SALFORD HEALTH & WELLBEING BOARD ... - Salford City Council

SALFORD HEALTH & WELLBEING BOARD

Salford Integrated Care Programme (ICP) for Older People Service and Financial Plan (2014/15 – 2017/18)

Incorporating planned use of the Better Care Fund (BCF)

Version 1.0 DRAFT PLAN February 2014

Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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VERSION CONTROL Drafts subject to change upon receipt of national direction Version Date Editor Number 0.1 10/12/13 K Proctor 0.2

10/01/14 K Proctor

1.0

14/01/14 K Proctor

Purpose/Change Contributions from J McG, JS, KP, CD, KD, MW Contributions from KP Reflects national planning guidance published 20/12/13 Contributions from KP, JT, JMcG, JS, MW, SD Version for consideration by Salford Health & Wellbeing Board as a draft plan

1.1 1.2 1.3 2.0

March 2014

Version for submission to Salford Health & Wellbeing Board as the final plan

This draft document contains Drafting Notes in red covering points requiring further work before the national submission dates of 14 February (Draft) and 4 April 2014 (Final).


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RECORD OF STAKEHOLDER ENGAGEMENT Stakeholder Group Salford Integrated Care Board Salford CCG Programme Management Group

Version No

Date

Outcome/Feedback

0.1

17/12/13 Agreed as ‘work in progress’

0.1

18/12/13 Minor comments on content

Assistant Mayor

0.1

08/01/14

City Issues Briefing Salford Integrated Care Board Salford Health & Wellbeing Board Salford Integrated Commissioning Board for Health & Wellbeing Salford CCG Programme Management Group

1.0

20/01/14

1.0

21/01/14

1.0

21/01/14

1.0

31/01/14

1.0

05/02/14

NHS ENGLAND/ LGA Salford CCG Programme Management Group Assistant Mayor City Issues Briefing Salford Integrated Care Board Salford Health & Wellbeing Board Salford Integrated Commissioning Board for Health & Wellbeing NHS ENGLAND/ LGA

Draft Plan Version 1.0 to be shared when available

14/02/14 SUBMISSION OF DRAFT PLAN 05/03/14

18/03/14 2.0

18/03/14 For Sign Off of Final Plan

31/03/14

04/04/14 SUBMISSION OF FINAL PLAN


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CONTENTS 1.0

PAGE

Executive Summary

PART A: CONTEXT AND BACKGROUND 2.0

Introduction

3.0

Purpose of the Service and Financial Plan

4.0

Vision

5.0

Overarching Principles & Approach

6.0

Better Care Fund

7.0

Existing health & social care joint commissioning

8.0

Stakeholder Financial Outlooks

9.0

Greater Manchester System Reform Programmes

PART B: INTEGRATED CARE PROGRAMME (ICP) 10.0 Salford Integrated Care Programme 11.0 Alliance Agreement 12.0 Cost Benefit Analysis 13.0 Citizen Engagement 14.0 Workforce Planning 15.0 Equality Impact Assessment 16.0 Communications Strategy 17.0 Evaluation & Review

PART C: BETTER CARE FUND (BCF) 18.0 Better Care Fund Financial Allocation


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19.0 National BCF Conditions 20.0 7-day working 21.0 Data Sharing 22.0 Assessment and Care Planning 23.0 Performance Measures 24.0 Performance Measures – baselines and targets

PART D: FINANCE AND COMMISSIONING INTENTIONS 25.0 Utilisation of existing funding streams 26.0 Integrated Care Programme/BCF Financial Plan 27.0 Summary of Commissioning Intentions 28.0 Stakeholder Impact Assessment 29.0 Shared Risk Register 30.0 Programme and Alliance Governance

PART E: NEXT STEPS 31.0 2014/15 Workplan

PART F: STAKEHOLDER SIGNATURES 32.0 Stakeholder Signatures Drafting Note: add page numbers to contents & appendix list


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APPENDICES A.

LGA/NHS England BCF Planning Template Part 1

B.

LGA/NHS England BCF Planning Template Part 2: Finance and Outcome Metrics Embedded document

C.

Draft Delivery Framework for Assessment and Care Planning in Salford

PAGE

D. Governance and Programme Structure


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1.0

Executive Summary

Drafting

Note:

To

write

once

content


complete/agreed

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PART A: CONTEXT AND BACKGROUND 2.0

Introduction

Almost two years ago, Salford City Council (SCC), Salford Clinical Commissioning Group (SCCG) and Salford Royal NHS Foundation Trust (SRFT) commenced working in partnership on an ambitious programme of work on integrated health and social care for older people in Salford. More recently, Greater Manchester West Mental Health NHS Foundation Trust (GMWFT) also joined the partnership. Salford GP practices and the Local Medical Committee (LMC) are also actively involved, as well as a range of other providers and stakeholders. The Local Government Association (LGA) and NHS England issued a joint statement in August 2013 on the Health and Social Care Integration Transformation Fund (ITF), now named the Better Care Fund (BCF). This financial allocation aims to provide a catalyst to develop integrated provision to improve care and value for money. By 2015/16, £3.8 billion worth of funding is to be made available nationally to deliver closer integration between health and social care.

3.0

Purpose of the Service and Financial Plan

In order to access the BCF, each locality needs to agree a two year local plan setting out how progress against integration priorities will be made in 2014/15, how the 2015/16 BCF will be used and how the national and local targets attached will be achieved. This plan needs to be developed by CCGs and Local Authorities and endorsed by the Health & Wellbeing Board. The plan will then go through a process of assurance via NHS England and the LGA. Issues of serious concern may be escalated to Ministers and involve them meeting local representatives from the CCG and Local Authority. In Salford, this plan will be presented in the context of the Salford Integrated Care Programme (ICP) for Older People, for which the intention is to pool all health and social care budgets for older people services, the BCF being just one element of the overall pooled programme resource. This service and financial plan aims to: • outline the agreed use of the BCF, in the context of the Salford Integrated Care Programme for Older People, • demonstrate how the plan meets the national BCF conditions, • describe the expected outcomes and benefits of the plan, • propose shared programme risks,


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• outline the process of agreeing the plan between SCC, SRFT, GMWFT and SCCG, and • document the principles by which these organisations will work together to effectively utilise the BCF within the wider pooled programme. The plan is to be used to inform and consult with relevant local boards and groups. Work is on-going to develop public-facing communications, which are complementary to local public engagement on changes to hospital configuration (managed by the Greater Manchester Healthier Together Programme). The plan is endorsed by the Salford Health & Wellbeing Board and forms the basis of Salford’s BCF planning templates (attached at Appendix A and B). Initial drafts of these templates are to be provided to the LGA and NHS England by 14 February 2014 and the final versions require submission by 4 April 2014. The national templates lay out the key information needed to assure that the plan addresses the conditions of the Fund. As partnership work continues throughout 2014/15, it is anticipated that this plan is refined and developed in line with the ICP for Older People. 4.0

Vision

Salford’s vision for integrated care aspires to contribute to the delivery of Salford’s Health and Wellbeing Strategy, which aims to improve the lives of citizens of Salford by improving health, wellbeing and removing health inequalities. The aim is to create an integrated system of support services that responds to local needs, gains public trust and helps people to help themselves to improve lives and the long-term health of the population. Whilst integrated care is not entirely new for Salford; it already works extremely well for individuals with a learning difficulty, remodelling all health and social services to work in a more integrated way has started in Salford by focusing on the care needs of older people. However, the changes that take place are anticipated to benefit others, not just those over a certain age. Whole services, such as district nursing and adult social care are involved in the changes. The aim is to learn from, and build upon, this start for other population groups in Salford, such as children, families and young adults. There is also growing evidence from within the UK and internationally on how better integrated care improves experience and makes better use of resources. In respect to older people, Salford's 2020 vision is for a radically changed health and social care system, where older people are enabled to retain their independence and take a much more active role in their own care. The plan is for GPs, community and social care staff, working with communities and third Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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sector providers, to work in an increasingly integrated way, with single needs assessments and rapid and effective joint responses, provided in and around the home. Much greater attention needs to be placed on how to support older people and communities to care for themselves and manage their own care. This means giving people more information and choice, and personalising the way care is delivered. Whilst specialist care and support will continue to be required for those with the greatest need, the focus will include giving older people more control and supporting them to be less dependent on services. More care will be delivered in a community setting, largely in people's homes, with a corresponding reduction in unplanned demand for hospital care and expensive packages of social care. Where individuals need to access specialist services, they will have confidence in the quality of care they will receive and be supported to return to their own home as soon as possible. As a consequence, quality of life should improve for older people and their carers. Older people should feel more able to manage their condition and service users should benefit from being able to access a much more integrated health and social care system, which is better able to anticipate and respond to their needs. 5.0

Overarching Principles & Approach

The work of Salford’s Integrated Care Programme (ICP) is driven by an overarching set of principles, agreed during the establishment of the ICP: • • • •

A partnership of equals, enabling a shift in organisational cultures and creating a new balance between system and organisational interests Service redesign has to deliver a reduction in costs whilst assuring safe and effective standards of service Significant engagement with health and social care staff, service users, carers and local communities to help develop new care models Costs must be reduced at a rate greater than any loss in income to service providers

The BCF will be managed as part of pooled budget within Salford’s Alliance Agreement. The following describes the intended relationship between the parties to this Agreement and their expected behaviour: • •

Working together as a single, integrated high performance team and making decisions to achieve outcomes that are best for older people and the public Joint responsibility for the achievement of agreed outcomes


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• • •

Encouraging cooperative behaviour between themselves and engender a culture of ‘best for service’1, including no fault, no blame and no disputes Working together on an open book basis (including cost transparency) Sharing the risks and rewards associated with good or poor overall performance

It has been agreed that decision-making within the Alliance should be unanimous wherever possible, but that majority decision-making should operate where a stalemate would otherwise occur. 6.0

Better Care Fund

The national funding allocation is described as “a single pooled budget for health and social care services to work closely together in local areas, based on a plan agreed between NHS and local authorities”. It is expected to be used to transform care, help deal with demographic pressures in adult social care and support significant expansion of care in community settings. The budget can be used for social and health care, subject to national conditions, including a plan which addresses 7-day working in health and social care, better data sharing and joint assessment & care planning. National guidance was published on 20 December 2013. The link to this is: http://www.england.nhs.uk/wp-content/uploads/2013/12/bcf-plann-guid.pdf 7.0

Existing health & social care joint commissioning

Agreements supported by Section 75 of the National Health Service Act 2006 (NHS Act 2006), aimed at promoting effective partnership working between NHS bodies and Local Authorities through formal partnership arrangements, have been in existence in Salford since 2003. The arrangements include the pooling of budgets, lead commissioning and integrated provision. Six such arrangements exist in Salford. These formal partnership arrangements have delivered both financial benefits and improved outcomes for citizens. Particularly relevant to the ICP is the formal Section 75 arrangement for Intermediate Care, which includes nine different service areas provided by a range of organisations which include Salford Royal NHS Foundation Trust, Salford City Council, independent sector residential, nursing and domiciliary care, services provided Greater Manchester West Mental Health NHS Foundation Trust and General Practitioner input. The intention is that these services will be subsumed into the new ICP partnership agreement. 1

The ‘best for service’ principle means that where partners are considering which party should undertake a particular activity then this should be determined on an objective basis as to which party can best achieve the required outcomes rather than just dividing up the work. Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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8.0

Stakeholder Financial Outlooks

Health and social care services are under unprecedented financial pressure, and it is known that this will increase in coming years. This is one of the key drivers for change in order to avoid services becoming steadily less sustainable. This section provides an overview of the financial position of the four organisations in the ICP. Salford City Council The Comprehensive Spending Review announced plans to reduce local government expenditure by 28% over the four years 2011 to 2015. This was front-loaded with a near 10% reduction in formula grant in 2012/13 and a further reduction of almost 8% in 2013/14. As a result, local government has seen the biggest reduction in government funding in living memory. For Salford City Council this has meant that savings of £85m were required over the first 3 years of the Government’s budget reduction plan (2011/12 – 2013/14). Looking to the medium term budget forecast, there are further budget reductions required for the Council of £75m during the 3 year period 2014/15 – 2016/17. This represents a 32% reduction on the current net budget resource for the Council of £234m. Whilst seeking to identify and continue to deliver further efficiencies wherever possible, the scale of the challenge has been such that it has been inevitable for cuts in services to be made to achieve a balanced budget. In such a challenging financial context, the Council have been clear that at the heart of these proposals, the council would seek to protect the most vulnerable who live in the city and every effort has been taken to preserve critical services. Salford City Council has always been at the forefront of the public sector reform agenda and it is clear that it will need to build upon its platform of efficiencies, neighbourhood reform and collaborative working with partners in the public, private and voluntary sector in responding to these challenges. Adult Social Care continues to work to a strong set of political priorities in relation to: • • • •

increasing personalisation, improving health and wellbeing, building on the capacity of communities, focussing on prevention and early intervention.


