Towards Health and Social Care Integration in Scotland. Dr Anne Hendry National Clinical Lead for Integrated Care

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1 Towards Health and Social Care Integration in Scotland Dr Anne Hendry National Clinical Lead for Integrated Care

2 Population 5.4 million 12 billion budget 14 Health Boards 32 Local Government Authorities Integrated healthcare delivery system Universal coverage Moving to health and social care integration

3 2020 Vision for Quality Everyone is able to live longer healthier lives at home, or in a homely setting. Integrated health and social care with a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. There will be a focus on ensuring that people get back to their home or community as soon as appropriate, with minimal risk of re-admission. Care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions.

4 Long Term Conditions Action Plan 2009 Self Management Strategy 2008 From 06/07-10/11 14% reduction in bed day rate for COPD; Asthma; CHD; Diabetes

5 Reshaping Care for Older People > 10 Year Programme to 2021 > 300 million Change Fund > 32 Partnerships between NHS: primary, acute, mental health LA: social care & housing Third and Independent sectors Older people and carers > Change Plans signed off by all partners > 20% of funding to be invested in direct or indirect support for carers > Cross sector improvement support and network

6 1300 fewer older people in emergency hospital beds than predicted

7 4000 fewer older people in long term care than predicted

8 People living in more deprived areas in Scotland develop multiple conditions around 10 years before those living in the most affluent areas

9 Public Bodies (Joint Working) (Scotland) Act Bringing together the accountability of statutory partners in an equitable way, to deliver better outcomes for patients, service user and carers - all adults Vision - People are supported to live well at home or in the community for as much time as they can and have a positive experience of health and social care when they need it

10 Public Bodies (Joint Working) (Scotland) Act (2014) Principles for integrated health and social care Integrated governance arrangements : delegation to a body corporate or lead agency Integrated budgets for health and social care Integrated oversight of delivery Strategic planning Locality planning Nine nationally agreed outcomes for health and wellbeing Self Directed Support

11 Integration Authority Strategic plan developed with the localities Include all adult care groups Housing Contribution - focus on home and place Population needs assessment Inequalities attuned 10 year horizon but 3 year implementation plan Integration Joint Board Chief Officer Clinical and Care governance Integrated budget

12 Integrated Resources- Minimum to be delegated 14,000 Scotland total = 12.3bn 12,000 Expendiure ( m) 10,000 8,000 6,000 Minimum to be delegated to Integration Authorities = 7bn 4,000 2,000 0 Hospital Community Health Family Health Services & Prescribing Social work

13 Information and Intelligence Framework Unique patient / client identifier Linked patient / client level longitudinal dataset Secure file transfer with governance safeguards Information Sharing Protocol Health and care dashboard activity / surveys Analysis of high resource individuals Resource consumption Linked information for a specific care group Local population profiles

14 Local communities and local relationships are key to effective integrated care and support

15 Action Plan coproduced with people living with multiple conditions What Matters to Me Coordination and continuity of care Trusted relationships Accessible information and advice Good communication with, and between, staff

16 Risk Prediction Tool How many previous emergency admissions has the patient had? What age is the patient? How many prescriptions? How many outpatient appointments? Any A&E attendances in the past year? Any prescriptions for e.g. dementia drugs? Or substance dependence? Hospitalisation (3 years) Psychiatric Admission (3 years) Any previous admissions for a long term condition (such as epilepsy? Outpatient (1 year) Emergency Department (1 year) Prescribing (1 year) What type of outpatient appointments did the patient have? Any recent admissions to a psychiatric unit? Outcome Year (1 year) PRE-PREDICTION PERIOD OUTCOME PERIOD

17 Anticipatory Care Plan and Key Information Summary Shared electronic summary Available 24/7 across Scotland in multiple care settings Total KIS Patients Demographics Medication Information Allergies and Adverse Reactions Next of Kin and Carer Details Agencies Involved Important Medical History Homecare Support Treatment ceilings Resuscitation wishes Feb Mar Apr May Jun July Aug Sept Patients

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19 Technology Enabled Integrated Care and Support

20 Patients accepted by ASSET in 29 Months 2,864 76% Supported at Home 76% are managed in their own home instead of Hospital by the ASSET team 5.7 days Length of Stay 5.6 / Day Beds Closed 50 Value 2Million+

21 Living it Up - Peer support and web based information and advice to help people manage their conditions

22 Everyone Matters working seamlessly with colleagues in NHSScotland and partners who provide care making more and better use of technology and facilities to increase access to services strengthening workforce planning to ensure the right people, in the right numbers, are in the right place, at the right time putting new and extended roles into practice

23 Adopt co-production and Personal Outcomes approaches

24 Creating the Conditions for Integration Political will cross party support Legislative framework Strong professional leadership Use of funding as catalyst for change Contractual levers in primary care Use disruptive innovation ( social and technology) Invest in voluntary sector as full partners Focus on place, home and community Relentless focus on outcomes that matter to people Learning and improvement culture

25 Local Path to Outcomes Build on individual and community assets Understand local context and how to create resilience Engage and develop the capability of the workforce Build trusting relationships across sectors at all levels One plan one budget investment decisions Work together to delver shared outcomes Manage political and public expectations Stay on the bus!

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27 JIT is a strategic improvement partnership between the Scottish Government, NHS Scotland, CoSLA, the Third Sector, the Independent Sector and the Housing Sector 27