Towards model of integrated healthcare in Camden by renata.vivien


									Towards a model of integrated healthcare in Camden
NHS Camden is part of the North Central London cluster of Primary Care Trusts who
are working collectively to address the many challenges facing the health system
today. The following overarching vision guides Camden’s local strategic design and
priority setting process:

Through working with local people and partners we will improve the health and
wellbeing of our population, reduce inequalities and maximise value in terms of
outcomes, quality and efficiency from services provided to patients.

This paper translates this headline vision into a programme of change in Camden.

Camden’s Ambition

In 2012, Camden will move to an integrated model of care that maximizes value
(quality and cost) across the healthcare system. It will ensure that the current
excellent clinical standards delivered by providers are located and accessed at the
right place and the right time. This means a realignment of the system to ensure that
care is centred around the patient and carer and that rather than having the patient
follow the clinical pathway, the pathway is adapted around the patient. Improved
case management will directly reduce the number of unscheduled care episodes,
support prevention and self-management and transform a system burdened by
unplanned demand into one that is integrated vertically between providers and
horizontally to meet the needs of those with complex health needs requiring multi-
professional co-ordination. The following diagram summarises this ambition.

                                        Wider determinants
                                 JSNA – Housing, Environment
                                 Education, Employment, Deprivation

                        PRIMARY CARE                                  HUB                   System supports
             •   GP & PN services                      • Specialist medical support
             •                                             - community clinics
                 Locality                                                                   • R&D
                                                           - one stop shops
             •   Locality based MDT
                                              Referral     - primary care / MDT
             •   Community Matrons                                                          • Health economics
                                            Management          • Admin support
             •   District Nursing                                                             outcomes
                                              & Triage          • REACH
             •   OT’s, Physios, SALT
             •   CMHT                                           • Rapid Response            • Best practice
             •   Social Care                                    • Re-ablement
             •   Care support                  Patient                • Specialist nurses   • NICE
             •   Community                     &Carer                    •Telehealth
                 Specialist     Unscheduled                                                 • Public Health
                 nurses                                  Hot clinics        • Dietician
                                   Care:                 Diagnostics
                              UCC / EP / OOH                                                • Medicines
                                       •Complex diagnostics
                                                                                            • Training and
                                       • Complex specialist care
                                       • Admissions
                                       • PACE                                               • IT integration
                                       SECONDARY CARE

The following section sets out where we are now and the third section sets out the
steps to deliver tangible local change and transformation.

Where are we now in Camden?

A recent review of services supporting Camden’s complex/frail population (defined as
those with multiple co-morbidities) identified a complex array of services across
multiple health and social care providers. Most contracts are set up to be reactive to
the need for an episode of care and current national funding mechanisms incentivize
providers to ‘get people through the door’ rather than focus on health and patient

Case studies following patients around the system showed that many are left to co-
ordinate their own care. As their frailty increases with additional diseases or
complications, their ability to navigate a fragmented and complex system decreases,
thereby perpetuating the problem.

The following diagram summarises the services map identified in the review:

        Camden Complex Patient Service Map                                                            Red                  Age                           Good
                                                                                                                                                                             CAB            Housing
                                                                                                     Cross                Concern                      Neighbour

      PACE                           PACE                                                                                                                                                Memory Service
        RFH only can refer
                                                        5 days                                                                                               Sensory                      Queen Mary
         via case finder                                                                                                                                   Needs (ASC)
   Free                             REDS
                                                                                                        Palliative Care
                                                                                                                                                          Review team
                                                         6 weeks
      Hot                           Stroke                                                                                                                                               Carers Centre
                                                                                                                                                          ASC OT
     Clinics                        REDS
                                                        6-8 weeks                                                                             Info &
  Referrals from acute                                                                                                                        Access      Reablement
       trusts only                St Pancras              Care Link
                                    Rehab.                                                                                                                                                    LiNKs
                                                                                     5 days – 6
                                                                                   weeks (referrer                                                         Assessment and
      S                             Rapid
                                                                                    dependent)                                                              care mgt. team
      E                      C                           10 days
                             C                                                                                                                                                            Age Concern
      C                      A
                             A                                                                                                                            Social Workers
                                  Ingestre Rd                                                                                                                                            Dementia Service
    referrals only           RI   Rehab beds
                                                         6 weeks
      N                      I                                                                                                                                                 G
                                    REACH                                                                                                                                      P
      D                      C       Neuro               6 weeks

