This case study describes Croydon’s progress developing integrated care arrangements. It is part of an evidence review commissioned from the Institute of Public Care.
Despite a history of poor relationships between partners, siloed working and failed integration attempts, Croydon is overcoming the challenges, and in 2018 has succeeded in putting in place a ground breaking, legally binding Alliance Agreement committing key health and social care partners including the Council, CCG, health providers and the voluntary sector to shared approaches and principles for ten years.
The shared commitment to improving local people’s health and wellbeing aligns well with the Borough wide priorities of early intervention and prevention and place based working. At the heart of the Alliance Agreement is a set of ‘I’ statements, devised by local people that powerfully encapsulate the outcomes they want to improve their lives.
By taking a careful step by step approach and evaluating impact at each stage, Croydon is already seeing the benefit of two new models of integrated care. The first - multiagency teams called ‘huddles’ - meet weekly at the GP surgery to proactively plan the care of people with complex needs to reduce the risk of hospital admissions. The second focuses on promoting independent living for older people through reablement, rehabilitation, and rapid response delivered seamlessly by an integrated team of social and health care professionals operating out of a single building with one budget.
Although Croydon is still grappling with the common challenges of IT systems that don’t talk to each other, inflexible employment rules, different rules on information governance, separate regulatory systems and trying to manage the transformation while doing the day job, the robust governance and leadership is sufficiently strong to keep the integration vision afloat and moving in the right direction.
The One Croydon Alliance is a partnership of health and social care organisations including Croydon Council, Croydon CCG, Croydon GP Collaborative (representing vast majority of local GPs), Croydon Health Services NHS Trust, the South London Maudsley NHS Foundation Trust, and Age UK Croydon. Having the same boundaries has helped to forge bonds, as have the overarching Croydon Council priorities of early intervention, prevention and place based working.
In 2014, the Council and CCG decided to establish an outcome based commissioning approach for people aged over 65. They undertook an extensive engagement exercise with local people to agree local outcome priorities which are summarised in the five ‘I statements’ below:
- I want to stay healthy and active for as long as possible Stepping up to the place July 2018 i
- I want access to the best care available in order to live as I choose and as independent a life as possible
- I want to be helped by a team or person that has had the training and has the specialist knowledge to understand how my health and social care needs affect me
- I want to be supported as an individual with services specific to me
- I want good clinical outcomes
Outcomes chosen by local people, to improve their lives are at the heart of the Alliance’s vision. As the Head of Older People’s Commissioning said “We integrated for the outcomes”. Alongside these very personalised aspirations, the two other main aspects of the vision are to shift activity to the “right place at the right time” and improve financial sustainability across the system.
The other key stages of the journey so far, have been the formation of an Accountable Provider Alliance in 2015 to design the new models of care followed by a commissioner provider alliance in 2016 with a joint commitment to delivering shared outcomes. In April 2017 commissioners and providers signed a one year Croydon Alliance Agreement to test out two new initiatives: Integrated Community Networks and Living Independently for Everyone.
By April 2018, sufficient benefits had been demonstrated to reassure partners that the new, integrated ways of working should continue and be expanded across the whole of the health and social care system taking a whole population approach. The legally binding agreement has been extended for a further nine years until the 31st March 2027.
Characteristics of the Croydon journey are that it began ‘under the radar’, has been relatively slow and has developed through a carefully phased approach. The Alliance has not attracted national funding (e.g. through the Vanguard or Pioneer programmes) and many of the people who have driven it have done so alongside their day jobs. The partnership work has also survived significant financial challenges which so often cause the failure of innovative agreements as individual organisations become internally focused and risk adverse.
Governance, leadership and commitment
The One Croydon Transformation Board, made up of chief executives and clinicians, steers the work at the top level with a forward focus, and is responsible for strategic decisions and for the governance of the Alliance Agreement. Underneath sits the director level Alliance Delivery Board holding the assurance and delivery function for work ‘in scope’, focusing on the present and holding partners to account. Both are independently chaired by the same person who has a public sector background but not from health or social care. The Boards are also supported by a professional cabinet that includes representation from local leaders of health and social care professions to scrutinise all proposals. Within this framework all strategic decisions of the Alliance are still subject to the governance of the sovereign organisations. Stepping up to the place July 2018
Other Boards, delivery groups and teams covering a range of workstreams and functions link with these two key boards including a service user reference group, the Health and Wellbeing Board and notably One Croydon Integrated Management teams, combining staff from across health and social care.
At the centre of the structure sits the Alliance Agreement and it is this that helps to glue the partners together. It clearly sets out the shared principles and approach to areas such as decision making, risk sharing, commercial strategy, termination and exit and contract management.
A well organised governance and operational structure and a set of principles on paper is not enough in itself to deliver change. Staff admitted that relationships between the partners have often been difficult and previous attempts at integration had failed. What seems to be making the difference this time is the investment in organisational development (OD) which is taking place at all levels right from the top. Unpicking behaviours and cultures that had previously driven silo working, this work has challenged senior leaders to frontline staff across the Alliance organisations to ask themselves the question “do we speak well of each other” and to reflect on how to improve relationships.
This has been helped by having a programme management team that draws on membership from different partner organisations. Working in an open plan work area are a combination of both commissioning staff and operational staff where they interact on a daily basis, getting to know each other, building trust, sharing ideas, learning and problem solving together.