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The Council’s continuous value for money approach reviews all service areas, redesigning and reshaping to protect direct service user delivery within the funding available. The joint planning around integrated Health and Social Care services is seen as a vital strategy to ensure the Council can provide the most effective interventions to keep people safe and thriving in their communities. The strategic direction for Adult Social Care recognises that virtually all services are now commissioned and the new pathways of support for vulnerable adults are more geared to supplying information and advice, building on local assets and networks of support, encouraging reablement, whilst protecting the most vulnerable. With increasing demand for older people’s services (predicted at 4% per annum and 6% for people with learning disabilities between 2010-2015), and with less money, the approach has been to: • • • • •

consider alternative ways of providing support, have less reliance on buildings based services, have more locally available services, reduce unit costs and offer services in a different way, re-enable people by providing support for shorter, but more intensive periods.

This has meant increasingly that people are being asked to consider different types of provision, such as technology rather than people, with some concern and anxiety about this approach. The council believes that continued partnership work and integration which achieves effective interventions for Salford people is essential for a sustainable Health and Social Care system. Salford CCG Salford CCG has inherited a strong financial position from its predecessor commissioning organisation (Salford PCT). The CCG has inherited a surplus brought forward from previous years and is on track to deliver a surplus over and above the minimum requirements for the next 3 years. The level of productivity savings required to balance the financial position of the CCG is relatively low compared to other NHS organisations. However, whilst the financial position of the CCG is strong, the accumulated, historic under spends are non-recurrent in nature. Projecting forward beyond a 3 year time frame, shows the CCG will be in recurrent deficit if nothing is done to deal with the continued growth in secondary care admissions and the consequences on health budgets as a result of changes to the demographics in Salford. It is


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therefore paramount that the CCG works with partners now to ensure a safe and sustainable future health and social care system across Salford. Greater Manchester West Mental Health Foundation Trust The planning guidance for the 2014/15 financial year, “Everyone counts: Planning for patients 2014/15 to 2018/19,” confirmed the financial planning assumptions for NHS organisations. Although, funding for NHS commissioners will rise from £96bn to £100bn over the next two years, efficiency requirements and the Tariff assumptions for NHS Providers, confirm a reduction in the amount that will be paid for commissioned services. In addition, the ‘Call to Action’ programme launched in July 2013, confirmed the £30bn challenge that was facing the NHS, as the supply of funding is clearly going to struggle to match the growing demand for healthcare. Greater Manchester West Mental Health NHS Foundation Trust is in the process of developing its Operational and Strategic plans for the Foundation Trusts regulator, Monitor, for the next 2 and 5 financial years. The Trust is a successful organisation and has strong record of delivering its financial targets. The financial plan for the next 2 years (Operational Plan) will be based on the guidance included in the above documents, which is further supplemented by guidance provided by Monitor. For the financial years 2014/15 and 2015/16, the main planning assumptions are: Efficiency & Tariff Assumptions

2014/15

2015/16

Health cost Inflation Efficiency requirement Tariff Uplift

2.1% 4.0% -1.9%

2.2% 4.0% -1.8%

For the Trust, this equates to a recurrent savings requirement of circa £5m for each of the two financial years. This does not include the impact of any savings required as part of the ‘Call to Action’ programme. The Trust wants to continue to deliver the services commissioned whilst maintaining quality and access to services. To meet the efficiency challenge, the Trust has developed a proposed future model of adult mental health services. In general terms, HOME: home–based mental health care, plans to strengthen Community Mental Health Services and redesign the Acute Care pathway. In summary, this will result in a change in the number of acute adult mental health in-patient beds, with more investment going into community services. In addition, the Trust will take every opportunity to review service areas, redesigning services to minimise the impact of the reduction in the level of resources available.


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The Trust will continue to work with health and social care partners in Salford to ensure the best use of all the resources available. The Better Care Fund and the opportunity of transforming health and social care will be a major challenge for all the partner organisations in Salford Drafting Note: SRFT – to be added 9.0

Greater Manchester System Reform Programmes

The Salford Integrated Care Programme for Older People is set within the context of a wider review of Health and Social Care in Greater Manchester aimed at improving outcomes, at a lower cost. Specifically this involves three Greater Manchester major strategic change programmes: 1. Greater Manchester Integrated Care (Community based) Programme the development and implementation of 10 to 12 new locally derived models of integrated care and more accessible services, 2. Healthier Together Programme - the review and reform of secondary care services, which are safe and sustainable 3. Staying Well, Living Well - a 5 year strategy for improving primary care within Greater Manchester. Salford is playing an active role in these major programmes, all of which are vital in order to develop services for the future. Critically, the success of the ICP for Older People is dependent upon achieving ambitious aspirations to radically improve the quality and range of primary care based services in Salford. It is recognised that progress on this needs to be accelerated and that the CCG, being a membership organisation of GP practices, is ideally placed to invest in and deliver the benefits of reforming primary care. Changes to the General Medical Services (GMS) contract from April 2014 will also support more proactive integrated and personalised care through: • • •

Ensuring that all people aged 75 and over have a named, accountable GP who is responsible for overseeing their care Introducing more systematic arrangements for risk profiling and proactive care management, under the supervision of a named GP, for patients with the most complex health and care needs, and Giving GP practices more specific responsibilities for helping monitor the quality of out-of-hours services for their patients and supporting more integrated working with out-of-hours services.


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PART B: INTEGRATED CARE PROGRAMME (ICP) 10.0 Salford Integrated Care Programme Salford’s Integrated Care Programme (ICP) seeks to transform the health and social care system, promoting greater independence for older people and delivering more integrated care. It has a triple aim of: (1) delivering better care outcomes, (2) improving the experience of service users and carers, and (3) reducing care costs. Whilst recognising the need to respond to short term challenges, the overall approach has been to take a long term view. This includes balancing the short term goal of reducing service duplication and waste with the longer term aim of securing greater population health and reducing future service demand. Salford’s model has three component parts, focussed around a fictional older person (‘Sally Ford’) and her family: • • •

Promotion and increased use of Local Community Assets to support increased independence and resilience for older people Establishment of an integrated Centre of Contact to support navigation, monitoring and support Establishment of Multi-Disciplinary Groups supporting older people who are most at risk as well as a providing a broader focus on prevention and signposting to community support

During 2013/14, this model has been tested and refined in two of Salford’s neighbourhoods (Swinton & Pendlebury and Eccles, Barton & Winton; together accounting for 40% of Salford’s 65+ population). A ‘Collaborative Improvement’2 model has been used involving in excess of 120 staff and stakeholders. The ICP is underpinned by a formal partnership between four statutory partners: SCCG, SCC, SRFT and GMWFT. Critically, however, a range of other partners are involved in the programme. The programme is overseen by an Integrated Care Board, which has dual accountability to the parent Boards/committees of the statutory partners and to Salford’s Health & Wellbeing Board. SRFT host the Programme Management Office.

2

www.ihi.org/knowledge/Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievi ngBreakthroughImprovement.aspx Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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11.0 Alliance Agreement The intention is that the four statutory partners, with the addition of General Practice, form a legally binding ‘Alliance Agreement’,3 to support and enable the provision of integrated care and services to older people and other subsets of the adult population. The Alliance provides a financial, governance and contractual framework that:• • • • •

Secures best value for the public sector in terms of outcomes per pound spent Ensures that the new integrated care model is delivered coherently and services are not fragmented by organisational, professional or service boundaries Directs resources to the right place in order to adequately and sustainably fund the right care as defined by the new care model Financially rewards positive outcomes for the population’s health and wellbeing Supports the process of transition to the new care model from the existing one

A Memorandum of Understanding (MOU) sets out the proposed population focus, service content, aims and improvement measures to be adopted by the Alliance. The MOU was considered by each of the statutory partners during October 2013. It is anticipated that the Alliance Agreement will commence on 1 April 2014 and be implemented on a phased basis. The intention is that the agreement has an initial duration of five years, but with a break clause after 12 months and an option for a further three year extension. The Integrated Care Board will be reformulated as an Alliance Board for Integrated Care, from April 2014. The intention is to operate shadow management arrangements in year 1 but to move towards an integrated management arrangement within a defined time period. Incorporating learning from section 75 arrangements, a review is to be undertaken of international evidence and best practice for the management of integrated care services. 12.0 Cost Benefit Analysis

3

An Alliance Agreement is a mechanism that enables partners to align services and financial resources within a single contractual framework, with joint standards and performance indicators agreed for all parties. It also provides a vehicle to implement different payment regimes and facilitate financial risk and benefit sharing.


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As part of work taking place at a Greater Manchester level on integrated care, each locality has been asked to submit a detailed Cost Benefit Analysis (CBA) utilising a standard template. Salford is in the process of producing a cost benefit analysis for the Integrated Care Programme for Older People. This has involved quantifying the likely funding deficit across the health and social care economy under ‘business as usual’, and using this to help determine the budget/cost savings required from Integrated Care new delivery models, and how this splits across health and social care. The savings likely to be incurred from acute and social care spend due to deflections of patients/users into the community form a cost envelope which set an upper limit on the new model’s spend. In parallel to this, work is on-going to define the operational delivery, service standards and workforce consequences based on the early findings of the projects completed so far. It has also been recognised that for those services that play an important role in the new model and incur significant spend, work is needed to understand whether the services need to be reorganised around the new system or whether they are fit for purpose as they are. This is a very detailed modelling process, completion of which will need to be iterative and will inform the financial model of the ICP. 13.0 Citizen Engagement The ICP’s vision of citizen engagement work is to involve and engage Salford older people in the planning and shaping of future services, ensuring they have a clear voice in the development and delivery of the Integrated Care Programme. A key priority was the establishment, in April 2013, of a Citizen’s Reference Group comprising people over the age of 55, living in the pilot areas of Swinton and Eccles. The aims of the Citizen’s Reference Group is to involve local older people in the pilot areas’ ‘tests of change’, asking them to suggest their own small tests based on what they think is important to them and their families. Members have also had the opportunity to input into discussions around the wider programme. The Citizen’s Reference Group contains more than 70 people keen to be involved in the programme via email, face to face 1:1 conversations or telephone conversations. A core group of 6–12 people meet monthly, supported by a Development Worker. Managers in the Programme often attend to discuss aspects of the programme and to gain suggestions. Wider engagement is conducted via a network of older people in Swinton and Eccles and adopts a consultative approach, supporting involvement of people with less detailed knowledge of the programme. There are also a number of Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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community groups in the pilot areas that input to the work without being formal members of the Citizen’s Reference Group. Throughout the past 9 months, a range of projects and learning has been developed by the Citizen’s Reference Group with support from wider local older people and community groups. Learning has been shared with project managers and other work streams to ensure that the information shape the model. 14.0 Workforce Planning In order to support the effective implementation of the new integrated care model and embed changes in practice a full integrated workforce plan will be developed which sets out plans specifically for the workforce of the future and identifies how any gaps in the current workforce will be met to deliver the future workforce requirements. Salford’s integrated workforce plan will be achieved by involving all parties and stakeholders in the process of workforce planning. A range of methodologies are available to shape a workforce plan, however a person centred approach putting the person at the heart of the services or a population centred approach using local demographics are recommended when looking at the workforce requirements across organisational boundaries. The financial climate and the challenges this brings means organisations will need to make better use of the workforce and not be restricted by organisational silos and professional boundaries. Whatever the organisational structures are for the future, it is likely that the workforce required to work in a more integrated way will look different from the workforce of today. There is a need to ensure sufficient workforce capacity, with the right knowledge, skills and competencies to support the delivery of choice and good outcomes, through effective integrated and cohesive strategic and operational workforce plans, which are underpinned by sound financial planning, service activity planning and performance reporting. The following outlines a 5-step model for workforce planning that will be used to support the development of the Salford Integrated Workforce Plan: 1. 2. 3. 4. 5.

Describe the population/patients and the strategic environment Build the service around the population and patients Define the required skills, competencies and knowledge profile The future workforce – what does it look like? Gap analysis - what is the current position and what needs to be done to achieve what we really need and want?

