North East Lincolnshire Care Trust

Plus

Jane Lewington Chief Executive 4 June 2010

CTP Developed in Context of…• Male life expectancy – 75.9 years

(below national + regional average)• Female life expectancy – 80.8 years

(below national average)• 49% of most deprived out of the 354

local authorities in England (2007)• 24% of lower level super output areas

in North East Lincolnshire are amongst the most deprived 10% in England

• High teenage pregnancy rates• High level of smoking prevalence• Third worst area in England for alcohol

abuse• High dependency ratio

Overview of North East Lincolnshire Care Trust Plus

• Population of 168,000• 89 GPs and 34 General Practices• 1,500 directly employed staff• 4 Commissioning Groups• 2010/2011 budget – NHS is £287 million and Adult

Social Care is £47 million• 37 contracts for provision of health care• 130 providers of social care

Care Trust Plus

• Established September 2007• Three elements:

─ Delegation of planning, purchasing and delivery of Adult Social Care (Council to CTP)

─ Delegation of planning, purchasing and delivery of health improvement (CTP to Council)

─ Development of Children’s Trust─ Council as preferred provider of Community Child Health

Services

Care Trust Plus –Accountabilities

NHS Care Trust Local Authority

Children’s TrustCommissioning

Board

Adult Social Care

Health Improvement

Characteristics of the CTP

• A health and well-being organisation

• Commissioning groups: front line integration

• An organisation rooted in its community

• Working as part of a wider care community

CTP – Role and Functions

• Planning and purchasing of health and adult social care - £320m

• Planning and purchasing at the level of the individual, the locality and the population

• Contract management and procurement ie contract consortia for main Acute Hospital provider

• Delivery of community health and personal care services

CTP Current Provision

• Adult Mental Health services• Learning Disability • District Nursing and complex case management• Integrated Tier 2 services• Palliative Care and Specialist Nursing• Drug Intervention Programme• Meals on Wheels and transport services• Day Care – Older People and Physical Disability• Supported employment schemes

Four Commissioning Groups

• Based on GP Practice populations• Hold budgets for:

– Hospital care– Prescribing– Community nursing

• Care Management Teams aligned • Community nursing Teams fully aligned • Community membership scheme• Lay Boards

Integration

What We are Trying to Achieve

Goal 1 - Creating a healthy community

The initiatives to deliver this goal are:

Increase access to screening by 10% Reduce childhood obesity by 10% Reduce CVD mortality by 4% (NELC will be lead for initiatives 2 and 3 under our legal partnership agreement)

Goal 2 - Accessible, responsive, quality care

The initiatives to deliver this goal are:

Reduction in the number of avoidable emergency admissions by 50% Increase the number of stroke patients receiving effective, timely treatment

What We are Trying to AchieveGoal 3 - People in control of their own care

The initiatives to deliver this goal are:

Increase by 35% the number of people diagnosed with dementia that receive early intervention Increase by 20% the number of personalised care plans Increase the number of people by 3% that feel they are treated with dignity and

respect

Goal 4 – Build a sustainable care system

The initiatives to deliver this goal are:

To manage within available resources To actively promote community leadership Contribute to reducing climate change locally

The Integration Journey

Driving forces:– Co-terminosity– Greater and faster progress needed in delivering

better outcomes– Long and strong history of collaboration– Local stability within the NHS system– High trust relationships amongst local leaders– Strong sense of place and sound financial

performance

The Integration Journey

Key challenges:– View of the region and DoH– Robust but lengthy application process– Building local political and lay member

support– Managing the impacts of organisational

change – Building on belief rather than hard

evidence

Joint Governance

• Legal Partnership Agreement• Three Year Strategic Agreement• Financial Risk Share Agreement• Continuing dialogue:

– Executive Officers Group– Good Governance Group– Performance Group

Key Governance Issues

• Handling reserved matters

• Political representation

• The role of the Director of Adult Social Services

• Communication and awareness

• Answering the difficult questions at the start of the journey

The CTP: What Has Worked

Putting in the building blocks:– Harmonisation of terms and conditions

– Working alongside as a precursor to integration

– Integrated management structure and integrated support services

– Developing a new language

– Commissioning Groups at the heart of the new organisation

The CTP: What Has Worked

• Development of whole system thinking

• Integration driven at the strategic, tactical and individual level

• Broader ownership and greater influence eg Carers

• A wider set of levers deployed

CTP: Emerging Benefits

• Significant increase in quality ratings of Care Homes

• No direct admissions to Care Homes from hospital

• Redesign of Tier 2 services – reduction in hospital admission

• Doubling the number of people helped to live at home

CTP: Emerging Benefits

• Use of co-production models for health and personal care

• Philosophy of normalisation developing within front line teams

• Broader set of PIs and standards in contracts reflecting total care issues

• Cost shunting ie NHS continuing care, transitions

• NHS funding of care substitution• Management of winter pressures/incidents

CTP: Emerging Benefits

• 35% reduction in formal social care referrals

• Greater focus on prevention and re-enablement driving redistribution of

resources• Use of integrated care to reduce costs and

improve quality for those with the most complex needs

CTP: Challenges We Still Face

• Two external regulation processes

• Two external performance regimes

• Increasing difficulty in meeting the silo processes of the wider system eg use of resources

• NHS policy drivers that undermine integration – TCS

CTP: Challenges We Still Face

• On-going commitment to relationship management

• The partnership journey needs constant development

• Ensuring progress against the full breadth of our agenda

Stakeholder Management

• Maintaining performance in Year 1• Improving performance in Year 2

onwards• Sharing early wins and the impact on

individuals • Timely and robust response to issues/

concerns• Staff settled into the new organisation

Stakeholder Management

• Council membership of the CTP Board

• Importance of CE to CE relationship

• Importance of Council Leader and CTP Chair relationship

• Supporting the Portfolio Holder for Adult Social Care

• Opening up internal processes

Financial Approach

Managing ResourcesClear and explicit documentation for each budget that sets out:

─ Which partner is accountable

─ Which partner is responsible

─ Who funds the risks that arise in-year and the approach to recurrent resolution

Establishing Partnership Budgets

• Use 3 year costs and trends to inform partnership budgets

• Formally agree how the budgets will be negotiated going forward (cost pressures, inflation, savings, investment priorities)

Moving to Pooled Budgets

• Understanding each partner contribution but loss of identity on spend

• Need to have built sufficient trust

• Able to demonstrate accountability and delivery to everyone’s satisfaction

• The services really need it

• Start small

Language and Culture

• Need a common language and process/ approach for:– Assessing and demonstrating VFM– Reshaping the use of resources to support

delivery of priorities and outcomes

• Transparency and trust need to be in place between the DOFs

Language and Culture

• DOFs need to meet regularly and take a lead in strategic financial management, setting the tone of the overall financial relationship and unblocking problems

• Expect to learn from each other and be open to this

• Sharing teams and TUPE of back office staff really does help

Use of Shared Services

• Reduces costs eg Council could reclaim VAT on community equipment purchases but the NHS couldn’t

• Make best use of existing expertise/systems - debt collection

• Can add assurance: use of LA internal audit service for Adult Social Care services

• Reduce residual costs: £800k of back office services bought from the Council

Where Next on Our Integrated Journey?

NHS funding and regulation

Prevention

Personalised

Extended primary care

Intermediate care

Acute

Specialised

Interventions

Citizenship

Neighbourhood

Information access

Lifestyle

Practical support

Early intervention

Enablement

Community support

Institutional avoidance

Timely discharge

Complex needs

Substantial needs

Low to moderate needs

General populationRegeneration

Housing

Transport

Children's Trust

Outcomes (Financial sustainability, user

experience, quality)

Shifts in investment

Integrated Care Model

Integrated Care Organisation (ICO)

Joint Strategic Commissioning Board

AnnualPlan

ICO Delivery Arm(Personalised

Commissioning and

provider function)

Primary Care

CommunityProvision

Acute (DPOW)

(Medicine and Emergency Care)

What We Plan to AchieveThe integrated care organisation is a means to improve services on how we:

– generate cash release efficiency savings by increasing productivity, reduce costs and remove the duplication of services

– reduce admissions to acute hospitals, improving quality and care outcomes by changing the way we deliver care

– improve the experience of service users by providing better coordination of care with fewer handovers between providers

– create more local engagement for users and citizens

1. Individuals influencing their own care2. Improving employment3. Users more satisfied with the service4. Reducing the use of institutions5. Users able to become more independent6. Reducing inequalities7. Affordable services

Judgingsuccess

Questions?