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Hull BCF Jan 2014 V1

Hull Better Care Fund

A Plan for Integration and Transformation

First Draft Submission

Erica Daley Strategic Lead Planning and Integration NHS Hull CCG

Clare Brown Assistant Head of Services, Adult and Social Care Hull City Council

http://www.hullcc.gov.uk/pls/p


Forward Hull City Council and Hull Clinical Commissioning Group have a vision to transform health and social care through integration to ensure delivery of three interdependent strategies for the City

The City Plan

Hull’s Joint Health and Wellbeing Strategy (2013 -2016

Hull CCG Strategy Hull 2020 The Better Care Fund (BCF) provides a vehicle to deliver the required transformational change at scale and pace governed through a collective responsibility for the city wide outcomes. We are committed to aligning additional resources to the BCF in order that service commissioning is fully joined up within the City of Hull for the benefit of our citizens One of the principle objectives of the Better Care Fund in Hull is to achieve a shift of care across a continuum of co-ordinated services. The shift must take place from hospital to community, from residential care to home care and from service led to more personalised support for those who require it. Many more people will be in control of and managing their own care. Hospital admission and a reliance on residential care will no longer be the default option; this will require a major cultural shift and a strong collaborative approach to joint commissioning, contracting, care delivery and market management. We acknowledge the development of our workforce as a key priority. We believe that the delivery of system transformation requires the support of existing and additional providers, the voluntary, community and social enterprise organisations that thrive in our city and public sector partners in the widest sense. Whole system transformation is our vision and the Better Care Fund is our enabler. This is Hull’s plan to begin to realise ambitions for an integrated whole system of care that enables the people of Hull to improve their health, resilience, wellbeing and aspirations for the future.

People in Hull will expect better care

and better care will be organised around them.

Councillor Colin Inglis Chair Hull Health and Wellbeing Board

Emma Latimer Chief Officer NHS Hull CCG

Trish Dalby, Deputy Chief Executive On behalf of Darryl Stephenson, Chief Executive Hull City Council

Dr Dan Roper NHS Hull CCG Chair


Contents Forward ................................................................................................................................................... 1

Contents .................................................................................................................................................. 2

1. Introduction .................................................................................................................................... 4

1.1 About Hull ............................................................................................................................... 6

1.2 Our Challenges ........................................................................................................................ 7

1.3 Deprivation and poor health outcomes .................................................................................. 7

1.4 Reliance on Acute and Residential Care ................................................................................. 8

1.5 Demographic pressures ........................................................................................................ 10

2. Our Vision for Better Care ............................................................................................................. 12

2.1 Evidence Base - The Wennberg Model ................................................................................. 14

2.2 Model based on Hull’s population ........................................................................................ 15

3. Supporting Strategies .................................................................................................................... 16

3.1 Hull’s Joint Health and Wellbeing Strategy (2013 -2016) ..................................................... 16

3.2 Hull CCG Strategy Hull 2020 .................................................................................................. 16

3.3 The City Plan.......................................................................................................................... 17

3.4 Transformation Map ............................................................................................................. 18

3.5 Care Hub Concept ................................................................................................................. 18

3.6 Extra Care Housing ................................................................................................................ 19

3.7 Transforming the system ...................................................................................................... 19

4. Outcomes ...................................................................................................................................... 18

4.1 Patients Voices ...................................................................................................................... 18

5. Care Coordination ......................................................................................................................... 20

5.5 Care Coordination Process .................................................................................................... 21

5.6 Case Example – Prevention and Resilience ........................................................................... 22

5.7 Case Example Self-Care and Support .................................................................................... 23

5.8 Case Example Early and Intensive Intervention .................................................................... 24

5.5 Complex Multi Care Need ..................................................................................................... 25

5.6 Progress so far – from co location to integration ................................................................. 26

6. Public Communications................................................................................................................. 28

7. Whole System Integration - Provider Impact ............................................................................... 29

7.1 Provider landscape ................................................................................................................ 31

7.2 In Hull .................................................................................................................................... 31

8. National conditions ....................................................................................................................... 33


9. Better Care Schemes ..................................................................................................................... 34

10. Finance ...................................................................................................................................... 37

11. Outcomes/metrics .................................................................................................................... 38

11.1 Baselines and Projections ..................................................................................................... 38

12. Governance ............................................................................................................................... 40

13. Risk/ Contingency Plan .............................................................................................................. 42

Appendix A – Hull Care Hub Example ................................................................................................... 44

Appendix B – National Voices ............................................................................................................... 45

Appendix C National conditions ............................................................................................................ 46

Appendix D Better Care Initiatives ........................................................................................................ 49

Appendix E Glossary .............................................................................................................................. 53


1. Introduction

Summary

Hull City Council and Hull Clinical Commissioning Group in a Strategic Partnership delivering the

BCF transformation programme

Progress around integration already made through reablement and social care funding

Aim to integrate the commissioning of health and social care services

Whole system transformation is the primary objective to address complex needs

Hull is one of the most deprived cities in the country: life expectancy is lower in Hull than in many

other parts of England; high numbers of emergency admissions of people aged over 65

Further scope for reductions in admissions through the utilisation of the Better Care Fund by

improvements in the more effective and earlier support of people with long term health conditions

and their often frail elderly carers

The biggest population challenge in Hull is the percentage of those people aged 65 years and over

Hull City Council (Hull CC) and Hull Clinical Commissioning Group (Hull CCG) are key strategic partners working together and leading on the delivery of a transformation programme for improvements to health and social care across the city. They serve a population of approximately 290,000 people and are committed to a collaborative approach to improving lives by optimising health and wellbeing within communities. We have made good progress through the use of reablement and social care funding to improve the delivery of more integrated care designed around individual need. Work to date has included commissioning integrated services to build capacity and develop the intermediate tier of care, with a multidisciplinary approach to reablement and end of life provision. These services have focused on improving transfer of care from hospital and for many more older and disabled people to access rehabilitation and increase or regain their independence. As a result the City now has a wider range of provision that is aligned but there is still much to be done to take these developments to the next phase; increase the scope and scale of services working together and finally progress to integration. To ensure success we will integrate the commissioning of health and care services and further develop a shared vision and commitment to providing seamless and sustainable health and social care services that local people want and need to lead healthier lives. The Better Care Fund provides us with the opportunity to progress our aspiration for a joint strategy to improve the access to advice and information for local people, the quality of the care they receive and increase the choice and control they have over their lives through agreed objectives and pooled resources. Our shared vision is for whole system integrated care and to achieve this ambition we have taken care to ensure our planned outcomes have been aligned to the 3 interdependent strategies for the City, the CCG Strategy – Hull 2020, Hull’s Joint Health and Wellbeing Strategy (2013-16) and the City plan which bring together key partners signed up to an improvement programme which will influence the wider determinants of health such as housing and jobs. These local documents provide the blueprint for whole system transformation and reinforce a shared commitment to improve care, quality and access to resources. Hull CC and Hull CCG acknowledge their collective accountability to ensure the best health and social care outcomes for the people of Hull.


Figure 1 Local Documents

The following plan describes the shared approach that Hull CC and Hull CCG will take to influence the scale and pace of change to reduce the City’s health and social inequalities. Hull is a City with high levels of deprivation, associated poor health outcomes and a sharply rising population of older people. There is also a need to work with communities to raise the expectations and aspirations of the people living in the city for better health and support and to capitalise on their own resources to self-care. The Better Care Fund (BCF) Plan for Hull will describe how it will complement the broader health and wellbeing ambitions for the City by recognising the skills of our workforce and the potential of local communities as partners in building whole system integration. Our initial two year plan for the BCF in Hull is focused on the needs of our population of older people and people with physical disabilities. As strategic partners Hull CC and Hull CCG realise it will not be enough to simply make incremental adjustments to existing services if we are to meet increasing demand and realise the full potential of integrated commissioning for this vulnerable groups. The local vision described within this plan represents our shared aspirations for Hull and provides us with the future state objectives and evaluation criteria. Individual case examples are also presented to illustrate how this plan will look, feel and impact on both the people living in the City and the people working together to provide integrated health and social care. Our Better Care Schemes and associated initiatives are derived from local principles of delivery and are set out with associated objectives and measures against the national conditions. A summary of the initial consultation with our service users and local providers is included to evidence our commitment to engagement and the development of a robust communication process with all stakeholders.


Finally the plan presents the local metrics that will provide assurance against the required patient experience outcomes and performance and the detail of the financial resource committed by each partner organisation. To date these are current estimates and demonstrate our intentions to align sufficient resource to achieve the radical service transformation for Hull.

1.1 About Hull Hull is an innovative and dynamic city that has faced significant challenges in respect of the health and wellbeing of its population. Much of this is linked to high levels of deprivation. The 2010 Index of Multiple Deprivation which uses a broad range of indicators to measure poverty and other problems identified Hull as the 10th most deprived local authority in the country. Life expectancy is lower than in most of England, with a difference of up to 10 years between the least and most deprived wards, over half of people aged 65+ have a long-term illness with 1 in 5 likely to have a mobility issue. Whole system transformation is our primary objective to address these complex needs. There are some good examples of how we have begun to join up care for our most vulnerable service users but there are very few services that are fully integrated to the point of being able to eliminate “hand offs” and transfer care with shared accountability. Assessment of our current care configuration for these service users presents a fragmented picture with areas where whole pathways can be developed further. Achievement of whole systems integration will be reliant on our main resource, our workforce. Our plan will provide the infrastructure for sharing information across care settings but the focus is to embed core values across all sectors and tiers of care that embody the principles of transfer of care, shared accountability and care coordination. These factors combined with the approaching demographic trends in Hull have informed the development of the Better Care Plan and provided the rationale for an initial focus on reablement services and care of the elderly.


1.2 Our Challenges The following section describes the challenges for Hull and presents some of the local demographic

information that has provided the rationale for our plan. Figure 2 highlights the 3 main areas that

the Better Care Fund is designed to address.

Figure 2 Better Care Fund Areas

1.3 Deprivation and poor health outcomes Deprivation is strongly associated with poor physical and mental health. Life expectancy is lower in Hull than in many other parts of England and there is a life expectancy gap of up to 10 years between the least deprived and the most deprived electoral wards. The city has suffered a decline in traditional industries, and despite considerable regeneration activity and inward investment in recent years, Hull remains the 10th most deprived local authority in England. This means that Hull continues to be the most deprived local authority, not only in the Humber sub-region, but in the whole of the Yorkshire and Humber region based on the Index of Multiple Deprivation (IMD) 2010 score. Hull is ranked as the 18th most deprived on grounds of income. Over 37% of households are in receipt of Housing Benefit and/or Council Tax benefit and 16,620 individuals receive pension credit. At May 2013, 14,270 people were claiming Employment Support Allowance and other incapacity benefits , making up 8.3% of the working age population compared to the national figure of 6.2%1. Around 37% of Hull residents over 60 claim pension credit. Average income (median weekly pay) in Hull is significantly low, within the lowest 10 of all local authorities in England. An estimated 31% of Hull households have an income of £15,000 or less compared to the mean average income for the city of £25,160 ( Experian data for Hull 2013) .The national gross household income of the middle fifth of households in 2010/11 (ONS) was £29,100. The impact of low income and poor housing on health and wellbeing cannot be underestimated and the relationship between the Better Care Plan and local housing strategies will be developed further as the plan is implemented.