An exercise is currently underway to map the current workforce across all parties currently providing services within the scope of the Integrated Care for Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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Older People programme. This information will be necessary when reviewing the future workforce requirements in order to carry out the `gap analysis’. At present, a number of staff from across the four organisations are engaged in workstreams/tests of change programmes in order to get frontline involvement in the evaluation of the new model and to ensure views and ideas are considered. This will be on-going and is essential in helping staff understand the aims of the ICP and also to be instrumental in delivering improvements to the patient/service user/carers. Trade union involvement is seen as essential to helping shape the service model and workforce for the future. Early briefing sessions have been held with the Regional Trade Unions which represent the workforce across the four organisations in order to start early engagement and share the background to the programme and the aims and outcomes. Trade Union Involvement will continue throughout the programme. Each organisation will be responsible for ensuring that staff are consulted appropriately in line with employment legislation and their own organisational policies. If there is any impact on the current working arrangements for the existing workforce, formal consultation would be required. Each organisation will have its own formally agreed mechanism for staff consultation. In order to deliver the outcomes set out in the programme and embed for future success, there is a need for the integrated workforce to be appropriately skilled, motivated and committed to its goals. Employees across the organisations will need to be supported to be flexible in their approach and any training and development needs will need to be identified and programmes designed to support skills development. Flexibility will be key and staff will need to be supported to be resilient and able to adapt to change by encouraging them to enhance their existing skills and develop new talents. Staff should be prepared to work in different ways to deliver new services and modify existing models of service delivery. An openness to working differently across organisations will be crucial. It is also evident that the pace of change will not relent and that the workforce will need to respond quickly to the demands placed upon it in order to maintain and enhance delivery of high quality services. Delivering successfully across an integrated service will require innovative and inspirational leadership. Existing organisational boundaries and bureaucratic processes will need to be worked through and a values based culture developed that places the patient/person at the centre of service delivery.


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15.0 Equality Impact Assessment A full Equality Impact Assessment has commenced involving stakeholders, and the public. The process is iterative and will involve gathering data from all sections of the community throughout the engagement and consultation process. The Equality Impact Assessment will be signed off by the Integrated Care Programme Board and will be available to the public on the Partners in Salford website. 16.0 Communications Strategy The ICP Communications Strategy aims to display appropriate values and behaviours of partnership working. All communications activity is to be tested to ensure it strategically supports the programme objectives and the vision of greater independence and improved wellbeing for older people in Salford. Communications will aim to achieve, display and communicate high standards of openness, transparency, honesty, integrity and accountability. An integrated multi-channel approach will be employed to ensure stakeholders are engaged and mutually beneficial relationships are nurtured. There is a commitment to celebrate successes and address challenges. Defined objectives to ensure that all key stakeholder groups are aware of the programme, its objectives and service model have been agreed. These will serve the wider objective of protecting and enhancing the reputation of the partnership and the services it provides. Stakeholder mapping has been completed. A Communications Manager is embedded within the project management team and is working closely with the citizen engagement lead. Service Level Agreements have been agreed with communications teams from three of the four partners to fully utilise existing communication channels. Detailed multi-channel activity plans will be created and delivered for each component of the model, for each campaign and phase of the roll-out. These will identify and agree key messages and campaign themes. Case studies and advocacy will form the basis of a partnership approach with local and regional media. A commitment to evaluation and plain English underpin the approach. 17.0 Evaluation & Review


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The Integrated Care Board undertakes regular, 6 monthly reviews of progress within the ICP, checking progress against agreed milestones and using the Advancing Quality Alliance (AQuA) Integration Framework to assess whether core integration ‘domains’ are being progressed. In terms of evaluating the impact of the ICP, Salford has partnered with the University of Manchester and CLAHRC,4 with an initial interim evaluation scheduled to be conducted between January and March 2014. A joint bid has also been submitted to the National Institute of Health Research (NIHR),5 to undertake a two and half year evaluation of Salford’s ICP – ‘Comprehensive Longitudinal Assessment of Salford Integrated Care’ (CLASSIC). The proposed evaluation framework is a variant of the cohort multiple randomised controlled trial, where a large cohort of older people are recruited and followed systematically over time, with subgroups used to evaluate different interventions. If the bid is successful, the plan is to undertake evaluation at four levels: • • • •

Population level: effect on overall population experience, selfmanagement and outcomes over time Cluster level: implementation of some aspects of the ICP will be tested first in a smaller number of practices or neighbourhoods in a ‘staged’ manner Individual level: there will be potential to allocate individuals to certain components of the ICP to allow a rigorous estimate of the contribution of individual components External comparators: comparisons with sites and cohorts outside Salford

4

CLAHRC: Collaboration for Leadership in Applied Health Research and Care in Greater Manchester www.clahrc-gm.nihr.ac.uk 5 www.nihr.ac.uk/ Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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PART C: BETTER CARE FUND (BCF) 18.0 Better Care Fund Financial Allocation The BCF allocation partly builds on existing funding streams, as shown in Table 1. Table 1: Composition of national BCF allocation (approximate) Better Care Fund Transfer from NHSE to social care to support adult social care services/have a health benefit Carers Breaks CCG reablement fund Capital Grant & disabled facilities grants New funding to support integrated care (for adult social care) Funded from NHS budget New funding to support integrated care (performance related) Funded from NHS budget Total

2013/14 2014/15 2015/16 (Billion) (Billion) (Billion) £0.90

£1.10

£1.10

£0.13 £0.30 £0.35

£0.13 £0.30 £0.35

£0.13 £0.30 £0.35 £0.90

£1.00 £1.68

£1.88

£3.78

The new 2015/16 funding is to be funded from NHS budgets and, in part, is expected to cover demographic pressures in adult social care and some of the costs associated with new duties from April 2015 of the Care Bill. Most of these costs results from new entitlements for carers and the introduction of a national minimum eligibility threshold. An element of the Fund is performance related (£1bn nationally), summarised in Table 2. Half will be available on 1 April 2015 based on progress against four of the six national conditions (see section below) and on 2014/15 performance on three measures. The other half is to be available in October 2015, based on further progress against national and local measures. The 2015/16 funding will be allocated to local areas into pooled budgets under Section 75 joint governance between CCGs and councils. The national BCF allocation represents the minimum amount to be included in pooled budgets. CCGs and councils are free to extend the scope of their pooled budget to support their health and social care integration strategic intentions.


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Table 2: BCF Performance related elements When Paid April 2015

Payment amount £250m

Progress against four of the national conditions: • •

£250m

Oct 2015

Paid for

£500m

protection for adult social care services providing 7-day services to support patients being discharged and prevent unnecessary admissions at weekends • agreement on the consequential impact of changes in the acute sector; • ensuring that where funding is used for integrated packages of care there will be an accountable lead professional Progress against the local metric and two of the national metrics:

• delayed transfers of care; and • avoidable emergency admissions. Further progress against all of the national and local metrics.

Table 3 shows the announced BCF allocation for Salford. Table 3: The BCF allocation for Salford Better Care Fund Transfer from NHSE to social care to support adult social care services/have a health benefit Carers Breaks CCG reablement fund Capital grant & disabled facilities grants New funding to support integrated care (for adult social care) Funded from NHS budget New funding to support integrated care (performance related) Funded from NHS budget Total

2013/14 2014/15 2015/16 (million) (million) (million) 4.71

6.04

6.04

0.46 1.58 1.91

0.46 1.58 1.91

0.46 1.58 1.91 4.74

5.26 £3.95


£9.99

19.99

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19.0 National BCF Conditions There are six national conditions for access to the Fund. The Salford response to these is incorporated into this plan and the completed national BCF template in Appendices A. 1. Plans to be jointly agreed 2. Protection for social care services (see financial plan section & Appendix A) 3. Plans to include 7-day service plans (see 7-day working section) 4. Better data sharing (see data sharing section) 5. Joint assessment and care planning (see assessment and care planning section) 6. Agreement on the impact upon acute sector (see stakeholder impact section) There is an expectation that the 2014/15 BCF funding will assist in making progress against the 2015/16 national conditions and performance measures, especially as some of the 2015/16 funding will be dependent upon performance in 2014/15. For 2014/15, the funding transfer to social services to support adult social care services will only be released if there is a jointly agreed and signed-off two-year BCF Plan. As in previous year’s this funding must be used to support adult social care, which also has a health benefit and its use be agreed by Health and Wellbeing Boards. 20.0 7-day working There is growing commitment across the health and social care system in Salford to improve access to services outside traditional 9 to 5, 5 days a week provision. This section summarises the extent to which this is already happening in Salford and some future intentions. The BCF provides a new opportunity to focus on the integration of increased access into the new model of care to support hospital discharge and prevent unnecessary admissions. This element of the plan will be continued to be developed during 2014/15. Salford Royal Foundation Trust SRFT has made significant progress in 7-day working as part of its wider Quality Improvement Strategy and a drive to reduce mortality and harm associated with the weekend. SRFT’s approach has been standards based; increasing the frequency of ward reviews, ensuring non-elective patients are seen within 14 hours of admission through increased consultant presence. This has contributed to the Trust’s improved mortality outcomes.


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The Trust has developed a Working Group and an outline proposal for organisation-wide strategy for increased 7-day working. This has a number of stages: • • • •

Review of national clinical standards (completed) Baseline of performance against national standards (in progress) Planned engagement with staff and stakeholders to determine how we deliver the standards (and where we may exceed the minimum requirements to meet local needs) Incorporation of agreed priorities in local CQUINs

Mental Health Liaison Service A £1m plus investment has been agreed to develop the existing Mental Health Liaison Service provided by Greater Manchester West Mental Health Trust, providing increased mental health services predominately for individuals presenting in A&E or admitted to Salford Royal Foundation Trust. This service will operate extended hours and at weekend. Intermediate Care The Intermediate Care Rapid Response Team is available seven days a week (8am – 12 midnight) Intermediate Home Support Service (IHSS) The IHSS deliver a seven day service 7am – 10pm (provision). There are no current plan to extend the assessment/co-ordinator part of IHSS from the current arrangement of Monday to Friday (8.30am – 4.30pm), but this is something that can be considered if resources were made available. Hospital Social Work Team The hospital discharge team have two full time social work posts, working on the within the emergency village. These posts cover extended hours including weekends. They facilitate discharges from Emergency Assessment Unit, Ambulatory Assessment Area and have limited input to A&E, although this is being built on. These posts are currently funded non recurrently from reablement monies to March 2014. Continued funding is being considered as part of the BCF plan. Emergency Duty Team (EDT) EDT cover Adult Social Care emergencies out of normal working hours i.e. between 4:30pm and 8:30 am, Monday to Friday and all day Saturday and Sunday.


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Care on Call Care on Call deliver a 7-day service which supports independence and keeping people at home. Work via the ICP has meant more integrated working between SCC Care on Call and the NHS Rapid Response team and a protocol is to be developed in order to define and strengthen this relationship. Ultimately, if Care on Call can refer to rapid response then it could mean individuals are deflected from admission to hospital or an intermediate care unit. When the rapid response service refer to Care on Call, they have the reassurance of knowing that the person has 24\7 support, plus a direct link back into the service if required. Centre of Contact One of the elements of the new service model is the development of a new contact centre for health and social care, consolidating some existing services. The new centre of contact will offer a single entry point for both health and social care. Staff, clinicians and the Salford population alike will be able to access the contact centre for help, advice and navigation. The centre of contact supported by an enhanced Salford Integrated Record will provide a mechanism for joining up care for people with complex health needs. This system would support for example the roll out of telehealth for symptom monitoring and patient education, and provide a mechanism to improve the use of planned care as well as supporting people following admission to hospital to reduce their risk of readmission. Initially the service will be available Monday to Friday 8.30am to 4.30pm, replicating current arrangements delivered by the teams (that are being integrated to form the centre of contact). Arrangements for contacting services outside these hours and at weekends will remain as they are now for example for adult social care, via the emergency duty team. There will be the potential, however, to look at future further expansion of the service offer incorporating some or all of these services outside the normal working hours. Equipment Store Funded from a CCG fund for managing winter pressures, the equipment store is trialling 7-day opening from January to March 2014, which should assist with weekend discharges. This will be evaluated as part of the BCF Plan. General Medical Services Interest is beginning to build within Salford GP practices in developing services which give greater access to primary care professionals outside of traditional times of the day and week. It is likely that different methods of doing this will be tested in Salford, in some cases involving groups of practices in a Neighbourhood. Such plans are in early stages in Salford and


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will be shaped, in part, by experiences from other areas involved in pilots and demonstrator projects. 21.0 Data Sharing From the outset of Salford’s ICP, data sharing has been identified as key enabler to integrated care. Building on the existing Salford Integrated Record, partners are developing an Integrated Care Record for older people to: • • •

Support any authorised professional, offering direct care, in each relevant organisation to access appropriate care information Provide a client/carer view of their care record Support the implementation of Shared Care Plans

This work is being supported by a Data Sharing & IT Subgroup, with representation from each of the partner organisations. This group also has responsibility to ensure that Information Governance controls are in place and consent issues addressed. During 2013/14, work has been undertaken to develop the specification for the Integrated Care Record. The NHS number will be used as the primary identifier; indeed, it is already used as standard within Salford’s health and social care services. The intention is to implement Salford’s Integrated Care Record on a phased basis during 2014/15. 22.0 Assessment and Care Planning Within the emerging ICP model for Assessment and Care Planning, all people who are identified as high risk of admission will have an agreed accountable lead professional called their 'key worker'. The key worker is defined as a qualified practitioner irrespective of their professional role, who has responsibility for co-ordinating care, keeping in touch with the patient/client and ensuring that the care plan is delivered and reviewed as required. The ‘Sally Ford’ Integrated Care Planning Model (SFICPM) is a delivery system for Salford's Older People which takes account of optimising and maintaining an individual's overall well-being, and where necessary involves provision of health and social care, through 6 essential elements. This is detailed in Appendix C and summarised as: 1. A systematic assessment of health and social care needs when required. 2. The appointment of a named key worker.