      A                                                                                                                                                                                       CMHT
                                    Target                        Dietetics                    SLT                          only accessible
   Community/Acute                   Gym                                                                                     if community                  3 months
                                                                                                                            rehab needed
      Yreferrals                                                   Nurse                   Psychology
                                  CRT – Comm.                                                                                                                                                 Sheltered
                                   Rehab Tm                                                                                                                   Virtual                         Accomm.
      C                                                                                                                                                       Ward
      A                           REACH Medical         6 weeks
                                    Falls Clinic
      E                            Respiratory – COPD                                                                      Phlebotomy                                                           Care
                                    /PR/Resp Nurse                                                                                                                                             Homes
                                    CPSS – Camden                 PR – 6 weeks
                                     Psychological                                                    CARIC/REACH – June 2011
                                                                                                                      Gospel Oak
   UCLH                              Stroke Service                                                   ACN            Kentish Town
                                                                                                     Central            Belsize
    Rapid                                                                                            Referral          Hunter St                                                              Hospices
  Response                                                                                            Team               ACN
  Discharge)                                                                                                                HF                Diabetes        Dietician
                                                                                                                                                                                           Ageing and
      Hot                                                                                                                                                                                  Mental health
     Clinics                                                                                                                                                                               Queen Mary

                                                                                                                                 Wheelchair                Continence           Day
                                                                                                        Careline                                                               Centres
                                                                           Telehealth                                             Service                   Service

The historical model of commissioning in the NHS is to commission reactive rather
than proactive services in line with forecasted needs in a given population. These
have tended to be location based with the patient travelling to the service. The
Virtual Ward model of care sought to test out a proactive model whereby patients
with co-morbidities are case managed within primary care rather than multiple
referrals along disease pathways.

The stark reality of the ‘bounce’ rate between services was evidenced by completing
a detailed review of two individual’s experience of the health care system over the
last two years. These are summarized in the following diagrams:

The following diagram summarises an 82 year old’s journey through the health
system in north Camden over an 18 month period:

     Case Study: Mrs A services accessed over 18 month period

                                                                           OP: Tissue      OP: Psych         OP:               OP:
                                                                            viability      Geriatrician    Colorectal       coagulation
                                                                           2 visits          1 visit          1 visit          2 visits

   5 home

                                            Sent                                            Hot clinics
                                            home                                               23 hrs
                                            Admission 4/7
                     Mrs A’s                                                                                  AMU/
                                            Admission 1/12                     A&E                            MAU
                      Home                                                     4 hrs                           48 hrs
       1                                       Sent home
                                                 home                                                                2 IP         Base
                                                                                                                    stays         Wards
                      25 home
 Podiatry              visits

                                          June             Virtual
                                          2011             Ward

The next case study summarises an 79 year old’s journey through the health system
in south Camden over a 2 year period:

     Case Study: Mrs B services accessed over 2 year period

                             IP                                OP:            OP:            OP:              OP:              OP:           OP:
 Haematology                              OP: Gynae
                          Elective                         Geriatrician   Orthopaedics   Ophthalmology    Rheumatology      Cardiology    G Surgery
  (Warfarin)                               1 appt.
                          Surgery                           3 appts.        3 appts.       2 appts          6 appts          3 appts      12 appts
   34 appts.

                                                                                                              OP:              OP:            OP:
                                                                                                          Dermatology       G Medicine     Neurology
                                                                                                             1 appt           1 appt        3 appts
                                     Outpatient Appointments


                                           Sent home - GP


                     Mrs B’s                Admission
                                                                            A&E                            AMU
                                           Sent home - GP
                     Home                                                   4 hrs                          48 hrs
                                          Sent home – OP Ref
                                                                                                              3 IP           Base
                                                                                                             stays           Wards
                   3 home visits
 Podiatry        29 appointments
                 14 telephone appt

                                        June            Virtual
                                        2011            Ward

These two case reviews (supported by the findings of the first 30 patients on the
virtual ward), identified five key findings:

    1. The number of service referrals/visits is influenced by the number of co-
       morbidities and (often patient determined) health crises, i.e. where the
       individual presents themselves at A&E or requests a home visit/telephone
       contact from their GP. This fragmentation is exacerbated by the lack of
       planned 24hr care and reliance on unscheduled care out of working hours
    2. Psycho-social issues were key factors in each patient’s reported need, as
       well as a particular health condition
    3. Patients move round the system differently, depending on where they live
       (north or south of the borough)
    4. Significant levels of condition based healthcare interventions over 2 years did
       not reduce the patient’s risk of re-entering the system.
    5. Access to the GP clinical system, the hospital system and the community
       services’ system (all key players in frail patient’s care) showed that no
       system contained a full picture of the patient’s assessment and intervention
       history. As would be expected, the GP clinical system was the most
       comprehensive, but in every case, summaries of hospital visits were missing
       from the patient’s history.

In this context, a stakeholder group was convened comprising representatives from
primary and secondary care, community services (provider services and voluntary
sector) and patient and carer representatives. The overwhelming conclusion from all
those present was that the current system is fragmented and is not effectively nor
efficiently serving patients’ needs. The fragmentation also places an additional
burden of coordinating care on providers who are often confused or unsure of where
to refer patients on.

The gradual increase in service access (secondary, social, voluntary and community)
that is seen in patients as they become more frail can itself be seen as a contributing
factor to the fragmentation. In the context of commissioning to fill gaps to episodic
interventions, the increased demand opens up gaps in existing pathways that are
filled by additional contracts. The increasing fragmentation and system complexity
can be considered as a cause of increasing demand which in turn is having a impact
on health and system sustainability.

The wider context
The review of the frailty pathway happened at a time of significant financial challenge
for Camden. In the current year, commissioners of healthcare have to make
efficiency savings and are facing the prospect of a further tranche of savings next
year, with possibly more in later years. In emergency turnaround situations, the
easy response is to pick off savings by reductions and closures or individual pathway
redesign. Whilst all large, fragmented systems offer opportunities for some
productivity and efficiency, these become harder after the initial savings have been

As with all other areas, Camden also faces the challenge of a growing population,
demographic diversity with significant pockets of deprivation, an aging population,
increasing demands for choice and expectations of a right to access.

In addition to the health, social and financial challenges, healthcare strategy and
planning is transforming from PCT led to clinically led commissioning in the borough.
The Clinical Commissioning Board met for the first time in July 2011.

The challenge
Camden must achieve significant efficiencies and productivity increases for each
NHS pound spent without jeopardizing access and quality. Failure to deliver savings
is a reputational and destabilizing risk to the new clinically led commissioning
approach. But delivering savings by service decommissioning alone, is equally a
reputational and destabilizing risk to the new clinically led commissioning approach.
The overall challenge is to improve value; quality of care and cost.

The opportunity
Stakeholder engagement and case study review shows that fragmentation of the
system is impacting on the clinical efficiency and quality of clinical and patient
outcomes and therefore costs. By taking a system wide approach, informed by
lessons from those health economies that are already some way down this road, we
can collectively begin to act on our collective finding: That integrated working with a
case management approach better meets patients’ needs, prevents unnecessary
hospital attendances, improves clinical co-ordination and reduces costs, thereby
increasing the value of the healthcare pound.

 Challenges                                      Opportunities
 Unsustainable – stemming demand                 Sustainable – managing demand

 • Acute centred, curative model                 • Transformational, prevention model
 • Dealing with the ‘parts’ of a person          • Dealing with the person
 • Rewarding ill-health                          • Rewarding health and well-being
 • Activity-based biomedical                     • Relational continuity
   measures/outcomes                               measures/outcomes

To address this and respond to the demographic, clinical and financial
challenges facing the healthcare system in Camden, a phased programme
approach to system integration is proposed. The new model of care requires a
shift from the old paradigm of an acute-centred, curative model of care delivery
to a transformational preventative model. The transformational shift should care
for the whole person, not the person’s parts, promote continuity in care and
working behaviours and have a long term focus on relational continuity rather
than activity-based, biomedical outcomes. The new model will be in line with the
Department of Health’s paper on ‘Transforming Community Services’.