1 http://www.nomisweb.co.uk

Deprivation and poor health outcomes

Reliance on Acute and Residential Care

Demographic pressures


The mortality rate from all causes under the age of 75 years is 30% higher than the mortality rate for England; the main causes of death in Hull being cancer and coronary heart disease (CHD). These two diseases account for more than half of all deaths of people under the age of 75 years, which with the associated health needs linked to deprivation and high numbers of smokers in the City presents a challenge to the current system in terms local people who need hospital and high intensity services whilst focusing efforts on prevention, wellness and self care.

1.4 Reliance on Acute and Residential Care Health and social care partners are working together to address the high numbers of emergency admissions of people aged over 65. A pilot study of the management of people on an ambulatory basis in A&E has demonstrated that there is significant opportunity to transform the care and the high levels of activity associated with frail older people, people who have respiratory disease and people with heart failure. Figure 3 shows the upward trends over the last 3 years in emergency admissions for people aged over 65. Without any intervention in the current pathway this group will present our greatest challenge in managing demand for hospital services. We also know that an admission to hospital for older people quickly reduces ability so that rehabilitation and reablement potential is diminished which in turn results in high risk of admission to permanent residential care and we know from public consultation that people would rather stay in their own homes whenever possible.

Figure 3 Non elective admissions over 65 year on year change

Work is underway to understand the presenting clinical needs of this group in order to employ a more ambulatory approach to their care. Recent pilots show that there is scope to improve the outcomes and experience of this group by improving the interface between primary, community and secondary care and managing pathways that avoid the need for admission and transfer care safely back to a community setting. The revised pathway will ensure that following an A&E attendance there is a follow up review at home of social and health care needs to provide focused support. The prioritisation of ambulatory approaches to elderly acute medical care is included in out Better Care Plan.


Figure 4 Emergency Admissions for falls, 65 and over

Falls can cause moderate to severe injuries, such as hip fractures and head traumas and can change lives - loss of confidence in movement may result in older people leading a more limited quality of life and trigger a ‘vicious circle’ of falls, hospital readmissions or a move to permanent residential care.

As shown in Figure 4 Hull has seen an increase in emergency admissions for injuries due to falls over the last three years. This shows a 12% increase for 2013-14 compared with the same period in the previous year. On average there are 45 emergency admissions per month due to falls and a challenging trajectory of an 11% reduction has been set for 2014/15 as the local metric.

Table 1 shows actual numbers of Council funded admissions to residential and nursing homes. This is an improving picture as a result of the more recent developments in reablement services and offset by NHS continuing health care (CHC). Where a nursing or residential home placement is fully CHC funded they are excluded from social care data in the tables below,

Period Total Admissions

2009/10 411

2010/11 402

2011/12 396

2012/13 336 Table 1 Total Council Funded Admissions to Residential and Care Homes

There is further scope for reductions in admissions through the utilisation of the Better Care Fund to

develop the more effective and earlier support of people with long term health conditions and their

often frail elderly carers. The best performing councils have reduced reliance on residential care

through focused efforts to improve the early support for people with needs and development of a

range of support for family carers including prompt access to respite, when needed. We will make

use of our existing networks in health and social care. Learning from others is a key part of a sector-

led approach to improvement for councils. Using this approach to make improvements in our

performance to deliver better outcomes for local people with stronger accountability through

increased transparency will help local people drive further improvement

Changes to service delivery alone cannot address the imbalance in the supply and quality of accommodation, creating a critical mass of Extra Care housing is essential for the provision of onsite care for people.


1.5 Demographic pressures In October 2012 the GP registered population was 290,002 with 266,363 City residents. The biggest population challenge for health and social care commissioners and providers in Hull is the percentage of those people aged 65 years and over; which is currently estimated to be at around 14% and is expected to increase to 17% by 2030. Figure 5 shows the projected increase in population of people aged 65 and over to 2020. This means a potential increase in the number of people in the city with significant health and social care needs.

A substantial number of the 112,596 households in Hull are single people households and around 36% of the over 65’s were living alone in 2011. 4,458 (34%) of the 13,075 one person households aged 65+ reported a long term health problem or disability. Around 10% of Hull’s population reported via the 2011 census that their day to day activities were limited a lot by ill health or disability compared to 9% regionally and 8% nationally. Information from our Joint Strategic Needs Assessment (JSNA) shows that many of our residents are living with disabilities that may affect their physical and mental health. Their ability to access appropriate services is a key priority. The prevalence of diagnosed serious mental health for Hull (0.8%) is similar to that for England, but in Hull mental health issues are a significant for people living in the most deprived areas. Mental health is the most common medical reason for entitlement of working-age claimants to Incapacity Benefit and Severe Disablement allowance in Hull (39% of claimants). The number of people diagnosed with dementia by Hull GPs is 1,362; and the numbers are expected to increase by around 500, however, the level of people diagnosed is expected to be lower than the number of people actually living with dementia. It is estimated that 3,194 people actually have the

Projected increase in population of people aged 65+ to 2020

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

2012 2014 2016 2018 2020

People aged 65-69 People aged 70-74 People aged 75-79 People aged 80-84 People aged 85-89 People aged 90 and over

Figure 5 Projected Increase in Population of People Aged 65+ to 2020


disease. In the next 15 years it is projected that this figure will increase by 29%2. This target is a key national and local requirement for the CCG, Hull CC, people and their carers. The JSNA identifies the population changes summarised above as a pressure, which is compounded by levels of deprivation, poor health and housing. The impact of the broader health issues of our local demographic issues has informed the alignment of public health resources to our plan. This will include a focus on self care and optimising the use of personal health budgets and psychological therapies to support people to co create their own care plans and have access to practical support and physiological support in equal measure.

2 Hull JSNA & Health and Wellbeing Strategy


2. Our Vision for Better Care

Summary

Health and Social Care organisational boundaries will be broken down to ensure that care is co-

ordinated across different care settings

Improved access to care at the point of need is delivered in local communities

Better Care Fund will be used to invest significantly in an improved, integrated health and social

care system, changing the way that health and social care services are funded to drive

improvements for older and disabled people

Many more services will be required to provide 7 day working across the range of primary and

secondary health and social care

Planned / elective care services will be streamlined to bring about efficiencies and improvements

to clinical pathways

Incentives will be needed to promote early detection, diagnosis, rehabilitation and integration,

which will in turn need to be balanced by a reduction in the incentives promoting hospital based

activity

Focusing on supported self-care, wellness and prevention can realise more benefits in terms of shifting

the reliance on hospital care and achieving better health outcomes

BCF Strategy aligned with Hull’s Joint Health and Wellbeing Strategy 2013-2016, Hull 2020 and the

City Plan

The concept of local integrated hubs that wrap early help, support and intervention around those

in need in a community setting is a feature of the Hull 2020 Strategy and City plan and supports the

implementation of the Better Care Fund plan

Increasing provision of Extra Care is expected to reduce reliance on residential care over time by

providing a viable alternative for all adults with support needs

Our local vision for Better Care is described below; it is our aspiration that local health and social care services will change significantly over the next 5 years. Health and Social Care organisational boundaries will be broken down to ensure that care is co-ordinated across different care settings. There will be easier access to care at the point of need delivered in local communities. People will have more choice and control to enable them to stay in their home. They will have the resources to self-care and the information to access coordinated care when required. People will understand their local services because they will be instrumental in the development and monitoring resources in Hull.

People in Hull will expect better care and better care

will be organised around them.

The Better Care Fund will be used to invest significantly in an improved, integrated health and social care system, changing the way that health and social care services are funded to drive improvements for older and disabled people. This will resource a joined-up health and social care service, shifting care away from hospital to home or community facilities, promoting self-care and independent living. It is expected that the secondary care sector will reduce as a result and that staff in all acute and community services will work differently as we progress our plans – teams without walls.


Our Better Care resources will be targeted at schemes that can achieve a shift from acute and residential care to community and self-care. Over the course of the Better Care Plan prevention and self care will become the norm, integrated community teams will be empowered to deliver whole system care and result in acute episodes of care being effectively managed and people being supported to return to independent living. This vision will be realised by working to deliver a transformational strategy that focuses on organising care into 4 delivery models based on need:

Supporting resilience and wellbeing

Self care and carer support

Early intensive intervention

Complex multi care need We will achieve this by:

Shift care from hospital to community, residential to home care

Care organised around Hubs

Lead care professionals and care coordination

7 day working

Information sharing across organisational boundaries

Whole system integration including commissioning

Community owned, designed and delivered In order to achieve sustainable change, many more services will be required to provide 7 day working across the range of primary and secondary health and social care. Urgent/unplanned care services will be transformed to ensure that services are able to respond rapidly to unplanned care needs, across a range of environments, so that patients are better supported by a new more cost effective model rather than the traditional system based around hospital care. Planned / elective care services will be streamlined to bring about efficiencies and improvements to clinical pathways, to deliver more productive elective care, which will improve services and free up the resources to be used for the Better Care Fund.

As models of care become increasingly centred on prevention, timely discharge and speedier recovery, the systems that finance care will have to shift accordingly. Incentives will be needed to promote early detection, diagnosis, rehabilitation and integration, which will in turn need to be balanced by a reduction in the incentives promoting hospital based activity. In Hull, under the mandate of the local unplanned care board work is already underway to provide more alternatives to admission and to facilitate timely transfer of care.


Figure 6 depicts how we expect that shift to take place across the 3 predominate care settings; one of our local measures will be to track the number of older people in each care setting over the next 5 years.

2.1 Evidence Base - The Wennberg Model The Kings Fund highlights evidence to support a focus on reducing the rates of hospital admissions through active management. Within the recommended evidence (Tian et al 2012) note that the rate of hospital admissions in the most deprived areas is more than twice the rate of the least deprived areas in England. The Wennberg Model demonstrates that opportunities to transform the system do not always rest with the high risk patients or the 5% of people at high risk of admission. Focusing on supported self-care, wellness and prevention can realise more benefits in terms of shifting the reliance on hospital care and achieving better health outcomes. Its application demonstrates the benefits of focusing effort on particular populations of a local health and social care economy rather than concentrating services on patients at high risk of admission. The Wennberg model assumes a population average of 63/1000 and breaks this down into tiers of care and the numbers of people admitted from those cohorts. In Hull the majority previous work has concentrated on the patient at high risk of admission and those already well known across our systems. However there is evidence that continuing to sustain this demand will not be sufficient to cope with a growth in demand and no growth in resources. The Wennberg model shown in Figure 7 has been applied to the population of Hull (Table 2) to inform the initiatives within of our Better Care Fund.

Hospital care

Ambulatory

Care

Residential

Care

Community

Care

Home Care

Self Care

Figure 6 Shift of Care


Figure 7 Rates of emergency admissions by different risk patients (based on Wennberg et al 1996). Percentage of all emergency admissions is equal to the relative rate multiplied by the size of the population group.

2.2 Model based on Hull’s population The local interpretation of the Wennberg model (Table 2) demonstrates that in Hull there are 13,601 non elective admissions that could be saved. This is a comparison of 2012/13 Non-Elective admissions of 31,828 to the Wennberg modelled activity 18,227 based on population size. The model provides a useful baseline for assessing the impact of any change on hospital services and the potential to shift the cost of admissions with associated integrated schemes.