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3. Joint working with all organisations/agencies involved, where multidisciplinary groups with a single entry/contact point for agencies/ services, will be the two focus points for delivery of joint working. 4. An agreed Shared Care Plan, based on the joint working and based on a 1to 4 stepped level of care need. 5. The sharing of essential information between provider agencies 6. Regular reviews to reconsider need and change plans as necessary Risk stratification will initially be deployed by applying the 4 levels (of Sally) Able Sally, Needs Some Help Sally, Needs More Help Sally and Needs a Lot of Help Sally. Able Sally is self-caring and independent, and Needs some help Sally may need low level review or intermittent input. These two levels will be low and low/moderate risk respectively. Needs more help Sally will be individuals assessed as ‘substantial' by social care, or/and in contact with district nursing services several times weekly, or in intermediate care. Needs a Lot of Help Sally are individuals who rely on 24/7 care, or assessed as 'critical' by social care. The latter 2 Sallys are high and very high risk cohorts. Additional triggers will also require a review by a member of the multidisciplinary group (MDG) with escalation to full MDG as required. Triggers will be where an individual's circumstances would appear to have changed in an unplanned way, such as an emergency admission or two A&E attendances within 3 months. The 65+ population in Salford is around 34,000 in an adult population of approximately 191,000 (all figures based on 2012 mid-year data from HSCIC). Needs a Lot of Help Sally cohort is presently estimated at 1,051 (excludes people who are self-funding in a care home or home package that would fit the defined population). Needs more Help Sally is currently estimated as 1,313 (excludes people admitted to intermediate care and emergency admissions who would be assessed as part of the wider MDG cohort but may not become residual within this group). The two high risk levels together are in the region of 2,360 adults. 2% of the adult population is around 3,822. Once the numbers of people accepting intermediate care and those assessed following an emergency admission are included, the coverage required by the extended MDGs will be in excess of 2%. The model of joint assessment and care management continues to be refined in Salford as part of the ICP and will be further reviewed in the light of the new GMS contract for 2014/15 in respect of named GP for over 75 year olds and systematic care planning. 23.0 Performance Measures There is some similarity between the improvement measures chosen for the Salford Integration Programme for Older People and those determined nationally for the BCF.


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Integrated Care Programme for Older People Seven improvement measures have been agreed for Salford’s Integrated Care Programme, with targets set for 2020 (see Table 4). The measures incorporate commitments contained within the three national outcome frameworks. Indicators were selected on the following basis: • • • •

They primarily or exclusively relate to older people Are consistent with the overall aims of the ICP Achievement is outside of the control of a single organisation There is a prima facie case that the measure could be positively affected by integrated care solutions

Salford has also collected time series data and, where available, benchmarked its performance against peers both within the North West and nationally. Table 4: Salford’s ICP 2020 Improvement Targets Improvement Measures 1. Reduce emergency admissions and re-admissions

2. Reduce permanent admissions to residential and nursing care

3. Improve Quality of Life for users and carers

2020 Targets 19.7% reduction in nonelective admissions (from 315 to 253 per 1000 ppn): a reduction of 2,071 against a 2011/12 baseline of 10,521 emergency admissions. Reduce readmissions from the baseline of 19.6%: absolute readmissions to be lower than the 2011/12 baseline of 2,062. 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn): a reduction of 84 admissions, against a 2011/12 baseline of 322 admissions. Maintain or improve ranking position (or equivalent) from

Rationale Presently in bottom quartile in the North West for both admissions and readmissions. Emergency admissions improvement target is to move mid-point between top quartile (best) and 2nd quartile.

Presently in bottom quartile in the North West. Improvement target is to move to the top quartile.

Presently quartile nationally.


in

upper position Subjective

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Improvement Measures 4. Increase the proportion of people that feel supported to manage own condition 5. Increase satisfaction with the care and support provided 6. Increase flu vaccine uptake

7. Increase the proportion of people that die at home (or in their usual or preferred place of dying)

2020 Targets 2011/12 baseline.

Rationale and difficult nature of measures recognised. Given infrequent national measurement, local ‘proxy’ measures will also be required.

Presently ranked 17th nationally (top decile). Improvement target would enable Salford to exceed the top performing area (the best performing area achieved 81.5% in 2011/12). Increase to 50% (from Presently in third baseline of 41% in quartile in the North 2011/12). West, though this position has improved over time. Improvement target would move Salford into the upper (best) quartile. Increase flu uptake rate to 85% (from baseline position of 77.2% in 2011/12).

BCF National Metrics The national metrics underpinning the Fund are listed in Table 5, which also shows the time period to be used to determine performance related payments. This varies due to the different time lags for the data. Detailed definitions for these metrics are available via the link: http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/


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Table 5: BCF National Metrics April 2015 Metric payment based on performance in 1. Admissions to residential N/A and care homes 2. Effectiveness of reablement N/A 3. Delayed transfers of care Apr – Dec 2014 4. Avoidable emergency Apr – Sept 2014 admissions 5. Patient/service user N/A experience

October 2015 payment based on performance in Apr 2014 – Mar 2015 Apr 2014 – Mar 2015 Jan – Jun 2015 Oct 2014 – Mar 2015 Details TBC

BCF Local Metric In addition to the five national metrics, each area must choose an additional indicator that will contribute to the performance related element of the Fund. The ICP Steering Group has considered the most appropriate local metric to recommend to the Health & Wellbeing Board. This included consideration of: - 9 possible metrics suggested in the national guidance - 7 ICP Improvement measures - 2 ICP Process measures The Steering Group’s recommendation is to select one of the national suggested metrics: - Estimated diagnosis rate for people with dementia This was recommended as it there is a strong link to the ICP and the Joint Health & Well-being Strategy and there is an established data reporting source, with historical data. This choice also reflects the recognition of the importance of mental health issues, which affect not only the individual, but also their immediate family. Carer support and the mitigation of crisis points for individuals are important focal points for Salford’s new delivery model of care. The CCG is investing in Memory Assessment and Treatment Services in 2014-15, so this measure will assist in monitoring the impact of this funding. The full list of national suggested local metrics can be found on page 10 via the link: http://www.england.nhs.uk/wp-content/uploads/2013/12/bcf-plann-guid.pdf


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This local metric will be confirmed in the final version of this plan. Performance Related Payment The total performance related funding will be split equally between the six metrics. Local areas are to set an appropriate level of ambition for each metric, though for some this needs to be consistent with national targets set for CCGs. Improvement targets are expected to be statistically significant. Failure to achieve the levels of ambition set out in local plans will not result in the withdrawal of performance related funding for 2015/16. Further consideration is being given to whether this should be introduced in subsequent years. However, if an area fails to deliver 70% of the levels of ambition set out in its plan, it may be required to produce a recovery plan, which if agreed will release the held-back portion of the Fund. 24.0 Performance Measures – Baseline and Targets As required as part of the national planning template (Appendix B), the following baselines and targets (Table 6) have been set for these indicators for Salford. Drafting Note: Metric baselines and targets awaiting calculation. Will need to reconcile with planning assumptions in the finance plan


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Table 6: BCF Metrics – baselines and targets Metrics

Current Baseline

Permanent admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services Delayed transfers of care from hospital per 100,000 population (average per month)

Metric Value

Avoidable emergency admissions (composite measure)

Metric Value

Patient / service user experience [for local measure, please list actual measure to be used. This does not need to be completed if the national metric (under development) is to be used] Estimated diagnosis rate for people with dementia (local metric)

Performance underpinning April 2015 payment

Performance underpinning October 2015 payment

Numerator Denominator

N/A (2012-2013)

(2014 - 2015)

Metric Value Numerator Denominator (2012-2013)

N/A

(2014-2015)

(insert time period)

(April - Dec 2014)

( Jan - June 15)

(TBC)

(April - Sep 2014 )

( Oct 14–Mar 15)

Metric Value Numerator Denominator

Numerator Denominator


(insert time period) N/A

Metric Value Numerator Denominator (insert time period)




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PART D: FINANCE AND COMMISSIONING INTENTIONS 25.0 Utilisation of existing funding streams For the four existing funding streams of the BCF, Salford currently has existing commitments to commissioned services and projects, summarised below. Prior to April 2015, all commitments will be reviewed, so that the most effective use is made of the overall BCF. Financial details of these funding streams are reflected in the ICP Financial Plan. Transfer funding to social care to support adult social care services In recognition of the importance of social care support to avoiding admissions to hospital, reducing the need to access primary care and assisting with hospital discharges, financial settlements since 2011/12 has included a provision for a transfer of funding from the NHS to Local Authorities. Plans have been developed in each of the transfer years and the funding has been applied to maintain existing adult social care services, which best meet the objectives of achieving high level health benefits/health gain. In future years, this funding will be applied to maintain community-based services for vulnerable people (living in their own homes, supported to live as independently as possible). These home care services provide help and support to approximately 1,200 people and involve up to 983,000 home visits per year, which on average is just over 2 visits per person per day. The service is commissioned from six providers, operating on a neighbourhood basis. The application of funding will support health outcomes and reduce potential demand on NHS services, specifically: • •

•

Reduce hospital admissions – by continuing to support vulnerable people to avoid the risk of personal accidents and reduce deterioration in each person’s ability to function independently and safely Support Hospital discharges – by maintaining capacity for supporting people with on-going care and support needs and who also have risks to being able to live independently without support (reducing the risk of readmission) Reduce the potential demand on primary care services – by supporting vulnerable people within the community to live safely and independently, slowing down deterioration in their ability to function independently of health interventions (reducing the risk of access to primary care NHS services)


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Carers Breaks The 2011 census identified that there were 23,403 carers in Salford and 6,449 of those were providing care for more than 50 hours a week. People providing high levels of care are twice as likely to be permanently sick or disabled6 and Caring has a negative impact on carers’ physical health (83%) and mental health (87%).7 Salford CCG and Salford City Council jointly commission a range of services to support carers including: • • • •

Salford Carers Centre; to provide a ‘first stop shop’ for support and advice Carers Personal Budgets; enabling carers to have greater control and flexibility of how they take a break from caring Generic and specialist carers support services; including services for carers of people with dementia, mental health problems, young carers and people with drug and alcohol problems. Carers healthchecks; to start to identify the health impacts of caring and identify necessary interventions

Salford CCG and Salford City Council have launched a new five-year Salford Carers Strategy (2013-2018), aimed at supporting the growing number of carers and reflecting the priorities identified in the National Carers Strategy8. Despite Salford’s ICP currently being aimed at older people, Salford’s strategy will continue to cover all ages. In Salford, 1.5% of young people are carers compared to 1.3% nationally, with one in ten young carers providing over 50 hours care per week. Reablement Fund Since 2010/11, there has been separate NHS allocations specifically provided to develop reablement health and social care services, with the objective of ensuring rapid recovery from an acute episode and reducing people’s dependency on social care services following discharge. This coincided with reduced income for hospitals relating to readmissions to hospital. Within Salford, plans have been agreed annually by Salford Primary Care Trust/Clinical Commissioning Group, SCC and SRFT which resulted in allocations to Salford Royal Foundation Trust, Salford Community Services, Salford Social Services, Age Concern and Marie Curie Nursing. These plans 6

http://www.carersuk.org/newsroom/stats-and-facts In Sickness and in Health (2012) Age UK http://www.ageuk.org.uk/Documents/ENGB/Campaigns/carers_week_2012_in_sickness_and_in_health.pdf?dtrk=true 8 Recognised, valued and supported: Next steps for the Carers Strategy’ (2010), which was the Coalition Government’s refresh of the National Carers Strategy ‘Carers at the heart of 21st century families and communities’ (2008). 7