The OD work has only scratched the surface so far as the ambitions of the programme is to see behaviour changes across six different organisations plus over 50 local GP practices, the voluntary sector and the local population. Future plans include shared staff induction content, shadowing, coordinating of recruitment and training.
Delivering integrated care
During the first phase of integration, two new models of care have been rolled out across the borough, focusing on delivering an Out of Hospital Strategy which aligns with the local STP business case.
The first, Integrated Community Networks (ICNs), has led to the development of multi-disciplinary locality working based on local GP networks. This includes the creation of a core multiagency team that meet weekly in a “huddle” to proactively plan the care of people with complex health and care needs. After testing the concept in a small number of practices at the end of 2016, this roll out of this model of working across all practices was commenced in September 2017 and completed in March 2018. Part of this person centred approach includes Personal Independent Co-ordinators (PICs), employed by Age UK Croydon, to work with people to set personal goals that will improve their health and build their independence, often linking them to community and voluntary sector support. Thornton Heath resident Robert is one of the people who has benefitted from this new way of working. Here, he tells his story.
Huddles focus on people with long-term conditions and escalating needs who are at risk of having future admissions to hospital. The initiative has already demonstrated evidence that it is reducing admissions to hospital amongst this high risk group. Early indications show there have been 14% fewer hospital referrals linked to this initiative. Getting all GPs on board has been achieved through a huge investment of time and effort including visiting every GP practice to win hearts and minds, producing a guidance manual and employing network facilitators to support the processes and ensure the weekly meetings happen.
Other aspects of the ICNs are still in development including the creation of Local Voluntary Partnerships which will be vital in organising and supporting the voluntary and community sector offer so that initiatives such as social prescribing and the PICs know who they can signpost and refer people to for help in their communities. If the Alliance vision “to support the people in Croydon to be independent and live longer, healthier and fulfilling lives…” is to be realised, thought will need to be given to the realignment of resourcing to community assets that support people to develop resilience, wellbeing and a self-care, preventative approach to their health. One of the sub boards of the Alliance, Together for Health and Care, will be leading on these developments.
The second model of care to be tested is Living Independently for Everyone (LIFE). The focus is on integrated reablement, rehabilitation, and rapid response services for people over 65 that need support for a safe early discharge or to prevent admission to hospital. Services from health and social care have been integrated into one team operating out of a single building with one budget. Already the ‘discharge to assess’ element has successfully reduced length of stay for people in hospital and seen a reduction in long term care packages post reablement. This service made a significant difference to Croydon’s ability to manage the 2017/18 winter pressures.
Both new models of care demonstrate that an integrated approach works, both in improving the quality of care for individuals and in making financial savings. These early successes have been important in maintaining commitment to the Alliance and the vision for transformation.
Commissioning and contracting
Croydon has introduced a number of tools to manage commissioning and contracting across the system. Each organisation in the Alliance is responsible for their own commissioning and contracting in line with their organisational policies and regulatory requirements but all are working to a shared performance management framework to ensure that shared objectives are being realised and risks are jointly identified and mitigated. A Services Operations Manual, which will be legally binding as it is incorporated into the NHS services contract is being written to direct staff on issues such as service change initiatives, contract variations, risk share principles and mechanisms to ensure a common approach.
Alongside these business models, there is a sense that attitudes to contracting are changing, moving away from a hardnosed business model where providers are held to account for transactional activity to a softer relationship based approach where commissioners and providers work together in partnership with a focus on improving qualitative outcomes for the individual. The Alliance has developed an outcomes framework and results will be published to demonstrate transparency, accountability and to promote shared ownership of goals across the Alliance.
Croydon has spent a lot of time on financial modelling. The bottom line that has emerged is that a do nothing position for over 65s would substantially increase budget pressures across the health and social care system and is not sustainable. Transformation and collaboration is widely acknowledged to be the only way to provide high quality services and manage budgets. With all organisations facing financial difficulties there is a recognition that it is better to tackle the issues together so the whole system can benefit.
An example of taking joint financial responsibility across the system was the shift of money from the CCG to the Council in recognition that additional social care is required to support timely discharge of patients requiring reablement.
In terms of contract payment systems, payment by results arrangements are seen to have been counterproductive to partnership working as it creates incentives in acute trusts to drive up activity to increase income. Going forward, the Alliance Agreement states an intention to introduce outcome based payments. The long term aim is that this will form an integral part of a capitated payment system for Croydon.
IBCF monies were used to fund LIFE and ICN in the first year. The Better Care Fund is currently being reviewed to focus all future projects on the Alliance models.
Some of the more challenging aspects of systems integration in Croydon have been around IT systems that don’t talk to each other and HR systems that don’t support the creation of new integrated roles. Even relatively small things like differences in VAT can be a significant barrier. More significant issues such as different regulatory systems and information governance rules are seen locally to be major barriers that need to be sorted at national level.
Going into phase two, with the security of knowing that the Alliance Agreement is now in place for another nine years, and ‘proof of concept’ has been evidenced for two key initiatives has generated a sense of confidence and optimism. With robust governance structures agreed, clear commitment and leadership from the top and increased staff morale from hands on experience that new models of care are benefiting local people, Croydon is in a good place for continuing its roll out of integration and delivering on its vision to “work together to help you live the life you want”.