Kirsten Major and Ruth Brown: Our integration journey in Sheffield

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Kirsten Major, Ruth Brown

Kirsten Major and Ruth Brown describe integrated care in Sheffield at The King's Fund's implementing primary and acute care systems conference.

Kirsten Major and Ruth Brown - our integration journey in Sheffield

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Kirsten Major

Our integration journey to some extent began when I arrived in Sheffield, so I arrived in Sheffield three weeks before the Acute FT took over the Community Provider Arm in Sheffield under The Transforming Community Services Programme. I was slightly daunted by that because I came as what had been the Executive leading the SHE in the North West, overseeing a portfolio of 60 odd PCTs doing the same thing and being quite anxious about it, so was very daunted to arrive in Sheffield and be there as a parent of this provider arm, worth around £50 million that was about to arrive in the Acute Sector.  With that brief introduction, I am going to tell you a bit just about Sheffield in case you don’t know anything about us, and then we are going to outline the journey we have been on in terms of Acute and Community integration: what our approach has been; what results we think we have had; what challenges we think remain outstanding and what our vision is going to be for the future.

So Sheffield has a population of 560,000 and is growing quite rapidly at the moment. We have a BME population of 20 per cent; our 20-24-year-olds have grown by almost 10 per cent since 2011 and that is clearly associated with some increase in the migrants that have been arriving in Sheffield.  Forty-three per cent of our households, not uncommonly for a northern ex-industrial city, are vulnerable to significant financial stress and we do have significant levels of health inequalities and of experiencing the widening of those in female life expectancy whilst seeing them narrow for men.

Just to give you a bit of a flavour – I will show you a nice picture of Sheffield’s town hall with its lovely Peace Gardens if you want to visit. It’s not the grimy industrial city you might expect, but we are one of the largest FTs in the country.  Our turnover tipped through the £1 billion mark for last year and we employ approximately 16,000 staff.  We are a large tertiary provider – it is about a third of the work we do as specialised services.  We do have the huge advantage – and I have felt extremely sorry for some of the previous speakers who have described the complexity of the system they are in because we are just not in that space – so we have a single CCG, a single local authority, we have one Mental Health Trust.  We do have a separate Children’s Trust which can be interesting in terms of handover but essentially we do all adult Acute Care for Sheffield and all tertiary care for a much larger population.

We have an active third sector and our Primary Care system is pretty stable and - apologies to Primary Care, apologies – we seem to have lost the word ‘quality’ on there – but it is relatively stable and of high quality. So on all the indicators you would pick we are doing pretty well in terms of Primary Care.  I am very nervous about the extent to which that might change in the next few years actually.  The corridor conversations about those ‘good eggs’ in their fifties that are just saying, “Actually, I’ve had enough,” and I’m not sure who is going to replace them.

So the drivers for integration have indeed been absolutely The Transforming Community Services Programme as a policy and I suppose I am a bit nervous that that policy was announced five years ago and I think we are probably just beginning to see the real impact of what that policy was, so I am slightly nervous about vanguards delivering with an 18 months to two years. I think that is a big ‘ask’ for us as a system, but a PC at the drivers that we need to respond to.  Alongside that, we have had some more specific Sheffield issues that we have responded to, so we have had the Right First Time programme which is described in the case study in the report.  That has been a wider framework within which The Transforming Community Services as an integration programme has operated.

We have also set up what we are calling ‘The Working Together’ programme which is a horizontal programme of ourselves and the six DGHs in the South Yorkshire Health Economy. Another really useful factor we have is that we are in an entirely FT economy so there is nobody regulated by the TDA in South Yorkshire which I also think is important in terms of clarity of message.

We have also had a really big piece of work around COBIC – Contracting for Outcomes in MSK – that goes live and sees its first patient under that contract next week, so all MSK services in Sheffield now come through us as the prime provider and we hold all the contracts with all the independent sector pain providers, physio providers, orthopaedic surgery, etc. That is feeling like quite a big live experiment that starts next week.

Then obviously there is the Integrated Commissioning Programme in Sheffield which is their name for the Better Care Fund. I think we have the second largest Better Care Fund in the country which runs to hundreds of millions of pounds of joint Health and Social Care commissioning budget.

So the journey we have been on has been both internal and external and what has been really important, I think, to balance has been that internal and external approach. Internally when the Community Services came across to the FT we created a single care group.  Despite being criticised for it somewhat at the time, we did do a complete ‘drag and drop’ of the entirety of the Community Services and maintained that identity in the initial period.  Alongside doing that, we created really senior and visible leadership from Community into our wider organisation structures.  So a very well established and senior district nurse with considerable local credibility became the first clinical director for that community group and joined our Clinical Management Board, and was a feisty and interesting contributor to that Clinical Management Board at the time.

