Update by Alan Steward, Havering CCG.
Minutes:
Conor Burke tabled a document concerning Individualised Personal Commissioning (IPC) on behalf of Havering CCG. He reminded the Board that this involved the hubs and referenced a new type of primary care relating to those who suffered from multiple conditions (a minimum of five), which could encompass a whole range of issues crossing several agencies. The basic concept was that the GP was not always best placed to decide what mix of support a patient needed and that whilst most of those receiving this sort of care package would be elderly, that need not always be the case.
The funding to pilot this came from a successful application to the PM’s Challenge Fund. So far, 79 patients had been taken onto the scheme and this was indicative that the scheme’s target of 1,000 by the end of the year would be achieved. Conor explained that this would be rolled-out across Barking & Dagenham, Havering and Redbridge and it was estimated that it ought to attract some 2,000 patients across the three boroughs.
So far the data showed that - including costs – each patient would cost between £25 - £30,000 and receive 24/7 support and advice. The bottom-line was that the team would deal with everything on behalf of the individual. Conor explained the illustrations. These had been put together from the accounts of those now using the pilot and showed how they perceived the change between having to arrange each component of their care themselves, to having a team member take control of the process and ensure that what they experienced was trouble-free and seamless.
The idea was to release the individual from the anxiety and frustration associated with complex socio-medical problems (which were usually encountered by patients who were probably least able to cope and more vulnerable than those with simpler, or single issues) and by removing the multiple and frequently conflicting processes, empower them to use their commissioning capacity effectively and within a secure, supported environment. It was, he said, the provision of a “concierge” service.
Not only were patients recording that they were now less stressed, but staff too were reporting that they were happier. It appeared that because the patient was more relaxed and confident, many underlying problems which raised tension between the practitioner and patient were correspondingly lowered or removed altogether.
Patients now considered that they were able to fulfil some life ambitions. The ethos of the team was to facilitate these ambitions and aspirations. The fact remained that some 30% of those on the programme would die within the next 12 months, so it was imperative that the team focussed on their needs – and delivers those expectations - and not simply provide immediate “care”.
The team were, in fact “care negotiators”. It would broker well considered and approved care plans. A Care Negotiator would work with an individual patient to provide a tailor-made package for that person – a package that factored in that person’s aspirations. Care negotiators would come from the voluntary sector and it was hoped to empower them further by providing essential funding. They would give a percentage of their budget to the patient for them to manage.
IPC would provide a directory of approved services from the healthcare market and patients would make their own choices. This was potentially a model for the future of provision of healthcare across the nation. Nowhere else in the country was piloting such a scheme and while there were undoubtedly risks, the outlook was potentially good.
The Chairman asked how it was proposed to expand across the three boroughs. Conor replied that King George had facilities and a clinic would be set up in Havering as soon as possible – though the teams were mobile, so the lack of a site in Havering should not prove to be a disadvantage.
Dr Aggarwal said that he would be meeting a medical director who had some 25 patients who might benefit from the programme. A question was posed about where assessments were to take place, and it was considered that they should be undertaken where the patient lived and not centrally as that was not necessary and ran counter to the patient-centricity of the scheme.
The Chairman asked whether there were sufficient patients to fill the places on an on-going basis and was assured by Dr Aggarwal that this would indeed be the case as some 50% of those put forward would take up the scheme and with a mortality of around 30% and an aging population, there should be no shortage of patients to keep the scheme moving forward. It was also a flexible scheme as it could embrace new conditions and accommodate unusual combinations of them. He cited references to diabetes and hypertension (30% of the population), COPD (25% of the population). These areas alone cost some £30m pa.
A question was asked about how this would be greeted by GPs as it would impact on their funding, but in answer, overall a GP would only lose £65 per patient per year – the greatest cost was in respect of hospital treatment.
The Chairman asked what would happen to those who missed the criterion of five conditions – even if those they had were unusual. Were there plans to provide something running in parallel to cater for those patients? In response Dr Aggarwal said that there was a need to be creative with provision. Integrated case management was important and different solutions needed to be tried. He mentioned that health analysis could be integrated A&E attendance forms.
Anne-Marie Dean added that this depended on the relationship between the A&E and the practices. It couldn’t all come from the GP, A&E needed to be proactive in alerting practices about frequent attendees. She drew attention to the need for “befriending” those who had mental health and/or social care issues and felt that social networks were very important.
The Council Chief Executive observed that Havering had a seemingly paternalistic stance in respect of social care. With reference to the scheme, nothing was really known, there was no data: no attrition rate and no-one had yet left the scheme. With regards to funding, the PM’s Challenge Fund money would run out – it was only meant to last two years, but it needed to be remembered that this was being conducted as an experiment. It was set up as such and programmed to run for two years.
Anne-Marie Dean added that if the experiment proved successful, there would be less dependence on GPs. At present it was more of a medical rather than a psychological process, but the psycho/social elements were real. She said that loneliness and uncertainly were factors which needed to be built in. There was a need to reassure people.
The Chairman suggested that perhaps NELFT should be considered as a topic for discussion by the Board. The Chief Executive said that studies needed to be more evidence-based as with work on the Care Act.