SYMPHONY Person-Centred, Co-ordinated Care

The Symphony ProgrammeA New Vision forSouth Somerset

Dr Berge Balian, Programme Board Chair

Our demographics are changing

Proportion of the Somerset population aged 65+ by LSOA - 2003

Proportion of the population aged 65+ by LSOA - 2013

Proportion of the population aged 65+ by LSOA - 2023

Proportion of the population aged 65+ by LSOA - 2033

Unscheduled Care Complex Co-morbidities Discharge Planning Generalised Vs. Specialist Services Integrated Care Comprehensive Care closer to home Resources: Space; Finance; Time; Workforce

Key Challenges for Secondary Care

Patient Demand Long Term Conditions Seamless Care Competition Vs. Continuity of Care Autonomy Vs. Scrutiny Call For Action Resources: Time; Finance; Workforce

Key Challenges for Primary Care

Demographic changes are driving up costs in the local health economy and across the NHS

NHS Plan: Five year Forward View

New care models are being piloted at ‘vanguard’ sites sponsored by NHSE

PACS Joint Venture (JV) between GPs and YDH.

Capitated Outcome Based Commissioning (OBC) contracts in Somerset

Integrated Accountable Care Organisation (IACO) holding the OBC contract

IACO = JV + other health and social care providers, including Public Health and Third Sector

Alignment of incentives and integration of care for all health and social care provision

Shift of work and resources from 2’ to 1’ to preventative care

Shared budgets and incentives reduce costs. Savings reinvested where need is greatest.

Patient Centred Care: Right care by the right person in the right place at the right time. This improves care and cost-effectiveness

The Case for Change

Outcomes-based commissioningSomerset CCG have confirmed their desire to move to a capitated, outcome-based contract in South Somerset by April 2016

Outcomes-based commissioning in practice Definition of outcomes-based commissioning

• “The results people care about most when seeking treatment, including functional improvement and the ability to live normal, productive lives” (ICHOM, 2013)

• Starts from the perspective of the patient

• Challenges the culture not the structures

• Aims to makes best use of capped resources

Multiple commissioner and provider relationships

Lead provider(s) and simpler commissioning relationships

Potential impact on GP financials: average1 South Somerset practiceControl over larger budget is an opportunity for GPs to improve care and benefit from shared savings

AC: I/P

elect

AC: O/P

GP income

Gain share

Prescribing

£m

AC: I/P

urgent

SC:Home+Day

MH: O/P

SC: Resi

SC: other

CC: other

CC: IP

AC: A&E

MH: I/P

Socialcare

Mentalhealth

Acutecare

List size 6,380 4,340 660 1,990 630 490 70 30 130 120 10 30 1,010

Cost per patient

£160 £210 £140 £340 £1,940 £2,770 £5,100 £12,500 £2,550 £2,230 £20,600 £9,790 £250

Communitycare

Pres

crib

ing2

1. Mean figures averaging across 19 South Somerset GPs.2. Prescribing cost is extrapolated from Mar 2015 (HSCIC), with prescribing list for 2013-14 (Symphony data)

0

1

2

3

4

5

6

7

8

Pote

ntial

ben

efit f

or G

Ps v

ia sa

ving

s

Total: £1.02m £0.93m £3.35m £1.02m £0.48m £0.58m £7.38m

37 Vanguards across the countryWe are one of 9 PACS Vanguards (Primary and Acute Care

System)Two years of funding for new care and organisational models.Leading Vanguard for Organisational Forms.Funding for programme costs, primary care staff and

remodelling, three Complex Care hubs.CCG also funded to develop OBC.National team working with us to break down barriers to

innovation and overcome national issues

Vanguard programme

SYMPHONYPERSON-CENTRED, CO-ORDINATED CARE

SYMPHONYPERSON-CENTRED, CO-ORDINATED CARE

‘Leading innovation and integration for a healthier, more independent

population.’Objectives:

Informed people, empowered to take responsibility for their health and

wellbeing.

An ambitious and adaptive workforce, working creatively to deliver

exceptional care.

A seamless, integrated and responsive network of care services, working

together to do the right thing for patients.

