This case study describes Plymouth’s progress developing integrated care arrangements. It is part of an evidence review commissioned from the Institute of Public Care.
Clear, visionary leadership from the Health and Wellbeing Board jump-started the integration process in Plymouth. The challenges of increasing demand for health and care services and severe financial pressures meant that a transformational shift was needed. Despite working to different geographical footprints, CCG and local authority leaders have joined forces to bring about whole system change for the city and the development of a can do, solutions focused culture. Relationship building with elected members early in the process helped to secure cross party support for a shared vision that the people of Plymouth should have ‘the best start in life’ through to ‘ageing well’ and that this would be delivered through a ‘one system, one budget’ approach.
The appointment of Livewell as the Community Care Interest provider in 2015 was a significant step in the journey towards the delivery of integrated health and social care services for the area. While general practice sustainability and capacity remain challenging within the city, GP views and clinical leadership have also contributed to the re-shaping of service provision. Innovative workforce development approaches are being developed to tackle the problem of recruitment across the health and care sector including a number of apprenticeship programmes.
Wherever possible, staff are co-located to facilitate effective team working across multi-disciplinary teams regardless of who employs them. This includes HR, finance, communications and estate management teams. Tackling the problem of IT systems that don’t talk to each other remains particularly challenging. A current priority is to develop ‘a single view’ of data and information by all relevant professionals, enabling the patient to tell their story once.
Plymouth’s journey towards the integration of health and social care services was driven by the vision of the Health and Wellbeing Board which challenged the system to deliver integrated commissioning, funding and service delivery and to invest in prevention and the promotion of wellbeing.
Plymouth’s Integrated Fund launched on 1st April 2015, pooling the city’s budgets for Wellbeing, Children and Young People, Community and Enhanced services, for both local authority and CCG spend, with no shadow period. At the same time, the local authority’s adult social care staff TUPE transferred to the appointed integrated provider of adult health and social care, which started to see significant improvement in delivery in 2015/16.
The journey has been built on:
- trust and relationships with a significant ongoing investment in joint organisational development
- clear shared vision: a purpose that was locally driven
- determined leadership overcoming barriers to deliver the vision
- the certainty that the single all-encompassing integrated fund was key to ensuring that everyone was motivated and engaged in delivering improved outcomes for the city
The vision set out by local leaders was one based on the growth agenda for the city. The system was clear that in order to address the challenges posed by changing demographics and disparity of need across the health and wellbeing landscape, a whole system approach was required which included access to improved housing, employment, education and skills. This ‘one system, one budget, delivering the right care in the right place at the right time’ approach enabled cross party support for the city.
Joint strategic leadership was key and the relationship between the Director of Public Health, Strategic Leader for People and Chief Operating Officer for the CCG ensured that where blockages were identified a solution focused approach was maintained. This was particularly apparent with the development of the Integrated Fund. Plymouth worked with Bevan Brittan LLP to develop the Section 75 agreement, financial framework and risk share arrangements. Where budgets couldn’t legally be pooled they were aligned.
Net pooled funds include:
‘Any pooled fund established and maintained by the Parties as a pooled fund in accordance with the regulations’
Net aligned funds include:
‘Budgets for commissioning prescribed services that the Regulations specify shall not be pooled, but which will be managed alongside the Pooled Fund’
The Fund is truly cradle to grave and covers:
- public health
- leisure services
- housing services
- children’s services (including the schools grant (DSG))
- adult social care
- primary care (CCG and PCC)
- community health services
- acute provision
- running costs.
There was a desire to build on existing joint commissioning arrangements with a focus on establishing a single commissioning function. Whilst staff are still employed by their host organisations they work as a single team, delivering to the four shared commissioning strategies and supported by an integrated finance team.
A significant amount of time has been invested in member engagement throughout the journey, including a number of joint sessions with local GPs. Gaining cross party political agreement on proposals has allowed the pace of change to progress unperturbed by changes in administration due to all parties owning the vision for health and wellbeing for Plymouth. In addition, the development of risk sharing protocols for the joint fund provided reassurance to the local authority’s corporate management team, the CCG governing body and the local elected members.
Governance, leadership and commitment
Work to develop Plymouth’s vision for integrated budgets and service provision commenced three years prior to the April 2015 go-live date. Data and information from the Joint Strategic Needs Assessment was used as the basis for developing strategies and plans and helped to draw in commitment from a broad range of partners.
A balance of formal governance meetings and informal gatherings has helped to cultivate a climate of trust and understanding among leaders and gain their input to the development of Plymouth’s shared vision.
Changes in culture have been led from the top with system leaders co-located, rather than siloed in separate offices. Working from hot desks, they are visible and accessible to staff and deal with problems together, using a strength based, can do approach. Leaders recognise the need to constantly align priorities across the system and to ensure that all parties or disciplines are represented when they are trying ‘to land’ something to ensure they have addressed all the key issues and have the right level of buy-in from everyone.
