Integrating Physical & Mental Health in Surrey - The King's Fund

Integrating Physical & Mental Health in Surrey - The King's Fund

  Integrating Physical & Mental
         Health in Surrey
           The King’s Fund ‐ Presentation
                  10 March 2017

                      Dr Helen Rostill
    Director of Innovation, Development and Therapies
   Surrey and Borders Partnership NHS Foundation Trust

                     Sue Robertson
    Head of Collaborative Programmes and Partnership
   NHS North West Surrey Clinical Commissioning Group

Surrey has three STP Footprints

Integrating Physical & Mental Health in Surrey - The King's Fund

Approaches to integrating care in Surrey
 • National initiatives and models:
   – NW Hampshire and Farnham Vanguard
   – Innovation: Technology Integrated Health
     Management (TIHM)– Internet of Things Test Bed
 • Locality hubs and integrated care models –
   Surrey Heartlands STP, incl. Epsom Health & Care
   and NHSI Guildford and Waverley
 • Surrey Heartlands Academy
 • Mental‐Physical health integration in primary
   care – developing our approach within the STP

   Integrated Care
National Initiatives and

Integrating Physical & Mental Health in Surrey - The King's Fund

Primary and Acute Care System

Integrating Physical & Mental Health in Surrey - The King's Fund

 Who we are – local context

       Our partnership

                              Salus Medical Services Ltd –
                                   (24 Member Practices)

                               Local third sector partners

North East Hampshire and Farnham Vanguard

Integrating Physical & Mental Health in Surrey - The King's Fund

 A shared vision to improve health and wellbeing


                 Our vision is that local people are supported
                 to improve their own health and wellbeing,
                 and that when people are ill or need support,
                 they receive the best possible joined up care

                    North East Hampshire and Farnham Vanguard

Secondary Care Our programme

                                            Designed by care
                                         professionals and local

                                    A new model
                                       of care

           A new                                                A new
        commissioning                                       provider model
                 Commissioners pooling                             Providers collaborating
                  budgets and aligning                             to manage population
                      incentives                                           health

                    North East Hampshire and Farnham Vanguard

Integrating Physical & Mental Health in Surrey - The King's Fund

          Model of care implementation

System wide                                      Primary care at scale
and self care

                                        New partnerships for acute
                                        care in the community

                North East Hampshire and Farnham Vanguard

Integrating Physical & Mental Health in Surrey - The King's Fund

  Patient reported Outcome Measures

Frimley STP Footprint

Integrating Physical & Mental Health in Surrey - The King's Fund

    Vanguard lessons and latest
• Progress is slow – our key learning it that it
  takes time to transform a system
• Our system leaders are working well together
  and experimenting as an “accountable care
  system board”
• PROMS and PREMS indicate improved
  outcomes and experience.
• Most acute system metrics not showing
  improvement yet

           IoT Test Bed

Integrating Physical & Mental Health in Surrey - The King's Fund

 Technology Integrated Health Management

                                Internet of Things Test Bed

                 Test Bed Objectives
• Improve health and care outcomes for people with dementia and
  their carers, enabling people to stay at home longer, reduce hospital
  bed days and postpone/delay nursing home care
• Test interoperable combinations of technologies combined into an
  Internet of Things
• Drive change in workforce practice and cascade learning into the
  care pathway
• Ultimately to deliver improved care at lower cost

Integrating Physical & Mental Health in Surrey - The King's Fund

                      Innovation Partners
Eight companies with 20 devices and services, including monitors, motion sensors,
apps, hubs, virtual assistants, location devices and wearables

        Locality Hubs and Integrated
                 Care Models

            Progress, Pitfalls and Learning…..