Vision:

Our Vision

A sustainable health and social care systemHelping people and their carers to manage

their own health and achieve their goalsSupported by a joined-up system including the

NHS, local authorities, the voluntary sector and the communities in which they live

Where staff enjoy their jobs and want to work.Focus on community and preventative care

Participating practices

developmentKaren Lashly

Programme Structure: Overview

Symphony Programme Board

Dr Berge Balian

EPC ModelDr Steve Edgar

• Develop EPC model

A2OpCo/Integrated

practices development

Mandy Seymour Hanbury

IACO stand up& OBC

John Kelly• Develop

detailed design, structure & governance

B1 B2

PMOAdvisory Group

IT and Technology Patient Safety& Quality

Comms & Engagement

ElectiveDr Jon Howes

• Orthopaedic pathway improvements

A3

Workforce

Urgent Care

Dr David Cripps

A4

• Develop and refine urgent care initiatives

Cross-Care Model Forum – Dr Berge Balian• Identify themes and ‘quick wins’ across new care models• Small Action Team to implement quick win initiatives

Core JV groupDr Berge Balian

Vol sector/Public health Paediatrics

B3

Technical group

Complex Care Model

Dr Ian Wyer• Refine model

& plan roll out

A1

Working Groups

Cross-CuttingThemes

(feed in as required)

78%~90k

18%~20k

4%~5k

~15%~£20m

~35%~£55m

~50%~£75m

% of population % of cost

Complex patients with many conditions

Less complex patientswith fewer conditions

Mainly healthy patients

Population segmentationand new care models

Complex care hubs

Enhanced primary care

Proactive health and wellbeing support

Complex Care: Extensivist care modelThe patient is assigned a care coordinator and offered more proactive care, support and attention through a number of services

Complex, Poly-chronic Patients Key Worker

Expert Generalist

Extended Care TeamTherapies e.g. Physio

Mental Health

Social Care

• Diabetes• Respiratory• CHF• Dementia• Other…

Network of Services

Care HomeAdvanced Diagnostics

Core Care Team Key Elements

Comprehensive assessment of physical, mental health and social care needs

Support and coaching for patients and carers

Co-ordination of integrated pathway

Routine contact and monitoring of patient’s health and care needs

Proactive development of personalised health and social care escalation plans

Rapid crisis response

Care Programmes

Care Coordinator

GP

FOPAS (Crisis

Support)

Enhanced primary care

New model of primary careBroader team (Physios, CPNs, pharmacists)New triage systemGPs focus on people with complex long term

conditionsHealth coaches to support patients 18 out of 19 practices involved in EPC and CC

Enhanced primary care modelThe patient and key worker are supported by the wider care team and a number of care programmes and services

Patient with Chronic

Condition

Key Worker / Health Coach

GP

Care Programmes

and Specialists

Other programmes…

Extended Care Team

Therapies e.g. Physio

Mental Health

Social Care

CHF

Respiratory

Diabetes

Dementia

Network of Services

Care HomeAcute Care

Advanced Diagnostics

InterfaceCore Care Team Key Elements

Team Working and Huddle

Triage

Stratification and Proactive Outreach

Care Planning and Coordination

Defined Workflows and Programme Integration

Aligned Resources and Incentives

Shared Clinical Data and Population Health Analytics

Practice Nurse

Other services…

Working with voluntary organisations and communities

Helping people to access support in their areas

Directory of servicesSupporting communities to support their

residents

Project area statistics Population:

– 2,172 (Experian), 932 households– 45% of Martock’s total

Comprises Martock East LSOA:– outside of Yeovil and Chard this area is

the most deprived in South Somerset– nationally in the lowest 40% across all

IMD areas and in the lowest 25% for education and skills, income and employment

Key Statistics:– 24% aged 65 and over– 36% one person households– 19% long term sick or disabled– 34% no qualifications (age 16+)– 23% household income <£15k pa– 22% no car or van in household

Largest proportion of social housing in Martock (34% live in social rented homes)

Over 90% of Martock’s free school meal entitlement

NHS and social service costs:– £4.48m per annum– consumption per head 1.8 x South

Somerset average

Volunteers

Resourcing

Community Youth Project

Youth Workers

Youth Services

Community Services Coordinator

Job Club Coordinator

Employability Service

Seniors Services

Coordinator

Befriending Service

Martock Parish ClerkInformatio

n Governanc

e

Information Centre

Martock Parish Council£125,000 pa investment

IACO JV Organisational Structure