Buckinghamshire Accountable Care System: A collaborative approach to integration

‘Everyone working together so that the people of Buckinghamshire have happy and healthy lives’

What is an accountable care system?

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What it is: What it is not:

Mature partnerships - a coalition committed to collective decision making

New statutory bodies or change to existing accountabilities

Partners making a single, consistent set of decisions about how to deploy resources

Employers, ways of managing financial or other resources

Stronger local relationships and partnership work based on common understanding of local priorities, challenges and next steps

Legally binding (deliverability rests on goodwill, commitment and shared priorities and objectives)

A clear system plan and the capacity and capability to execute it

Getting rid of the purchaser / provider split or of respective statutory duties and powers

Place-based, multi-year plans built around the needs of local populations and local health priorities

Tried and tested. There will be bumps along the way – the true test is in the relationships!

Delivering improvements Removing the need for consensus and collaboration

Our strategy requires system integrationPut Care in the Best PlaceInvest in prevention and early intervention, with increased community services to provide care at home, reducing bed-based care through our Providers, who are working together to make this happen

Living, Ageing and Staying Well

Prevention & Early Intervention

Rapid Response & Reablement

Long Term Care

Low dependencylevels

High dependencylevels

Living, Ageing and Staying Well

Prevention & Early Intervention

Rapid Response & Reablement

LongTerm Care

Current balance of spend Future balance of spend

Rebalancing spend over a 5 year period

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Integrating for our population

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Clusters - 50k population, several GP practices

Core integrated team

Specialist practitioner team; accessible to more than one cluster, working across primary and secondary care

Integrating skills

System Practitioner Networks –where those with specialist experience in diabetes, COPD, tissue viability, elderly care, paediatrics are accessible to the local population of professionals

Our distributive clinical leadership will include clinical health ‘scanners’ who ensure we have the best outcomes for our population’s health and care needs

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Integrating for value

Patient with multiple co-morbidities referred by GP

for hip assessment

Consultant agrees to active treatment; booked

for operation

Long period of rehabilitation for not much more

mobility

Current State….

Patient talks to GP, Community Nurse,

carer & family about options & risks of

treatment

Patient decides not to have operation- weekly

bridge and lunch club too important.

Management plan includes physio & OT for living safely, pain

managed through pharmacist prescriber

Health & care services based on outcomes that are important to the service user

Future State….

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Integrating our approach to quality

Community integrated team has awareness of level of independence that patient usually enjoys.

All providers working together to achieve the same quality outcomes for patientsepisode

Patient admitted for full assessmentShared information enables acute team to understand normal self management

Patient discharged; 4 week reablement programme to return him to his full pre stay wellness levels

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Integrating technology to support self helpFacebook/Twitter to comment real time

on health & social provision

Personalised Risk Profile

Baby Buddy App

On line Health Trainer & FitBit

Triage, then GP or Nurse appointment

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CM: our strong track record of delivery

‘A’ RATED stroke

services

1st

for helping people manage diabetes

DementiaINNOVATORS

mental health

TOP performers

for atrial fibrillation

LOWdelayed transfers of care

BETTERcancer survival

rates

9Your community, Your care : Developing Buckinghamshire together

Tangible improvements

Better outcomes

Developing our integration

• 600,000 contacts cared for outside of hospital annually • Working with partners to make health and care services safe,

sustainable and able to meet the future needs of our local population

• Investing over £1m to expand our community services• Delivering what patients and clinicians have asked for

Helping the people of Buckinghamshire to stay well

Through prevention and early-intervention we want to: • help patients to take greater control over their care and treatment• ensure we meet patients’ long-term needs to help them to stay

independent• make it easier to access the right services

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Developing across the whole of Buckinghamshire

• Locality teams

• Rapid response intermediate care

• Community care coordinators

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Community hubs• 6 month pilot at Marlow

and Thame hospitals • Co design with

stakeholder group• providing a new

community assessment and treatment service (frailty assessment service)

• more outpatient clinics• more diagnostic testing • working with the voluntary

sector

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How are patients benefitting?

• In total c.700 outpatient appointments delivered in community hubs

• Over 300 people referred, assessed and treated by the community assessment and treatment service at Marlow and Thame

• Over 1,000 patient referrals managed through the community care coordinator

• 2645 more care contacts a month by our rapid response and intermediate care team

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What have patients said about the service?

April/May June July Aug0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Overall, how did you rate the treatment you received?

Excellent Good Fair Poor

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Key learning

• Increasing levels of activity and increase in referrals to the frailty assessments service overall

• Need to continue to raise awareness of the hubs amongst GPs to increase referrals

• More time required to mobilise and evaluate outpatient clinics and voluntary service involvement

• Potential to provide more complex treatment locally such as chemotherapy

• Continue to recruit staff to support the continued expansion of the services

• Stakeholder engagement group has been an important independent voice

• Stakeholder engagement group and clinicians have recommended we need to assess performance during winter months

• Pilot more services in other localities

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Proposed next steps

• Extend the pilot for a further six months• Continue to roll out the model for out of hospital care and

community hubs: open up access to Amersham, Chalfont and

Buckingham to voluntary sector colleagues expand the offer at Thame and Marlow (e.g. ultrasound) explore potential outpatient clinics at our

Amersham, Chalfont and Buckingham sites

• Undertake a second wave of patient, public, staff and GP engagement

• Final report in March 2018

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Fast-tracking the joined-up services everyone wants

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Jean’s story

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