What is the Buckinghamshire Integrated Care System?

I attended the Buckinghamshire Health and Social Care Integration Summit in November 2017 when the new Integrated Care System was discussed by representatives from the local authorities, health care system, local charities & the voluntary sector and some members of the public (me included). 

Sadly the presentations went over time so there was no time for questions (not good!) but I did send my questions into the organisers.  I have now received the response to those questions.

Of course the name of the new system has been changed in the meantime.  However the purpose of the new system remains the same.  So for Accountable Care System (ACS) please read Integrated Care System (ICS).

Q1. Is there any extra funding for Buckinghamshire ACS to invest in Public Health & community services?

Answer: NHS England is offering Accountable Care System (ACS) transformation money to support us to meet our priorities and go further, faster. Opportunities to bid for further funds do often arise.

In addition to monies that may be made available through the ACS, we are investing £1 million in community services, bringing together nurses, therapists, social workers, GPs and other relevant organisations to provide 24/7 cover for people who need the greatest health and care support and give them better, more coordinated care in their homes. 

Q2. ‘Accountable’ to whom? How can the public hold this new organisation, which most know nothing & were not consulted on, to account?

Answer: The ACS is not a new organisation, it’s about further developing our system way of working, which supports:

•       Joined up working between health and social care services to provide better care and help people to stay healthier

•       Staff to work together easier across our provider and commissioner organisations

•       More local control and freedom to make decisions

•       Extra support to go further and faster in improving services

It will allow us to have stronger local relationships and partnership work based on common understanding of local priorities, challenges and next steps.

Q3. How will the public know that the ACS has achieved its purpose, indeed what is its purpose?  What baseline measures do you have for outcomes, organisational, financial and patient outcomes, so we can compare the improved public health & other outcomes in the future?

Answer: The purpose of our system working is to achieve our vision for “One Buckinghamshire, one integrated health and care system”, by further developing our community-focused approach to integrating services and collaborative working across the county. 

We have a track record of success on working collaboratively to improve quality, transform service models and build financial sustainability. Some of our successful working to date includes:

A system wide Primary Care Strategy,  agreed in 2015 and with strong clinical leadership across primary care that has seen the development of a nationally recognised innovative alternative, the Quality and Outcomes Framework, with outcomes that build a ‘fit for purpose’ future primary care service. This has established a care and support planning approach in primary care resulting in Buckinghamshire being the best for diabetic glucose control in the country.

A Buckinghamshire Provider Alliance agreed between FedBucks, Oxford Health NHS Foundation Trust and Buckinghamshire Healthcare NHS Trust, with a commitment to integrate seamless services for patients;

Care Closer to Home – Integrated Adult Community Healthcare teams have provided 24/7 services since 2012. Locality led initiatives include the introduction of the Airedale model remotely supporting care homes and enhanced primary care teams supporting frail elderly people developed from our system work on Multi Agency Groups;

We are piloting the development of Community Hubs including increased community based services, short term packages and a new frailty assessment service, reducing the use of overnight community beds;

A collective approach to engagement – with a single communications and engagement team across Buckinghamshire County Council and the Clinical Commissioning Groups working closely with colleagues in provider trusts.

Q4. One example of an ACS in Canterbury in New Zealand. This has taken ten years to achieve its aims and required extra funding for public health, community services & social care.  We do not have the luxury of time not it seems any investment.  We need improvements now to maintain the quality of care services & to improve outcomes. Can this ACS do in a short time what took Canterbury 10 years to achieve & without extra funding?

Answer: We do recognise that like Canterbury, we are not going to be able to achieve what we want overnight. Some work streams will take longer than others. However in the meantime we are equipping ourselves with the lessons learnt from the Canterbury project, as we have been able to meet with them and apply this where appropriate to our work.   We have also set ourselves some priorities to deliver for 2017/18, which include:

•       Providing more joined-up care closer to home, through community hubs and integrated teams working with groups of GPs, tailoring care to the needs of their local communities.

•       Making it easier for people to get urgent care when they need it, including out of hours.

•       Improving and simplifying care for diabetes and musculoskeletal problems.

•       Improving and increasing access to mental health services, including for children and young people.

•       Improving the prevention, diagnosis and treatment of cancer.

Q5. How will the Bucks ACS improve retention and recruitment of staff? What is the effect of the ACS on the working conditions of staff, on their Terms and Conditions, GP surgery & Pharmacy contracts etc.?

Answer: Staff will continue to be employed by the organisation they currently work for and as such there will be no changes to their terms and conditions or contracts as a result of Buckinghamshire becoming an ACS.