And then we did start a piece of work to look at pathways of care that would be ready for integration across Community and Acute and took them one at a time. Alongside that, externally we did quite a lot of work of confirming challenge with external experts, so bringing in those individuals who have written either policy or research around integrated care, and asking them to come and look at us and tell us what they thought; building more vertical and horizontal health economy partnerships through that Right First Time Programme which has got all of the Health and Social Care providers in Sheffield round the table.  Our Chairs and Chief Executives meet every month as a Board to review the decisions and work of that programme; then alongside that, building wider relationships with our DGH colleagues.

I think all of that together - several speakers this morning I think mentioned the issue about creating trust and how do you do that? I think part of the creating trust journey we have been on is that we all arrived with a set of baggage and expectations of how we would all behave and it was only through the passage of time, when we did not behave like that, that we did actually begin to trust each other.  I am just not sure there is a shortcut to that.  You need to do the “Kirsten will not care about this discussion on mental health,” and then when I do something different, people believe I might actually have skin in the game on a mental health conversation and want to work with my partners.  So you need to demonstrate your behaviour is not going to be to type and as expected.

This diagram tries to summarise the road to integration we have been on, somewhat ‘tongue in cheek’ but actually the more time goes on and the more we look back, the more we are convinced it is absolutely right. So we did start off with the STH trying to demand that the Community Arm came to us and their view was, “What’s mine is mine,” and we should ‘sod’ off and leave them alone and they would be quite happy.  Whilst we were doing, “How do we get our hands on that and try to steal the cookies out of the cookie jar?” there was tussling.  So there is no question, our first Clinical Director for Community Services, when she did come to that first Clinical Management Board, did have a queue of other clinical directors with a list of services they were going to take off her and put into their Acute Directorate.  So there was a huge amount of that tussling that went on, whereas I think now we are at Stage 4 and genuinely doing ‘it could and should be ours’ and things could be different.

Whether we will get to Stage 5 where it is about providing it together and being genuinely client and patient-centred we will see, but the successes we have had - we have genuinely reduced duplication and replication and some of that stuff comparatively was quite straightforward. So we now have an entirely integrated Sexual Health pathway.  When we first did the ‘drag and drop’ we had two completely Sexual Health Services and clinics about a 15-minute walk from one another, doing exactly the same services.  Obviously, one was always better than the other at different bits of it.  We now have a Single Heart Failure pathway where the Community Heart Failure team is now part of our Cardiology Department and works across hospital and community.  We have a single IV pathway for antibiotics in the community and we have now created a Single Transfer of Care team which works at the front door and the back door to either avoid admissions or expedite discharges.

We have created some entirely new models of care and probably the most challenging of those was dental services. We have a separate, tertiary dental hospital as part of STH and obviously as part of Community we have a very large community dental service, particularly focused around those with special needs.  That has now been entirely integrated and we are doing quite a lot of work to redesign whole care models, so musculoskeletal services which does everything from physio and pain management to complex revisions of joints and the Discharge to Assess pathways and Active Recovery which Ruth is going to tell you a bit more about.

I suppose, just to be specific on some successes, I am most conscious that some of those were mentioned this morning. We have almost forgotten about them really.  We have massively reduced (inaudible 0:10:11.4) area, checks associated I think in huge part to what we have done.  We have reduced the admissions for ambulatory sensitive conditions.  Despite the winter we have just had, Ruth and I were trying to tot it up at lunch, we think we only cancelled 12 elective procedures this winter and that was absolutely because of flexibility we had that first week in January when the whole of England was on its knees in terms of acute care.  The flexibility I had as a Director of Operations because I also had Community Services and could flex both Acute and Community, I think absolutely got us through what I think was the most difficult January we have ever had.

With that, Ruth is going to explain to you a bit more about Discharge to Assess the Act of Recovery.

Ruth Brown

I am Ruth Brown, Operations Director at Sheffield Teaching Hospital. I joined the hospital as Community Services moved over with The Transforming Community Services in 2011.

One of the things that Sheffield has been talked about within some of the Kings Fund papers and a variety of other things is around what we have done with Discharge to Assess in Active Recovery. Two things happened in parallel for us: one was around the Acute and Community Integration that Kirsten described, but also at the same time we were looking at how we were developing the roles managed out within intermediate care services and things that were provided by health and things that were provided by Social Care.

The journey started back in 2011 really where Professor Tom Downes, one of our Consultant Geriatricians, reviewed 25 sets of notes and the key message from that was that what could have been 515 bed days within the hospital were actually 2,259. That led to a journey for him and within care of the elderly of thinking about how we needed to do things differently and lots of windows of opportunity for when those patients could have been discharged had been missed.  We knew at the time that there were a lot of people who were waiting a long time for discharge from hospital; equipment would take a long time to be delivered and arranged; but also we knew that the discharge pathways were really complicated and we had this situation where actually if somebody was in their own bed, what had been commissioned was an intermediate care service that was able to respond within a couple of hours; if somebody was in the hospital and needed to be transferred home, actually they could be waiting way beyond 10 days for that care.