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aimed to improve post-discharge support and help prevent avoidable hospital readmissions. Due to initial uncertainty about the future of this national funding, most of these allocations were provided for non-recurrent investment. For the purposes of developing the BCF service and financial plan, all commitments against the reablement fund have been reviewed, with a view to either ending non-recurrent funding, confirming recurrent funding or agreeing to review initiatives at a later date. This is itemised within the detailed BCF financial plan. Capital Grant & disabled facilities grants From April 2015, the BCF will need to allocate the DFG to the council’s housing department to enable them to continue to meet their statutory duty to provide adaptations to the homes of disabled people, including young people aged 17 and under. The rationale for including the DFG into the pooled BCF is to allow the provision of adaptions to be incorporated into strategic integration plans. National conditions will apply to the Capital Grants element of the BCF to ensure that funding may be released from the pooled fund for capital grant purposes. Salford City Council utilises its Adult Social Care capital resources and Disabled Facilities Grant (DFG) to support integrated and effective interventions, focussing on keeping people as independent as possible. The funding is used over a programme that will encompass service redesign and development to meet strategic objectives for maximising independence and specific projects to support people to live safely in the Community with long term conditions. Specific annual programmes will be in place to deliver the following: •

Adult Social Care Services: -

-

•

Developing services to offer integrated health and social care support, including joint work with other public sector partners and the voluntary sector Remodelling services and service interventions to promote independence and skills building, to help people to remain independent for longer or support people to cope better with long term conditions

Disabled Facilities Grant:


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-

Providing environmental improvements for individuals, supporting them to retain or regain their independence, continue living in their neighbourhood and improve their control over their own lives

26.0 Integrated Care Programme/BCF Financial Plan The Alliance Agreement of the Salford Integrated Care Programme for Older People details the health and social care services and budgets to form part of the shared pool, including the BCF. A draft financial plan has been populated detailing the baseline financial resources to be pooled. This has been projected forward to 2017/18 to reflect: • • •

changes to funding (namely the BCF) reductions in funding as a result of allocation changes changes to expenditure to reflect the new service model

This plan assumes agreement to the following proposed general principles: • •

Organisations’ savings targets are also included in the Alliance Pool. Because both savings targets and additional funding are included in the pool, then decisions around commissioning, re-commissioning, redesign or decommissioning of services within the scope of the alliance contract will be made jointly, rather than one organisation taking decisions unilaterally

Table 7 below summarises the proposed pooled budget for older peoples services, which includes the BCF. Appendix B includes the national finance template for submission. The figures relating to investment and disinvestment are provisional and dependent upon approval of individual business cases. The total pooled budget amounts to £94.9m as the baseline fund (2013/14). This increases to £98.5m by 2017/18 and is significantly more than the £20m BCF (detailed in section 18). By pooling resources in this way, this gives: •

greater flexibility for organisations to meet the collective financial challenges facing all organisations in the Alliance. The financial model incorporates the savings targets of organisations, without significant levels of decommissioning

•

an opportunity to jointly create a system that meets the needs of the population. The financial plan reflects the service aims of the ICP with investment being made in each of the service aims

This finance plan will be regularly reviewed and refreshed at least annually. Changes to planning assumptions and investment and disinvestment decisions will be made collectively by the partners within the alliance, in line with agreed governance processes. Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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Table 7: Proposed Total Pooled Budget for Older People in Salford

Baseline funding Better Care Fund Customer and Client Income Commissioner Funding Added for Growth Commssioner Funding for Additional MATs Commissioners' QIPP/Savings Targets TOTAL FUNDING

2017/18 £000s £77,915 £19,994 £7,819 £2,934 £1,000 -£11,136

Movement Between Baseline and Future Model £000s £0 £11,314 -£466 £2,934 £1,000 -£11,136

£686

£98,526

£3,646

Future Model

Baseline

IN YEAR CHANGES

2013/14 £000s £77,915 £8,680 £8,285 £0 £0 £0

2014/15 2015/16 2016/17 2017/18 £000s £000s £000s £000s £0 £0 £0 £0 £1,323 £9,991 £0 £0 £119 -£293 -£293 £0 £676 £681 £891 £686 £1,000 £0 £0 £0 -£2,676 -£4,740 -£3,720 £0

£94,881

£442

Review of Non Recurrent Spend

£1,103

-£561

-£45

-£430

£0

£67

-£1,036

Investment in Mental Health Services

£6,866

£1,000

£0

£0

£0

£7,866

£1,000

£0 -£1,836 -£2,836 -£1,000

£34,904

-£5,672

Aim 1: Reduction in acute and residential admissions

£40,576

£5,639 -£3,121

Aim 2: Investment in Centre of Contact

£1,652

£200

£300

£0

£0

£2,152

£500

Aim 3: Investment in Community Assets

£1,049

£95

£378

£0

£0

£1,522

£473

£23,268

£928

£1,587

£0

£0

£26,042

£2,774

Investment in Quality Standards

£0

£0

£949

£0

£0

£949

£949

Inflation, Growth and New Responsiblities

£0

£799

£3,586

£724

£522

£5,632

£5,632

In Scope Services Remaining Unchanged?

£20,366

-£2

£0

£0

£0

£20,364

-£2

TOTAL COSTS

£94,881

£2,459

£4,919 -£2,542

-£478

£99,498

£4,618

£0

-£2,017

-£579 £1,164

-£972

-£972

Aim 4: Investment in Primary and Community Based Care

DIFFERENCE

£720

The pooled budget proposal presented in this version of the service and financial plan is the latest iteration and there are a couple of areas still being reviewed by the ICP Steering Group. The pooled budget as it stands has a financial gap of almost £1m which will need to be addressed by partner organisations, prior to final submission in February. The following should be noted: • • •

Service and financial planning will be an iterative process of reviewing the service model and refreshing the financial model. Without service specifications for the new model of care, it is difficult to accurately reflect the costs. The full level of efficiencies in pooling certain services together has not been reflected yet in the model (for example, Centre of Contact pools existing £1.6m currently spent in various services and adds an


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•

additional £0.6m investment. It is not yet clear what level of efficiencies can be realised from redesigning current teams into one service) Guidance on the BCF is still being clarified as, in part, it is unclear and conflicting. There is a reference to an element of the BCF for local authorities to meet “demographic changes and new areas of responsibility in the Care Bill”. Currently £4.5m has been set aside within the finance plan specifically for this. However it is unknown how much of these objectives (“demographic changes and new Care Bill responsibilities”) may be achieved from the service models being developed by the ICP, giving rise to some levels of efficiency.

Whilst the scope and current spend has been agreed, what is less clear is how spend will move from current to future model needs. Further work on the phasing of this is needed in order to consider: • • •

Double running - how quickly can providers reduce costs? Is nonrecurrent support required? Pump priming - non recurrent investment (programme management, MDGs for GP practices is time limited) Innovation, continuing tests of change - potential for non-recurrent fund or delegation limits to service managers to continue tests of changes

27.0 Summary of Commissioning Intentions Table 8 summarises the current commissioning intentions of the ICP within the scope of the Programme’s service and financial pool, including the BCF. This includes new investments and disinvestments or cost changes due to service redesign. Whilst the broad themes are clear and fully endorsed by all partners, financial values and service details are subject to further processes including the development, scrutiny and agreement of individual business cases. These will be developed throughout 2014/15.


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Table 8: Summary of Commissioning Intentions

Integrated Care Running Costs

All Other

Baseline

Future Model

2013/14

2017/18

CCG

Council

Total

CCG

Council

Total

£000s

£000s

£000s

£000s

£000s

£000s

£634

£0

£634

£0

£0

£0

Movement: Baseline & Future Model £000s

-£634

To cover costs until March 2016 of central programme management team, workstream and tests of change costs. This excludes management time being provided by each of the four organisations. Detailed breakdown of costs available Covers non-recurrent costs incurred in 2013/14 to support tests of change e.g. backfill for GP time which will be covered by alternative arrangements from 2014/15

£468

£0

£468

£67

£0

£67

-£402

Review of Non Recurrent Spend

£1,103

£0

£1,103

£67

£0

£67

-£1,036

GMW Mental Health

£6,866

£0

£6,866

£7,866

£0

£7,866

£1,000

Investment in Mental Health Services

£6,866

£0

£6,866

£7,866

£0

£7,866

£1,000

£22,613

£0

£22,613

£18,613

£0

£18,613

-£4,000

SRFT Acute


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Description

CCG investment in Memory Assessment & Treatment Service

Value of assumed reduction in non-elective activity, as result of ICP

Residential care

£0

£17,964

£17,964

£0

£16,292

£16,292

-£1,672

£22,613

£17,964

£40,576

£18,613

£16,292

£34,904

-£5,672

£470

£1,182

£1,652

£470

£1,182

£1,652

£0

£0

£0

£0

£500

£0

£500

£500

Aim 2: Investment in Centre of Contact

£470

£1,182

£1,652

£970

£1,182

£2,152

£500

Community Assets/ Voluntary Sector

£395

£655

£1,049

£895

£627

£1,522

£473

Aim 3: Investment in Community Assets

£395

£655

£1,049

£895

£627

£1,522

£473

£6,052

£0

£6,052

£6,052

£0

£6,052

£0

Aim 1: Reduction in acute and residential admissions Centre of Contact- existing teams

Centre of Contact- new single service

District Nursing


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Value of assumed reduction in permanent placements to residential care, as result of ICP

Includes the consolidation of service costs across five existing health and social care services into a new single service

Additional funding into new Centre of Contact service to deliver new model of care

Additional investment into third sector providers to deliver aspirations of the community assets workstream

Potential efficiency savings (value currently unquantified) resulting from new model of care, alongside overall increased investment

Integrated care, Hope Hospital, Contact Team and OP MH social work teams

£0

£3,072

£3,072

£0

£3,072

£3,072

£0

Intermediate Care

£6,434

£1,689

£8,123

£6,934

£1,430

£8,623

£500

SRFT Other Community

£5,884

£0

£5,884

£5,884

£0

£5,884

£0

£137

£0

£137

£411

£0

£411

£274

Community Care of the Elderly Clinicians


Investment in community intermediate care beds, particularly to support seasonal pressures


Investment in community based medical services

MDTs- GP backfill & enhanced service

£0

£0

£0

£1,000

£0

£1,000

£1,000

Potential costs to CCG associated with new GMS contract requirement relating to 'named GP' for over 75 year olds and active case management of 'at risk' registered population

MDTs- community nursing and social workers

£0

£0

£0

£1,000

£0

£1,000

£1,000

Investment in community based care and support

Aim 4: Investment in Primary and Community Based Care

£18,507

£4,761

£23,268

£21,281

£4,502

£26,042

£2,774


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Shared Care Records

£0

£0

£0

£500

£0

£500

£500

Estimated cost of investment in development of Shared Care Records

Quality Standards in Residential Care and Nursing Homes

£0

£0

£0

£449

£0

£449

£449

Investment in residential and nursing homes (& potentially other providers) relating to delivery of enhanced quality standards

Investment in Quality Standards

£0

£0

£0

£949

£0

£949

£949

Growth- Inflation

£0

£0

£0

£0

£1,132

£1,132

£1,132

Cost of annual inflation uplifts

Growth- demographic

£0

£0

£0

£0

£1,125

£1,125

£1,125

Costs related to changes to population size and demographics

Investment in New Responsibilities

£0

£0

£0

£0

£3,375

£3,375

£3,375

Estimated additional costs to deliver new responsibilities associated with the Care Bill

Inflation, Growth and New Responsibilities

£0

£0

£0

£0

£5,632

£5,632

£5,632


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Capital Grants

£0

£1,914

£1,914

£0

£1,914

£1,914

£0

£470

£0

£470

£470

£0

£470

£0

Community OT and Equipment

£1,535

£813

£2,349

£1,734

£613

£2,347

-£2

Continuing Healthcare

£6,450

£0

£6,450

£6,450

£0

£6,450

£0

Day care

£0

£977

£977

£0

£977

£977

£0

Direct payments

£0

£1,159

£1,159

£0

£1,159

£1,159

£0

Carers

Other services or budget allocations included in the ICP Pooled budget. All elements subject to consideration for redesign in line with the ICP priorities and work programme