We hope that being an ACS will help to improve retention and recruitment of staff in a number of ways.  By working closer together across the system it will make it easier to make sure we’ve got the right people in the right place at the right time. Job satisfaction will increase as together we will be able to provide better care in the community, at home or in hospital, helping people to stay healthier.  There will also be greater career development opportunities for our people, as they will have the opportunity to work in integrated teams or rotate across different health and care settings. As one of the first ACS we believe the opportunity to get involved in something that is exciting and innovative will also be an attractive prospect for some.

Q6. What will be done to improve access to Primary Care Services & GP services, especially in places like High Wycombe and the rural parts of Buckinghamshire?

Answer: Improving access to primary care services and GP services is central to NHS England’s Five Year Forward View (FYFV) and General Practice Forward View (GPFV) and so is a key part of much of the work at Aylesbury Vale and Chiltern CCGs.  We also have a number of work streams in place specifically designed to ensure the population of Buckinghamshire have timely access to appropriate primary medical services. This work is being done in the context of the development of an ACS for Buckinghamshire which encourages partnership working across the whole health and social care system and whose benefits are already positively impacting on improved access for primary care services.

NHS England launched the General Practice Resilience Programme (GPRP) as part of the GPFV, which is designed to secure sustainability of GP surgeries by tackling many of the issues that are creating pressures on general practice and threatening the viability of practices. A key part of the GPRP in Buckinghamshire is to encourage practices to work together in clusters on a range of projects which improve access to primary care services, for example, developing integrated teams with a focus on integration with other primary care professionals (nurses, pharmacists) or improved working with the voluntary sector, addressing the needs of high intensity users of primary care, out of hours services and A&E by better working with social services. We now have thirteen such clusters beginning to form local plans across Bucks.

In addition, GPRP funding is being used to train care navigators in general practice. Care navigators provide front of house signposting of patients to ensure they receive the right care from the right healthcare professional, or alternatively are able to access social care or services from the voluntary sector.

Many practices are also using or developing alternative methods for patients to access primary medical services such as on-line booking of appointments, Skype and telephone consultations.

So that access to primary care services in and out of hours is seamless for patients, we are also in the process of commissioning extended access into primary care services whereby patients will be able to book an appointment with a healthcare professional 8am to 8pm Monday to Friday.  We will also be looking at whether we need to commission this type of service at the weekend (although experience from elsewhere suggests that routine appointments for primary care services at the weekend are poorly utilised).  We anticipate that 100% of the Buckinghamshire population will be covered by this new service by March 2019.

The extent of the work means that all residents of Buckinghamshire should see an improvement in access to primary care services whether they live in a town or rural area. A key part of cluster working is for practices to understand and plan for the needs of their local area, including how different groups access services. As the CCGs develop working as part of the ACS this locality focus will widen out to other health and social care providers to create an integrated care system with timely and appropriate access at its heart.

Q7. Buckinghamshire has already squeezed the local health economy and has, just about managed its finances but there are now signs of stress in that a deficit is forecast for this year.  Is the ACS really just a means to balance the books rather than improve quality of care? Buckinghamshire has already made many changes to remain within the financial targets so what other changes can be made in the way that hospitals deliver acute care more efficiently?

Answer: Becoming an ACS is certainly not just a means to balance the books although we are hoping that by working better together we can find ways of delivering higher standards of care more cost efficiently.  For Buckinghamshire Healthcare NHS Trust, being part of an ACS is about how we can work with our partners in the system to ensure the residents of Buckinghamshire stay healthier for longer - now and in the future. Research shows that it is in the best interests of patients to stay at home and receive treatment locally. We are working as a system to achieve this, ensuring that acute care is there for those that really need it and that all patients are seen at the right time, in the right place, first time.   We believe greater transparency and openness between organisations – working towards a common goal – means that we would reduce duplication and stop moving money around the system, instead focussing on where the greatest support and investment is required.

Q8. There is a mismatch between what senior managers/civil servants NHSE say and the views of those providing and reviewing care on the wards, in outpatients & GP surgeries!  We need to bridge that gap – what is being done to do so?

Answer: We take the views of our staff extremely seriously and hold regular informal and formal feedback sessions to understand any issues or to hear suggestions for how we can improve things.

We know that our staff have the solutions and so an important principle for our ACS is for there to be strong clinical and staff leadership, and that we actively involve and engage our patients and communities to co-design future services.

Better Care Fund - Mission Impossible?

The government having just made the biggest re-organisation of the NHS is now insisting that local health and social care economies now embark on another! 

Health and Wellbeing Board which only came into existence 12 months ago are now developing plans to use the Better Care Fund.   This fund is drawn from existing funds from health and social care commissioners. The total could be around £4 billion for England and in Buckinghamshire the fund will be nearly £100 million. This is three times the size of the fund that other areas are implementing!  Are they being too ambitious?