So we have got a real mismatch of people who were waiting, depending on what type of bed you were waiting in, actually what that access was. One of the things that really became apparent to us was there was this huge need to build trust, confidence, relationships across Acute and Community.  When Community Services moved into the organisation, what we brought with us was our relationships with Social Care, with Primary Care, with the third sector, and all of those different things that we had in terms of working in locality bases.  So Discharge to Assess was a model that we developed over time.  It was very much focused on developing care of the elderly patients at the time but which we have since rolled out across the organisation.  It is a model that has obviously been replicated across the country in different areas but the way that we had to approach that was very much about building up patient by patient different ways of working.  So literally we took one patient, the therapist that would have done the assessment on the ward previously actually came out and did the assessment at home, and would then go back and talk to their colleagues about just how different that patient was when they had got home in their own environment, and how much less they needed compared to what they had thought about when they were in hospital.

Alongside developing all of that, we also developed Active Recovery. Active Recovery is an umbrella term that we use for the Health elements of intermediate care and the Social Care elements of intermediate care.  So there are two services in Sheffield that have been commissioned: one known as Community Intermediate Care Service; the other is the Short Term Intervention Team.  They both provide rapid response to treatment and treat patients in their own homes.  It is a full inter-disciplinary team.  We have nurses, therapists, the consultant geriatrician, pharmacists, etc, all within there.  What we also had was both us and Social Care had a workforce of support workers, Band 2 equivalent type workers, all providing re-ablement.  What would happen is Health would go in first and then Social Care would follow on.

So that pathway of care was about 12 weeks. What we have done over time – we had to use our language very carefully – is reduce that pathway to a six-week pathway.  We have done a lot of re-training of that workforce particularly.  For example, if a patient was at home and needed help to go up the stairs, it had to be a Health support worker that would do that because they were trained to do that.  The Social Care support worker would have to get a Health worker in to do it.  We have done a lot of training of our colleagues across the system, the same with medicines management as well, to enable actually whoever is in the home to be able to undertake that care when they are there.

What that has led us to is very different decision-making processes over the course of the last year or so and very much hourly, daily planning that takes place. The key significant thing is that all those patients that were waiting within the hospital which we had not appreciated when we arrived within Sheffield Teaching Hospital, that were waiting well over 10 days for a very complicated discharge pathway; equipment, etc , etc.  Actually, we now see all patients within 2-24 hours regardless of where they are coming from.  Right First Time, the programme that Kirsten mentioned, is one of the things that enabled that to happen for us, enabled the investment and the training of all the workforce at pace.  So we increased the capacity within that team significantly.  We have the ability to take 180 new patients a week on that service and some of those are coming from hospital and not a lot of them are obviously coming from home.

We have developed a training programme with Sheffield Hallam University so we have generic training: nurses, OTs and physios – whether they are working at a patient’s home or at the front door of the hospital, are able to undertake that generic assessment. There are a number of things that we had not anticipated we would measure previously but we saw a reduction in falls and other things, on a lot of the geriatric wards.  As Kirsten says, in terms of the resilience that we gained over winter, that had a significant impact for us as an organisation, but also as a system, across with Social Care.

We have had some major challenges over the last few years, whether that be about the integration and community, trying to make sure it retained its own identity and integrity within a very large Acute Trust, Teaching Hospital Trust and maintain the confidence and trust of Primary Care and Social Care, the third sector and so on, as well as trying to develop new relationships within the organisation. I think Sheffield Teaching Hospital is a big organisation and trying to have conversations with colleagues about whole person care in an environment where actually there are a lot of sub-specialties was very difficult.

Lots of process problems around transport, admin, IT – all of those kinds of things as well. Engagement from Primary Care actually was one of our toughest ‘asks’ over that period of time in terms of their ability to contribute to some of the changes that we were making, but also their anxiety around what was happening with their district nurses.  One of the biggest lessons for me personally was about actually really making sure that you were taking the time to understand each other.  When somebody asked me if we could roll the Discharge to Assess work out to what I had heard as the #NOF Pathway which is actually the Fracture Neck of femur pathway.  It was quite a big learning curve for me so I am obviously young and trendy as a Twitter person but not a clinician!  It just demonstrated that it takes that time.