Hull Population 289,000

Relative Risk No. in Hull (all

ages)

Rate of emerg. adms per 1,000 *

Predicted adms (all

ages)

% of total emerg. adms

Very high 0.50% 1,445 1,170 1,691 9.3%

High 5% 13,005 346 4,500 24.7%

Moderate 20% 43,350 107 4,638 25.4%

Low 100% 231,200 32 7,398 40.6%

TOTAL 289,000 18,227 100.0%

*Proportions based on the Wennberg Model. ( Wennberg D 2006) Kingfund The Combined Model was developed on a total population of 560,000 patients from two PCTs using three years of hospital data (April 2002 – March 2005), including inpatient (IP), outpatient (OP), and accident and emergency (A&E) attendance data. Table 2 Local Interpretation of The Wennberg Model


3. Supporting Strategies Our shared vision of whole system integrated care and planned outcomes have been aligned to the 3 interdependent strategies for the City, the CCG Strategy – Hull 2020, Hull’s Joint Health and Wellbeing Strategy (2013-16) and the City plan which bring together key partners signed up to an improvement programme which will influence the wider determinants of health such as housing and jobs. These local documents provide the blueprint for whole system transformation and reinforce a shared commitment to improve care, quality and access to resources.

3.1 Hull’s Joint Health and Wellbeing Strategy (2013 -2016) Will ensure the co-ordination of key services and delivery as close to communities as possible to improve access for overall health and wellbeing. Our Strategy identifies the need to:

develop an integrated approach to service provision;

increase the availability of affordable and appropriate housing, including Extra Care, and the provision of appropriate repairs and adaptations;

complete a cross-partnership review of current and future provision of services for people transferring from hospital recovering from illness;

develop a multi-agency approach to reduce social isolation for vulnerable people;

implement telehealth and telecare technology for health, housing and social care use to support people in their own homes and empower them to manage their own health and wellbeing;

provide support to people on discharge from hospital by reablement and intermediate care services – ensuring that they are able to achieve independent living.

3.2 Hull CCG Strategy Hull 2020 The CCG strategy sets out a vision that will be delivered by public services collaborating to bring about an integrated map of Health & Social Care, informed by an ongoing dialogue with the people of Hull. The CCG will deliver a personal wellbeing agenda, including resilience and mental wellbeing, aspirations and expectations. As this will require the full buy-in of the local population, service and public incentives will be utilised to inspire individuals and communities to work towards a common purpose. By 2020 the organisation will ensure that communities hold the purse for service commissioning at as local a level as possible. The model that delivers this vision is based on several key principles:

Public focused (access, experience, safety, quality) not patient focused

Driven by the people of Hull, clinicians, expert staff, and partners in recognition of the need for local solution requirements

A single delivery organisation moving beyond traditional primary and secondary care boundaries

Addressing the process and system issues - reducing waste, inefficiency and frustration

Sustainable skill base to meet wider public need

Makes best use of partnerships across all sectors, particularly through the voluntary sector and exploration of options regarding community owned initiatives

Clearly defined role for primary care including a GP job description

Work within existing infrastructure to develop optimum model of Health & Social Care plus Welfare

It is a key aim of the CCG to allow the individual to take ownership of their own care and development. This will empower them to pursue happier, healthier more independent futures and develop a sense of aspiration and hope for the future. The priority of this work stream will be to provide access to interventions to promote self-confidence and competence to self-manage, e.g.


increase use of email and telephone advice to patients as well as focussing resource on education and self-care skills development. The Better Care is central to the delivery of the strategy and has been designed to support delivery of these aims.

3.3 The City Plan The 10 year City Plan aims to create 7,500 jobs for local people, delivering a £1 billion investment in the city, reducing the bills of every household, cutting the city’s carbon footprint by one million tonnes and reducing the welfare bill. The Plan currently incorporates 65 projects to be delivered over the next 10 years, but will continue to develop and evolve as local residents – and everyone who has a stake in Hull’s future – are given the opportunity to contribute their own projects and ideas.

The Plan has five key ambitions –

To harness all Hull’s assets to become the leading UK Energy City

to make Hull a world-class visitor destination

to help residents to make their money go further

prevention and early intervention

safeguarding the most vulnerable residents

The latter points have a direct relationship to the delivery of the Better Care Plan. The City Plan states that Hull will be a place where vulnerable residents are supported to stay as independent as possible - for as long as possible. When extra support is needed, it will be provided in such a way that enables residents to keep as much control over their lives as possible.

Projects and proposals include -

Care and support advice and information on-line – as digital connectivity spreads across the city, so the possibilities for bringing support and advice right into an individual’s home increase to help them live as independently as they can;

Preparation for the Care Bill, care capping and the new tranche of people who will require local authority assessment

The PFI Extra Care – at least 250 additional self-contained apartments on three sites. These sites are designed as hubs with on-site care services available at all times.


3.4 Transformation Map The transformation map (Figure 8) is taken from the Hull 2020 Strategy and depicts how the vision will be realised and how it is underpinned by the required system changes and associated work streams. The Better Care Schemes form the foundation for delivery of the broader objectives.

Enabling Work

Packages

Focused on:

Co

nti

nu

um

of

Care

Prevention and Resilience

Self-Care and Carer Support

Early and Intensive Intervention

Complex Multi-need Care

CCG Priorities21st Century

Primary careNext GenerationIntegration

VisionFor Hull 2017 to be the year of Health and Wellbeing for the City; working toward 2020 Where

organisations work in an integrated whole system of care, that enables the people of Hull to

improve their own health, resilience, wellbeing and aspirations for the future.

Better Care

Schemes

Primary Care and Self Care

Ambulatory Care Falls

Acute and Residential Care Long Term

Conditions &

Dementia Prevention

Principles

Of Delivery Care HubsSingle Care

Navigator

Translation of

High Intensity

Services to Care

Closer to Home

Integration

Public /

Community/

Individual

Designed and

Owned

National

Transformation

Priorities

Citizens fully

included in all

aspects of

service design

and change and

that patients are

fully empowered

in their own care

Wider primary

care,

provided at

scale

A modern

model of

integrated

care

Access to the

highest

quality urgent

and

emergency

care

A step-

change in the

productivity of

elective care

Specialised

services

concentrated

in centres of

excellence.

Figure 8 Transformation Map

3.5 Care Hub Concept The concept of local integrated hubs that wrap support and intervention around those in need in a community setting is a feature of the Hull 2020 Strategy and supports the implementation of the Better Care Fund plan. Traditional models of primary health and social care, and General Practice in particular, are key elements but this model it is also focused on delivering far wider care and wellbeing services; set up to help patients find the appropriate support in a single location. The care hub supports the delivery of care through the early help and intervention programme

recently developed by the Hull Children and Families Board now includes the work with older

people. As part of the public health life course framework, it is a settings approach from which key

services can be integrated around vulnerable families and individuals. These hubs will develop

around a range of community, health and social care facilities.

Hull’s city plan confirms a commitment to create community based hubs that operate as Centres of Excellence in Care as part of the ongoing improvements to service delivery. The Extra Care and Rehabilitation projects are seen as catalysts to establish Centres of Excellence in Care and service delivery promoting hub and spoke service delivery at local level. An example of the care hub can be seen at Appendix A – Hull Care Hub Example on page 44.


3.6 Extra Care Housing Extra Care is a subsidiary of the Housing Strategy and sets out how Hull CC aims to provide increased personal choice for adults who need support through development of Extra Care housing through new build and conversion. Currently, for those with high level support needs who cannot continue to live independently the only alternative is residential care, on which the City is over-reliant. The other main option for older people is sheltered housing but the local stock is variable in quality, with some schemes of poor design. Even the better quality stock is only suitable for older residents with low to medium levels of support needs and is, in any case oversubscribed. Increasing provision of extra care is expected to reduce reliance on residential care over time by providing a viable alternative for all adults with support needs. Over 250 extra are apartments on 3 sites are planned to be delivered in 2016 providing an alternative to sheltered housing for older people and increasing personal choice. Extra Care will be instrumental in providing the range of accommodation needed to support delivery of the BCF plan and also support the concept of organising care around care hubs which will be described further later in the plan

3.7 Transforming the system A transformed health and social care system will see:

A single system of integrated governance and partnership

Empowered and skilled health and social care workforce who are positive about their role and supported to improve the care and treatment they provide The best use is made of the whole public service £, and funds that are community earned/community owned Reduced “hand offs” in the system with a shared accountability to transfer care

Individual treatment and care will be through a process of care coordination and lead care professional

People are able and motivated to look after and improve their health and wellbeing, so more people are living in good health for longer, with reduced health inequalities People choose what, where and when they access services

The most effective use is made of resources across health and social care services, avoiding waste and unnecessary variation Shared information to speed up response, coordinate care and reduce duplication 7 day access to quality services

People providing support to unpaid carers to others to maintain their own health and wellbeing Right-sized high quality estate and support infrastructure that is conducive to the best outcomes and most productive implementation of resource across the system Informed, educated and consequently engaged public who are empowered to drive their own outcomes

People will be living safely and independently in the community and have control over their care and support Clearly defined and equitable services are available to all on the basis of need


4. Outcomes

Summary

Person-centred co-ordinated care and support is essential to improving outcomes for individuals

who use health and social services

Hull BCF plan requires organisations to work together, think creatively and identify new ways of

doing more for people who use services so that every £ spent on care and support counts

Public engagement and consultation in Hull has demonstrated that a service that prolongs

independence and allows people to remain in their own home for longer is a priority

Hull has an established People’s Panel, which is a joint venture between the CCG and Hull City

Council

Person centred coordinated care and support is essential to improving outcomes for individuals who use health and social services. Our plan requires us to be working together, thinking creatively and identifying new ways of doing more for people who use our services so that every £ spent on care and support counts as we endeavour to improve outcomes

4.1 Patients Voices The National Voices narrative of integrated care and support - something that an individual person would recognise as integrated care and support- describes the understanding of an individual’s experience of person-centred coordinated care and support.

We have used “I” statements to illustrate what people should be able to experience from the health and care system. In describing these experiences in a personal way we hope that people are more empowered to challenge the system if it falls short of this.

This is shown in Appendix B – National Voices on page 45.

Our Schemes and subsequent services will be required to fit the National Voices narrative of integrated care and support;

“I can plan my care with people who work together

to understand me and my carer(s), allow me control and bring together

services to achieve the outcomes important to me” The Hull BCF plan has adopted the National Voices approach to empower and to involve more

service users in the local measuring and monitoring of success; we expect the ‘I ‘ statements will be

instrumental in the development of services that they want.

Local outcomes are based on what people in Hull have told us is most important to them. Public engagement and consultation in Hull has demonstrated that a service that prolongs independence and allows people to remain in their own home for longer is a priority. Hull has an established People’s Panel, which is a joint venture between the CCG and Hull City Council. The Panel has a membership of around 8,000 local residents who take part in surveys and consultations on a quarterly basis. The people’s panel and CCG Ambassadors will be used to support the ongoing public engagement and consultation with regard to the organisational vision and BCF plans.