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Domiciliary placements

£0

£4,426

£4,426

£0

£4,426

£4,426

£0

£1,401

£0

£1,401

£1,401

£0

£1,401

£0

Housing related

£0

£382

£382

£0

£382

£382

£0

Supported tenancies

£0

£839

£839

£0

£839

£839

£0

£9,857

£10,509

£20,366

£10,055

£10,309

£20,364

-£2

Hospice

In Scope Services Remaining Unchanged


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28.0 Stakeholder Impact Assessment A condition for accessing the BCF is that CCGs are expected to engage with local health care providers to assess the implications on existing services of diverting NHS funding to the new fund. As Salford’s ICP is a partnership endeavour, including agreed principles relating to transparency and an ‘open book’ approach, joint impact assessment is an integral part of the Programme’s service and financial planning processes. In addition, all four organisations are collaborating in respect of their strategic planning processes. The ICP plan includes agreed: • • •

activity deflections from both secondary care and care homes shared, system level improvement targets priorities for reinvestment to support Salford's integrated care model

This includes a target to deliver a 19.7% reduction in non-elective admissions (from 315 to 253 per 1000 65+ population) by 2020: a reduction of 2,071 against a 2011/12 baseline of 10,521 emergency admissions. This relates to activity in the 65+ population only and equates to approximately 5% of all nonelective activity. As with previous schemes in Salford, this plan will be accompanied with an acute bed reduction plan, ensuring that capacity is removed in a planned manner. NHS and social care planning savings and assumptions are reflected in the ICP Financial Plan. This will be refreshed on at least an annual basis to reflect tariff changes and efficiency requirements. 29.0 Shared Risk Register The following high level risks have been identified for the ICP/BCF. Risksharing principles are included in the Programme’s Alliance Agreement. Risk The planned health and social care savings within the ICP pooled budget are not realised/fully realised.

Risk rating High, as local evidence base on impact of integrated care still being developed

Mitigating Actions Monitoring and governance arrangements in place for the ICP. Mitigating actions to be agreed as part of the Alliance Agreement across the four organisations. All partners agree to share the benefits and risks of the ICP. Adjustment to the service model and/or savings requirements will be jointly agreed. The cost of delivering High, Although assumed in the financial the revised service as service plan, commitment of resources to Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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model is greater than planning in assumed in the early stages financial model or there are ‘double running’ costs

The introduction of the Care Bill, will result in a significant increase in the cost of care provision from April 2016 onwards which is difficult to estimate at this stage. This will impact the sustainability of current social care funding and plans. Primary Care providers (or single primary care body) unable to commit as an equal partner in the Alliance Agreement and/or planned service model Other, interdependent strategic change programmes (Greater Manchester Healthier Together and Primary Care Strategy) fail to deliver to planned timescales. Decisions/actions by partner organisations relating to services not directly included in the pooled budget, but which negatively impact upon delivery of the new model of care for Older People e.g. back office functions

services will only take place following scrutiny of business cases. Governance arrangements in place. Adjustments to financial model will be jointly agreed by all four alliance partners. The CCG, in developing its five-year strategic plan, will consider the use of nonrecurrent budgets on its service transformation programmes. High, due There will be ongoing refinement of the current the planning assumptions lack of associated with the Care Bill. detailed financial modelling

Medium, as new GMS contract supports local model

Medium

Medium

CCG developing a Primary Care Development Strategy aiming to significantly improve the quality and scope of general medical services in Salford and to develop a more robust local primary care marketplace. Local and Greater Manchester commitment and focus on the three strategic change programmes.

As part of the Public Sector Reform Programme, top-tier leadership meetings are established to align strategic direction and support transparent communication.


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The Programme fails to deliver against its planned improvement measures, risking receipt of some performance related funding from the BCF

Medium, Initially as Ministers decided that funding should not be withheld if a recovery plan can be agreed

ICP improvement measures and BCF metrics to be monitored on a frequent basis with underperformance reported to the ICP Board for recovery actions to be agreed.

30.0 Programme and Alliance Governance ICP Governance Since May 2012, an Integrated Care Board (ICB) has overseen the Programme. The ICB includes the four partner organisations and representatives from the LMC and Salford HealthWatch, setting direction and overseeing delivery of the programme. The Assistant Mayor for Adults and Older People’s Services also has a place on the ICB. It is jointly chaired by Salford CCG’s Local Authority Liaison Clinical Lead and the City Council’s Strategic Director of Community, Health and Social Care. The ICB reports both to the constituent organisations, to Salford’s Health and Wellbeing Board and to the relevant Neighbourhood Partnership Boards (Appendix D). The ICP is managed through a Programme Office, hosted by SRFT. A range of enabling workstreams have been established, which are overseen by a Steering Group which meets on a weekly basis (see Appendix D). A Citizens Reference Group is in place to support engagement and involvement. Pooled budget governance As previously described, the intention is that the four statutory partners will form a legally binding ‘Alliance Agreement’ to support and enable the provision of integrated care and services to older people and other subsets of the adult population. Alongside this, the plan is for the ICB to be reconstituted to form an Alliance Board with delegated authority from the four organisations.


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PART E: NEXT STEPS 31.0 ICP 2014/15 Workplan Salford’s ICP is being delivered in five phases and is presently nearing the end of phase 2: • • • • •

Phase 1: Refine Scope and Prepare for Implementation (completed, undertaken July 2012 to Jan 2013) Phase 2: Neighbourhood ‘Tests of Change’ (in progress, started Feb 2012, scheduled completion March 2014) Phase 3: Interim Review of Impact (scheduled January 2014 to March 2014] Phase 4: Extend to other Neighbourhoods / City-wide (April 2014 onwards) Phase 5: Formal Evaluation (April 2014 to March 2019)

The focus of 2014/15 is to roll-out Salford’s Integrated Care model across the City. This will be undertaken on a phased basis over a 14 month period, to enable the model to be effectively embedded and ensure learning is shared between neighbourhoods. Work will also continue in a number of enabling workstreams, including: • • • • • • • • •

Phased implementation of an Integrated Care Record for older people Development of key workers and new roles to support integrated care Development of Alliance governance processes Phased implementation of Alliance Agreement Monitoring of improvement measures and establishment of evaluation framework Awareness raising and engagement with older people, staff and other stakeholders Development of the integrated workforce plan Development of a Primary Care Development Plan Continued refinement of the service and financial plans


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PART F: STAKEHOLDER SIGNATURES 32.0 Stakeholder Signatures Signed by [insert name once approved] For and on behalf of SALFORD HEALTH AND WELLBEING BOARD

We confirm our agreement to the above …………………………………………

Signed by [insert name once approved] For and on behalf of NHS SALFORD CLINICAL COMMISSIONING GROUP


Signed by [insert name once approved] For and on behalf of SALFORD CITY COUNCIL

We confirm our agreement to the above …………………………………………..

Signed by [insert name once approved] For and on behalf of SALFORD ROYAL NHS FOUNDATION TRUST


Signed by [insert name once approved] For and on behalf of GREATER MANCHESTER WEST MENTAL HEALTH NHS FOUNDATION TRUST


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APPENDICES


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APPENDIX A:


Better Care Fund planning template – Part 1 Please note, there are two parts to the template. Part 2 is in Excel and contains metrics and finance. Both parts must be completed as part of your Better Care Fund Submission. Plans are to be submitted to the relevant NHS England Area Team and Local government representative, as well as copied to: [email protected] To find your relevant Area Team and local government representative, and for additional support, guidance and contact details, please see the Better Care Fund pages on the NHS England or LGA websites.

1)

PLAN DETAILS

a) Summary of Plan Local Authority

Salford

Clinical Commissioning Groups

Salford

Boundary Differences

N/A

Date agreed at Health and WellBeing Board:

21/01/2014 Draft Plan

Date submitted:

14/02/2014

Minimum required value of ITF £10.00m pooled budget: 2014/15 2015/16 £19.99m Total agreed value of pooled £95.32m budget: 2014/15 Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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2015/16 £100.96m b) Authorisation and signoff Signed on behalf of the Clinical Commissioning Group By Position Date

Salford Dr Hamish Stedman Salford CCG Chair 14/02/14

Signed on behalf of the Council By Position Date

Salford 14/02/14

Signed on behalf of the Health and Wellbeing Board By Chair of Health and Wellbeing Board Date

Salford 14/02/14

c) Service provider engagement Please describe how health and social care providers have been involved in the development of this plan, and the extent to which they are party to it This plan has been developed as part of Salford's Integrated Care Programme for Older People, which is underpinned by a formal partnership between Salford CCG (CCG), Salford City Council (SCC), Salford Royal NHS Foundation Trust (SRFT) and Greater Manchester Mental Health West NHS Foundation Trust (GMW). This also includes the LMC and in future the Salford primary care provider organisation. The plan includes agreed:- activity deflections from both secondary care and care homes - shared, system level improvement targets - priorities for reinvestment to support Salford's integrated care model The plan is supported by the co-commissioners (CCG and SCC), SRFT, GMW and SCC in its capacity as a social care provider. The plan is approved by the Integrated Care Board, which is the partnership board for the programme in addition to the Salford Health and Wellbeing Board. Wider engagement with providers (including nursing homes, third sector providers, and primary care practitioners) has taken place as part of the ICP in relation to the redesign of services e.g. working groups, learning events and Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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workshops. For further detail, see Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18)

d) Patient, service user and public engagement Please describe how patients, service users and the public have been involved in the development of this plan, and the extent to which they are party to it The Salford ICP seeks to work with citizens based on the ladder of participation model, with a view to increasing the level of involvement from passive engagement through to citizen control. The ambition is to involve and engage Salford older people in the planning and shaping of future services, ensuring they have a clear voice in the development and delivery of the Integrated Care Programme. This has started with the establishment of a Citizen’s Reference Group comprising people over the age of 55, living in the ICP’s pilot areas. The aims of the Citizen’s Reference Group is to involve local older people in the pilot areas’ ‘tests of change’ and asking them to suggest their own small tests based on what they think is important to them and their families. Members have also had the opportunity to input into discussions around the wider programme. This group was recruited in April 2013 via adverts placed in existing partner engagement mechanisms including: Salford Council Development Boards/Integrated Engagement Board, Salford Royal Foundation Trust’s Patient Group, Salford CCG’s NHS Patient Panel, Greater Manchester West’s User Action Team and the Healthwatch Salford Shadow Board The Citizen’s Reference Group contains more than 70 people keen to be involved in the programme via email, face to face 1:1 conversations or telephone conversations. A core group of 6–12 people meet monthly, supported by a Development Worker. Managers in the Programme often attend to discuss aspects of the programme and to gain suggestions. Wider engagement is conducted via a network of older people in and adopts a consultative approach, supporting involvement of people with less detailed knowledge of the programme. There are also a number of community groups in the pilot areas that input to the work without being formal members of the Citizen’s Reference Group. Throughout the past 9 months, a range of projects and learning has been developed by the Citizen’s Reference Group with support from wider local older people and community groups. Learning has been shared with project Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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managers and other work streams to ensure that the information shape the model. For further detail, see Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18)

e) Related documentation Please include information/links to any related documents such as the full project plan for the scheme, and documents related to each national condition.

