Evaluation of Integrated Resource Framework Test Sites

6 CASE STUDY LEARNING

6.1 This chapter describes some of the learning from worked examples in each of the test sites. The first three examples (one each from the Ayrshire and Arran, Lothian and Tayside test sites) trialled integrated working with pilot populations based around localities, care groups or disease programmes. These were nominated by test sites as exemplars of work where demonstrable progress has been achieved, and where lessons have been learned which may be applicable in other areas. The final example gives some of the emerging learning from Highland which has introduced a lead agency model between NHS Highland and Highland Council.

East Ayrshire - adults with complex needs

6.2 The East Ayrshire IRF pilot focused on researching the individual elements of care provided to adults with complex needs. The pilot looked to describe and improve understanding of the profile of clients within the target group, the range and cost of services provided for the target group, and the provision of joint commissioning of services for the target group.

6.3 Key elements of this methodology included:

• Identification, by NHS and Local Authority learning disability and mental health teams, of caseload clients considered to be 'complex'
• Data collection in relation to those clients regarding service involvement and needs
• Interviews and focus groups with staff and management designed to survey their experiences of integration
• Exploring the application of Self Directed Support approaches across Scotland.

A pragmatic approach

6.4 The East Ayrshire pilot was widely acknowledged to have been a useful project that initially resulted in improved information for a particular patient grouping and subsequently produced a joint action plan to respond to this analysis. The project team reported that progress was linked to an existing knowledge of the services and of realistic appraisal of the extent of partnership working, together with a sense of optimism about what it would be possible to achieve. The project carefully considered the funding level, the timescale and other local drivers and barriers before defining a realistic opportunity for better integrated working.

Balancing partners' aspirations with their sphere of influence

6.5 The pilot remained focused on areas that were within what partners saw as a realistic sphere of influence. The range of options explored reflected the sense that integration could be implemented at a variety of levels and did not necessarily require new or changed resources to affect change. For example, recommendations from the initial pilot work ranged from a simple change in terminology (changing "risk assessment" to "safety assessment") through to consideration of joint funding of support workers in Community Mental Health Teams.

Positive partnership relationships

6.6 The analysis was carried out by staff seconded from NHS Ayrshire and Arran and from East Ayrshire Council. This was seen as underlining the partnership approach to the work and encouraged "buy-in" from staff in both organisations. These individuals already had a network of relevant professional relationships and were reported to have the respect of their peers. This gave the pilot credibility and a "running start" in accessing relevant partners and in sharing information.

Balancing qualitative and quantitative information

6.7 This pragmatic approach continued throughout the pilot as evidenced by its recognition of the limitations in mapping quantitative service costs to a patient level, balanced by qualitative information on what service providers thought could improve delivery.

Prioritisation of actions

6.8 The East Ayrshire pilot undertook some detailed research which produced a detailed report with 21 high impact recommendations. Partners prioritised these into a detailed action plan for implementation.

Importance of understanding shared aims and outcomes

6.9 Shared ownership of the project was reflected in partners' commitment to undertake the research and follow this up with an action plan to take forward recommendations. Partners acknowledged limitations in transferring budgets to support this work stream. A more detailed understanding of shared strategic aims matched with a suitable set of metrics to monitor shared outcomes were reported as potential next steps to improving integration on a larger scale.

Edinburgh - orthopaedic and stroke rehabilitation

6.10 The objective of the NHS Lothian and CEC orthopaedic and stroke rehabilitation workstream was to shift the balance of care from hospital to community settings. A related objective was enhancing rehabilitation in hospital to increase the functional level of patients at their point of discharge. Ongoing rehabilitation and care needs would be delivered to patients within their own homes, through enhanced rehabilitation and social care support. This would in turn support a higher volume of earlier discharges from hospital for patients. Performance measures such as length of stay (LOS) were used to assess impact. Additional resources were targeted across hospital and community settings.

6.11 A full financial evaluation will be conducted when IRF data is fully updated with information from the period of time during which the exercise was conducted. The longitudinal data for 2008/9 to 2010/11, which the full IRF dataset will contain, will be revealing here in providing information about resource impact along the whole care pathway. While reduced LOS will reduce marginal acute inpatient costs (and eventually potentially some fixed costs if the new model of care is rolled out on a big enough scale) it will be instructive to find out the cost impact on other parts of the system e.g. re-ablement and other aspects of home care packages.

