sutton joint better care fund plan updated for 2017/19 · are working together to transform the way...

1 v1 Final 20 September 2017

Appendix A

Sutton Joint Better Care Fund Plan

Updated for 2017/19

Area London Borough of Sutton

Constituent Health and Wellbeing Boards

Sutton Health and Wellbeing Board

Constituent CCGs NHS Sutton CCG

Page 49 Agenda Item 5


Contents

Introduction ......................................................................................................................................... 4

Local Vision for health and social care services ........................................................................... 4

Background and context to the plan ................................................................................................ 6

Progress to date ................................................................................................................................. 8

Progress against National Performance Metrics 2016/17 ......................................................... 13

Metrics 2017-19 15

Evidence base and local priorities to support plan for Integration ............................................ 17

Current Provision of Services ......................................................................................................... 21

Opportunities for Improvement ...................................................................................................... 22

Local Needs ...................................................................................................................................... 24

Proposed future model .................................................................................................................... 26

Case Study examples ..................................................................................................................... 28

Better Care Fund plan ..................................................................................................................... 29

National Conditions .......................................................................................................................... 29

Delayed Transfers Of Care Plan 30

Overview of Funding Contributions 36

Programme Governance ................................................................................................................. 37

Assessment of Risk and Risk Management ................................................................................ 38

Appendices 40

Page 50Agenda Item 5


Local Authority London Borough of Sutton

Clinical Commissioning Groups Sutton Clinical Commissioning Group

Boundary Differences N/A

Date to be agreed at Health and Wellbeing Board: 25th September

Date submitted: 11th September 2017

Minimum required value of CCG contribution

to BCF pooled budget: 2017/18 £11,603,520

Minimum required value of LA contribution to BCF pooled budget: 2017/18

£4,142,600

TOTAL £15,745,120

Agreed value of CCG contribution to BCF pooled budget 2017/18

£11,990,809

Agreed value of LA contribution to BCF pooled budget 2017/18

£6,547,791

Total agreed value of pooled budget 2017/18 £18,538,600

a) Authorisation and signoff

Signed on behalf of the Clinical Commissioning Group

By Dr Chris Elliott

Position Chief Clinical Officer Date 06 September 2017 Signed on behalf of the Council By Tolis Vouyioukas Position Strategic Director – People Directorate Date 11 September 2017 Signed on behalf of the Health and Wellbeing Board

By Chair of Health and Wellbeing Board Councillor Ruth Dombey Leader of London Borough of Sutton

Date 11 September 2017



Introduction The Sutton health and care economy is facing significant challenges in the context of

increasing demand from an ageing and a growing population. As the population ages and

long term conditions (LTCs) increase in prevalence, providers and commissioners are

being asked to do more with less, making the economy unsustainable in its present form.

To ensure the Sutton economy can effectively support the population in the future, partners

are working together to transform the way services are delivered.

Sutton’s Better Care Fund plan for 2017/19 is a continuation of the programme of work

commenced in 2015/16 and continued throughout 2016/17 acknowledging that BCF and

integration in Sutton are part of “business as usual”. This plan should be read in

conjunction with the original 2015/16 and 2016/17 plans which contains the details of our

strategic direction, needs assessments and programme of work.

Local Vision for health and social care services

In June 2014, the six South West London CCGs submitted their 5 year strategy for health

services across South West London. This strategy, which is the culmination of joint

working since January 2014, seeks to address the rising demand for healthcare in South

West London, and the quality and financial gaps that exist at present in its provision. The

clinical input to the strategy was developed by seven Clinical Design Groups (CDGs), with

integrated care being both a CDG in its own right and a major component of the strategy as

a whole. Patient feedback was sought as part of this process and used by the CDGs in

developing the initiatives in the five-year strategy.

Our vision in Sutton for integrated care is:

“Our shared vision is for integrated care to achieve seamless, consistent and efficient

support through our services and to support people to live healthy, independent and

fulfilling lives based on choices that are important to them. We all share a common

purpose to enable people to stay healthier at home for longer, by doing more to prevent ill

health, supporting people to manage their own health and wellbeing and providing more

services in people’s homes and communities”

Since that time, The Five Year Forward View and requirements for integration of health and

social care by 2020 have been published. In November 2016 South West London

published its Sustainability and Transformation Plan (STP)

http://www.swlccgs.nhs.uk/2016/11/our-plan-for-south-west-london/ . This Five Year

Forward Plan sets out how we can work together across South West London to support

people to keep healthy and well, and intervene early and deliver the right care in the best

place to support them if they do get ill. Proactive, preventative care will mean fewer people

need to access emergency or specialist services.