Lessons from Sweden and Canada and a wider literature
Healthcare integration is used to describe different models, in different financial
(funding) contexts with a mix of many different providers. Neither Sweden nor
Canada reflects the UK NHS funding system, so opportunities and lessons that are
taken forward are interpretations and hypotheses for further investigation, more than


(Informed by : ‘A decade of integration and collaboration: the development of
integrated health care in Sweden 2000–2010’; BengtAhgren, PhD, MPolSc, 2011,
Journal of Integrated Care)

The key lesson that Camden takes from this review was that a mix of ‘Chains of care’
(Inter-organisational networks based on clinical guidelines) within a context of ‘local
health care’ (looser integration achieved by chains of care) was the method adopted
in the absence of complete funding/provider alliance. The success of this model was
impacted by some key factors:

      The ‘chains of care’ model was more successful if bottom up led – i.e.
       clinician defined rather than legislative or management imposed;
      ‘Collaborative advantage’ needs to be proved at each stage. If there is none,
       then integration can be destructive as players work against each other to
       seek to maintain their own standing;
      The model proved to be useful in bringing together health and social services,
       particularly in relation to care of the elderly and long-term psychiatric care.
      The model moved the system from ‘a division of functions to an integration of
       multi-functional activities’
      The system allows patients to be allocated to the most cost-effective care


(Ten key principles for successful health systems integration; Suter et al 2009,
Healthcare Quarterly)

In their 2009 literature review of different models and approaches to Health system
integration in Canada over the last 10 years, Suter et al found that whilst the models
differed, they were able to identify a number of principles that each model associated
with successful integration.

Ten key principles for integration

   1. Comprehensive services across the care continuum
      Across the Canadian models, whilst there were different degrees of
      integration, there was a principle that the integrated system will plan, provide,
      purchase and co-ordinate all core services. Effectively, they become the
      commissioner and provider, with a key focus on forecasting and planning
      provision. Whilst Camden is some way from this contractual position, a key
      lesson is to understand the need to include a comprehensive range of
      services within the integrated model to allow the integration to ‘manage’ the
      patient through their health journey, and not fragment around treatments as is
      currently the case.

   2. Patient focus
      A key principle across all models was the need to keep the patient at the
      centre of the design. When the system is designed around the patient rather
      than providers, it becomes easier for the patient to navigate, becomes more
      responsive to changing population needs and is therefore assumed to be
      more cost effective as services are responsive rather than contracted. The
      model challenges the hospital centric approach of being the centre of

   healthcare delivery. Instead, placing the patient/population at the centre of
   required system modeling.

3. Geographic coverage and rostering
   This principle looks at the scale of population required to be ‘allocated’ to a
   system to enable it to be cost effective. Evidence from the USA suggests that
   a minimum requirement to be cost effective in the ‘commissioner/provider’
   role is 1m people. Canada has had to look at alternatives to this given the
   widely dispersed nature of their population. Further research is required. But
   the principle of a ‘ring-fenced’ population is evident across US, Canada and
   Europe. This requires some consideration in relation to the UK focus on
   ‘patient choice’.

4. Standardized care delivery through inter-professional teams
   The multi-disciplinary team approach is a central tenet of integrated
   healthcare. To achieve that, a number of shared protocols are required as a
   minimum including best practice guides, clinical pathways, standardized care
   across services and shared performance to review levels of care and
   outcome. They note that communication is key to ensure that key information
   seamlessly crosses organizational boundaries including team meetings,
   shared electronic information systems and co-location of services.

5. Performance management
   They note the importance of performance management as a tool rather than
   a stick - to set up frameworks that measure outcomes, to use the data to
   improve services and potential use of payment by outcome rather than

6. Information systems
   The principle of shared communication through information systems is key to
   the success of integrated models, but the paper notes that implementation of
   such a system is time consuming, complex and expensive. Developing a
   local IT strategy that recognizes the importance of this principle and defining
   how that can be achieved in the short term will be a limited, but important
   step in the early phase of implementation.

7. Organisational culture and leadership
   Congruence between vision, culture, leadership and organizations is key.
   Clashing cultures between providers or clinicians is one of the reasons
   named across the literature for failed integration attempts. Another is the
   acute care mindset of placing clinical focus in a hospital setting, as well as
   clinic and service provision design, rather than seeing the design being built
   around the patient and ‘population based healthcare delivery’.