Document or information title Synopsis and links All relevant related documents are included in the Appendices of the Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18)


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2)

VISION AND SCHEMES

a) Vision for health and care services Please describe the vision for health and social care services for this community for 2018/19. • What changes will have been delivered in the pattern and configuration of services over the next five years? • What difference will this make to patient and service user outcomes? Salford's 2020 vision is for a radically changed health and social care system, where older people are enabled to retain their independence and take a much more active role in their own care. Much greater attention needs to be placed on how we support older people and communities to care for themselves and manage their own care. This means giving people more information and choice, and personalising the way care is delivered. Whilst specialist care and support will continue to be required for those with the greatest need, the focus should be giving older people more control and supporting them to be less dependent on services. More care will be delivered in a community setting, largely in people's homes, with a corresponding reduction in unplanned demand for hospital care and expensive packages of social care. Where individuals need to access specialist services, they will have confidence in the quality of care they will receive and be supported to return to their own home as soon as possible. As a consequence, quality of life will improve for older people and their carers. Older people will feel more able to manage their condition and service users will benefit from being able to access a much more integrated health and social care system, which is better able to anticipate and respond to their needs. For further detail, see Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18)

b) Aims and objectives Please describe your overall aims and objectives for integrated care and provide information on how the fund will secure improved outcomes in health and care in your area. Suggested points to cover: • What are the aims and objectives of your integrated system? • How will you measure these aims and objectives? • What measures of health gain will you apply to your population? Salford’s Integrated Care Programme (ICP) seeks to transform the health and Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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social care system, promoting greater independence for older people and delivering more integrated care. The ICP has a triple aim of: (1) delivering better health and social care outcomes, (2) improving the experience of service users and carers, and (3) reducing health and social care costs. Seven associated improvement measures have been agreed, with targets set for 2020:1. Reducing emergency admissions and re-admissions; 2. Reducing permanent admissions to residential and nursing care; 3. Improving Quality of Life for users and carers; 4. Increasing the proportion of Older People that feel supported to manage their own conditions; 5. Increasing satisfaction with the care and support provided to Older People; 6. Increasing flu vaccine uptake for Older People; 7. Increasing the proportion of Older People that die at home (or in their preferred place of dying).Salford’s Integrated Care Whilst recognising the need to respond to short term challenges, the overall approach has been to take a long term view. This includes balancing the short term goal of reducing service duplication and waste with the longer term aim of securing greater population health and reducing future service demand. For further detail, see Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18)

c) Description of planned changes Please provide an overview of the schemes and changes covered by your joint work programme, including: • The key success factors including an outline of processes, end points and time frames for delivery • How you will ensure other related activity will align, including the JSNA, JHWS, CCG commissioning plan/s and Local Authority plan/s for social care The BCF will form part of a pooled budget that will support Salford to deliver a new integrated care model, This model has three component parts, focussed around a fictional older person (‘Sally Ford’) and her family: • • •

Promotion and increased use of Local Community Assets to support increased independence and resilience for older people. Establishment of an integrated Centre of Contact to support navigation, monitoring and support Establishment of Multi-Disciplinary Groups supporting and care planning older people who are most at risk as well as a providing a broader focus on screening, primary prevention and signposting to community support


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During 2013/14 this model has been tested and refined in two of Salford’s neighbourhoods (Swinton & Pendlebury and Eccles, Barton & Winton; together accounting for 40% of Salford’s 65+ population). A ‘Collaborative Improvement’ model has been used involving in excess of 120 staff and stakeholders. The focus of 2014/15 is to roll-out Salford’s Integrated Care model across the City. This will be undertaken on a phased basis over a 14 month period, to enable the model to be effectively embedded and ensure learning is shared between neighbourhoods. Salford's model and ICP is underpinned by a formal partnership between the four statutory partners. The programme is overseen by an Integrated Care Board, which has dual accountability to the parent Boards/committees of the statutory partners and to Salford’s Health & Wellbeing Board. The Programme addresses some of the key priorities of Salford's Health & Wellbeing Strategy which has been endorsed by each of the statutory partners. For further detail, see Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18)

d) Implications for the acute sector Set out the implications of the plan on the delivery of NHS services including clearly identifying where any NHS savings will be realised and the risk of the savings not being realised. You must clearly quantify the impact on NHS service delivery targets including in the scenario of the required savings not materialising. The details of this response must be developed with the relevant NHS providers. Salford has set a target to deliver a 19.7% reduction in non-elective admissions (from 315 to 253 per 1000 65+ population) by 2020: a reduction of 2,071 against a 2011/12 baseline of 10,521 emergency admissions (relating to the 65+ population). This is modelled in the ICP Financial Plan. As with previous schemes in Salford, this plan will be accompanied with an acute bed reduction plan, ensuring that capacity is removed in a planned manner. NHS and social care planning savings are modelled in the ICP Financial Plan. This will be refreshed on at least an annual basis to reflect tariff changes and efficiency requirements. The risk of non-delivery of planned savings will be dealt with within the Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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planned Alliance Contract covering the four organisations, who have committed to jointly managing the benefits and risks of the ICP. For further detail, see Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18)

e) Governance Please provide details of the arrangements are in place for oversight and governance for progress and outcomes ICP Governance Since May 2012, an Integrated Care Board (ICB) has overseen the Programme. The ICB includes the four partner organisations and representatives from the LMC and Salford HealthWatch, setting direction and overseeing delivery of the programme. The Assistant Mayor for Adults and Older People’s Services also has a place on the ICB. It is jointly chaired by Salford CCG’s Local Authority Liaison Clinical Lead and the City Council’s Strategic Director of Community, Health and Social Care. The ICB receives regular reports on finance and performance against improvement measures. The ICB reports both to the constituent organisations, to Salford’s Health and Wellbeing Board and to the relevant Neighbourhood Partnership Boards (Appendix D of Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18). The ICP is managed through a Programme Office, hosted by SRFT. A range of enabling workstreams have been established, which are overseen by a Steering Group which meets on a weekly basis (Appendix D of Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18). A Citizens Reference Group is in place to support engagement and involvement. Pooled budget governance As previously described, the intention is that the four statutory partners will form a legally binding ‘Alliance Agreement’ to support and enable the provision of integrated care and services to older people and other subsets of the adult population. Alongside this, the plan is for the ICB to be reconstituted to form an Alliance Board with delegated authority from the four organisations.


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3)

NATIONAL CONDITIONS

a) Protecting social care services Please outline your agreed local definition of protecting adult social care services Salford has agreed under the terms of the Integrated Care Programme for Older People that Adult Social Care Services will be protected where they contribute the strategic partnership outcomes of 1) Better Outcomes, 2) Improved Experience, 3) Whole economy best use of resources. Please explain how local social care services will be protected within your plans The Integrated Care Programme has developed an effective governance framework and strategic and financial plan which ensures there is a foundation for effective integration whilst protecting and recognising the value of Adult Social Care Services. b) 7 day services to support discharge Please provide evidence of strategic commitment to providing seven-day health and social care services across the local health economy at a joint leadership level (Joint Health and Wellbeing Strategy). Please describe your agreed local plans for implementing seven day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends

There is growing commitment across the health and social care system in Salford to improve access to services outside traditional 9 to 5, 5 days a week provision. The Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18) includes a summary of the extent to which this is already happening in Salford and some future intentions. The BCF provides a new opportunity to focus on the integration of increased access into the new model of care to support hospital discharge and prevent unnecessary admissions. This element of the plan will be developed further during 2014/15. For further detail, see Salford Integrated Care Programme (ICP) for Older People, Service and Financial Plan (2014/15 – 2017/18)

c) Data sharing Please confirm that you are using the NHS Number as the primary identifier for correspondence across all health and care services. Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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Yes all main health and care systems in Salford will use the NHS Number. If you are not currently using the NHS Number as primary identifier for correspondence please confirm your commitment that this will be in place and when by N/A Please confirm that you are committed to adopting systems that are based upon Open APIs (Application Programming Interface) and Open Standards (i.e. secure email standards, interoperability standards (ITK) Partners in Salford are committed to adopting systems wherever possible that are based upon Open APIs and Open standards. These requirements are incorporated within specifications when undertaking procurement for new systems. Please confirm that you are committed to ensuring that the appropriate IG Controls will be in place. These will need to cover NHS Standard Contract requirements, IG Toolkit requirements, and professional clinical practise and in particular requirements set out in Caldicott 2. Partners in Salford confirm that we are committed to ensuring the appropriate Information Governance (IG) controls will be in place covering NHS Standard Contract requirements, IG Toolkit requirements , professional clinical practise and requirements set out in Caldicott2. d) Joint assessment and accountable lead professional Please confirm that local people at high risk of hospital admission have an agreed accountable lead professional and that health and social care use a joint process to assess risk, plan care and allocate a lead professional. Please specify what proportion of the adult population are identified as at high risk of hospital admission, what approach to risk stratification you have used to identify them, and what proportion of individuals at risk have a joint care plan and accountable professional. All people who are identified as high risk of admission will have an agreed accountable lead professional called their 'key worker'. The key worker is defined as a qualified practitioner irrespective of their professional role, who has responsibility for co-ordinating care, keeping in touch with the patient’s/client, ensuring the care plan is delivered and reviewed as required. The Sally Ford Integrated Care Planning Model (SFICPM) is a delivery system for Salford's Older People which takes account of optimising and maintaining an individual's overall well-being, and where necessary health and social care input through 6 essential elements. The elements are as follows:


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1. A systematic assessment of health and social care needs when required. 2. The appointment of a named key worker. 3. Joint working with all organisations/agencies involved, where multidisciplinary groups with a single entry/contact point for agencies/ services will be the two focus points for delivery of joint working. 4. An agreed Shared Care Plan, based on the joint working and based on a stepped level of care need 1-4. 5. The sharing of essential information between provider agencies. 6. Regular reviews to reconsider need and change plans as necessary Risk stratification will initially be deployed by applying the 4 levels (of Sally) Able Sally, Needs Some Help Sally, Needs More Help Sally and Needs a Lot of Help Sally, where Able Sally is self-caring and independent, and Needs some help Sally may need low level review or intermittent input. These two levels will be low and low/moderate risk respectively. Needs more help Sally will be individuals assessed as ‘substantial' by social care, or/and in contact with district nursing services several times weekly, or in intermediate care. Needs a Lot of Help Sally are individuals who rely on 24/7 care, or assessed as 'critical' by social care. The latter 2 Sallys are high and very high risk cohorts. Additional triggers will also require a review by a member of the multidisciplinary group (MDG) with escalation to full MDG as required. Triggers will be where an individual's circumstances would appear to have changed in an unplanned way, such as an emergency admission or two A&E attendances within 6 weeks. The 65+ population in Salford is 34,317 in an adult population of 191,107 (all figures based on 2,012 midyear data from HSCIC). Needs a Lot of Help Sally cohort is presently estimated at 1,051 (excludes people who are self-funding in a care home or home package that would fit the defined population). Needs more Help Sally is currently estimated as 1,313 (excludes people admitted to intermediate care and emergency admissions who would be assessed as part of the wider MDG cohort but may not become residual within this group). The two high risk levels together are in the region of 2,360 adults, and 2% of the adult population is around 3,822. Once the numbers of people accepting intermediate care and those assessed following an emergency admission are included the coverage by the extended MDGs will be in excess of 2%. The model of joint assessment and care management continues to be refined in Salford as part of the ICP and will be further reviewed in the light of the new GMS contract for 2014/15 in respect of named GP for over 75 year olds and systematic care planning.


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4) RISKS Please provide details of the most important risks and your plans to mitigate them. This should include risks associated with the impact on NHS service providers Risk The planned health and social care savings within the ICP pooled budget are not realised/fully realised.

Risk rating High, as local evidence base on impact of integrated care still being developed

The cost of delivering the revised service model is greater than assumed in the financial model or there are ‘double running’ costs

High, as service planning in early stages

The introduction of the Care Bill, will result in a significant increase in the cost of care provision from April 2016 onwards which is difficult to estimate at this stage. This will impact the sustainability of current social care funding and plans. Primary Care providers (or single primary care body) unable to commit as an equal partner in

High, due the current lack of detailed financial modelling

Medium, as new GMS contract supports

Mitigating Actions Monitoring and governance arrangements in place for the ICP. Mitigating actions to be agreed as part of the Alliance Agreement across the four organisations. All partners agree to share the benefits and risks of the ICP. Adjustment to the service model and/or savings requirements will be jointly agreed. Although assumed in the financial plan, commitment of resources to services will only take place following scrutiny of business cases. Governance arrangements in place. Adjustments to financial model will be jointly agreed by all four alliance partners. The CCG, in developing its five-year strategic plan, will consider the use of non-recurrent budgets on its service transformation programmes. There will be ongoing refinement of the planning assumptions associated with the Care Bill.

CCG developing a Primary Care Development Strategy aiming to significantly improve the quality and scope of general medical


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the Alliance Agreement and/or planned service model Other, interdependent strategic change programmes (Greater Manchester Healthier Together and Primary Care Strategy) fail to deliver to planned timescales. Decisions/actions by partner organisations relating to services not directly included in the pooled budget, but which negatively impact upon delivery of the new model of care for Older People e.g. back office functions The Programme fails to deliver against its planned improvement measures, risking receipt of some performance related funding from the BCF

local model

Medium

services in Salford and to develop a more robust local primary care marketplace. Local and Greater Manchester commitment and focus on the three strategic change programmes.

Medium

As part of the Public Sector Reform Programme, top-tier leadership meetings are established to align strategic direction and support transparent communication.

Medium, Initially as Ministers decided that funding should not be withheld if a recovery plan can be agreed

ICP improvement measures and BCF metrics to be monitored on a frequent basis with underperformance reported to the ICP Board for recovery actions to be agreed.