In addition the CCG has a group of Ambassadors who have volunteered to get involved in supporting the CCG’s engagement and public involvement work and provide a mechanism for feeding information into the CCG and out to the local population. The locally recruited Ambassador team is currently 25 strong, representing people from all walks of life; many are active community leaders, and others provide a vital link with other voluntary and community groups with which they are involved. Ambassadors along with and other members of the People Panel are regularly surveyed on their views about local service developments and public expectations. The most recent People’s Panel survey included a question relating to statements about health and social care. A sample of responses is detailed in Table 3. Question: How much do you agree or disagree with the following statements about health and social care

Response Rate 1692 Out Of 2000 Surveys Sent %

Care or treatment should be available at all times (including evenings and weekends)

Strongly disagree 1.5%

Tend to disagree 2.8%

Neither 3.6%

Tend to agree 39.2%

Strongly agree 52.8%

I would like all of my care or treatment to be managed through a single point of contact

Strongly disagree 2.9%

Tend to disagree 9.1%

Neither 23.5%

Tend to agree 41.1%

Strongly agree 23.4%

Table 3 Responses to People's Panel Survey


5. Care Coordination

Summary

Care co-ordination will be allocated from within 4 groups; care may flow up or down the

continuum dependent on need

Progress has been made in Hull to co-locate some services

Multi-disciplinary teams aligned to transfer care and offer alternatives to admission will be in place

Hull has introduced the use of a risk profiling tool in primary care the intention is to increase the

access to and use of self care programmes

Well established expert patient programmes in place but the challenge is to engage more people in

the most deprived communities giving them the confidence to make small changes, see benefits

and feel better, become healthier or reduce risks

The following diagram shows the process for allocation of care coordinators and lead care professionals. Care will be organised within the 4 delivery models:


Self-care and carer support


Complex multi care need


5.5 Care Coordination Process Care coordination will be allocated from within these groups; care may flow up or down the continuum dependant on need

Prevention and Resilience 75 + routine health checks or targeted groups 50+ Care Coordinator At time of visits discussion will focus on maintaining and whenever possible improving health and

wellbeing. Decision will be to assign care coordinator responsibility to GP practice Or Third sector team

to access:

social prescribing, community hubs. Review annually.

Self Care and Carer Support Diagnosis of LTCs and early stages of conditions and primary carer

- Care Coordination

Carers who provide regular and ongoing support to relative or friend with health and care needs

- Lead Care Professional

GP practice or third sector - care coordinator as routine with:

Community nurses.

LTC / specialist nurse - access to lead care professional, identified at review.

Social worker - active involvement in times of need.

Therapist.

Early and Intensive intervention People receiving intermediate care or reablement, falls services , A& E attendance - at the outset

will have Lead Care Professional – assigned a Care coordinator when transfers to long term

team

Memory clinics - Lead Care Professional assigned to complete assessment and inform treatment

and care planning. Once initial care/diagnosis then moves to self-care or info multiple need.

Complex Multi Care Need People with advanced stages (level 3+) long term health conditions includes physical and MH needs and people with substantial learning disabilities often with associated physical care needs. End of life and Palliative care. High cost /intensive and specialised support eg Virtual Ward or Hospital at Home support

People will be receiving a number of services in addition to primary and community care services. There will be ongoing support from specialist community teams / secondary care and In/Outpatient monitoring of condition.

Lead Care Professional assigned who ma also provide care coordination role or an additional Care coordinator is assigned due to numbers of services/complexity of multi –needs

.


The following cases demonstrate how Better Care Services in Hull will meet with the outcomes

people identify.

5.6 Case Example – Prevention and Resilience Marianne is a frail 80 year old with dementia. She lives with her 85 year old partner, Bert who is her main

carer and it’s clear that he wants to continue caring for his wife without people ‘interfering’. No family

members live nearby except for Bert’s younger sister. Bert and Marianne’s son who lives in Sheffield

wants to ensure that his parents stay together; in their own home if possible, as this is what they have

always said they wanted.

Bert’s son is feeling the pressure of supporting his parents without outside help. Bert doesn’t want his

son to contact the GP; he doesn’t want people in his home or to see how much Marianne has changed.

Bert has been fearful about what might happen if other people were to get involved, he refused help

when Marianne was first told she had dementia and back then they could cope

Marianne is becoming aggressive, unsteady on her feet and just seems “unwell”. One day this week she

was very restless and tried to leave the house in the early hours of the morning. Feeling as tired as he does

Bert’s losing patience with Marianne’s changed behaviour she is more restless and no longer recognises

him. After a very difficult day Bert decides he can no longer cope and calls his GP at 4pm on Friday.

Outcomes for Marianne and Bert Better Care Services

To be able to stay at home where she feels safe

A care coordinator acts for the family – someone who knows the situation so they don’t have to tell their story again and again and can arrange care around them There’s a Hospital at home service (Geriatrician and Community Psychiatric Nurse) available out of hours through a single access point to assess for delirium and provide any treatment within the home.

To feel calm and well again Dementia cafe and care groups. Bert and Marianne feel part of their community since the city has developed dementia friendly communities Access to pharmacy supplies available out of hours, to ensure medication can be provided as soon as possible. Access to psychological support services will also be available, to ensure longer term psychological needs are assessed and addressed

Bert and his son feel able to cope

Overnight care can be provided by suitably experienced home care staff to provide extra support for family carers. Family also directed to the local carers information and support service for extra help and support over the longer term

The family have a plan for the future

A Lead care professional keeps in contact with Marianne and Bert and a care coordinator ensures their personal outcomes are met. The Lead care professional will also complete an advance care plan, recording all decisions on the care and support provided and any longer term care needs, such as psychological support. GP also kept well informed and involved in decision making

Table 4 Outcomes and Better Care Services


5.7 Case Example Self-Care and Support Dorothy is now 68 years old and lives alone in sheltered housing and has family who live nearby and a

number of friends who support her.

Dorothy is getting a bit unsteady on her feet and has had a few falls at home, her family have noticed,

and Dorothy agrees, she is a bit forgetful at times but she is very much in control and wishes to retain this

independence

Dorothy has a history of urinary tract infections. Recently she had a fall resulting in a head injury but did

not lose consciousness and used her lifeline to raise the alarm. The wardens called for an ambulance.

Dorothy was taken to A&E. and she was admitted to AAU although she’d wanted to go home and she’s

still waiting to be discharged as tests show she has high blood pressure and probably had a minor stroke

Outcomes for Dorothy Better Care Services

To get out of hospital as soon as possible return to her own home To receive regular therapy to continue recovery and be fully independent again including communication

Assessment & Discharge Planning An outcomes based assessment is begun whilst Dorothy is recovering in hospital. A Multi-Disciplinary Team contributes; the community team are involved from the early stages to ensure relevant information about Dorothy is available to support her recovery. Housing Rapid assessment by the community team is carried out to establish whether she can go home with rehabilitation, her Housing Scheme Warden and Occupational Therapy are fully involved from the outset to ensure any equipment or adaptations required are in place

To be in control of her future

Voluntary Sector contribution Links are made with local voluntary organisations that can provide support and companionship for her when she returns home. Her GP recommends a social prescription and Dorothy is given a 6 week programme of activity based on her interests. It includes joining physical activity and singing groups and a lunch club

Her personal outcomes known and respected.



5.8 Case Example Early and Intensive Intervention Catherine is 54 and has been living with multiple sclerosis for many years. Julie her daughter is a shift worker and so visits to her mother are scheduled around her work and family commitments. Catherine has home care staff visiting 3 times daily to help her with personal care and housework. She manages shopping and bill payments on line. Her support plan also includes a visit to a day centre once a week. Catherine is finding life pretty dull; family and friends call in when they can but she often feels quite alone and anxious about her future and how long she will cope.

Catherine was provided with equipment to help her around the home, a further OT referral was made some time ago but things are getting more difficult – she cannot easily get upstairs and is finding she can’t get to the toilet in time. A physiotherapist is due to visit too.

Last week her carers noticed a significant change; Catherine was increasingly tired and listless and her sight is deteriorating. Her GP visited her and changed some of her medication but Catherine made a mistake with her tablets and took too many, her home care worker called the pharmacist who gave her advice. A community nurse has assessed for and arranged for continence aids to be delivered

Outcomes for Catherine Better Care Services

To stay in her own home with the carers who understand her daily routines

To provide a full medical assessment, care plan and follow up treatment and support. Integrated Community rehabilitation service review her needs and Catherine is offered option to stay put and have major adaptation of her home or move to extra care.

Have contact with family, ensuring they are involved in care.

She chooses to move to extra care and the Care coordinator works with the family to ensure transfer of care and house move takes place.

Not feel so isolated and have more

things to do at and away from home

This helps the family to support Catherine and services

and a programme of activities is available on the extra

care site

To feel well, and have more energy

The accessible facilities in extra care provide Catherine with the ideal built environment. Her health and wellbeing improves and she feels more independent and in control

To have a plan in place should health and function deteriorate with a Lead Care Professional on whom she can call for support

Telecare and other technology solutions are in place to ensure contact can be made with her daughter on a daily basis

To have a Care Coordinator - one person who knows her well and will coordinate care making sure personal outcomes are met.

Advance Care Plan A Lead care professional is allocated permanently to ensure that a relationship is built, and s/he carries out a full personal outcomes based assessment. This assessment, along with the initial medical assessment is included in the advance care plan to ensure future care needs are addressed quickly and effectively.



An agreed plan of care is in place to manage disease progression. People have a choice of local services, their coordinator supports and accesses additional support e.g. respite whilst the Lead Care Professional monitors health and changing needs

7 day working , care is more consistent and if a crisis or unplanned care is required it is easy to access, people receive help in their community and avoid admission to hospital and care homes with the help of staff who are well informed, clear about their roles and work together

The Therapy services team (with social work, nursing, geriatricians and pharmacy support) provide both early, focused and intensive care and support. Advanced care planning is enacted by coordinators when needs dictate more support is needed. GPs remain involved when a patient is in hospital to add support and assist discharge

Homes are adapted with various simple aids around the home much more quickly with less risk of falls. Waits for major adaptations to homes are reduced; with extra care housing offering choice and more options for disabled. Care hubs contribute to improving specialist care

GP and surgery staff work well with community services; one worker is nominated to coordinate our care which is set out in a single care plan. Single patient and care records, as they become available can be accessed by the individual and used by their clinicians and care staff to ensure we only have to tell their story once. We know we will have continuity of care and support, seven days a week, even if hospital admission is needed

Figure 9 Complex Multi Care Need

5.5 Complex Multi Care Need

Communities provide more practical help e.g. volunteer drivers to get people to community out patients appointments. Social prescriptions are issued for a good range of activities, reducing isolation, improving health & well being Dementia friendly communities are developing, so people with dementia and carers can participate and contribute, Bert and Marianne feel well served in local shops and services.

When circumstances change people are reassessed. They each have a care coordinator whose role is ensuring that support is available to people in their communities. People have access to the Lead Care Professional particularly in difficult times.

A single care plan is in place equipment has been provided with support that allows care and health conditions to be managed on a daily basis. Information and advice is clearer and professional support is available as and when needed. People and carers feel in control.


5.6 Progress so far – from co location to integration Progress has been made in Hull to co locate some services such as Intermediate care and reablement to successfully provide a range of support delivered across all three of the care settings, hospital, community and home. Multi-disciplinary teams are aligned to transfer care and offer alternatives to admission. We have seen benefits from breaking down professional barriers between services, and clinicians are working toward a culture of shared accountability planned around the patient’s needs. A good example of this is Thornton Court a development of reablement units refurbished from empty sheltered housing stock with Multi Disciplinary Team (MDT) care provided on site 24/7 in an independent living environment. This service is resourced from local reablement monies and therapy and social care led referrals from community and hospital to offer a period of rehabilitation and reablement Thornton Court was established in 2012 as a partnership initiative between Hull CCG and Hull City Council. It provides a combined nursing, therapist and social package of care that supports people to recover from illness and regain their independence to confidently return to their own homes. The facility has been praised by patients and families for the transformation it has made to peoples' lives. The personalised care planning and daily input from nursing, therapy and social care teams has helped patients regain skills to live independently or semi-independently, where they might previously have entered long term residential care Here's what difference Thornton Court made to Betty (62) from Hull.