8. Clinician integration
   Integration of clinicians is a key principle of success both in terms of playing a
   leading role in the design and implementation of an integrated model, but also
   in clinical terms of agreeing the clinical pathways and interactions. Focusing
   on achieving ‘stronger physician – system alignment’ is recommended as a
   important and necessary requirement of a successful system.

9. Governance structure
   Governance findings relate more to the contractual relationships necessary to
   bring together organizations into an integrated system. These need to
   include effective accountability structures and decision making processes.

   10. Financial management
       Studies have shown that it is key to establish the funding principles of the
       system as a whole (i.e. global capitation for a defined period of time) and the
       payment terms within the system, i.e. to clinicians. In Canada, the latter has
       been the cause of debate as it was not clearly defined in the design process.
       This therefore failed to address the physician integration principle. Locally, it
       is necessary to consider both the contract strategy to effect a phase I move to
       integration, but also a remuneration/rate card approach to ensure that local
       providers are clear about financial parameters.


Camden finds itself facing a fragmented healthcare system, based around contracts,
providers and treatment rather than the patient, disintegrated in relation to
information and technology and culturally distinct and separate. The financial impact
of this lack of co-ordination and the resulting ‘bounce’ rates between services for
complex patients is plain to see. Locally, Camden has a system that incentivizes
getting people through the door rather than ensuring it is the right door, in the right

From a commissioning perspective, the system is fragmented largely because the
historical model of commissioning across the NHS is fragmented. As the holistic
view of the patient has given way to the increasingly specialist role of clinicians and
services, people are broken down into sub-sets of particular clinical needs rather
than whole person assessments and interventions. Whilst this model is applicable
for the person with a single disease who is otherwise able to co-ordinate their needs,
it increasingly fails to meet the needs of those with complex care needs or frailty, as
their abilities to co-ordinate their care package breaks down.

Camden’s Vision for Change
‘Right time, right place, right person’: Commissioning a model of integrated
care (Liam Donaldson)


The new commissioning strategy is based around a structural and functional shift in
care delivery.

The functional shift in care delivery should be considered as move towards inter-
disciplinary, cross-boundary working that embeds care delivery within primary care
and encourages secondary care specialism to be aligned in one system closer-to-
home. Fundamental to success will be to achieve robust continuity in practitioner-
patient and practitioner-practitioner working practices (e.g. GP-ACN, GP-consultants,

The structural shift should be considered as a realignment of services to enable the
functional shift in service delivery. The structural realignment needs to appreciate the
growing demand of frail patients with end-of-life needs, together with a cohort of the
patients requiring specific chronic disease management programmes.

The aim of Camden’s commissioning intentions for 2012/13 is to shift unscheduled
care episodes into more planned provision by integrating services to achieve more
streamlined, co-ordinated transfers of care and an improved patient experience.

This then provides a platform for future commissioning to support a fully integrated
system of healthcare delivery.

Commissioning Intentions - 2012/13

The following commissioning intentions will deliver two key outcomes:

  i.    A shift from unscheduled care into planned care for all patients but
        particularly for complex patients. This will involve reductions in secondary
        care interventions in the following areas, due to improved community and
        primary care co-ordination:

           a.   Non-elective admissions
           b.   <48 hour admissions
           c.   Reduced GP home visits/unscheduled telephone consultations
           d.   Reduced LAS calls
           e.   Reduced A&E attendances
           f.   Reduce out patient attendances

  ii.   Alignment of clinical pathways into horizontal (cross cutting) chains of
        care and vertical chains of care (right place, right person).
        A change in working practices that encourages MDT working and case
        management of patients across boundaries will help:

           a. Improve healthcare co-ordination and Quality of life measures

           b. Ensure that the services and referral activities are aligned to patient
              goals and outcomes.

The following diagram sets out the proposed alignment structure:

                A&E – Trauma / Stabilising

                                        AMU/MAU – ACP and GPs
                                                  <48 hr care
                UCC – Triage & treat              Case manager/coordinator
                OOH Minors and wound clinic       Expected patients
                111       Ambulatory clinics/EP

          S                               Highly Complex Patients
          O                                                                             M
          C            GP/ACN                 GP/ACN                 GP/ACN             E
          I                                                                             N
          A                                                                             T
          L                                                                             A
                                       MDT (N)       MDT (S)                            L
          E                                                                             H
          R                                                                             E
          V                                                                             A
          I                                                                             L
          C                                                                             T
          E                                                                             H

                                Case Management / Disease Management

               GP         GP                GP        GP             GP          GP

              ACN/Th    ACN/Th            ACN/Th    ACN/Th          ACN/Th    ACN/Th

               North Locality               West Locality              South Locality

Process of change

The process of integration needs to be achieved through a phased programme to
allow for full clinical and stakeholder engagement and iterative learning.      The
prioritization process is based on quality improvements to the patient’s experience,
innovative new ways of working, and increased productivity from existing resources
and measures that reduce the risk of re-admission/attendance in secondary care.

