Context
The setting was Salford in the north-west of England. At the time of CLASSIC, the population of Salford was 234,916 (of whom 34,000 were aged ≥ 65 years). There are comparatively high levels of deprivation (Salford is one of the 20 local authorities with the highest proportion of areas in the most deprived decile) and illness (22.8% living with a long-term illness, compared with a national rate of 17.9%) (SICP unpublished internal briefing document).
The health and social care system in Salford is largely coterminous, with one local government partner (Salford City Council), a single health commissioner [Salford Clinical Commissioning Group (CCG)], a mental health provider (Greater Manchester West) and a provider of acute and community services (Salford Royal Foundation Trust). Salford contains 52 general practices in eight neighbourhoods.
Salford Integrated Care Programme
The SICP is a large transformational project designed to achieve integration between health and social care to achieve the ‘triple aim’: delivering better health and social care outcomes, improving the experience of service users and carers, and reducing costs.
There is strong history of local integrated working. In 2007, Salford introduced Salford’s Health Investment For Tomorrow programme, a ‘whole economy’ approach to care pathway redesign and the transfer of care from secondary care into community and primary care.
In 2011, Salford Royal Foundation Trust was approached by the Advancing Quality Alliance (AQuA, a quality improvement organisation) and asked to participate in an integrated care programme along with the Salford CCG and Salford City Council (SICP unpublished internal briefing document). With time, a working group developed a case for change and from May 2012 formal governance was established for the SICP. The initial plan was for three programmes:
- the promotion of local community assets to support increased independence
- the establishment of an ICC to provide navigation and support
- the formation of MDGs supporting older people at most risk.
The SICP model and operational plan (Figure 1) outlines aims and ‘primary’ and ‘secondary’ drivers. There are seven improvement measures for the SICP for 2020: (1) reduced emergency admissions and readmissions, (2) reduced permanent admissions to residential and nursing care, (3) improved quality of life for users and carers, (4) an increased proportion of people supported to manage their own condition, (5) increased satisfaction with care and support provided, (6) increased flu vaccine uptake and (7) an increased proportion of people who die at home (or in their preferred place).
FIGURE 1 Salford Integrated Care Programme and programme ‘drivers’. Reproduced with permission from Salford Together from SICP background briefing materials. (Figure not reproduced here; see the original article.)
As discussed in Chapter 1, one of the drivers of integrated care was the patient perception that care was not ‘joined up’, which led to the production of a number of ‘principles’ of integrated care designed to enhance the patient experience of care.3–5 To enhance that ‘patient-centred’ perspective, SICP implementation was based on a fictional character (Sally Ford) and her family. Sally Ford is a 78-year-old woman, who is divorced with no children and experiencing average health. She has family consisting of siblings and their partners, who all experience varying levels of health. The aged > 65 years population was categorised into four different levels of health need (Table 1).
| Level of ‘Sally’ | Level descriptor |
|---|---|
| ‘Able Sally’ | Able to support and sustain own health and well-being needs |
| ‘Needs some help Sally’ | Likely to have contact with at least one service agency. A need for education/intervention to enable self-management. Lower level of social care needs. Provides informal care to another individual. Early diagnosis of dementia |
| ‘Needs some more help Sally’ | Regular visits from health (including mental health) and/or social care services. Intermediate care/reablement. Meets social care eligibility criteria,5 receives formal or informal care |
| ‘Needs a lot of help Sally’ | Needs 24/7 care either in a residential, nursing or EMI home, or at home with high level of need (e.g. often over a 24-hour period) |
The SICP was to be delivered in five phases:
- phase 1 – refine scope and prepare for implementation (completed)
- phase 2 – neighbourhood ‘tests of change’ (completed)
- phase 3 – interim review of impact (scheduled January to March 2014)
- phase 4 – extend to other neighbourhoods/city wide (April 2014 onwards)
- phase 5 – formal evaluation (April 2014 to March 2019).
Three core mechanisms of integration were included in the specification of the SICP (Box 1).
The SICP also involves a wider range of mechanisms. The local health improvement agency [Haelo; see www.haelo.org.uk/ (accessed 3 April 2018)] conducted interim evaluation work alongside CLASSIC, and their report included a schematic, which detailed the full range of mechanisms within the SICP as well as some indication of the relative scope of investment in each (Figure 2).