Betty had been in hospital for six weeks following heart surgery which had left her with complications including a collapsed lung and pneumonia; she entered Thornton Court needing full support with personal care, meal preparation, administering medication and domestic tasks. Her carers followed an individual care plan put together by her social worker, home care organiser, occupational therapist and physiotherapist. They focused on Betty’s individual needs and worked on each rehabilitation task specifically. Over the next two weeks with this intensive support Betty was able to administer her own medication with no support and she began going out to do her own shopping. After five weeks she felt ready to go home, as her time living semi-independently at Thornton Court had helped rebuild her confidence. At her request, a lifeline was installed in her home to help her feel safe and secure. Shortly after this Betty was discharged from Thornton Court to her own home independently with no need of support services.

We believe this type of development will be critical to our plans for integration but also believe that the benefits of aligning person centred goals can be improved further with shared information systems and joint proactive support and care planning. Our Health and Wellbeing Strategy outlines our 3 year plan to reduce the numbers of people who are at risk because of unhealthy lifestyles or as a result of home or personal circumstances. We have a wide range of activities that focus on providing alternative and healthy choices and have developed innovative schemes targeted at the areas of highest deprivation and led by community groups. An example is the recipe boxes ( available from food banks) as part of a cooking chain; the recipe box contains the ingredients and recipe to cook a healthy and inexpensive meal together, passing on skills from one person or household to another. This is just one example where combination of an enjoyable and inclusive social activity and choices for better health can reach many people at little cost.


The take up of Health checks through invitation to people aged 40-74 is steadily rising. We want to progress the development of local schemes which address health inequalities, access to information and care closer to home as a priority for health and social care, services delivered out of buildings which are central to communities. The BCF will support the progress of this approach through the use of social prescribing. Our social activity and health programmes are aimed at

improving health of people with needs,

reducing numbers of lonely and isolated vulnerable people,

enhancing support for family carers and

Strengthening local communities to coordinate deliver and develop a significant proportion of the programmes.

Hull has introduced risk profiling tool in primary care through regular meetings of multidisciplinary groups; which will be developed through improved access to and use of self care programmes. Our biggest resource, individuals and families, need to be more able to help to improve their own personal health outcomes. To do this well they need to apply the skills and knowledge in practice. We have well established expert patient programmes but our challenge is to engage more people in our most deprived communities giving them the confidence to make small changes, see benefits and feel better, become healthier or reduce risks.


6. Public Communications

Summary

Existing information on public views from recent surveys (e.g. Hull People’s Panel) and NHS Hull

CCG engagement events has informed the BCF plan

Work to date confirms that people want services that maintain their independence and provide

more choice and control over care being delivered in their community and in their own home

Engagement on BCF will be integrated into a rolling programme of information and engagement

events across the city

Work will be undertaken with a wide range of voluntary and community sector organisations

through the Building Health Partnerships programme and through the established network of GP

Practice Participation Groups

On March 12th 2014 a public event is planned to begin the more formal consultation and

engagement process; this will herald the beginning of a structured public communications strategy

which will include invitations to get more involved in individual BCF schemes

Existing information on public views from recent surveys (Hull People’s Panel) and NHS Hull CCG engagement events has informed this plan. Work to date tells us that people want services that maintain their independence and provide more choice and control over care being delivered in their community and in their own home. The Hull People’s Panel is, and will continue to be, central to developing the patient, service user and public engagement required to take this plan forward. In addition, CCG patient Ambassadors and representatives from Health Watch are already members of some existing work streams and continued engagement will be specified as a core requirements of each of the BCF schemes. Engagement on BCF will be integrated into a rolling programme of information and engagement events which the CCG currently undertakes at a wide variety of community locations across the city. In addition, work will be undertaken with a wide range of voluntary and community sector organisations through the Building Health Partnerships programme and through the established network of GP Practice Participation Groups. Council and CCG websites and associated social media (shown below) will be utilised to inform and gather views. The Council and the CCG will also harness mainstream media opportunities to encourage public engagement and participation. https://www.facebook.com/hullpeoplespanel https://twitter.com/NHShullCCG On March 12th 2014 a public event is planned to begin the more formal consultation and engagement process. This will herald the beginning of a structured public communications strategy which will include invitations to get more involved in individual BCF schemes. This strategy will be overseen by our BCF public and provider forum that will operate as a network across patient and provider groups to share information and create and shape change. The principles the forum will operate within are;

A commitment to putting patients, clinicians and carers at the centre to influence change

An open and transparent approach

An objective culture, using evidence of best practice to inform transformation

An commitment to working in partnership to achieve the common goals as described in the BCF plan

https://www.facebook.com/hullpeoplespanel

https://twitter.com/NHShullCCG


7. Whole System Integration - Provider Impact

Summary

Our BCF plan is designed to facilitate change through pathway development and investment in

systems to support the workforce to integrate and particularly how they interact with patients and

each other

The CCG and local authority commissioners are committed to working together to generate change

in the marketplace, and to effect the cultural change required to reduce single provider control and

create confidence to share risk, share accountability and share achievement of common outcomes

for service users

Mechanisms will be created that allow funding to flow to the point of need, in order that the shift

of care is mirrored by a shift in resource

Hull has one main acute hospital provider, Hull and East Yorkshire Hospitals NHS Trust (HEYT)

Two main community providers, City Healthcare Partnership (CHCP) a social enterprise that

delivers the majority of community care and Humber Foundation Trust (HFT) which provides

mental health, learning disability and community service

The plans for the Better Care Fund in Hull have been presented to the local council of members

and CCG Board members.

Intention to create a BCF provider forum to consult and engage with providers on the impact of the

implementation of the plan and enable a two way communication into pathway development and

associated workforce strategies

Homecare and residential providers have asked for a focus on a whole systems medicines

management policy to support staff working with people who need medicines as part of their care,

to improved transfer of care from hospital, reduced need for hospital admission and less waste

Local providers see a shift to co-operative and joined up working through integrated

commissioning involving service users and providers at every stage

To achieve this it is clear that a significant change in the local provider landscape needs to take place. Our plan is designed to facilitate change through pathway development and investment in systems to support the workforce to integrate and particularly how they interact with patients and each other. The CCG and local authority commissioners are committed to working together to generate change in the marketplace, and to effect the cultural change required to reduce single provider control and create confidence to share risk, share accountability and share achievement of common outcomes for service users. This will include sharing the benefits of cost reduction that can be reinvested in joint services. Our plans include investment to ensure that existing systems will not be a barrier to the provision of integrated care. We will also develop contractual levers that improve co-ordination of care and incentivise providers to coordinate with one another. This will be specified in joint contracts that ensure that there is accountability for the outcomes achieved for individuals regardless of the provider and that payment is more outcomes focused rather than just for specific activities. We will create mechanisms that allow funding to flow to the point of need in order that the shift of care is mirrored by a shift in resource; we expect the impact of this to be measured by the movement of investment from secondary to primary and community care and primary prevention.


Figure 10 and Figure 11 represent the potential activity shift over the next six years as a result of

transformational initiatives across the City of Hull, from base case activity to activity following the

implementation of initiatives.

NB: the charts are purely indicative at this stage

Figure 10 Base Case Activity

Figure 11 Post Initiative Activity

Commissioners are clear that centralisation of health and care services will not save money; in many cases as the same number of patients would need to be treated. In some cases it may even cost more to move services into one location, as there could be some building/relocation costs. Centralisation considerations are to improve quality and safety. Whole-system changes to existing health and care services will be required if commissioning intentions and national recommendations are to be implemented. This may include changes to organisational constructs, or reconfiguration of organisational boundaries.


7.1 Provider landscape Hull has one main acute hospital provider, Hull and East Yorkshire Hospitals NHS Trust (HEYT)

HEYT provides a comprehensive range of acute hospital, specialist and major trauma services for approximately 1.25 million people living in the Hull, Yorkshire, East Riding and Northern Lincolnshire area. The only major acute services not provided locally are transplant surgery, major burns and some specialist paediatric services.

There are 2 main community providers, City Healthcare Partnership (CHCP) a social enterprise that delivers the majority of community care in Hull and Humber Foundation Trust (HFT) which provides mental health, learning disability and community services. There is a range of voluntary and third sector provision. There are 57 GP practices and 42 residential and nursing homes providing care for older people and physical health needs and 4 providers of homecare. The provision of in house adult social care is under review.

7.2 In Hull There are 57 GP practices in Hull and the principles and plans for the Better Care Fund in Hull have been presented to our local council of members and CCG Board members. Hull GPs support the plans to arrange services around the individual and welcome the inclusion of care coordination and the lead processional role. The new GMS contract in place from April 2014 includes an enhanced service for GPs to better manage unplanned admissions. GPs will be able to opt into this and we will be promoting its use and making links between this and the Better Care Plan

Key elements of the contract will include

Practices will be required to review emergency admissions and A&E attendances of their patients from care and nursing homes.

Practices will use risk stratification to aid identification of vulnerable older people, high risk patients, and patients needing end of life care and those who are at risk of unplanned admission to hospital. A minimum of 2% of the practice's adult population (aged 18 and older), identified as being at the highest risk of admission, will be case managed proactively.

Practices will put together a personalised care plan for patients on the case management register. Each care plan will also identify, if different to the named accountable GP, a care co-coordinator who would be the most appropriate person within the multi-disciplinary team to be the main point of contact for the patient or their carer to discuss or amend their plan.

Following discharge from hospital, practices will ensure that patients on the case management register or patients newly identified as vulnerable are contacted by an appropriate person (practice or community staff) in a timely manner to ensure coordination and delivery of care.

Practices will ensure there is a named accountable GP assigned to each patient aged 75 years or older. Where required (based on their clinical judgement), the named accountable GP will need to work with relevant associated health and social care professionals to deliver a multidisciplinary care package that meets the needs of the patient

With the changes to the nationally imposed inspection and assessment regime, councils:

are responsible for their own performance and improvement and for leading the delivery of improved outcomes for local people in their area

are primarily accountable to local communities (not government or the inspectorates) and should foster stronger accountability through increased transparency which helps local people drive further improvement

have a collective responsibility for the performance of the sector as a

whole (e.g. sharing best practice, offering member and officer peers)


The role of the LGA is to maintain an overview of the performance of the sector in order to identify potential performance challenges and opportunities – and to provide tools and support to help councils take advantage of this new approach

Amongst Hull CC’s responsibility is the performance of the 42 residential and nursing homes providing care for older people and adults with physical health needs and 4 main providers of homecare. We will continue our work with these providers to ensure we have the correct balance of capacity and choice of provision and how; as expectations change they can evolve. We want to build on our intentions that all services will enable, care providers will re-able and more rehabilitation is available for those who need it.

We will continue to develop the quality of care for example through the systematic use of dementia care mapping, raising awareness about the needs of people with dementia and their carers with local business and how these services can help.

One of the most challenging areas for development locally and nationally is the scope and future use of our information technology systems. Our present systems for the provision of advice and information about care and support are do not serve us well .We would want to see families and individuals choose care services informed by quality ratings from those who have experienced their care services .