In Sutton, to further support development of our joint approach we created the Sutton



Integration and Transformation Board (SITB). However with the continuing development of

the Sustainability Transformation Plan (STP), new governance arrangements have been

put in place and the Local Transformation Board has been set up. As a significant number

of integration schemes will be delivered through the Sutton Health and Care programme,

the BCF will be reported through the Sutton Health and Social Care Executive (further

details are shown in the Section ‘Governance and Performance management’) which

reports directly to the Health and Wellbeing Board (HWBB).

We have also ensured significant involvement in the development of SW London

Sustainability and Transformation Plans and for integrated care services in particular; the

vision across South West London is to develop services that:

● help people to self-manage their condition and helps understand how, when and

who to access care from when their condition deteriorates;

● help to keep people with one or multiple long term conditions (LTCs) and complex

needs stable;

● allow people to get timely and high quality access to care when they are ill,

delivered in the community where appropriate;

● support people who are in hospital to be discharged back home as soon as they no

longer require hospital care, with appropriate plans in place for care to continue at

home

● provide people who are discharged from hospital with the right level of support

delivered at home or in the community to prevent readmission and promote

independence

● support people requiring end of their life care to receive their care at home and die

in their preferred place.

● support and provide education to both family and carers to ensure their health and

wellbeing needs are met.

Our long-term vision for integrated health and social care services for Sutton aligns with the

following strategic plans:

● The South West London STP

● The Joint Strategic Needs Assessment (JSNA) for Sutton, informed by the voice of

patients, service users and members of the public

● The Joint Health and Wellbeing Strategy

● The Joint Strategy for Health and Social Care in Sutton

● Sutton CCG operating plan

● Sutton Health and Care

Our vision involves a step change in the way that we plan care, from reactively providing

services when people fall ill, to proactively supporting people to stay healthy. We, as co-

commissioners, Sutton CCG and LB Sutton, and in partnership with our community, acute

and mental health providers, will deliver services in an integrated way that enables patients

to receive effective care closer to their homes. Services will be person-centred and many

3 Agenda Item 5


schemes will be targeted at those groups identified at most risk of hospital or care home

admission, and those with multiple long term conditions.

Given the ageing population, the approach is especially relevant to older people. Nationally,

unplanned admissions for people over the age of 65 account for 68% of hospital

emergency bed days.1 In addition, there is a range of risks associated with emergency

admission, such as increased dependence, reduced mobility and contracting a Hospital

Acquired Infection.2 There are therefore clear advantages to avoiding hospital admission

from both the perspective of patient outcome and experience as well as reducing demand

on acute services.

Furthermore, we will promote a universal offer to the residents of Sutton. We will provide

services which enable people to be proactive about their health and wellbeing, and remain

independent for as long as possible. This will be a whole-system approach which will also

strengthen the relationships between services and professionals, including primary care,

third sector services and the other community organisations.

Background and context to the plan 1. Nationally, Sutton can be compared to a basket of ten other areas that have similar

demographic profiles and therefore by extension could be expected to have similar health and social care outcomes: Barnet, Bexley, Bromley, Crawley, Havering, Kingston, Solihull, Southend, Swindon and Trafford. A range of resources are available, including the NHS Atlas of Variation, Public Health National Outcomes Framework, the SALT returns for all councils and the Joint Strategic Needs Assessment, which measure how Sutton compares to its basket of peers. These resources have informed the LB Sutton and the CCG to define and agree local priorities. The mid-2013 Census population estimate showed an increase in population growth to 195,914 from the 2011 figure of 191,123 in line with a forecast upward trend of 14.3% over 10 years, higher than the rate of growth either for the capital or the country. The forecast population growth is defined by local births, longer life, and net migration into the borough. Over recent decades the ethnic profile of the borough has gradually become more diverse with only 71.9% expected to report white ethnicity by 2022. Older adults aged 65 and over are expected to comprise 21% and over 4,000 of these are aged 85+ years. This is in line with the profile for London and England. Increasing numbers of older adults along with the trend towards living longer, impacts on services that provide support for long-term conditions and for the vulnerable and frail elderly.

