Somerset County Council and Somerset CCG have been developing joined up care for several years, and this has accelerated through initiatives such as joint commissioning, an integrated data system, and the BCF programme. A model for ambitious, whole-system reform is now being developed.
Somerset County Council and Somerset CCG have been developing joined up care for several years, and this has accelerated through initiatives such as joint commissioning, an integrated data system, and the BCF programme. A model for ambitious, whole-system reform is now being developed, with agreement in principle to work towards outcome-based commissioning with a capitated payment system and pooled budgets. Somerset is a PACS vanguard site providing joined-up care in three community hubs.
How public health became involved
When the public health team moved to the council, it developed an operating model for how it could best promote health and wellbeing. One strand of the model was focused on influencing across organisational boundaries and providing specialist public health support to the whole health and wellbeing system, as well as to the CCG through the public health core offer. This approach means that public health has been involved at an executive level in planning and shaping the plans for integration.
Public health contribution to integration
Strategic leadership and vision
Public health strongly supports Somerset’s vision for joined-up care as the best way of promoting health and wellbeing, and tackling health inequalities. The current organisation of health and social care has many disadvantages. Fundamentally the system is too disjointed, largely with a focus on treating ill health and fostering dependence. Not only is this detrimental to promoting health and wellbeing, it is costly and unsustainable.
The proposed new model aims to ‘flip the system’ by introducing levers and drivers to shift from being demand driven to prevention led, and from provider-focused to person-centred. Rather than paying NHS providers for the activity they do, the new model will pay providers for achieving health outcomes which are geared to promoting good health and independence and which are valued by service users.
The supporting mechanism will be a payment system based on delivering care for individuals (year of care) which is aligned with financial incentives that encourage providers to prevent or reduce the need for clinical intervention. For example, providers could help people with long-term conditions learn to manage their illness, or provide health and wellbeing support to keep people active in their communities.
Providers will be encouraged to come together as a coordinating body which will hold the contracts with commissioners. They will be able to be innovative and flexible, redesigning services and switching resources to best meet contract outcomes.
Somerset has consulted on the proposals, and is developing a business case with a view to establishing an outcomes-based approach in April 2017. Public health has influenced the details of the business case. It supports the view that to make the biggest impact on public health, the new model should eventually include the widest range of services and people, for both adults and children. This would avoid the need to double run different systems, which would be costly and could also lead to health inequalities.
What others say – Dr Matthew Dolman, Chair Somerset CCG:
"The public health team has been fundamental in driving forward a bold and ambitious approach to population health. Their expertise has been critical in supporting the development of joined-up care at general practice, community and system-wide levels. Somerset is working to ensure that services are joined up around the needs of individuals, and the public health team has made an important contribution to the model we are developing. In particular, public health provides a focus on population health, tackling health inequalities and developing preventative support.
"Public health intelligence makes a link between people and places, which is central to our model. One of the strengths of public health in Somerset is that it presents information, such as community profiles, in a way that it is clear, understandable and meaningful. This helps us to see where the challenges lie, and to identify ways of tackling these.
"It also allows us to look to the future, and how our priorities may need to change. Information is provided at the levels of GP practices and wider communities, and in system-wide approaches, developing the outcomes and metrics for integration.
"As the model is rolled out, providers will need to develop their understanding of population health and promoting health and wellbeing so they can continue ‘flipping the system’ – the shift towards prevention. Public health will continue to have a crucial role in supporting this."
Overall, public health’s move to local authorities has been helpful; it provides a useful bridge between the council and the NHS, bringing together the potential of both to improve health and reduce health inequalities. As organisations work ever more closely together, a new type of leadership will be needed to combine understanding of systems and communities, and public health is well placed to provide this leadership.
Evidence, outcomes and evaluation
The demographic and geographical issues facing Somerset are a key driver for pursuing integration. It faces challenges in sustaining services across such a large geographical area as well as additional challenges in the health and care workforce. In 2014, public health refreshed the JSNA to provide detail about the current situation to establish a clear analysis of the case for change.
Another significant step forward for integration has been learning from the integrated data system in South Somerset, which has now developed into the vanguard PACS programme. This programme involved a partnership between several organisations, focusing on providing a very different model of care for an initial group of approximately 1,500 residents with long-term conditions.
he project developed an innovative integrated dataset providing invaluable information about health and social care usage for people with long-term conditions. Public health’s role in local government and NHS integration 23 The DPH chairs the workstream responsible for delivering the commissioning outcomes framework for the new model of care. It is envisaged that contracts in the future would be over a longer period of time, thereby enabling much more potential for achievement against public health outcomes, which tend to have a longer gestation. Outcomes are currently being devised within three domains:
- population health and wellbeing eg healthy life expectancy
- quality and value eg safeguarding, patient safety
- transformational metrics – outcomes used to support the system as it goes through the transition stage.
Outcomes and metrics are being informed by National Voices ‘I’ statements, local consultation, the local JSNA and the annual public health report, as well as the work of the vanguard and other integration programmes.
What others say – Steven Foster, Director of System Transformation Programmes, Somerset Council and Somerset CCG:
The DPH is a key member of the leadership group involved in developing the Somerset Together programme, contributing a focus on population health and health inequalities which has been very influential in shaping the programme. Rather than focusing on specific public health activity, such as drugs and alcohol, a strategic approach has been taken, providing the evidence base and intelligence for preventative approaches such as self care, and helping to put wellbeing at the heart of the system. The DPH is responsible for supporting the work of the HWB. As a two tier authority, the five district councils in Somerset are represented on the county HWB as well as some operating their own local boards.
This has ensured that district councils, which make an important contribution to public health, are included in strategic planning. Districts are involved in several initiatives that support integration, including collecting information about housing adaptations in a study to see the extent to which they prevent or delay emergency hospital admissions.
Developing preventative approaches
The topic of prevention has an increasingly high profile across partners in Somerset. As part of the development of new models of care, and to help increase preventative activity in the health and social care system, public health was asked to identify a suite of evidence-based preventative activities that could be taken forward by partners in the next year or two. These include delivering brief lifestyle interventions and MECC, increasing staff take-up of flu vaccination and working towards healthy workplace awards. Organisations in the system have each nominated a representative to join a working group to progress this work, and have undertaken a self assessment against the top tips, with action plans expected in the new year.
Contact
Trudi Grant
Director of Public Health
Email: [email protected]