FIN(4)-20-12 Paper 3
National Assembly for Wales: Finance Committee
Inquiry: Invest-to-Save
Evidence Paper Provided by Fiona Jenkins, Director of Therapies and Health Sciences for Cardiff University Health Board, and Senior Responsible Officer for the Wyn Campaign. (November 2012)
Background
The Wyn Campaign is the Frail Older People work stream of the Cardiff & Vale of Glamorgan Integrating Health and Social Care Programme. The stated aims of this partnership are:
· Raising the quality of our services through service and process redesign;
· Maximising the independence and well-being of our citizens and their families in the context of their lives and communities;
· Continuing to develop our staff expertise – working differently together;
· Maximising finance by pooling our resources to benefit citizens.
The Campaign seeks to align and co-ordinate initiatives to support the translation of policy and strategy into operational reality, by creating the ‘Team Around Wyn’ as detailed below:
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The Wyn Campaign is a long-term transformational change programme that will be implemented in 2 or 3 Phases.
In May 2012 the Campaign successfully submitted an Invest-to-save bid to complete Phase 1. This will provide consistent community based services, via the three local Community Resource Teams, focused on the following activity:
o Facilitated early discharge from hospital: maximum response time 3 days from referral to Wyn being supported at home;
o An alternative falls pathway to avoid unnecessary conveyance to hospital by Welsh Ambulance Service Trust;
o The delivery of the evidence-based Otago strength and balance programme to housebound patients who have fallen;
o In-reach into care homes to prevent avoidable hospital admission;
o Multi-disciplinary support to people with one or more chronic condition, who are most at risk of admission to hospital;
o Prioritised support to patients identified by the Frail Older People’s Advice & Liaison Service (skilled multi-disciplinary team in the Emergency Unit) and the Elderly Care Assessment Service (community hospital – based ‘hot clinic’).
Q1. What impact is Invest-to-save having, is it meeting its intended purpose - “supporting organisations involved in public service delivery make the transition to more efficient, more effective and more sustainable forms of service delivery”?
The aims of the Wyn Campaign are highly consistent with this approach. It is founded on the theory that by ‘up streaming’ timely, tailored and targeted support, we will support Wyn to remain independent for longer and delay the requirement for more expensive forms of care. This not only makes sounds financial sense, it is also consistent with what older people, nationally and locally, tell us they want (e.g. Joseph Rowntree Trust, 2011).
The case behind the submission runs as follows:
Ø The investment in targeted community services will improve hospital in-patient flow:
Ø This will reduce the annual requirement for surge capacity to meet winter pressures etc;
Ø The capacity created will, in the first instance, be utilised to improve performance in waiting times for elective activity;
Ø In the second year, the more managed approach will enable the taking down of the previous surge capacity to release the resource required to sustain the new community services;
Ø By the third year, the shift in activity will enable the closure of sufficient hospital beds to enable full pay back of the Invest-to-save loan.
There is a strong policy drive to move to the type of service delivery illustrated by the ‘Team Around Wyn’ model, and the Cardiff and Vale of Glamorgan partnership is one of several such transformational change programmes in Wales. The Invest-to-save programme is proving pivotal in providing guidance and support in evaluation and the sharing of good practice.
The issue faced by the Cardiff and Vale of Glamorgan partnership is that of significant cost pressure on all statutory organisations and the voluntary sector. The opportunity for Invest-to-save was therefore seen as the best avenue to enable us to progress the first phase of this ambitious programme. The focus on step changed delivery of the better evidenced type of intervention means that the risk regarding payback is minimised, and therefore tolerable in the current climate.
However the challenge has been developing the underpinning business case to identify future sustainability of the model as a whole. The evidence-base for the type of model illustrated is substantive in terms of quality and citizen satisfaction, but less so in terms of finance, particularly in the longer-term.
Evaluation of schemes such as the Wyn Campaign will help to build that evidence, but at this stage it is not possible to state with confidence that each £ spent on early intervention, in avoiding social isolation for example, will produce x amount of savings in secondary NHS care. Nor is it possible, using the current evidence or modelling information available to the partners, to directly attribute savings from such interventions in longer-term social care – even though there is a clear logic that this will be the case. To date the only draw down from the fund has been from the University Health Board with Local Authorities preferring not to incur payback costs.
So whilst the Invest-to-save facility has been invaluable to ‘kick start’ the step change that will lay the foundations for the implementation of the new model of service delivery, the risks in using it as a mechanism for achieving larger-scale health and social care integration and transformational change are likely to be deemed too great by organisations under financial pressure.
Q3. What are the lessons learned and could examples of good practice be shared and extended more widely across the public sector?
The Invest-to-save team has actively encouraged organisations seeking to implement similar schemes to work together, to share experiences and to develop common evaluation frameworks which will support stepped service change across Wales.
For the Wyn Campaign, this has led to regular meetings with programme leads in Cwm Taff and Hywel Dda, with Gwent to join in the near future. Negotiations are underway to work together with OPAN/University of Glamorgan to progress a robust common evaluation framework.