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APPENDIX B:


Appendix B National Template 2.xlsx


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APPENDIX C:

Draft Delivery Framework for Assessment and Care Planning in Salford

DELIVERY FRAMEWORK- ASSESSMENT AND CARE PLANNING The delivery framework has 3 component parts: • • •

Development of local community assets Establishing an integrated Centre of Contact Shared care planning where the older people most at risk will be reviewed and a joint care plan agreed by Multidisciplinary Groups

The three component parts or delivery strands will work together to deliver a holistic and integrated programme. This appendix provides more detailed information on the approach of shared care plan development and the multidisciplinary groups (MDGs). A - OVERVIEW OF PROPOSED MODEL The proposed model has been designed to provide an open and explicit structure for integrated care within Salford, which promotes wellbeing and independence to everyone who is 65 and older, whilst enabling the effectiveness of the different components to be measured at both an individual and a population level. The model can be described by; • The environment • The individual The environment describes the offer from the ‘bigger picture’, the city, the community and services provided. The offer is being developed and adopted through standards. Standards are across Sally’s environment, which include standards for Sally, as a citizen, the city and for health and social care, including private provision.


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The individual describes the offer based on a ‘wellbeing and independence plan’. The plan operates at 4 levels, where the onus is to enable Sally to maintain her independence, and when intervention is required it is with ‘just enough support’. Where ever possible Sally’s plan will be to assist her to return to or maintain herself at the ‘able Sally’ status – • Able Sally - where Sally is independent, active and self managing

• Needs some help Sally- where Sally is more vulnerable, may be a carer or live alone, have early dementia or may have an acute issue which is short term and once addressed will be self managing once more. • Needs some more help Sally- has more sustained intervention for a period of time such as a home care package, regular district nursing support or intermediate care. • Needs a lot of help Sally- requires 24/7 support, where most likely they will be in a care home or care may be provided by their immediate family. The plan becomes cumulative through the levels, as an individual’s need increases. Able Sally’s Wellbeing plan focuses on the ‘5 ways to wellbeing’ and promotes activity and social interactions based on Sally’s preferences. Needs a lot of help Sally has a Care plan with detailed information such as her key worker, who to contact in hours and out of hours, as well as her shared care plan agreed with herself and the services providing care. The Care plan will also include her End of Life Care plan. The model aims to support the concept that Sally would be supported/enabled to access services to meet her current needs so that she can drop back to the previous level of care plan, or at least be maintained for as long as possible at her current level of care, with proactive crisis management and support aiming to prevent escalation of needs and services to the next care level.


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The diagram below shows the potential relationship between ‘Sally’s plan’ and the ‘offer’ across the environment depending on the level of plan required by Sally.

RISK STRATIFICATION Risk stratification - will initially be deployed by applying the 4 levels (of Sally) – • • • •

Able Sally Needs Some Help Sally Needs More Help Sally, and Needs a Lot of Help Sally

Able Sally is self-caring and independent, and Needs some help Sally may need low level review or intermittent input. These two levels will be low and low/moderate risk respectively. Needs more help Sally will be individuals assessed as substantial' by social care, or/and in contact with district nursing services several times weekly, or in intermediate care. Needs a lot of help Sally are individuals who rely on 24/7 care, or assessed as 'critical' by social care. The latter 2 Sally's are high and very high risk cohorts. Additional triggers will also require a review by a member of the multidisciplinary group (MDG) with escalation to full MDG as required. Triggers being where an individual's circumstances would appear to have changed in an unplanned way, such as an emergency admission or two A&E attendances within 3 months. Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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The 65+ population in Salford is 34,317 in an adult population of 191,107 (all figures based on 2012 midyear data from HSCIC). Needs a lot of help Sally cohort is presently 1051 (excludes people who are self-funding in a care home or home package who would fit the defined population). Needs more help Sally currently at 1313 ( excludes people admitted to intermediate care and emergency admissions who would be assessed as part of the wider MDG cohort but may not become residual within this group). The two high risk levels together are in the region of 2360 adults, and 2% of the adult population is around 3822. Once the numbers of people accepting intermediate care and those assessed following an emergency admission are included the coverage by the extended MDGs will be in excess of 2% of the total adult population. B - SALLY FORD INTEGRATED CARE PLANNING MODEL (SFICPM)

THE ESSENTIAL ELEMENTS OF THE SF ICPM

Overarching principles of Sally’s delivery model Promoting independence and resilience • Self care and self management • Reducing demand on services • Supporting carers • Choice and control • Earlier intervention, rehabilitation and reablement • Just enough support •

The ICPM is a delivery system for Salford’s Older people which takes account of health and social care with six essential elements: 1. A systematic assessment of health and social care needs when required. 2. The appointment of a named Key worker. 3. Joint working with all organisations/agencies involved in order to deliver person centred co-ordinated care. 4. An agreed shared Care Plan, based on the joint working and based on a stepped level of care need 1-4. 5. The sharing of essential information between provider agencies. Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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6. Regular reviews to reconsider need and change plans as necessary The detail of these six elements is described below: 1. A systematic assessment of health and social care needs. The assessment process for the ICPM will reply on the existing individual specialist assessments being carried out by the relevant professionals based on the presenting need/needs. The outcome of the assessment will then be documented on the shared care record and the interventions to meet the identified need populated on the shared care plan for that individual. The outcome of the assessment/s and treatment/interventions required will also be relayed to the key worker.

2. The appointment of a named Key worker. The key worker is defined as a qualified practitioner irrespective of their professional role, who has responsibility for co-ordinating care, keeping in touch with the patient’s/service user, ensuring the care plan is delivered and reviewed as required. Whilst an unqualified worker may carry out straightforward day-to-day care, the responsibility to assess, develop and share plans and review the care provided will remain with the key worker. The key worker must document a plan of care in the shared care record, and a copy given to the patient/service user and this will document how treatment and care will be carried out, by whom and when, and when this will be routinely reviewed. The key worker will usually be the person best placed to oversee care planning and resource allocation and can be of any discipline depending on capability and capacity. Key workers must be qualified professionals employed by one of the two statutory services, (Health or Social Services), and experienced in working with Older People. They should have the authority to co-ordinate the delivery of the care plan and ensure it is respected by all involved in its delivery, regardless of agency of origin. The Key worker is not necessarily the person delivering the majority of care. Actual care, support or therapeutic input may be provided by a number of others, particularly where more specialist interventions are required. The aim is to use the skills of all in the most appropriate, effective and efficient manner. Decisions about who should be the key worker will be made through local systems of MDT and case allocation. These should take account of: o The patient/service user’s needs and preferences in respect of gender, ethnicity, culture, language and religion. Salford Health & Wellbeing Board Integrated Care Programme & BCF Draft Plan Feb 2014 Version 1.0

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o Where the major issues in the care plan lie: whether these are medical, social, or mental health. o Training, experience and current workload of proposed Key worker The professional assigned the role of Key worker, if not present, should have given prior consent to accepting the role. Any change of key worker must be handled sensitively and the service user informed throughout, and only after a full handover has taken place. The role of the key worker is to: o Carry out or co-ordinate the on-going assessment of the patient’s/service user needs and associated risks, involving the patient/client, and taking into account the views of carers and of other agencies e.g. probation, housing, voluntary sector; o Formulate a care plan, detailing the patients/client’s needs and how they will be met The Patients/clients must be included in the formulation of their care plans, which should be clear and intelligible. They should always be offered a copy. This will be subject to regular audit. o Acts as a first point of contact for the patients/client, carer and other professionals o Ensure that an out-of-hours contact number is specified in the care plan for patients/clients and carers is offered to the patients/client with the explanation that it sets out the plan for their care. o Be responsible for co-ordinating the efforts of others in delivering the shared care plan. o Make contingency plans with the patient/ client if a situation changes and implement as necessary, monitor the overall care plan and call reviews as agreed, or when the need arises; o Ensure that all relevant information is communicated to those involved and liaise with wider health community where practicable (e.g. on admission to acute inpatient care). o Distribute shared Care Plan details to independent sector providers as appropriate. o Maintain contact with the patients/client if an in-patient and continue to act as key worker. o Share information with carers, having due regard to the patient’s/client’s wishes o Ensure that when a patient’s/client moves out of the area appropriate liaison with receiving authorities takes place. o Be responsible for maintaining an up to date risk assessment and management plan. 3. Joint working with all organisations/agencies involved


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An essential feature of the ICPM is joint working between all the relevant professional and departments who are working will older people in Salford, from the four statutory organisations and the 3rd sector providers. Joint working will be underpinned by a clear vision for the service for older people in Salford , a shared value set in working with older people, a clear communication process between the various agencies, clear clinical pathways and protocols and commitment to information sharing and shared care planning.

4. An agreed Care Plan, based on the joint working and on a stepped level of care need 1-4. All care plans should include: o o o o o o o o o o o o

Name the Key worker Relate clearly to patient’s/service user’s assessed needs and choices. Be devised and agreed with service users, and where appropriate, their carers Include strengths, promote wellbeing, independence and where relevant aid recovery Specify realistic outcomes, and how they will be measured. Give an estimated timescale for achievement or review of outcomes Show contributions expected of all agencies involved Contain crisis and contingency plans, including out of hours telephone numbers. Reflect diversity of culture and ethnicity, gender and sexuality Be accessible in language and format Contain advice to GPs on how they should respond if additional help is needed Give date of next planned review

The shared care plan model described 4 levels of need, see Sally’s shared care plan. 4.1 Able Sally- Staying well and able Plan o People who are living well at home, with little or no specific health or social are need. o People who are able to maintain their wellbeing and independence and understand what is important to them to enable them to keep well, able active and connected. 4.2 Need some help Sally


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o People who require the support or intervention of one agency or discipline, or have an acute need which intervention/ education will assist in resolving to a level whereby the individual is able to largely self manage. o People who are more able to self-manage their health problems; o They have an active informal support network; o They are more likely to maintain appropriate contact with services

4.3 Need some more help sally People who are supported by services through any of the following – o Regular domiciliary visits from district nursing service o social care needs meeting the ‘substantial’ risk to independence when Fair Access to Care Services (FACS) criteria applied o Intermediate care/ reablement 4.4 Need a lot of help sally o Needs 24/7 care, be that in a residential/nursing or EMI home o Needs 23 hour package of home care. o social care meeting ‘critical’ risk to independence when FACS criteria applied 5. The sharing of essential information The success of an integrated care model is partly based on the ability to proactively share essential information and have joint decision making between the person, the provider organisations and the 3rd sector when appropriate. This sharing of information will take place in two ways. o The development and implementation of a shared care record, which includes an updated copy of the shared care plan. o The attendance of relevant professional at the regular locality MDT meetings. 6. Regular reviews to reconsider need and change plans as necessary The review of people under an ICPM will be on-going. There will be a formal multidisciplinary, multi-agency review, led by the key worker. Frequency of review will vary dependent on need: Able Sally- 12 month minimum review frequency- MDT not required, will be escalated by key worker as required. All other 3 Sally’s (needing help) - 6 month minimum review frequency, but more frequently if needed.


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Review may be at the request of service users, carers, or any member of the care team The review must consider all the person’s assessed health and social care needs as documented in the previous shared care plan and how they may have changed, and agree any changes needed to the care plan in order to meet future need and maintain current health and optimal level of independence and wellbeing.

MULTIDISCIPLINARY GROUP PROCESS As part of the forward plan the pilot MDGs are testing out the process identified below which will be amended in response to the feedback received. • Pre Meeting: o Live stratification to inform client lists o Receipt of ‘Patient Lists’ to be discussed/reviewed at MDG one week in advance of meeting o Risk Stratified (as detailed above) o List produced by ‘Administrator’ with all reference numbers (NHS, P and Hospital) o Process of where/who the list should be sent to, to be confirmed o Would be advantageous to have the template as a shared document (electronic Shared Care Summary Record being progressed) •

Each MDG Member undertakes pre-planning/work from the patient list (within the template) o Update of any issues/actions since last meeting o Investigation of any information/knowledge of new patients on the list

•

Attend Meeting o Discuss each patient o Clarify actions to be taken and outcomes expected assigned to individuals o Update/record template o Confirm named Care Co-Ordinator/Key Worker (where it isn’t GP) o Confirm next review date

•

After Meeting o Administrator circulates updated template with actions o Undertake actions and update individual professional care record


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o Share information on further actions prior to next MDG where necessary o Care Summary Record updated when operational


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APPENDIX D: Governance and Programme Structure


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