                    Locality Hub – conceptual model (one‐stop‐shop)
A physical building next to a community hospital providing an integrated frailty service for
people & their carers with all locality GP practices and services operating in a network
                                                                           Locality Hub
                                                        Assessment, Care Coordination & Care Planning
                            Hub out‐reach
                                                                   Adherence & Persistence
   Place of residence
   e.g.                                                    Adaptive Environment & Assistive Tech.                              Hospital
   • Home
   • Nursing Home
   • Residential Home
                                                                Medical Monitoring & Testing

   • Extra Care Housing                                            Medication Management
            Self Care
                                                            Carers, Family, Friends & Community Support
         Care packages
                                                                        Emotional Resilience

                                                                             Transitions

                                                                           Support services                        Hub out‐reach into
  People are referred to the Hub
                                                                                                                   hospital to proactively pull
  from local services based on flags                                         Diagnostics                           people through the urgent
  for high risk & formal screening at
                                                                                                                   care system
  GP surgeries                                                                Pharmacy

           Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector

                                             Multi‐disciplinary Team working

                        A multi‐disciplinary team approach supports people in the Hub

                                                                 Locality Hub

    Associate           Community                           Locality hub manager                       Social Care Mental Health
   Practitioner           Matron                                                                        Specialist  Specialist

   Social Care       Community
                                                                                                       Specialist         Specialist
    Worker          Mental Health
                                                                                                      Geriatricians        Nurses

                                                                                                       Therapist      Other specialists as
   Pharmacist           Wellbeing Co‐                                                                                     required
                                                        Practice Nurse         Person’s GP

                                  (MDT attendees may flex depending on patient need)


NW Surrey Integrated Health & Care – Logic Model
Context: The Five Year Forward View, a growing elderly population with long term conditions and multi‐morbidities will exert pressures on the system and on informal unpaid carers.
Rationale: NW Surrey has 15,000 frail elderly, or at significant short term risk of becoming frail. Each complex patient averages seven inpatient admissions per year. Audits show that half of inpatient stays on
medical units were avoidable and 29% did not meet the criteria for acute care admission; 30% spent at least half of their stay waiting to be discharged. Our vision is to create a coherent health & care system
delivering the best possible outcomes with a highly effective acute trust working alongside a primary care‐led integrated out of hospital service wrapped around the community. This will promote independence,
physical and mental health and deliver better value for money.

               Inputs                                           Activities                                              Outputs                                       Outcomes
                                                                                                                                                                Efficiency Metrics
  • The people and financial resources &               • Access to Bedser integrated care hub              • MDT’s in all 3 Localities focused on               • Reduction in A&E visits
    leadership capacity of commissioners                 Woking ‐ local experience                           care for the 15,000 patients with                  • Reduction in non elective admissions
    and providers of health and care for               • Integrated patient‐centric frailty service          highest risk & need seven days a week              • Reduced bed days/LOS
    local people: NW Surrey CCG, Ashford                 operating in a single network in                  • Robust care coordination by named                  • Reduced re‐admission
    & St. Peter’s Hospitals, Surrey County               Integrated teams                                    staff.                                             • Reduction in admissions to nursing
                                                                                                           • Single Point of Access for referrals                   and care homes
    Council, GP Practices (, Thames Medical            • Hubs based around physical buildings                                                                   • Reduction in social care packages
    14, SASSE 13, Woking 13), Surrey &                 • Uses risk stratification to identify those        • Rapid Response available in the
                                                                                                                                                                • Maintaining people at home for
    Borders Partnership Trust, Surrey Age                with the most complex needs                         community for patients at immediate                    >91days post discharge
    UK, Surrey CC, Virgincare, Elmbridge,              • Consultants providing direct clinical               risk of admission                                  • Increase in identification & treatment
    Woking, Spelthorne & Runnymede                       input to manage patients with complex             • Activity measures                                      of people with dementia
    Borough Councils                                     needs at home                                     • Extended access 8 – 8                              • Reduced annual costs of head of
  • Better Care Fund                                   • Assessment, care coordination, shared             • Regular well attended MDT meetings                     population
                                                                                                             of a core team of health & social care             • No of IBIS registered Hub patients
  • Service user and carer representatives               care planning and care record utilising                                                                • 999 calls matched to IBIS patients.
    Volunteers from colleges, universities               ‘7 elements care plan’                              staff & extended team of specialist &
                                                                                                                                                                • IBIS: Hear & Treat, See & Treat, See &
    and/or user representative groups                  • Provides proactive and reactive care with           voluntary input                                        Convey.
                                                         focus on prevention                               • Access to a shared care record                     • IBIS Conveyance Rate, Conveyance
                                                       • Discharge to Assess model                         • Governance arrangements between                        Avoided, Admissions Avoided.
                                                       • Provides opportunities for socialisation            organisations enabling population                  Care & Quality Metrics
                                                         & engagement activities – groupwork                 health management                                  • Improved personal wellbeing
                                                                                                           • Estate that is fit for purpose & well              • Increased confidence of people to
                                                         and community based, including                                                                             take responsibility for own health
                                                         provision of hot meals, exercise classes            utilised.
                                                                                                                                                                • Improved experience of care
                                                         & social activities.                              • Clinical teams and leaders undertaking                 (patients & carers)
                                                       • Standardised multidisciplinary care,                team development                                   • Improved staff satisfaction, staff
                                                         evidence based individualised tasks and                                                                    confidence and staff
                                                         activities, utilising self‐management                                                                      recommendation
                                                         concepts which maximise health and                                                                     Health & Wellbeing Metrics
                                                                                                                                                                • Improved mental & physical
                                                         help maintain independence and                                                                             outcomes (mobility, daily living,
                                                         functioning.                                                                                               cognition & mood)
                                                       • Inclusion of carers and volunteers
                                                       • Provision of transport.
                                                       • Utilises technology to enable remote
                                                         communication for staff and patients &
                                                         telehealth interventions.