It has also necessitated closer cooperation between the partnership organisations which has been positive for all parties.
Q4. What savings have been achieved as a result of awards from the fund?
The final stage of Phase 1 ‘went live’ on 1st November 2012. Circa 50 new members of staff have been recruited to the Community Resource Teams and they will be equipped with mobile devices to support greater efficiency (more time with service users and less travelling back to base and completing documentation).
This has co-incided with activity which did not require additional investment, but has optimised existing resource by working differently together. This includes for example:
o the Frail Older People’s Advice & Liaison (FOPAL) Service, which brings geriatricians and the multi-disciplinary team to the ‘front door’ of the hospital to ensure that Wyn receives timely and skilled assessment and intervention, that will provide community support wherever this is best for him/her as an alternative to hospital admission;
o the Integrated Discharge Service which brings together NHS, Social services and third sector workers to provide a more seamless experience for patients with more complex discharge needs;
o workforce development including workshops on pathway redesign and the ‘Roadmap to Integration’.
A Baseline Evaluation is being progressed, and there are early indications that some of the targets we set ourselves (e.g. 3 day maximum response time from referral to facilitated discharge with the CRT) have already been achieved.
It is early in our Programme to identify what savings have been made. The savings are planned to be released over the next 3 years. We have modeled the re-design to develop community provided care and support and reduce the dependency on in patient hospital beds. It is our intention to reduce in-patient beds in the medium term to ensure a sustainable model and re-payment of the invest-to-save loan. We are currently finalising the business plan to identify to identify the relationship between increased community activity and reduction in bed numbers.
Q5. Are there any barriers to entry i.e. are there any elements of the Invest-to-save fund process that make it difficult to participate in the scheme?
The Invest-to-save team have been extremely open and helpful and have provided guidance and support throughout the process. We have not experienced any barriers to participation in the scheme.
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The Wyn Campaign: Sources of Information |
10 High Impact Changes for Complex Care. (Continuing NHS Healthcare National programme, 2011)
A Better Life; What Older People With High Support Needs Value
(Joseph Rowntree Trust, November 2011)
A Guide to Crisis Response Services (Department of Health, 2009)
Achieving greater efficiency in Older People’s Services for Wales. (John Bolton. SSIA Cymru, 2010)
Avoiding Hospital Admissions: Lessons from evidence and experience
(The Kings Fund, 2010)
Integrated care for patients & populations: Improving outcomes by working together (The King’s Fund and Nuffield Trust, January 2012).
Integrated Care: What is it? Does it work? What does it mean for the NHS? (The Kings Fund, 2011)
Joining up health and social care: Improving value for money across the interface (Audit Commission, December 2011)
Turning the Page: Writing the next chapter for older people in Wales
(The Older Peoples Commissioner for Wales)
National Evaluation of the Department of Health’s Integrated Care Pilots
(RAND Europe, Ernst & Young LLP for the Department of Health, March 2012)
Evaluation of the Implementation of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail older People in Quebec
(Herbert et al, 2008. Journal of Integrated Care, Vol 16, Issue 6 pp 4-14)
Quality, Development & Leadership: Lessons to Learn from Jonkoping
(Gozzard & Willson, 2011. 1000 Lives+ Improving Healthcare White Paper Series –No.4 )
An assessment of the future health and social care needs of older people in Cardiff and the Vale of Glamorgan 2010-2030: trends in demography and the morbidities leading to health and social care needs.
(Linda Davies: Cardiff & Vale of Glamorgan Public Health Team, 2011.)
Integrated Care for Patients and Populations: Improving outcomes by working together
The King’s Fund 2011,
http://www.kingsfund.org.uk/publications/future_forum_report.html
Intermediate care: what do we know about older people’s experiences?
Joseph Rowntree Foundation, 2003.
http://www.jrf.org.uk/sites/files/jrf/185935131x.pdf
The Kings Fund Data Briefing (April 2012) Emergency hospital admissions for ambulatory care sensitive conditions: identifying the potential for reductions.
Quality Care for Older People with Urgent & Emergency Care Needs.(‘The Silver Book’) 2012.
Setting the Direction; Primary & Community Services Strategic Delivery Programme (2010) Welsh Government
Fulfilled Lives; Supportive Communities (2010)
Welsh Government
Together for Health; A Five Year Vision for the NHS in Wales (2011)
Welsh Government
Integrated care for older people: Examining workforce and implementation challenges. (2011) Centre for Workforce Intelligence.
Transforming the Delivery of Health and Social Care: the case for fundamental change.
Ham, C; Dixon, A; and Brooke, B. The Kings Fund, August 2012
Cross sector working to support large-scale change
The Health Foundation, August 2012
Appleby, J; Ham, C; Imison, C; Jennings, M. (2010)
Improving NHS Productivity: More with the same not more of the same
The Kings Fund