We await the publication of the ADASS strategy around on-line advice and information and supporting generic business case to support the local development of an integrated health and care advice and information to which all providers will contribute

Work has begun on provider consultation and will continue as the plan develops. It is our intention to create a BCF provider forum to consult and engage with providers on the impact of the implementation of the plan and enable a two way communication for input into pathway development and the associated workforce strategies. Our plan is based on the theory that integration should be based on clinical and service integration and not necessarily from organisational merger. The initial feedback from provider consultation highlighted the following points to cover in the plan:

Homecare and residential providers asked that there be a focus on a whole systems medicines management policy to support staff working with people who need medicines as part of their care, to improve transfer of care from hospital, reduce the need for hospital admission and reduce waste.

A shift to cooperative and joined up working can only be achieved through integrated commissioning and involve service users and providers at every stage

Continence management was highlighted as one main reason for admission to residential care settings and a primary reason for loss of independence.

Ambulatory care was highlighted by the Acute Trust as an area that they want to tackle as a system wide response with support from primary and community care.

Local GPs have welcomed the Better Care Concept and expressed a view that multi-disciplinary pathways organised around community hubs is a positive development


8. National conditions Hulls response to the delivery of the national conditions is presented in Appendix C National conditions

on page 46. Table 7 sets out our initial action plan and associated timelines to begin implementation.

What When

Consult wider on the BCF first draft submission

Provider forum

Public engagement

GP Council of Members

Hulls Peoples Panel

By End of March 2014

Finalise shared financial risk agreement between Hull CC and Hull CCG based on the principles of a section 75 agreement

By End March 2013

Develop public facing information

Public version of Better Care Plan

Schedule events in local communities

Identify GP champions

By end April 2014

Initiate Better Care work streams , reviewing existing groups and adjusting terms of reference to reflect Better Care priorities

By End march 2014

Conclude provider impact assessment and embed Better Care into integrated business plans

By April 2014

Establish programme management arrangements for Better Care and Care Bill implementation

April 2014

7 day working current provision reviewed across all sectors , gaps identified and plan agreed to commence 7 days as per local definition

By September 2014

Data sharing – programme management approach established including feasibility appraisal of data warehouse. We will look at evolving business case for on line support and advice

By May 2014

Lead care professional – specification written to describe lead professional role May 2014

Risk Plan populated and included in programme management arrangements for monitoring by Better Care Steering Group

April 2014

Commence Better Care Schemes April 2015

Table 7 Initial Implementation Action Plan


9. Better Care Schemes Table 9 presents a high level overview of the Better Care schemes. The schemes and associated initiatives are presented in full in Appendix D Better Care Initiatives on page 49. Change is required to fit with;

“I can plan my care with people who work together to understand me and my carer(s), allow me

control and bring together services to achieve the outcomes important to me”

Initiative Description Key Outcomes

Prevention Building community resilience and working with people in their communities and in partnership with communities & voluntary groups to co design, co-develop and co-produce improved health and social care outcomes

Social Care related quality of life

Adult Social Care User Survey - Social contact with people

The proportion of people who use services who feel safe

Primary Care and Self care

Proactive risk stratification in primary care to identify people at risk of disease progression and management of people with a diagnosis more proactively. Organising care around ‘hubs’ of whole system integrated teams in primary care settings

Reduced Attendance at accident and emergency

Reduction in the number of GP appointments

Patient experience of GP and other primary care services

Avoidance of Falls

Redesign current pathways in line with NICE guidance. Embed an integrated pathway and network of support across the whole system from self- care to post episodes of secondary care.

Reduced falls

Reduced Hospital admissions

Avoidance of injury as a result of falls

Reablement and Rehabilitation

Maximising reablement and rehabilitation pathways as an alternative to hospital and to maintain independence following a hospital stay, avoiding unnecessary admissions and delayed discharges

Effectiveness of reablement

Increase in number of 65+offered and provided with rehabilitation services (at home at 91 days post hospital discharge.

Reduction in delayed discharges



Ambulatory care 24/7 rapid assessment and diagnosis. Multidisciplinary pathways across primary community and secondary care focusing on COPD, heart failure and Frail elderly supported by an integrated case management model supported by risk profiling and named care coordinators.

Avoidable emergency admissions

Reduced ED attendance

Patient experience

Acute and residential care

Maximising reablement and rehabilitation pathways as an alternative to hospital and to maintain independence following a hospital stay avoiding unnecessary admissions and delayed discharges. Sustaining current service and building on the models of good practice Extending current provision to provide full 7 day services.

Admissions to care homes

Reduced attendances at A&E

Support at times of crisis.


Long term conditions including Dementia

Build on the work of the Dementia academy and design a whole system of integrated care and network of support for people and their carers from self-care to secondary care. Underpinned by a named Lead Care Professional and /or Care coordinator Academy model provides wider development of care in the community, services and businesses are dementia aware and support people to live well in their communities Work with local groups to build good, local access to information that empowers and informs individuals and communities.

Feeling supported to manage their condition and have control over their daily lives

Nos diagnosed with dementia

Preferred place of death

Nos of organisations who achieve dementia friendly award status

Avoidable emergency admissions

Reduced ED attendance

Patient experience

7 Day working Extending current provision to provide full 7 day service Integrated and 7 day discharge hub Increasing capacity and scope of ambulatory care and A& E liaison

Reduced length of hospital stay

Staff satisfaction surveys

No of complaints


Workforce development

Skilled and empowered workforce who are positive about their role Cultural and organisational shift so that leadership is developed at all levels ; staff feel supported to improve the care and treatment they provide Dementia Hull has developing dementia -and disability- friendly communities

Support from local services or organisations to help manage long term conditions

All workforce have had awareness training/ basic understanding of dementia



IT development and Information sharing

We aim to create the infrastructure to ensure our care providers can all use the same patient record; the BCF will help ensure this happens by joining up Health and Social Care data across provider systems linked via the NHS number, and guaranteeing that the required governance is in place to ensure individual information is shared in an appropriate and timely way Provide information when and where people want it - communities will decide this and linked to the single point of access Secure interface to simplify electronic care and support for health and social care and support. Also enables the individual to have more control over their information and treatment. An integrated technology platform that enables professionals and users of services to plan, record & monitor in real time wherever the care and support setting.

The proportion of people who use services who find it easy to find information about services

People confirm that they can easily access services

Support for Carers

Increasing the support to carers through the development of health and care hubs; emergency respite for carers developed from help at home services Improving service responses and local carers experience

Carer reported quality of life

People and their informal carers will be more self-reliant

Integrating systems and health and care commissioning

Commissioners and providers work together to deliver outcomes Development of a single shared electronic health and social are record based on use of the NHS number Outcome based use of resources, building on payments by results, year of care tariff and other procurement and contracting methodology Pooling our resources for optimal integration; Building system wide incentives and contracts that encourage innovations and secure best value throughout all parts of the person’s experience

Number of jointly commissioned services

People confirm that they can easily access services

Reduced costs

Reduced delays and duplication

Service and care hub

The creation of care hubs will assist in the effective deployment of staff and reduce the overheads of 7 day working Care hubs will also be developed beyond existing plans for 3 extra care site and East Hull Facility i.e. in sheltered housing , health centres – this will also give us the opportunity to review and rationalise local health and Council building’s use

User and staff satisfaction surveys

Universal use of Outcome based care plans

Nos of extra care units

Table 8 High Level Overview of the Better Care Schemes


10. Finance As previously noted the developing plans for jointly funded and commissioned services in Hull began with existing reablement and transfer of social care monies from NHS England. The current 2014/15 section 256 is for £1.745m reablement and £5.448m social care. Our current estimate of the minimum value of the BCF in Hull is £10.582m growing to £21.709m by 2015/16. It is the intention of Hull CC and the CCG to further align resources to ensure that we achieve maximum benefit from pooling resources to facilitate whole system integration. In developing our plans for jointly funded services from 2014/15 onwards, our starting point has been the scale and scope of our existing transfers from health to local government and the services that they support. Table 9 shows both the minimum and maximum contributions for both financial years.

2014/15 2015/16

National Hull (min) Hull (max) National Hull (min) Hull (max)

£bn £’000 £’000 £bn £’000 £’000

Existing Social Care Funds

0.9 5448 5448 1.1 6659 6659

Additional Social Care Funds

0.2 1211 1211 0 0 0

Existing Reablement

Provision 0.3 1745 1745 0.3 1745 1745

Existing Carers Grant

0.1 445 445 0.1 445 445

Redeployed CCG / LA Revenue

0 0 800 1.9 10975 18323

Revenue Sub Total

1.5 8849 9649 3.4 19824 27172

Capital Grants 0.2 1733 1733 0.4 1885 1885

Overall Total 1.7 10582 11382 3.8 21709 29057

Table 9 Contributions for 2014/15 and 2015/16


11. Outcomes/metrics Hull City Council and Hull CCG have reviewed the metrics collaboratively and used the BCF ready reckoner calculator to understand improvement in activity against baselines at different levels of confidence.

Local intelligence has been applied to measure historic trends and consider any impact on year on year activity reduction to support assumptions made in the planning process which includes seasonal fluctuation. In addition guidance has been sought from national teams in forming decisions on the metrics to ensure they meet SMART criteria.

11.1 Baselines and Projections

Table 10 Baseline and Projections

Permanent admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population

Current Baseline data is taken from national data, from the ASCOF (Adult Social Care Outcome Framework). Data is published annually. 90% confidence limit used in the statistical significance tool. Denominator is taken from Mid-Year ONS Estimates from 2011-2021, Hull LA Population, 65 and over. (Mid-year 2014 population applied for October 2015 payment)

Justification: 90% confidence limit has been set as the activity recorded in the baseline (295 admissions) is lower than historically seen and 2013-14 activity is higher. Therefore using the April 2012 – March 2013 baseline as reflected in the technical guidance, the plan reflects a 10% reduction in line with the payment 2 reporting period of April 2014 – March 2015, which a reduction of 19 admissions and rate of 720.739 per 100,000

Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services

Current Baseline data is taken from national data, from the ASCOF (Adult Social Care Outcome Framework). Data is published annually. 95% confidence limit used in the statistical significance tool. Denominator is the number of older people aged 65 and over offered rehabilitation services following discharge from acute or community hospital. As collected, 1 October to 31 December for the relevant year

Justification: Denominator does not change from Baseline to Payment Year, as per guidance. Using the April 2012 – March 2013 baseline a 9% increase has been agreed. The plan reflects an increase of 7 older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services using April 2014 – March 2015 reporting period. This will increase the metric value to 91%

Delayed transfers of care from hospital per 100,000 population (average per month)

Baseline taken from published data from BCF for December 2012 - November 2013, most recent 12 months of data. Denominator is taken from Mid-Year ONS Estimates from 2011-2021, Hull LA Population, 18 and over and 95% confidence limit has been used in the statistical significance tool to calculate payment 1 and payment 2

Justification: 12 months data has been used so that seasonality is taken into account. Therefore using the baseline of December 2012 - November 2013 and taking a seasonal 6 month average a reduction of 2% is planned for payment 1 and a further 1% by payment 2 (3% total) giving a rate of 710.666


Avoidable emergency admissions (composite measure)

Baseline taken from published data from BCF for April 2013 - September 2013. October 2013 – March 2014 calculated based on previous year seasonality. Denominator is taken from Mid-Year ONS Estimates from 2011-2021, Hull LA Population, all ages and 95% confidence limit has been used in the statistical significance tool to calculate payment 1 and payment 2. (Mid-year 2014 population applied for April and October 2015 payments).