                                                                               Evaluation (Surrey Heartlands Academy)


           Progress in North West Surrey
• North West Surrey CCG launched the Woking ‘Bedser’
  Hub – the first of three multiagency health and social
  care multi‐agency hubs aimed at providing integrated
  care for frail older residents with co‐morbidities to help
  them live healthy and independent lives for as long as
• The Hub is staffed by health and social care providers
  who give comprehensive mental and physical health
  assessments, diagnostics, treatment interventions and
  follow up care.

                   Outcomes to date

  • Since the Hub opened in December 2015, there
    has been a 1.3% reduction in non‐elective
    admissions across all patients over the age of 75
    registered to Woking practices, compared with an
    increase in activity in the other two localities.

  • Whilst A&E attendances for the over 75s have
    risen across all three localities, the percentage
    increase for the Woking population was 1.2%,
    compared to 4.5% and 12.3% for the other two
    localities without hubs.


Challenges                       Why                                     Mitigation
Activity slower than expected,      Some patients refused to attend     Eligibility criteria expanded
cohort not identifying as many       as they were ‘too well.’            WBC contracted as ‘Data Processors’ acting on behalf of GP
patients as the original model      GPs slow to refer                   Practices allowing them to directly contact cohort patients
identified                          Hub capacity insufficient to        prior to explicit consent being obtained
                                     provide an outreach service to      Procedures agreed for patients accessing the D2A scheme
                                     care homes                          (early supported discharge), A&E, wards and specialist
                                                                         nurses to refer into Hub; Future integration of care home
                                                                         team with Hub team

Patient assessments taking           Staff were not familiar with the   Workshop held with staff to ensure clarity of roles.
longer than originally                documentation and there was        Assessment procedure being reviewed to reduce
planned, resulting in                 some duplication of work           duplication, following which appointment times will be re‐
increased impact on Hub                                                  evaluated.
Reactive service not yet             Unable to recruit suitably         Training and peer support arranged for existing GPs to take
established                           qualified lead GP                  on the role
                                     Financial constraints              Lead ASPH consultant identified to support the service