In addition, the commissioning intentions will also focus on improving prevention
through health promotion utilizing the opportunities afforded through the Health and
Well-Being Board. Two initiatives specifically focus on improving health outcomes
identified in the Camden JSNA for Camden’s population

Phased process to achieving integration

Taking lessons from reviews of successful integration initiatives, as set out above, as
well as NHS North Central London’s commitment to ‘Improve health…involving all’,

all projects will be fully clinically inclusive of all providers as well as patient and carer

Headline timetable (subject to confirmation)

Step 1 - All providers have agreed to make available for one day a week either a
management or clinical resource to support data analysis and scoping, complete the
clinical reviews and co-ordinate communication flows and implementation plan –
‘clinical advisory team’.

Step 2 - The scoping and design elements of the programmes will commence in
October 2011.

Step 3 - The programme plans will be completed by end of October, with all clinical
workshops booked with partners.

Step 4 - The programme plans will specify when services move to implementation
via contract variation in order to be in transition no later than April 2012 and
operational no later than June 2012.

Step 5 – Commence the review of children’s services

Step 6 – Commence the mental health reviews.

Initiatives to deliver integrated working

1. Complex Needs Pathway (Frailty)

Clinical redesign

Patients with complex needs/frailty require ‘continuity of care’ and robust integrated
care pathways that promote a seamless ‘transfer of care’. The clinical
commissioning approach will look at the entire patient pathway, but focus in more
detail on the ‘interface/cross boundary working’ involved in patient care.

To bring about improved integration in Camden there will need to be a step-by-step
approach to service redesign that focuses on both structural change (e.g. shift of
service delivery) and functional change (e.g. working practices).

To redesign a complex needs pathway, the clinical advisory team will have to focus
on the historical ‘care settings’ and review both internal and interface working
arrangements in order to make sustainable and robust ‘entire pathway’ service

  i.    Integration in a Hospital setting: Functional redesign that promotes
        integration of and between A&E, AMU, UCC, OOH and 111 to establish a
        more coordinated and streamlined step up and step down model of care.
        This may include concepts such as a frontline triage and treat service, a
        primary care minors service and ambulatory clinics. Delivery of these
        services will involve a working arrangement that includes both primary care,

            community and secondary care professionals with the introduction of a ‘step
            up, step down interface team’.

  ii.       Integration in a Community setting: Functional redesign that promotes
            integration of community services to establish a more co-ordinated and
            streamlined step up and step down model of care. This may include
            concepts such as single point of access, establishment of a ‘step up, step
            down interface team’ and multi-disciplinary integration to include locality
            based nursing and therapy services to support case management.

 iii.       Integration in a Primary care setting: A stronger identity to locality based
            nursing and therapy team working with a move towards proactive case
            management of patients with long term conditions supported by specialist and
            community team working.

 iv.        Mental health and social care services will be cross cutting themes across
            each of the pathways.

2. Long Term Conditions Pathways
The projects will facilitate a shift from condition specific pathway design to a ‘clinical
system and condition’ pathway approach that will allow for the delivery of care for
both patients with single LTC and complex needs. All pathways will be redesigned to
fit a model of care that encourages and supports our commissioning aim of achieving
a robust transfer of care through integrated working and entire pathway design.

A ‘clinical system and condition pathway’ approach may see a pure COPD care
pathway move into a respiratory pathway which has a level of fluidity that allows for
reflection and redesign based on changing population needs. Managing a frail,
elderly person in a rigid COPD care pathway is often not possible as either there are
accessibility obstacles or evidence based practice obstacles.

