least intensive level of care and in their own homes wherever possible. In addition everyone entering the service receives an assessment of their level of frailty which has been incredibly revealing and valuable. ‘We have learned that people who have been assessed as having high levels of frailty are also found to have high mortality levels’ says Mr Taylor. ‘We are continuing to study early outcome data for people who have received this screening but we are beginning to consider whether this gives an indication of palliative care planning needs and/or end-of-life care needs. This therefore gives potentially extremely useful information that can be used by our integrated care teams so that we can make sure people are on the most appropriate care pathway for their specific needs.
We will continue to study the outcomes and this may lead to further future changes and improvements.
Historically, in Rochdale the trust did not provide community services. However, an innovative joint commissioning approach in the area to integrated intermediate tier services now sees the trust as part of a provider collaborative which successfully tendered as preferred provider. The trust is working as prime provider, in a provider collaborative model involving the local authority, GP out-of-hours service, GP federation and other organisations, including Age UK Rochdale. The service, which went live in September, has seen the transfer of staff from Rochdale Borough Council under TUPE to the trust as part of service mobilisation (in North Manchester social care staff within the integrated team have remained employed by their original employer/local authority).
What have been some of the challenges for the trust in setting up these different approaches? ‘Pensions
and TUPE have been important areas, as has been ensuring appropriate information sharing arrangements and IT systems’, says Mr Taylor. All partners have been fully committed to making this integration a success so have worked together closely to find solutions to problems that have arisen. The challenges arising from the need to manage integrated governance between organisations who are delivering integrated care in this way cannot be understated.
‘We are developing an integrated governance toolkit that covers such areas as: clarity of purpose – service model roles and responsibilities, application of partner principles, leadership and strategic relationships, staff management, care pathway management, quality improvement, patient safety and clinical risk management, information governance, financial and contractual reporting, management of risk and reward, and stakeholder management which will support our operational and contractual delivery.’
Integrated and provider collaborative delivery models are complex for several reasons such as the major differences between how local authorities and the NHS approach some issues. A GP practice may have some patients who fall outside a local authority boundary, for which health will provide a service but the local authority cannot. How can boundaries be delineated? In addition there is the distinction between how some local authority services are means tested and are chargeable whilst health services remain free at the point of delivery.
At the moment the approach to some of these challenges to integrated care delivery, whilst our integrated governance arrangements are being developed, has been to be flexible while they are worked through, says Mr Taylor.
‘There are also softer issues such as overcoming cultural differences, accountability and governance (with local authority staff used to an elected body overseeing them). Longer term, there are questions about the skills the workforce will need to deliver much of this care and we believe different roles are required. Locally it is likely that GM Devo will bring a focus on standardised outcomes for patients and how they can be delivered.’
With the thrust of these developments very much in line with devolution plans, Mr Taylor hopes there will be lessons that other areas can learn from the integration work undertaken by the trust. Of significance is the need to recognise the importance of partnership and collaborative relationships: ‘It is important to start the conversations with other providers and taking that first step,’ he says. ‘There has been a tendency for local authorities and the NHS to blame each other for each other’s problems and this has to be overcome’, he says.
Better services for people and potential savings exist for all organisations through removing duplications and designing integrated community based care offers which keep people out of hospital. None of this could be achieved without the commitment of the trust’s staff. Dr Fairfield adds: ‘Engaging with our staff is key to innovation and change. Through our use of new crowd sourcing technology and our Pride in Pennine initiative, we are reaching out to our staff to seek their views and input into everything we do. We are delighted to be a finalist in this year’s HSJ awards for our staff engagement work.
I am proud to be CEO of Pennine Acute. Driven by our staff, supported by our partners and enabled by GM Devo we are playing our full part in ensuring that our health system is transformed and we provide the best healthcare for our populations.
Trust profile
The Pennine Acute Hospitals NHS Trust is one of the largest in the North West of England and has some of the largest services by volume in the whole of England. It employs over 9,000 staff and provides high quality general and specialist hospital services to around 820,000 residents across the north east of Greater Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham and Rochdale and parts of East Lancashire. The Trust runs North Manchester General Hospital, The Royal Oldham Hospital, Fairfield General Hospital in Bury and Rochdale Infirmary. In addition, it also provides highly regarded and increasingly integrated community health and care services in the North Manchester and Heywood, Middleton and Rochdale areas.
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