6.12 The model is now being rolled out across all 12 clinical sites in Edinburgh treating orthopaedic and stroke rehabilitation patients, with funds allocated from Change Fund resources for Community Therapy services; re-ablement; day services; community nursing; enhanced supported discharge; and equipment and adaptations

Significant reductions in length of stay for patients

6.13 Average LOS for orthopaedic inpatients reduced by just less than 14 days, and for stroke inpatients by just less than 13 days (although it should be noted that numbers of stroke patients were small). A net increase of 36 percent was recorded for the re-ablement caseload, attributable to patients being discharged via the orthopaedic rehabilitation pathway at the RVH. A net total increase of 10 per cent was recorded by the entire re-ablement service, compared with the previous year's performance. In terms of patient outcomes, patients were able to access downstream hospital and community services more quickly than previously, fewer waits for onward care were experienced, and a higher throughput of patients from rehabilitative hospital settings into the community was achieved against the baseline.

6.14 It is estimated that the phased implementation project tackled up to 90% of the "delayed discharge" element of existing pathways, and that the pilot removed logistical barriers in care pathways. It was also reported that the remaining 10% will be much harder, if not impossible, to tackle, in part because of received wisdom and entrenched ideas about the treatment of frail elderly patients. Some Charge Nurses have been very proactive in organising discharge decisions. The bulk of LOS reduction has come from removing logistical barriers in care pathways, followed by organising more timely rehabilitation on the ward. One observer predicted that LOS will eventually plateau, as more elderly patients are admitted with more complex needs.

Differing perceptions of risk

6.15 Some clinical specialists (AHPs as well as clinicians) are wary of discharging patients into what they consider to be less specialised community services. This is affected by perceived levels of risk. A series of sub-decisions are involved in deciding to discharge a patient and only when these are all perfectly aligned does the patient actually leave the acute setting. Not all clinicians and AHPs recognise that it may not be possible to control all elements of a discharge plan, and that every discharge entails some management of risk.

The importance of networks and relationships

6.16 This pilot recognised the importance of networks and relationships in creating a natural momentum for integration. However, delays between the original project and the decision to fund a broader roll-out showed that, without ongoing attention, networks could be diminished and momentum lost.

Scalability

6.17 The roll out of this model of care to all clinical sites in Edinburgh providing orthopaedic and stroke rehabilitative care represents one of the biggest workstreams receiving Change Fund resources in Lothian. One of the remaining questions for this workstream is the extent to which this approach could be applied to other conditions. It was reported that application of this model to other conditions would be necessary if the resource realignment was to attempt to release fixed costs. As a health service manager commented:

"We cannot have the luxury of focusing on one or two conditions only."

NW Perthshire - consumption fund

6.18 Perth and Kinross Council and NHS Tayside are developing the concept of a consumption fund which uses mapped data to provide a picture of consumption which would enable partners to consider:

• Whether consumption patterns are appropriate to enable achievement of objectives
• Costs per capita and whether the cost and/or the variation is appropriate and offers the best value
• Whether existing models of care are appropriate to meet the needs of the locality
• Opportunities to release resources for reinvestment to areas like preventive care, or to streamline models of care.

New requirements for provider budgets

6.19 The mechanism relies on the flexibility of provider budgets and resources to continuously adjust to changing patterns of consumption by moving resources across to maintain the right capacity in the right place and with the appropriate agency. The consumption fund concept is in the process of being tested, and Tayside partners have identified a number of challenges which will need to be overcome, for example:

• Breaking down budgets to a locality level - this is a particular issue within Health
• Development of unit costs
• Setting the right level of accountability/authorisation to transfer resources
• Frequency of monitoring dependency on the periodicity of data mapping
• Frequency of transfer of resources particularly for the third sector, which may suffer from cash flow issues.

Potential use of data warehousing

6.20 The use of data warehousing whereby each partner securely submits data files which can be accessed via dashboard software is being considered in the context of developing a live mapping tool which can be updated with appropriate frequency. A suitable data warehousing solution would be required and in addition it would be necessary to ensure that any existing data sharing protocols continue to be appropriate. This currently falls within the remit of the Tayside Data Sharing Partnership Group

Defining the scope of services in the consumption fund

6.21 This pilot is developing a consumption fund which will potentially include a range of services that extends beyond health and social care. This will build on existing networks at senior levels in the Council, for example between Environmental Services and Community Care. Frontline managers are leading local discussions with the potential to enhance local buy-in. The possibility of different models developing in different localities is acknowledged as important, given the need to harness local knowledge of service needs and the networks and relationships required to meet those needs.

Non-partisan support from elected members

6.22 It was reported that service reconfiguration is sensitive and can be readily derailed. In NW Perthshire, considerable effort has been expended to keep councillors informed about service development plans. Development days have taken place involving a wide range of stakeholders, including the police, GPs and councillors. Non-partisan support from elected members was reported to be repaying this investment of time and effort.

Highland - Lead Agency model

6.23 In December 2010, NHS Highland and Highland Council announced their decision to move towards a Lead Agency Model for Health and Social Care services. This aimed to restructure services so that NHS Highland will deliver all adult health and social care on behalf of both partners, and Highland Council will deliver some children's care on behalf of both partners. This new arrangement started in April 2012 and involves transfer of staff, buildings and budgets between the two agencies.