Justification: 12 months used so that seasonality can be taken into account. There is a significant difference between the summer and winter period in terms of activity and in order to create a meaningful and appropriate baseline, 12 months was calculated up for 2013/14 and a position for the end of 2014/15 calculated. Overall reduction of 3% will avoid 158 emergency admissions (74 admissions payment 1, 84 emergency admissions payment 2) and a rate of 1363.836

Patient and service-user experience

No survey has been selected to date as we wait for further guidance on this metric

Local Measure: Injuries due to falls in people aged 65 and over

Baseline data is the most recent 6 months data taken from SUS (Secondary Uses Service). Criteria used matches with the latest national definition for falls. 95% confidence limit has been used in the statistical significance tool for payment 2 only. Denominator has been taken from Mid-Year ONS Estimates from 2011-2021, Hull LA Population, 65 and over (Mid-year 2014 population applied for April and October 2015 payments

Justification: The statistical tool has been used for calculating the payment 2 but not payment 1 as this shows an appropriate level of reduction and appropriate timeframe to reach this level. For payment 1 the target has been set as the midpoint between the two periods as we expect a linear rate of improvement and previous data shows that seasonality does not have a statistically significant bearing on the level of activity. Taking this into consideration a 7% reduction has been set which will aim to reduce admissions for injuries due to falls by 15 from the baseline. Payment 2 during the winter reporting period October 2014 – March 2015 is expected to continue to see a reduction of a further 16 admissions showing an overall reduction of 11% across the April and October payment periods resulting in a rate of 919.204 per 100,000


12. Governance Delivery of the BCF for Hull will require a robust governance structure that transcends organisational boundaries. Hull has begun to operate in this way through The Health and Wellbeing Board, the objectives of which reflect the joint commissioning intentions of the CCGs and the local authority. The Hull Health and Wellbeing Board will provide assurance for the delivery of the BCF plan against the national conditions. Hulls response and plans to meet the national conditions are set out in Appendix C. In addition to this the CCG and LA have established a The Hull 2020 Programme Board. The Boards main objective is to establish cooperation between city wide partners in order to bring together individual strategies, drive forward purposeful development and the implementation of a single vision. This Hull 2020 programme Board will provide the strategic oversight of the Better Care Fund initiatives to ensure alignment of the plan with wider transformation ambitions for the City. Responsibilities include

Provide strategic leadership and direction to the transformation agenda, with focus on advocacy for an integration model

Ensure alignment of major strategic plans (e.g. Better Care Fund, East Hull Community Facility, City Plan)

Consider the potential impacts of the strategy on the wider population of Hull and ensure that wellbeing is at the forefront of all planned developments

Consider reports on proposed models and strategies with regard to: sustainability, affordability, effective use of existing estate, risks, patient access, compliance with national guidance, achieving good patient outcomes, impact upon workforce

Ensure all partnership organisations work collaboratively and support each other over the period of transformation

To ratify the Programme structure and to approve the resources required to deliver the Programme

Ensure the strategy is aligned with, and optimises the benefits of, Hull 2017: City of Culture initiatives

Work strategically to navigate change through the political environment and be advocates for the vision within partner organisations

Maintain pace of delivery and development through strategic guidance and intervention where required

Offer constructive challenge where proposed approaches lack sufficient innovation

Operate within legal and statutory requirements for all partnership organisations The statutory responsibilities of the BCF and governance of the financial elements of the plan will be overseen by the Health and Wellbeing Executive Group with the Joint commissioning forum and BCF steering group reporting in for sign off on the use of resources and performance reporting against BCF metric . A Better Care Provider Forum will be established as part of the local consultation and engagement arrangements. The Governance structure is shown in Figure 12.


Hull CC

Cabinet

Hull CC & Hull

CCG Joint

Commissioning

forum

Hull 2020

Programme Board

Health & Wellbeing

Board

CCG Governing

Body

Better Care Fund

Steering Group

Group

Gr

Health and Wellbeing

Executive Group

Better Care

Public & Provider Forum

BCF schemes

Figure 12 Better Care Fund Governance Structure


13. Risk/ Contingency Plan Due to the complex nature of the Health & Social Care system and its interdependencies significant attention will continue to be paid to the impact of and unintended consequences of the Better care Schemes.

Risk Mitigation

Managing the transition of shift of care across care settings whilst the schemes are in development

Performance monitoring; exception reporting and adjusting actions to maintain care quality and capacity Develop cross sectors communication plans and feedback mechanisms Develop leadership and culture of empowerment of local people to monitor change

Implementation of the Better Care plan is reliant on cultural change and shared accountability across organisational boundaries

Empowerment of the workforce to innovate and deliver differently through creative thinking and agile implementation as a critical enabler for change

Sustainable medical workforce in primary care , low number of GPs (WTE) per head of population

The CCG primary care workforce development plan

Sharing information between multiple systems and service providers to facilitate and enable new and improve patient pathways

A BCF information technology working group which will draw on the resources of the national ADASS Information Management Group

Achieving national timescales working across multi agency multi sector environments

Better Care Plan recognised as a vehicle for delivery of the 3 major local strategic plans. Peer support and sharing best practice across Y& H

The requirement to release expenditure from existing commitments without de-stabilising the system in the short term

Financial risk sharing agreement based on section 75; monitor use of programme funds and consider use of under spending to be set aside for contingency fund / special projects which will focus on improving performance failures

Destabilising current providers during process of commissioning for outcomes and transferring resources across care settings.

Robust planning and engagement, phased introduction of new contracts and procurement

Slow or non achievement of the BCF outcome metrics

BCF metrics aligned to CCG QIPP plans and LA performance trajectories. Monthly tracking of performance against the metric and national conditions at BCF steering group. Buddy system to progress performance across Y&H

Introduction of the Care Bill Programme management and actions to support emerging details as they are released. Information systems, will need to be able to Transfers between LAs Assume NHS no. as unique national identifier and progress local use Keep informed through regional networks Confirm lead and resources for project support from partners to ensure whole system information is in place


Risk Mitigation

Workforce recruitment and development Workforce development to be picked up as key work stream of provider forum All staff to receive regular newsletters/updates on progress and next steps. Clear and simple messages without jargon All staff will be trained on detail and change of practice resulting from BCF programme and Care Bill Policy and procedural updates to support practice. On line training and use of all media to keep staff informed; encourage feedback and ensure this can be given in all services at all levels Skills analysis – training needs identified and met

Working agreements amongst all partners is key to monitor whole system impacts, together with individual partners’ plans and their separate governance arrangements

Strategic direction provided by Hull 2020 Board

Table 11 Risk and Mitigation of Better Care Schemes


Appendix A – Hull Care Hub Example

Ambulance or

Unscheduled Care

YAS 111

Advanced

Care Plans

CARE HUBS – Primary Care , Community Care,

Intermediate Care, Wellbeing and Social Care

Rapid Assess Units

/ Clinics

24/7 single point of

access

Advanced Care Plans

Acute Hospital

E

DMAU

Frail

Elderly

Wards

Outpatient

Clinics

Community

in-reach

team

Discharge

planning

Discharge

lounge

Patient Self-

Attends

Patients At Core

Nursing

homes

Care homes

Night sitting

service at

home

Domiciliary Care at

home

Individual’s

home

Self care and

self

management

promoted

OOH Primary Care

Primary Care

In Hours

Community

Matrons based at

GP Practices

DAAT

Community

based

geriatricians

Locality based

Integrated Care

Teams

Virtual

Wards

Long Term

Condition

Community

Hubs

Enhanced

Specialist

Teams

Social

Care

End of life

Team –

Voluntary

organisations

Specialist

Palliative

Care Team

Intermediate

Care Teams

24/7

Intensive

home care

Night sitting

GPs with

specialist

skills Day

Hospital

Social

care beds

Step up /

step down

beds in

community

Wider Community

Support Stations

Police

Probation

VCS

DWPLA

(Housing,

PH,)

Self care and

self

management

promoted

Therapies

Wellbeing Services

Active

Pursuits

(Gym)

Community

Groups

Training,

Numeracy

and Literacy

CAB

Community

Projects

Self care and

self

management

promotedSubstance Misuse

Support

Community

Maternity services

and Parenting

support

Children’s and Young peoples

services

Domestic

Violence Supprt

Social

Prescribing

Specialist

services

Referrals

UNDERPINNED BY NEW CARE COORDINATION

WORFORCE IN HUB AND COMMUNITY

9


Appendix B – National Voices Goals/outcomes Communication Information Decision making Care planning Transitions Emergencies

All my needs as a person were assessed and taken into account. My carer/family had their needs looked at and were given support to care for me. I was supported to set and achieve my own goals. Taken together, my care and support helped me live the life I want to the best of my ability. I was in control of planning my care and support. I could decide the kind of support I needed and how to receive it

I was always kept informed about what the next steps would be. The professionals involved with me talked to each other. I could see that they worked as a team. I always knew who was the main person in charge of my care. I had one first point of contact. They understood both me and my condition(s). I could go to them with questions at any time. That person helped me to get other services and help, and to put everything together

I had the information and support I needed in order to remain as independent as possible. I could see my health and care records at any time to check what was going on. I could decide who to share them with. I could correct any mistakes in the information. I have Information at the right times. The information is appropriate to my condition and circumstances. It is was easy to understand and up to date. I am told about the other services available to someone in my circumstances, including local and national support organisations. I was not left alone to make sense of information. I could meet (or phone / email) a professional when I needed to ask more questions or discuss the options

I was as involved in discussions and decisions about my care and treatment as I wanted to be. My family or carer was also involved in these decisions as much as I wanted them to be. I had help to make informed choices if I needed and wanted it

I worked with my main professionals to agree a care plan. I know what is in my care plan. I know what to do if things change or go wrong. My care plan was clearly entered on my record. I had regular reviews of my care and treatment, and of my care plan. I had regular, comprehensive reviews of my medicines. When I used a new service, my care plan was known in advance and respected. When something was planned and agreed to, it happened without me having to chase around for it

When I moved between services or settings, there was a plan in place for what happened next. The plan was delivered without unnecessary delays. I knew in advance where I was going, what I would be provided with, and who would be my main point of professional contact. I was given information about any medicines I was taking with me – their purpose, how to take them, potential side effects Information about me, including my views and preferences and any agreed care plan, was passed on in advance. I was still allowed to see and work with, as appropriate, preferred professionals who I already knew and knew me.

I could plan ahead and stay in control in emergencies. I had systems in place so that I could get help at an early stage to avoid a crisis


Appendix C National conditions Condition Hulls Response

A plan that is signed off by the Council, its Health and Well- being Board and the constituent Clinical Commissioning Groups with demonstrable engagement of providers

The Hull BCF plan has been presented in draft form to the Hull HWBB and the final plan is scheduled for sign off at the March HWBB and Hull CCG March Board meeting. The Council and CCG have undertaken a provider day and shared HWBB papers with Providers. Key local providers are members of the Hull 2020 Board that will oversee implementation of the plan.

Protection of social services (not spending)

Hull City Council will maintain eligibility at critical and substantial (Fair Access to Care Services)

We do not anticipate no increase in waiting time for referrals and with the roll out of BCF schemes we expect to improve from request to delivery time

Resources to keep people at home

Protected frontline services by aligning to the BCF but changing the focus and type of provision

Public health fund

Aligned existing CCG resources to reduce duplication

Seven-day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends

7 day services currently operate in Hull. Services locally have moved to 7 day working by deployment of 5 day provision working over 7. However we will improve on this position by increasing to ensuring service provision is the same any day of week. The creation of care hubs will create effective deployment of staff and reduce the overheads of 7 day working. Extending this to social care OTs, pharmacy (meds management, therapies and creating the multi-agency worker role that can implement an agreed plan on behalf of a qualified health or social care practitioner. The local Integrated discharge hub model will be developed with community and hospital teams working together to facilitate safe transfer of care across the week. Our plans include Supporting ambulatory care and A&E liaison across 7 days with a single point of referral


Condition Hulls Response

Better data sharing between health and social care, based on the NHS number

We aim to create the infrastructure to ensure our care providers can all use the same patient record; the BCF will help ensure this happens by joining up Health and Social Care data across provider systems linked via the NHS number, and guaranteeing that the required governance is in place to ensure individual information is shared in an appropriate and timely way. To date we have established

All health services use the NHS number as the primary identifier in correspondence.