FIGURE 2 Schematic showing range of SICP activities. Reproduced with permission from Haelo (Haelo, Salford Integrated Care Programme: Summary and Lessons Learned, 2016, internal report). CRM, customer relationship management; QA, quality assurance; SCR, shared care record; SIRP, single integrated referral point; W2W, Ways to Well-being. (Figure not reproduced here; see the original article.)
Two mechanisms were a core focus for the CLASSIC study: MDGs and ‘health coaching’ via the ICC. The MDGs were developed by the SICP team, and we describe their broad nature shortly, with data on their implementation and effects discussed in Chapters 11 and 13. Health coaching via the ICC was developed based on existing local services, but the precise model used was led by the academic team and evaluated through a formal trial. For this reason, the detailed description of the health coaching is provided as part of the trial description in Chapter 8.
Multidisciplinary groups
To describe MDGs, we have drawn on a published descriptive framework40 (Table 2) and mapped the groups in the SICP. There are features of the SICP model that may facilitate effectiveness. At a system and organisational level, the impact of the groups is potentially enhanced by the partnership underlying the SICP model (the CCG, city council, acute trust and mental health trust sharing risk and benefits), the alignment of goals and frameworks that this may achieve, and the potential for effective and co-ordinated leadership. Engagement of general practices should be facilitated by the proposed structure of the groups and the involvement of the CCG as a core partner organisation. The importance of self-management is reflected in the interface between the groups and other core aspects of the SICP (community assets and health coaching). A focus on ‘continuous quality measurement and improvement’ has been identified as an important success factor, and the local development of the model is supported by quality improvement teams to assess the model through small-scale ‘tests of change’.
| General description | Objectives | Development stage | Target population | Population coverage |
|---|---|---|---|---|
| MDGs provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support | The aim is to achieve greater independence and improved well-being for those aged ≥ 65 years by integrating care within communities. The focus is on reviewing and problem-solving complex cases, providing anticipatory care plans and assisting with navigation through the health and social care system | Piloted in two sites, with support from a quality improvement team and regular use of PDSA cycles to develop model | Older people with long-term conditions and social care needs | All older people in local area, although focus is on certain levels of need |
| Caseload | Funders | Breadth and degree of integration | Shared medical records | Risk stratification |
| Each group holds a register of all people who are aged ≥ 65 years. The register is based on the ‘list’ of the practices that are members of the group | Funding comes from the SICP. The four statutory partners (CCG, council, acute trust and mental health trust) have all formally signed up to the SICP and delegated authority to a board | Horizontal integration with some vertical integration based on improvements in co-ordination between primary and acute providers, and between health and social care professionals | Local integrated records provide unique linked primary care and secondary care data. Current linkage with social care less well developed | Uses a four-strata model of risk, with the role of the MDGs focused on those identified at levels 3 and 4 and at risk of escalation |
| Providers | Single point of referral | Patient eligibility criteria | Single assessment | Care planning |
| GP/nurse (with link to community geriatrician when required), social care worker (link into housing and health trainers when required), district nurse (link to hospital and discharge support), mental health, OT and administrator | Patients identified by risk stratification tool complemented by professional judgement, as well as direct referral from members of the MDG | As identified by risk stratification tool or professional judgement, based on risk of hospital emergency admission (and readmission) and admission to care homes | Yes | An integrated care plan is agreed with each individual. Content varies depending on risk and need, but includes a focus on primary and secondary prevention. All individuals are reassessed with frequency determined by level of risk |
| Care co-ordinator/case manager | Multidisciplinary team | Financial and non-financial incentives | Self-management support | Carer assessment and support |
| A small number of individuals with the most complex needs will be discussed at a MDG meeting to help plan and co-ordinate their care. Individuals are assigned a key worker to support their needs. The key worker will be identified based on who is likely to have most input into care for that individual patient | Yes | Partners have signed up to a high-level risk and benefits sharing agreement. As part of the SICP, the partners are exploring pooled budgets for health and social care, a joint venture/alliance contract and a capitation funding model | Provide links to ICC (including care navigation and health coaching) and community assets strands of the SICP (including self-help groups in the community) | Although carer needs may be part of the person-centred assessment and care planning, formal involvement of carers is not prioritised at present |
| Voluntary sector and peer support | Co-production | |||
| Although not a formal part of the MDG remit, the voluntary sector and peer support were identified as important issues in the early piloting and may be involved through MDG links to the community assets theme | Patient involvement has not been a high priority in the design of the MDGs, although there has been input from patients in some of the higher-level learning sessions in the development of the SICP |