Unable to provide patients           Patients found it too tiring to see Patients are now brought in to see professionals over two
with all services on one single       everyone on a single visit          visits
visit                                                                     Physiotherapy and OT are provided as outreach as found to
                                                                          be more effective in patients own home
ChenMed model: patients stay         Patients didn’t like being left     Patients return to the waiting room between appointments,
in one room while the                 alone, and it was difficult to      with one member of staff supervising them.
professionals move about              ensure adequate supervision
The provision of regular             Voluntary sector slow to engage Continuing to provide creative seated dance, reviewing
activities is limited                 due to increasing demands on    options for other activities
                                      their time

     Epsom Health and Care (EHC)


Roadmap for  EHCforservice
         Roadmap    EHC serviceprovision       April
                                provision for April     2017‐2018

                                          Care            Epsom Health and Care Whole
                                         System           Service:
                                                          • Co-located
               April                     Budget:
                                         £12.3m           • Transformed reablement /
                                                            rehabilitation service
               2018                                       • Integrated bed base
                                                          • Fully integrated teams
                                                          • Integrated management

          Epsom Health
          and Care                                              Epsom Health
          Stroke                                                and Care
          service:                                              Cardiology
          • Integrated                                          service
          • Enhanced                                              Legally
            discharge                                             binging          Epsom Health
                                                                Consortium         and Care
                                                                Agreement          @home service
      Health and
      Integrated GP
      in A&E
      service                                                                       April 2017

               NHS Improvement – Guildford and
                 Waverley exploratory project
     • Take the area as proof of concept– identify initial metrics of system efficiency
       and productivity which can be applied in other systems
     • Enable local partners to realign and re‐embed productive relationships for
       local long‐run change to be self‐sustaining
     • Potential for whole system transformation – health and social care
     • Focus on:
          1.   Frail Elderly and long term conditions (over 65s with co‐morbidities)
          2.   Dementia and older people in acute, and pathway to community
          3.   Working age adult psychiatric liaison and acute interface
          4.   Working age Long Term Conditions



Learning from our integrated care
•   Fragmentation locally and nationally
•   Variance
•   Established ways of working and commissioning services
•   Transformation can destabilise the system and lead to unmitigated risks
•   Information sharing

•   Meeting local need
•   Improving access
•   Improving patient outcomes and experience
•   Building relationships and understanding each others’ roles/business

          Learning From Experience
• Relationships are at the core of success
• Collaboration not competition
• Willingness to think differently and
• Transparent conversations
• Holding onto what we do well
• Recognising that change is hard and takes


Surrey Heartlands


                                             Surrey Heartlands STP

                                         Mental Health

        Our approach – overview of initiatives
Initiative            Outcomes and benefits                                                                              How will we achieve this
Operating         System:                                                                                            •    Co‐design a Surrey Heartlands coordinated model/system for mental health, learning disabilities & dementia
                  •    Better coordination of heath & social care system (‘no wrong door’) approach across all       •    Continue to develop a one person, one assessment, one plan approach
model for              ages & abilities to improve experience of citizens within the footprint                       •    Develop SPA & core assessment process
Mental Health ‐   •    Standardised interface processes/SOP’s                                                        •    Establish a common governance framework
                  •    Evidence joint assessment & care planning, escalation plans & shared understanding of risk.   •    Embed Digital Road Map
within the        Outcomes:
wider system      •    Reduced variation through delivery of evidence based NICE compliant pathways.
                  •    Outcome‐focused, intelligent & data driven commissioning

Prevention:       •    Citizens will be better equipped to participate in co‐designing services.                     •    Establish Surrey Heartlands Wellbeing prescribing model
                  •    Citizens will be encouraged and helped to make healthier choices to achieve positive long‐    •    Develop a series of engagement events to explore engagement & leadership concepts – bit undefined. Is it
Citizen Led            term behaviour change and adopt different approaches to self‐care and mental health                to co‐design self‐management options This is about working with local citizens to look at how we can
Health & Social        prevention strategies.                                                                             empower them to get more involved in looking after their mental health.
                                                                                                                     •    Ensure good mental Health messaging is embedded into self care initiatives & healthy lifestyle campaigns –
Care                                                                                                                              •    Implement Making Every Contact Count
                                                                                                                                  •    Develop Virtual Wellbeing Centre