Delivering integrated care
Livewell is the Community Care Interest provider commissioned by the CCG and the local authority to deliver integrated community health and social care services from 2015. This organisation works closely with the acute hospital, University Hospital Plymouth, however at this stage they are not formal partners.
Livewell includes all primary health community-based services, excluding GPs and works closely with the voluntary sector within local communities. The city has continued to invest in preventative services, illustrating the city’s vision that prevention is as a key enabler to wellbeing and health improvements.
Plymouth has started more recently to implement Community Wellbeing Hubs with the first one now in place. There is an ambitious roll out planned, including consideration of whether some future sites can be wrapped around remodelled GP practices. The Hubs will serve as flexible bases for the multi-disciplinary teams including primary health and social care where colleagues engage in social prescribing, hold case reviews, collaborative working and where the public can access information, advice and support.
The plan is to have one within each GP area. They form part of Plymouth’s ‘One Public Estate’ strategy which focuses on making better use of all public buildings across the system.
Whilst significant progress has been made in delivering integrated care, leaders are honest enough to admit that the current system configuration is still not delivering optimum benefits and a number of significant challenges remain. Elements that are proving hard to improve include financial sustainability and equity; system flow; primary care; planned care, workforce and market sufficiency. Recently the biggest challenge for the local system has been around key NHS Constitutional targets in particular delayed transfers of care (DToC) and emergency department four hour wait. In December this generated a CQC system review. Over recent months DToC performance has seen steady improvement as the whole system has worked to deliver significant change.
In 2015, Plymouth’s Integrated Commissioning service went through a process of co-development with system partners to design four integrated commissioning strategies: Wellbeing, Children and Young People, Community and Enhanced and Specialised Care as illustrated in the diagram below.
Plymouth took the decision to weave mental health into all strategies rather than holding it separately to promote a ‘No Health without Mental Health’ approach across the Health and wellbeing system.
The wellbeing strategy and accompanying action plan focuses on prevention and includes planned care. Specialised care includes end of life care and children and young people currently have a separate commissioning strategy and plan.
These are each underpinned by the Joint Strategic Needs Assessment with its own system design group and an integrated scorecard based on the public health framework which is reported quarterly to the Integrated Commissioning Board, performance is also overseen by scrutiny committee.
Throughout Plymouth’s journey towards integration, shared systems have been used as the catalyst for change. Not only have they pooled budgets and commissioned an integrated health and social care provider, they have moved on to integrate ways of working within their central teams. This includes finance and commissioning and the move towards a single asset strategy which built on a number of successful ‘One Public Estate’ bids and a desire to align resources across the city.
They are also working to integrate IT systems. This has been particularly challenging and the original vision for a single IT system for all partners has not been achievable. In a solution focused way the team have identified a system and reporting approach that will enable data and information to be seen in a single view, enabling the client/patient to tell their story once, removing duplication. Staff will be able to view all relevant information which will help to speed up decision making around discharges as well as helping to prevent admissions and overnight hospital stays and better analysis of working practices.
The council and CCG established a shared services provider, DELT, in 2015, initially set up to manage, develop and maintain IT systems with ICT staff from both organisations TUPE transferring into the new entity to enable the retention of skills within the area. The company’s configuration lends itself to additional back office functions being transferred at a later stage and recently this has included payroll services from the council.
The system is well aware that the local workforce remains an area of concern, this has been highlighted through the CQC system review and to this end Plymouth has started to develop an ambitious workforce strategy to improve recruitment across the health and wellbeing market. The strategy is part of the local economic development and growth agenda and linked into a recent international GP conference in the city. There are close ties with the University of Plymouth and a real sense that the solution to the challenge cannot be achieved through a single organisational approach. Working with the university and the unions, new apprenticeship programmes and career pathways have been developed which enable staff to gain skills in both health and social care disciplines through a set of generic competences. The recruitment model has been changed to recruit for attitude and aptitude and provide the necessary skills training. This has resulted in district nursing teams going from 50% down on staff numbers to being oversubscribed. The local authority has been on a significant transformation journey since 2013/14, upskilling existing employees from within the organisation to become specialists in delivering change. This has included a project management apprenticeship programme which has now developed key project leaders from entry level to experts.
In addition, they have been broadening the remit of support workers and undertaking joint working to enable staff to develop a better appreciation of each other’s skills, capacity and pressures. This has resulted in improved relationships across teams and helped with the implementation of ‘discharge to assess’, where assessment is undertaken by Livewell staff and embeds positive, person-centred, strength-based principles into the model.
Plymouth are working towards their next ‘big bang’ with the implementation of a single contract for all community health and social care by 2019. Their commissioning intentions have just been published and these build on the work to date but also create the landscape for greater integration. At the heart remains the focus on meeting the needs of the whole person. They will ensure the three aims of the Five-Year Forward View are met: increasing health and wellbeing, delivering safe and high-quality care, and providing cost- effective care. The local system will continue to be configured to provide the “best start to life” through to “ageing well” by promoting independence, wellbeing and choice. Services will be integrated, local, accessible, seamless and responsive.