Just briefly, as an organisation we have come a long way in terms of that integration and are really signalling now where we want to be in the future. The organisation is grouped into nine different care groups and the one on the end is the one that I have the remit for.  You will not necessarily be able to see the detail within there but we have grouped ourselves into four different areas.  The purpose of us doing that is about describing the services that will come together and integrate from the hospital and community perspective but also enable Social Care and Primary Care, the third sector and independent sector to be able to work with us in a much more seamless way.  So the integrated community teams of the locality areas are structured in four different localities.  We have aligned ourselves so that we work in the same way as Social Care as well, and the GPs have aligned their teams.  We provide a single point of access but the GP out-of-hours services as well; we have all the stroke pathway within our service; geriatric medicine and palliative care.  So for the first time we have brought a number of different pathways together across the organisation that are the Acute and Community ends of things.

The way that we have described that to our colleagues is about the span of what is within our control but also with influence in terms of areas where we are working with other colleagues, so we do have at home and intermediate care in a bed which we provide in care homes across the city. We have access to specialist advice and assessment so that is consultant geriatricians, for example, or respiratory consultants that can provide GPs with different specialist advice.  What this demonstrates really is that for the first time we have lots of examples where whether it be somebody with a musculoskeletal problem or the stroke patient, an older person, palliative care type pathways, we are developing what that looks like across the whole and trying to think about that step up and step down care in its entirety.

So in terms of what we are describing will be different, what we have noticed is that there is a lot of what we describe as the kind of integration and the importance of that integration with Social Care, with Primary Care, with the hospital, but actually within our own Community Teams we needed to make sure we were fully integrated as well. We knew that there were patients who were being seen two or three times by different teams, so we have done a lot of work to map out who those are and make sure that actually we are integrated ourselves and then able to integrate with others.

The opportunities that we have at the interface are tremendous and we are developing some ways of working that are about use of our single point of access, just asking simple questions about what is known and not known about any particular patient. If that patient is on our case load somewhere within the community, how are we taking that information across into the hospital; developing a core model of care for older people so thinking about the care plans that are within Primary Care and within the community, and how we empower all our workforce and staff to make sure that they are sticking to that care plan; and thinking about how we have a different kind of assessment area where patients do not come and get changed into their pyjamas.  They stay dressed because they are not staying very long, but then when they go onto the ward actually we are creating a different type of ward environment as well.

In terms of the integrated pathways of care, as I say we have lots of opportunities where we are starting to think in terms of whole system change. We are also trying to research some specific pathways that we can develop.  The stroke pathway is a good example where we know we have too many acute beds.  We want to reduce that number and redesign the pathway so that we have some more of the resource out in the community as well.

Then finally, just on culture. From a cultural perspective I just echo Kirsten’s point about the last four years which have through things like Active Recovery, Discharge to Assess – those different models and ways of working – demonstrated that culture, trust and ways of working as one of the biggest things that we have needed to invest time and energy in.  So we are at a point now where we have developed new roles within the organisation as integrated pathway manager –type roles; whether that be led by a social worker, a nurse, a therapist, non-clinical staff as well, and really encouraging people to be boundary spanners across the system; not to feel that they are working within a particular silo but being those boundary spanners and creating a flexible and adaptable workforce with a future.  That is one of the areas that we are developing moving forward.

Kirsten Major

Very briefly, I think the very, very digested version of the presentation and our experiences, that I think we have become symbiotic between Acute and Community, that we are genuinely intertwined and co-dependent and co-producing pathways of care for our patients. Perhaps just an eye to a bit of the future: The Better Care Fund and integrated commissioning feels like it could be another big set of changes and we slightly anticipate ‘baby and bath water’.  Some of the slightly confusing policy conversations which I think we just need to find a way through.

Collaboration and integration are all really good but we are in the midst of a conversation with our Commissioners about whether they are about to put all of what we have described out to tender and that is a challenge. We have done lots of work focusing on the front door and back door submissions avoidance and expediting discharges, but really want to get our teeth into the house in between.  How do we really change every pathway, whether it is in patients’ homes or whether it is in hospital?  The Prime Minister’s Challenge Fund and how does all of that play out in terms of the funding we have received extend the provision of Primary Care and how will it lock all of this together?  Our relationships with Primary Care and genuine sense of growing fragility in Primary Care and what that might mean for patients as well as how we design systems for the future.  Obviously changing demographics and I think the ‘biggie’ for us that we would like to get into is not just parity of the stream between mental and physical health but actually a huge number of our patients have both diagnoses and how do we work together to deliver holistic care?  And then finally obviously the financial context.  It feels huge.

So I get to finish with this, just because of my accent, and I am allowed to make references to Scottish Independence, but stealing the banner from the successful referendum campaign last year in Scotland, I think we do genuinely think we are Better Together than we are delivering very different care for some very vulnerable cohorts of patients in Sheffield.

Thank you very much for your time.

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