What will this fund do?

The Better Care Fund is to be used to integrate health and social care services, especially for older people.  It is hoped that this integration will reduce costs and improve the quality of care (in that order).

Many of us have asked for a closer integration of health and social care and so we should be welcoming this new work.  But should the timer scale for developing the project be longer than 12 months?  Can these new organisations, barely out of nappies, successfully implement such a big change in the way services are commissioned?

 Patients, especially those with long term conditions  & the elderly need care and support and they get that support from many different agencies – the NHS, Social services, the voluntary sector, the private sector, families and friends to name a few. Currently some care is called health care and some is called social care. But patients don’t really care what it is called. Or who commissions & funds it.  What they want is for it to be provided without any gaps, when and where they need it.  

They don’t want to have to go to one lot of people for one sort of care and then go through another assessment for more support! They just want to go to one point to ask for help.

So this Better Care Fund sounds as if it a good idea. But some say it will not save money and will not improve services.  They say there is no evidence that it will achieve these objectives.

I am also concerned that locally the public and patients have not been involved in the design of this new service.   As usual we will be involved and consulted with in the middle of the process rather than at the beginning.   Who is to carry out that involvement?  It is Healthwatch Buckinghamshire who are virtually unknown to the population of Buckinghamshire.   Will they be able to carry out a meaningful engagement with the public, let alone real involvement in the design of the new service?

Finally who is going to manage this fund, who will monitor the quality (and quantity) of the care? Who will be accountable?

It’s a mystery!

You can see the latest update on Buckinghamshire Health and Wellbeing Board's plans here

Here is a review of the evidence recently published by the University of York which suggests that these schemes should be rolled out cautiously and may increase overall costs.

My small part in the history of Liver Transplantation. Every interaction has an impact.

I have been blogging for a few months now and I wonder if my thoughts have had any impact on anyone. However a twitter conversation with Michael Seres (@mjseres) made me think about how little things can influence the bigger picture.

He tweeted about the death of the American surgeon, Dr Joseph Murray, who with Dr David Hume carried out the first successful kidney transplant in 1954. What got my attention was that Michael added the name of Thomas Starzl to that of Murray's and said that they were his heroes - the doctors who had made his own transplant possible.

The name of Thomas Starzl made a connection for me because I did some technical work as part of his research on liver transplantation back in the distant past. I used to work at St Mary's Hospital Medical School in the Department of Experimental Pathology. It was my second job after leaving university with a simple zoology degree in 1970. Between 1971 and 1988 I was technician carrying out diagnostic work and research as part of a team.  It was an exciting time, lots of research going on, the buzz of student life, living in London - you know the sort of thing.

There were lots of researchers who passed through the labs, learning and sharing ideas, and we were involved in their work. One of those people was Tom Starzl.

He and my boss, Prof Ken Porter, had worked together for many years on kidney and liver transplants.  In fact they developed an understanding of how rejection of the transplant happened and that discovery in turn led to the development of the immunosuppressive drugs that prevent rejection. Starzl carried out the first successful liver transplant in 1967 in Denver, Colorado and later developed the use of cyclosporin, a crucial immunosupressive drug, in 1982. Their original work had taken place well before I arrived at the lab but their transatlantic collaboration had continued and they often shared ideas and carried out research together.

So there I was, a relatively new graduate technician, still learning and I suddenly found myself contributing to the work of these amazing scientists. We did diagnostic work on the transplants from Denver and also lots of research into improving the chances of survival for transplants. Prof. Starzl would come over to London every couple of years but there was a constant flow of samples to be processed, cut and stained. We did light and electron microscopy but the most exciting technique was the auto-radiography that I did to see how the liver cells were regenerating.

I am sure the two professors could have done all the technical work we did but we did it all the time and they did all the thinking! They always appreciated the work we did and occasionally added our names to their scientific papers describing the results of the experiments. It was a great honour to be associated with them in this way.  Tom Starzl was always very friendly, a charming man. I remember that he used to ride around London on a push bike.  He would bring it into the lab and store it in one of the offices.

My conversation with @mjseres made me think about that part of my life again. I did a little research (Thank you Google) and found how just how important the work of these men was to the success of transplantation.  I realised that I, in a small way, contributed to their work and to the effect it had on the thousands of people who have successful transplants.  I now realise how fortunate I was to be associated with these amazing people and the wonderful things that they achieved.

So, thank you Michael, for reminding me about how important teamwork is and how everything, no matter how small, insignificant or routine it appears, is important.

We all have influence, every interaction has an impact and can produce slight changes in the way that others think and act.