Hull Social Services are in the process of adopting this and have a plan in place to use the NHS number as the primary identifier

Commitment to collecting the NHS Number as a primary identifier

Project work to match user records with the numbers has commenced.

Full compliance is expected to be in place by March 2015

Hull City Council & Hull CCG is committed to adopting systems that are based on Open APIs and Open Standards.

Hull City Council is committed to ensuring that the appropriate IG Controls will be in place. Hull is IG Toolkit compliant Systems already in use

Systm One, a clinical computer system that allows service users and clinicians to view information and add data to their records

Emis Web, a clinical computer system that allows service users and clinicians to view information and add data to their records

Vision, a clinical computer system that allows service users and clinicians to view information and add data to their records

CareFirst is the Council’s social care system which facilitates the recording of social care data including the processing of financial payments

To enable cross-boundary working, we will investigate solutions that improve interfaces between systems with a view to creating mechanisms for data sharing that will aggregate data from different sources into a consistent format. The aim is to provide one view across health and social care systems and allow queries and analyses to take place across separate systems, using the NHS Number as the primary identifier. This should also improve data quality by identifying gaps or inconsistent records

We currently have over 70% of Hull GP practices on Systm One IT system in addition to our main community provider. By April 2015 we aim to provide the opportunity for our care providers to use the same patient record; the BCF will help ensure this happens by joining up Health and Social Care data across the borough linked as above via the NHS number


Condition Hulls Response

Work is taking place within the information governance framework and we are committed to maintaining five rules in health and social care to ensure that patient and service user confidentiality is maintained. The rules are: 1. Confidential information about service users or patients should be treated confidentially and respectfully. 2. Members of care team should share confidential information when it is needed for the safe and effective care of an

individual. 3. Information that is shared for the benefit of the community should be anonymised 4. An individual’s right to object to the sharing of confidential information about them should be respected. 5. Organisations should put policies, procedures and systems in place to ensure the confidentiality rules are followed

A joint approach to assessments and care planning and, where funding is used for integrated packages of care, an accountable professional

The new GP GMS contract will be used as an enabler to support care planning and allocation of an accountable professional in primary care. The wider introduction of the accountable professional the assignment of the lead professional will be in line with development of our local delivery model for care coordination


Self-care and carer support


Complex multi care need This model will be commissioned as one of the outcomes we expect form providers of better care services

Agreement on the consequential impact of changes in the acute sector

The plan aims for 3% reduction in acute hospital care for older people the shift of ambulatory care and high risk patient groups will redeploy hospital capacity into primary, community and social care to enable reduced hospital utilisation. Better use of community and social care services will enable closure of beds and reduction in hospital based activity The plan will include includes regular tracking of activity levels in hospital and residential care against the national metrics. and plan to delay investment in primary, community and social care services in event of sustained higher levels of appropriate activity in hospitals and residential care homes


Appendix D Better Care Initiatives Scheme Initiatives Actions & Milestones

Prevention Building community resilience and working with people in their communities and in partnership with communities & voluntary groups to co design, co-develop and co-produce improved health and social care outcomes We will look at a focus on

Combat loneliness and improve wellbeing for older and disabled people, use of social prescribing and befriending schemes as part of our actions to reduce social isolation and low mood in vulnerable people.

Progressing our work to achieve Dementia friendly communities and ‘Making Hull a place to remember’ contributing to the work for City of Culture 2017

Active lifestyles and a healthier Hull – people aged 45+ to be more active and play a greater part in their communities – volunteering , taking part in activities that maintain health and wellbeing

Developing community hubs (aligned with care hubs )

Arts in health arts based creative projects in any art form or multiple art forms (e.g. dance, music, textiles, storytelling, etc.), working with disabled and older people including those with dementia in community settings in Hull. There is significant evidence of the positive contribution to health and wellbeing that participating in creative activity can bring. The programme aims to improve quality of life; extend access and encourage participation; increase skills and creativity; improve physical and mental wellbeing and raise awareness of the benefits of creative activity.

Reducing excess deaths of older and vulnerable people – progressing the multi-agency work of Warmzone to improve the home environments and support of vulnerable groups

Work with people in their communities to design, develop and produce improved community, health and social care services that promote wellbeing and more active lifestyles Progress our work to achieve Dementia friendly communities and ‘Making Hull a place to remember’ contributing to the work for City of Culture 2017 Reduce loneliness and improve well being for older and disabled people, use of social prescribing and befriending schemes as part of our actions to reduce social isolation and low mood in vulnerable people. Increased capacity in place by September 2015 Active lifestyles and a healthier Hull – people aged 45+ to be more active and play a greater part in their communities – volunteering, taking part in activities that maintain health and wellbeing. Ongoing review progress by March 2015 Developing community hubs and care hubs – Estates Strategy in development to inform locations by April 2014. First community hub prototype planned for October 2014


Scheme Initiatives Actions & Milestones

Primary Care and Self Care

Proactive risk stratification in primary care to identify people at risk of disease progression and management of people with a diagnosis more proactively. Organising care around ‘hubs’ of whole system integrated teams in primary care settings.

Promoting and extending self care for people with long term conditions. Self-care improves quality of life and appropriate utilisation of services Building on existing schemes ensure people are able to develop skills and increase their knowledge to manage their condition in a way that enables them to participate fully in society. Case finding and focus on those who are newly diagnosed. This approach will require changes in culture and redefining roles of practitioners so workforce development will be critical to ensure success. Supporting family carers to be involved and work with communities

Developing the care coordinator roles and improving access and quality of information available about services available. Supporting people to become more self-reliant and to help them find appropriate support from family and communities

Promote the use of social prescriptions across health and social care

Telecare and telehealth provision – promote its use and rollout

Proactive risk stratification in primary care to identify people at risk of disease progression and management of people with a diagnosis more proactively. Organising care around ‘hubs’ of whole system integrated teams in primary care settings. Building on current risk profiling work and incorporating the requirements of the new GMS contract from April 2014. In place by April 2015 Promoting and extending self care for people with long term conditions. Capacity building on existing schemes in place by April 2015 Developing the care coordinator roles and improving access and quality of information available about services available specification written to describe lead professional role by May 2014. Consultation with providers to develop the model and establish a workforce plan with phased pilot across care hubs. By September 2014. Telecare and telehealth provision – promote its use and rollout. 900 people being monitored by March 2015

Avoidance of Falls

Redesign current pathways in line with NICE guidance. Embed an integrated pathway and network of support across the whole system from self- care to post episodes of secondary care. Support development of prevention measures and information

Review current service

Develop cross sector Intervention programmes including

strength and balance training

home hazard assessment and intervention

Review current service, redesign current pathways in line with NICE guidance by March 2015 Increase use of community medicines reviews by June 2014 Include visual review as part of level one falls service by April 2014



vision assessment and referral

medication review with modification/withdrawal

Develop cross sector Intervention programmes by April 2015

Reablement and Rehabilitation

Maximising reablement and rehabilitation pathways as an alternative to hospital and to maintain independence following a hospital stay, avoiding unnecessary admissions and delayed discharges.

Sustaining current service and building on the models of good practice

Ensuring integration and development across help at home services

Integrating rehabilitation and therapy services

Reducing the numbers on, and waiting times for access to OT assessment and provision of equipment and adaptations

Develop and deliver a single point of contact across health and social care, review current entry points, triage assessment and internal referrals over 7 days. April 2015. Review current therapy and rehabilitation services to inform plans for integrated teams. By April 2015

Ambulatory Care

Ambulatory care 24/7 rapid assessment and diagnosis. Multidisciplinary pathways across primary community and secondary care focusing on COPD, heart failure and Frail elderly supported by an integrated case management model supported by risk profiling and named care coordinators

Build on current ACS pathway development with Hull and East Yorkshire Hospitals. Progress the current pathway work on COPD, Frailty and Heart Failure to a wider disciplinary model. Extend to Falls and Syncope. By September 2014 Introduce a community model, modelling activity to inform development of a community ambulatory care facility by September 2014. Linked to the development of the wider community hub model.

Acute and Residential Care

Improving the range, flexibility and quality services of help at home Developing home care in the community hubs – progressing the extra care models of delivery into sheltered housing schemes – review and develop specification and jointly commission help at home services Review and develop continence management services Developing / review existing policies to facilitate integrated working including

Moving and handling

Medicines management

Promoting continence and management of incontinence

Progressing the extra care models of delivery, 250+ units by 2016 Developing home care hubs into sheltered housing schemes – first scheme by September 2014 Consult on existing services and trail new approaches to support people in their own homes to support developing ambulatory care in community settings March 2014 –



March 2015 Review and develop specification and jointly commission home help services by September 2015 Developing / review existing policies by April 2015 to facilitate integrated working including

Moving and handling

Medicines management

Promoting continence and

management of incontinence

Review current End of Life pathways by October 2014

Long term Conditions Including Dementia

Design a whole system of integrated care and network of support for people and their carers from self-care to secondary care. Underpinned by a named care coordinator and Lead Care Professional approach for qualified SW, CPN , Community Nursing Care coordinator role – locally define and consult and the pilot - Review and consult on Help at home contracts including domiciliary care to ensure care coordination is provider led and agreed. Outcome based contracts to ensure lead provider / collaborative work is developed between public and third sector Developing the use of health and personal budgets and explore efficiencies/ effectiveness of joint processes etc.

Care coordinator role – locally define and consult on the pilot. By September 2014 Develop the operational model for the multi disciplinary support to care hubs by April 2015 – Implement the model September 2015 Developing the use of health and personal budgets and explore efficiencies/ effectiveness of joint processes. June – September 2015 Jointly commissioned outcome based contracts to ensure lead provider / collaborative work is developed between public and third sector - September 2015 – March 2016


Appendix E Glossary

A&E Accident and Emergency

ADASS Association of Directors of Adult Social Services

ASCOF Adult Social Care Outcome Framework

BCF Better Care Fund

CC City Council

CHC Continuing Healthcare

CHCP Community Healthcare Partnership

CCG Clinical Commissioning Group

CHD Coronary Heart Disease

CISS Carers Information and Support Services

COPD Chronic Obstructive Pulmonary Disease

CPN Community Psychiatric Nurse

EWD Index Excess Winter Deaths Index

HEYT Hull and East Yorkshire Trust

HFT Humber Foundation Trust

HWBB Health and Wellbeing Board

IG Information Governance

IMD Index of Multiple Deprivation

JSNA Joint Strategic Needs Assessment

LA Local Authority

LGA Local Government Association

OT Outreach Team

ONS Office National Statistics

QIPP Quality, Innovation, Productivity and Prevention

PCT Primary Care Trust

PFI Private Finance Initiative

WTE Whole Time Equivalent

YAS Yorkshire Ambulance Service

Y&H Yorkshire and Humber

YHPHO Yorkshire and Humber Public Health Observatory