North West Surrey's locality hubs - delivering integrated care

Introduction : North West Surrey CCG (NWSCCG) is establishing Locality Hubs – physical buildings offering a fully integrated GP-led, multi-disciplinary ‘one-stop-shop’ services in the community for a defined cohort of frail elderly patients with multiple core morbidities. Hubs will ultimately deliver proactive and reactive care, available 24 hours a day, 365 days a year. The key drivers are; Ageing population, people living longer & more people living with chronic conditions Cost & demand pressures Overreliance on hospitals & residential care Not enough focus on prevention & early intervention Disconnect between social & medicalised care Fragmented delivery of services leading to duplication & lack of coordination GPs as mainstay of the local care system Description of practice change implemented : Together as a system we unpacked what each organisation did, alongside best practice evidence, to articulate what helps most for whom and how we can provide it to every older person who needs it. We devised a simple yet powerful model (in operation at the Bedser hub in Woking) that will deliver preventive, proactive and reactive care from a comprehensive MDT based in a single location, to keep people safe and well at home in the community, without the need for acute admission. Aim : To get upstream of the health problems that lead to hospital admissions and loss of independence, and to get ahead of those issues that reduce people’s ability to function optimally. Targeted population and stakeholders : We are targeting a clearly defined cohort of patients who are over 75 and at risk from functional decline and avoidable admission. Stakeholders involved in the project design and delivery include : Age UK Surrey Ashford and St. Peter’s Hospitals NHS Foundation Trust Local Borough and District Councils NWSCCG South East Coast Ambulance Service Surrey and Borders Partnership NHS Foundation Trust Surrey County Council Virgin Care Woking Community Transport Patient representatives Timeline : Research / concept development phase                               May 14 – Feb 15 Bedser hub mobilisation                                                        Mar - Dec 16 Opening and operationalization of Bedser hub                     Dec 15 – Mar 17 Mobilisation of remaininghubs                                               Dec 16 – March 18 Highlights : Core team of; GPs, consultants, hub matrons/ hub practitioner, AP, wellbeing co-ordinators, mental health practitioner, social service workers and pharmacist. Additional services; heart failure nurses, dietician, rapid response (OT & PT), IAPT, podiatry, counselling, SALT, seated dance, TICCS ultrasound, diagnostic and treatment centre. 1002 patients, average 130 appointments per week. Pseudonymised data identified just under £100k acute activity avoided for Hub patients in six months to Sept 2016. Reduction in A&E attendance and inpatient activity for Bedser hub patients compared to an increase for the equivalent group in other localities. 586 care records uploaded to the ambulance service system, with conveyance rates 11.4% lower than the wider population. Sustainability : The way the locality hubs model has been developed is to allow existing resources to be utilised in a different way, therefore making sustainability achievable. Transferability : The Locality Hub project is a relatively straightforwad initiative that coudl quite clearly be replicated to other localities and other populations. It currently focusses on proactive preventative care for the frail over 65s, but the same model could work for younger age groups, and in particular for patients with disabilities. The Bedser Locality Hub is now well established, with the cohort increasing daily, a wide range of services in place and work in progress to put in place a full reactive service. From the start of this project, creating the right forums for consultation, consensus and agreement has been key, and formed the cornerstone of our strategy. The Locality Hub initiative draws together providers from the Acute Trust, Social and Mental Health care, Community and Primary care and the voluntary sector to provide single-site integrated care. Regular involvement and reporting back to the wider community has really helped get the local GPs involved, and in spite of initial reservations they are now extremely supportive of the service. A year in, we are beginning to demonstrate that the Hub has positively impacted on patient care, resulting in a reduction in A&E attendance and inpatient activity for Bedser hub patients, thus avoiding £100,000 of acute activity at the hospital. Activity data from the opening of the Hub until the end of September 2016 is presented below. For each patient, we have quantified what the CCG spent on their A&E, Inpatient and Outpatient activity in the period since they joined the Bedser Hub (variable for each patient). An ‘After Hub’ total spend is calculated. We then looked back at the same period and quantified what we spent on the patient in the previous year. A ‘Before Hub’ total spend is calculated. The difference between these two numbers is defined as the cost avoidance for that patient. Activity for Woking is compared with the other localities (SESSE and Thames Medical) which have similar populations but no Hubs service. There has been an impact seen in A&E attendances for the Woking locality, however this has not yet translated into a reduction in spend. There has been a 3.6% reduction in non-elective admissions across acute providers in NWS in the over 75 age group for Woking, compared with an increase in activity in the other localities. This equates to a saving of £89,967.