Implementation of a respiratory care pathway, that manages diagnostic uncertainty
and can be tailored to the frail, will be delivered through integrated working
partnerships (e.g. geriatrician, GPs, community HCP side-by-side with specialty
practitioners) and monitored by clinical audit of the entire patient journey and not just
targeted clinical measures.

The pathways to be prioritized will be:

                      Cardio-vascular (including atrial fibrillation, stroke &HF)
                      Respiratory (COPD)
                      Renal (to include cross reference to diabetes)
                      Endocrine (to include diabetes)
                      Locomotive
                      Vascular/skin
                      Cancer

In addition, the following treatment focused pathway reviews will be undertaken to
ensure best quality, access and productivity from contracted pathways:

           Uro-gynaecology, continence assessment and continence service

      Wound pathway (linked to the vascular/skin pathway above)

3. Public health

4. Conduct a quality and productivity review of all mental
   health contracts (children and adults)

5. Complete a review of all children’s services and deliver a
   map and transition plan into an integrated model.

6. Patient led Outcomes and Case Management project

This programme will develop and cement ‘best practice’ principals around care
delivery and patient-focused outcomes metrics. The clinical advisory group’s aim will
be to achieve Camden vision of improved patient-focused care and develop
evidence-based outcomes that promote continuity of care and reward health and

      A shift from process metrics to outcome metrics.
      A focus on both PROMs and PREMs with health and social components.
      A robust integrated data collection process that allows for audit and
       performance monitoring of pre-determined outcomes.
      Innovative working practice across the complex needs pathway and clinical
       system LTCs pathway that promotes ‘best practice’ and reflective practice
       e.g. Development of a ‘butterfly scheme’ in the community to support
       information and history taking for those with dementia.

7. Contract review and consolidation project
The key finding from the first stakeholder workshop held in May 2011, was that not
one of the 40 attendees from secondary, primary, community or patient
representative groups could map out the service pathway available in Camden to
complex, frail patients.

Following that workshop, community audits were undertaken to try to map out the
services that a frail individual may need to access. The level of fragmentation,
evidenced by the map, showed a need to review all current contracts, assess for
value for money and alignment with Camden’s new commissioning intentions and
negotiate consolidation where appropriate.

8. Infrastructure redesign

In parallel with a review of clinical redesign, there will be key Infrastructure
requirements that are needed to support integration. The aim of this programme is to
set out the key infrastructure value added elements that will be required to deliver
‘Collaborative advantage’ to learn the lesson from Sweden and to ensure that
‘performance and information’ principles are applied from the Canadian experience.

The quality projects that make up the programme will include:

   Shared clinical information system – access, update and consult protocols
   Agreed EMIS data dictionary adopted by all partners to ensure Read Coding (and
    therefore reporting) is accurate
   Shared central booking service – consolidation of community and primary care
    booking services
   Agreed referral assessment protocol (to include consideration of consultant to
    consultant referrals, paper referrals, community triage protocols)
   Shared formularies
   Shared learning and development options
   Shared health checks/prevention initiatives

8. Engagement initiatives

Camden’s commissioners are working with patient and public stakeholders to
develop a network of user involvement groups including Voluntary Action Camden,
Links and local borough groups. This is underpinned by a proposal to the
Department of Health for funding under the Voluntary Sector Investment Programme
to fund community coordinators linked directly with localities of practices and local
community and children’s centres. These will inform all future commissioning
intentions and will be a mechanism for delivery of both health promotion initiatives
and an opportunity to educate and support appropriate use of health services.

Scoping the impact of the Integration initiatives

Over the last 6 months, local Camden health stakeholders have been working
together to review the current frailty and complex patient pathway and long terms
conditions and identified a significant need to move to a more integrated model of

Developing the vision and direction has been the key focus in starting to scope out
the impact of the programme. The next phase is to plot current patient journeys,
service performance numbers and ‘bounce rates’ and extrapolate forecasts of
existing pathway resource costs (both to the healthcare system and the patient and
carers) and future quality and efficiency improvements.

Integrated working is a new approach for which there is little evidence, beyond
partnership understanding of the costs of a fragmented system. To assist in
establishing the current baseline for current activities and costs from which to
forecast and monitor further impact, Camden has made contact with academic
colleagues and associates at University College London Partnership for advice and
guidance. A number of meetings have already taken place and UCLP will be joining
the programme partnership in taking the initiatives forward.


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