Evolution of integration terminology

6.24 The IRF programme is not the first time that NHS Highland and Highland Council have considered how best to use cost and activity data to inform the planning of services. Throughout the evaluation, stakeholders repeatedly made mention of similarities with the "cost cube" methodology which provided a database of activity and cost for NHS Highland. Discussion of this dates back for almost a decade.²⁵

6.25 The cost cube was acknowledged by the Scottish Government, COSLA and NHSScotland as the forerunner to the IRF mapping process. It provided a "starting point" which the IRF then developed by seeking to include local authority data on cost and activity.²⁶ Over the past decade, NHS Highland and Highland Council have considered a number of ways of integrating the planning and delivery of health and social care services. Discussions have used a variety of terminologies including 'aligned budgets', 'collaborative commissioning' and the 'integrated resource framework'.²⁷

6.26 When the national IRF programme was launched in 2009, partners in Highland put together proposals to use the IRF funding from the Scottish Government to pilot four different approaches (see Appendix 1). However, at a joint meeting of Highland Council and NHS Highland in December 2010, partners discussed three options for more ambitious integration of services on a larger scale: single operational management; establishing a new Care Trust; and single lead agency model. Consideration of these approaches resulted in the decision to commit to introducing the third option. The lead agency model was one of the financial mechanisms promoted by the IRF programme and work on this replaced the smaller pilots.

Leadership for large scale structural change

6.27 The decision in go for large scale change resulted from negotiations at a senior strategic level within both partners' organisations. Chief Executives in NHS Highland and Highland Council showed clear and public commitment, along with political support, to proposals to move both organisations towards greater integration using a Lead Agency model. Once the decision was made public, the process of implementing it and the actions required to integrate the two services involved a much larger group of stakeholders.

Influence of IRF alongside other drivers for change

6.28 The history of discussions about potential integration between NHS and local authority partners predated the national IRF programme. The impetus for introducing a lead agency model was closely related to long term drivers such as cost pressures and demographic trends.

"...we are all familiar with the changing demographics of the area and the need to plan for this. Whilst the medium to longer term fiscal climate is not yet fully clear, what is evident is that if we are to meet the growing expectations our communities have of the range and quality of services we provide in the current climate, we will need to do things differently in the future. Continuing to plan and deliver services in the way we currently do will not serve our local communities, nor our staff or other stakeholders, well in the future."²⁸

6.29 Within this context, the national IRF programme was reported to have helped facilitate discussion on the options for integration; promoted consideration of variation in activity and cost; and encouraged partners to look at efficiency and effectiveness of resource use. Senior executives were exposed to working models of integration (such as the lead agency model in Torbay in North East Lincolnshire) through the IRF national events. This was reported to have provided valuable learning which influenced the discussion of integration options.

Commitment to addressing barriers

6.30 The experience in Highland has highlighted the variety of ways in which the two partner organisations are different (e.g. different planning cycles and different political accountability). The differences in accounting systems - which were noted by all sites during the IRF mapping - were shown in stark relief in Highland where moving staff, buildings and resources has encountered additional challenges such as:

• Different legal requirements for dealing with aspects of VAT
• Different systems for paying employees (including different pay periods)
• Different terms and conditions for staff (holidays, qualifications and remuneration)

6.31 NHS Highland and Highland Council have undertaken significant work to address these issues. They have shown strong commitment to integration and have, where necessary, developed temporary solutions to these problems in order to avoid delays to the introduction of the Lead Agency model.

Structural change and measurable change in costs and outcomes

6.32 Highland is undergoing large scale structural change which will require time and effort to implement. It was reported that service continuity is a key priority during the transition to the lead agency model. The new approach may provide opportunities to consider reallocation of resources in a more integrated way and should remove any perverse incentives for cost-shunting between partners. However, it was reported that structural change will take time to implement and partners expect that significant changes in outcomes or costs are unlikely to be achieved in the short term.

Key findings

• Progress with trialling new models of integrated working was linked to existing knowledge of the services and of realistic appraisal of the extent of partnership. Pilots reported the importance of balancing the funding level and timescale alongside local drivers and barriers in order to define realistic opportunities for better integrated working.
• The commitment at a strategic leadership level from Chief Executives in NHS Boards and in Local Authorities was important where large scale integration was considered. Non-partisan support from elected members was also reported to be valuable and worthy of investment.
• The test sites recognised the importance of networks and relationships in creating a natural momentum for integration. When introducing new models of working the test sites encountered a number of barriers and used strong relationships and a shared commitment to create solutions or work around these problems.
• The test sites reported the value of work amongst partners to articulate and understand the shared aims and outcomes that gave purpose to integration. It was acknowledged that variation in perceptions of risk could undermine this.