Increase access   •    Increased access to:                                                                          Further develop/co‐design coherent & consistent models of care that span the Surrey Heartlands system:
                               •   IAPT services by 25% by creating better interfaces for those with LTCs            •    Recovery College combining physical and mental health
to early                       •   completion of IAPT treatment                                                      •    Primary Care (Team around the Practice)
intervention                   •   specialist perinatal services                                                     •    IAPT expansion to LTC’s, MUS, Common MH and SMI to improve access rates
                               •   eating disorder services                                                          •    Extend eating Disorder services inc. children
                               •   50% of those diagnosed with first episode psychosis get access to evidence        •    EiIP services meeting national targets
                                   based EiIP packages of care within 2 weeks                                        •    Employment services e.g. IPS
                               •   early detection & assessment to physical care (SMI &LD)                           •    Review & expand health psychology in acute hospitals
                               •   Employment for people with SMI                                                    •    Develop a resource e.g. Lester model to enhance physical health care SMI.
                               •   Trauma services                                                                   •    Develop NICE compliant care pathways/outcomes based models
                  •    Learning from the Technology Integrated Health Management

Managing crisis   •    More connected networks of services to manage crisis and lead to system efficiencies,         •    Implement SPA 24/7 Crisis Care (no wrong door – interfaces with children’s pathways HOPE)
                       reducing:                                                                                     •    Evaluate & expand innovative models of care: e.g. Safe Haven
well                           •   admissions to acute MH care                                                       •    Review existing model, define & scope enhanced model ( to include children & LD) of Psychiatric Liaison in 3
                               •   A&E visits                                                                             footprint acute hospitals to assess against Core 24.
                               •   lengths of stay –acute care                                                       •    Gap analysis ‐ review/expand CRHTT to provide intensive home treatment 24/7
                               •   use of SECAM                                                                      •    Expand Carers Support/Healios approach
                               •   And more appropriate use of S136                                                  •    Expand model of MH staff in police call centres
                               •   10% Reduction in suicides                                                         •    New MH Hospital site expansion
                  •    Increase access to psychiatric liaison                                                        •    Implement a suicide prevention initiative
                  •    Complete the second hospital for acute MH admissions
                  •    Optimise use of Estates

Dependency:       •    Increased capability across physical & mental health workforce in recognising MH              •    Develop eLearning package and Embed MH Training into all standard induction processes across the system
                       issues/mind body connect                                                                           for all new starters
Workforce         •    Improved wellbeing of the workforce                                                           •    Scope what is already being offered e.g. through Health Ed. England, Public Health etc.
capability and                                                                                                       •    Develop ‘Wellbeing of the Workforce’ sessions & deliver through Recovery College
                                                                                                                     •    Sponsor GP’s to undertake Accredited Diploma in MH
wellbeing                                                                                                            •    All organisations to sign up to Wheel of Wellbeing


          Latest STP Workshop
• 180+ attendees from public, private and
  voluntary sector health and social care providers,
  commissioners and partner agencies on 7 March
• Our focus on Primary Care: Team around the
• Checking with partners: what’s working well,
  challenges and ideas/solutions
• Challenges and ideas significantly outnumbered
  what’s working well!

The overlap between long term conditions & MH


 Mental health workshop: what people told us
       Working well                  Challenges                 Ideas/Solutions
Crisis support improving,   CPD for GPs, practice staff   Enhanced professional
e.g. Safe Havens            and other health/care         training in mental health
                            professionals in mental
Mindsight Surrey CAMHS      Navigating the system and     Enhanced use of
model and pooled budgets    care continuity               technology – e.g. virtual
                                                          support for GPs
IAPT self‐referral          Early identification of       Team around the person
                            mental health problems        and whole family approach
Voluntary sector            Stigma                        Social prescribing and time
involvement, e.g.                                         banking – community
Community Connections                                     activation
                            Co‐morbidities and          Improved signposting and
                            pigeonholing by ‘condition’ service directories
                                                          Ongoing service user
                                                          consultation and co‐design

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