A detailed approach to an integrated health care system in Scotland presented by Dr. Anne Hendry from National Clinical Lead for Integrated Care. Source Page: http://www-01.ibm.com/software/city-operations/curam-research-institute/curam-roundtable/index.html

1. Approach to Integrated Care
in Scotland
Dr Anne Hendry
National Clinical Lead for Integrated Care

2. Population 5.4 million
– £12 billion budget
– 14 Health Boards
– 32 Local Government
Authorities
– Integrated healthcare
delivery system
– Universal coverage
– Moving to health and
social care integration

3. 2020 Vision for Quality
Everyone is able to live longer healthier lives at home, or in a homely setting.
• Integrated health and social care with a focus on prevention, anticipation
and supported self management.
• When hospital treatment is required, and cannot be provided in a
community setting, day case treatment will be the norm.
• There will be a focus on ensuring that people get back to their home or
community as soon as appropriate, with minimal risk of re-admission.
• Care will be provided to the highest standards of quality and safety, with
the person at the centre of all decisions.

4. Reshaping Care for Older People
> 10 Year Programme to 2021
> £ 300 million Change Fund 2011-15
> 32 Partnerships between
NHS: primary, acute, mental health
LA: social care & housing
Third and Independent sectors
Older people and carers
> Change Plans signed off by all partners
> 20% of funding to be invested in direct
or indirect support for carers
> Cross sector improvement network

5. 1300 fewer older people in emergency hospital
beds than predicted

6. 4000 fewer older people in long term care than
predicted

7. People living in more deprived areas in Scotland
develop multiple conditions around 10 years before
those living in the most affluent areas

8. Public Bodies (Joint Working)
(Scotland) Act
• Bringing together the accountability of statutory partners
in an equitable way, to deliver better outcomes for
patients, service user and carers - all adults
• Vision - People are supported to live well at home or in
the community for as much time as they can and have a
positive experience of health and social care when they
need it

9. • Principles for integrated health and social care
• Integrated governance arrangements : delegation to a
body corporate or lead agency
• Integrated budgets for health and social care
• Integrated oversight of delivery
• Strategic planning
• Locality planning
• Nine nationally agreed outcomes for health and wellbeing
• Self Directed Support
Public Bodies (Joint Working) (Scotland) Act
(2014)

10. Integration Authority
• Strategic plan developed with the localities
• Include all adult care groups
• Housing Contribution - focus on home and place
• Population needs assessment
• Inequalities attuned
• 10 year horizon but 3 year implementation plan
• Integration Joint Board
• Chief Officer
• Clinical and Care governance
• Integrated budget

11. Integrated Resources-
Minimum to be delegated
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Expendiure(£m)
Hospital Community Health Family Health Services & Prescribing Social work
Scotland total
=£12.3bn
Minimum to be delegated
to Integration Authorities
=£7bn

12. Information and Intelligence
Framework
• Unique patient / client identifier
• Linked patient / client level longitudinal dataset
• Secure file transfer with governance safeguards
• Information Sharing Protocol
• Health and care dashboard– activity / surveys
• Analysis of high resource individuals
• Resource consumption
• Linked information for a specific care group
• Local population profiles

13. Risk Prediction Tool
Outpatient
(1 year)
Emergency Department
(1 year)
Prescribing
(1 year)
Outcome Year
(1 year)
OUTCOME PERIOD
Hospitalisation
(3 years)
PRE-PREDICTION PERIOD
Psychiatric Admission
(3 years)
Any recent admissions to
a psychiatric unit ?
Any A&E
attendances in
the past year?
What type of
outpatient
appointments did
the patient have?
Any prescriptions for e.g.
dementia drugs? Or
substance dependence?
How many outpatient
appointments?
What age is the patient?
How many previous
emergency admissions
has the patient had?
How many
prescriptions?
Any previous admissions
for a long term condition
(such as epilepsy?

14. Anticipatory Care Plan and
Key Information Summary
Shared electronic summary
Available 24/7 across Scotland
in multiple care settings
• Demographics
• Medication Information
• Allergies and Adverse Reactions
• Next of Kin and Carer Details
• Agencies Involved
• Important Medical History
• Homecare Support
• Treatment ceilings
• Resuscitation wishes

16. Supported at Home
76% are managed in
their own home
instead of Hospital by
the ASSET team
2,864
Patients accepted by ASSET in 29 Months
5.6 / Day
5.7 days
Length of Stay
76%
Beds
Closed
50
Value £2Million+

17. Local communities and local relationships are
key to effective integrated care and support

18. Technology Enabled Integrated Care and Support

19. Living it Up - Peer support and web based information
and advice to help people manage their conditions

20. Creating the Conditions
• Political will and legislative framework
• Visible leadership and trusting relationships across sectors at all levels
• Contractual levers – eg primary care
• Develop skill mix and the capability of the workforce
• Funding used as a catalyst for change
• ‘One plan one budget’ investment decisions
• Disruptive innovation ( social and technology)
• Build on individual and community assets and invest in voluntary sector
• Focus on place, home, community and outcomes that matter to people
• Understand local context and how to create resilience
• Build trusting
• Learning and improvement culture

21. http://blogs.scotland.gov.uk/health-and-social-c
www.jitscotland.org
anne.hendry@scotland.gsi.gov.uk
@jitscotland
21
JIT is a strategic improvement partnership between the Scottish Government, NHS Scotland, CoSLA, the
Third Sector, the Independent Sector and the Housing Sector