2. Sutton has some of the lowest early mortality rates in the country (defined as avoidable deaths before age 75). The area continues to rank well on most of the wider determinants of health but it is notable that there is variation across the borough with some electoral wards being significantly worse off.

1 Older people and emergency bed use: Exploring variation (2012), Imison, C. et al., London: The King’s Fund 2 Ibid.



3. Life expectancy is a very good measure of overall health inequality and Sutton has good life expectancy, exceeding the national average for men and similar for women. However, this varies within the borough. The Slope Index of Inequality (SII) is a measure of how much life expectancy varies with deprivation. In 2012-14, the variation between the least and most deprived wards for males in Sutton is 7.4 years. This represents the range in years of life expectancy across the social gradient within the borough, from most to least deprived. For females the variation is 4.4 years.

4. A measure of forecast burden on the health and social care system is the number of years of healthy life expectancy vs. overall life expectancy. In Sutton at birth it is 65.9/80.9 for males and 66.6/83.4 for females.

5. Significant amongst local health challenges is weight with one in five 4-5 year old children in Sutton overweight or obese rising to one in three for 10-11 year olds although there is wide variation within the borough. These levels of excess weight increase with age and two thirds of Sutton adults are overweight or obese. The World Health Organisation cites obesity as one of the greatest health challenges of the 21st century and Sutton’s results confirm this. Obesity therefore presents challenges for the future for any commissioning organisation due to the increased risks of associated major diseases including diabetes, heart disease, cancer, and musculo-skeletal conditions.

6. Respiratory disease has been prioritised locally due to the perceived gap between the observed rate for COPD (1.4% as reported in QOF) and the expected prevalence rate. For diabetes, expected local prevalence is 6.1% or about 1 in 16 residents forecast to number 4,000 people aged 65 years and over by 2018. Dementia diagnoses have risen to 68% this year but a gap remains in identifying the full cohort and putting Sutton in a position to offer suitable packages of care to sufferers and their carers who may carry an unnecessarily-heavy burden. Sutton’s standardised rate for hip fractures from falls is 97.5 which, although similar to England overall, represented 995 emergency hospital admissions in the aged 65+ age group in the 5 years to March 2013. Further, rates of injuries due to falls in this age group are statistically higher in Sutton than for London or England.

7. Although overall Sutton compares relatively well in many indicators of health and wellbeing, the latest statistics from Public Health England (Public Health Outcomes Framework http://www.phoutcomes.info/ show that female life expectancy has reduced in the latest time period (2012-14). Some of this could be due to an increase in rates of female mortality from respiratory disease (which includes COPD, related to levels of smoking) and cancer rates in females aged under 75 where Sutton’s rate is statistically higher (worse) than for London, and rose in the latest three-year time period.

8. In summary, levels of health and wellbeing are good in Sutton. The borough has comparatively high life expectancy and low mortality rates. The health of people in Sutton is generally better than for England overall. However, there are variations within the borough and for some indicators we do not compare as well as would be expected given our relatively low levels of deprivation. Sutton is one of the least deprived boroughs in London, although again there is variation. Wards with small areas in the most deprived quintile (20%) are Beddington South, Belmont, Wandle Valley, St Helier



and Sutton Central. Our aim is to improve the outcomes for residents in Sutton in these areas through the BCF.

Progress to date

Key areas for success 2016-17

The 2016/17 Better Care Fund Plan focused on 5 key work streams. We have used the

learning from the Vanguard Care Home initiative to improve our approach to delivering

these schemes. Highlights of successes from each work stream are detailed below, which

we intend to continue for 2017-19:

Integrated Localities

Integrated Locality Hubs help Sutton achieve two of the key BCF aims:

● A joint approach to assessments and care planning clarify roles and

responsibilities - “make one visit count” and

● Jointly funded integrated packages of care

The establishment of integrated locality hubs also support achievement of a number of the

national BCF metrics, including:

● Admissions to residential care

● Reablement (people still at home 91 days after discharge)

● Reduction in Non-Elective Admissions

● Reduction in delayed transfers of care

Progress has been made towards creating Integrated Locality Hubs (ILH) that will co-locate

staff from both health and social care with the first ILH planned in the Wallington Locality by

December 2017. These moves will provide opportunities for integrated working and

facilitate and promote joint assessment and care planning and the use of multi-disciplinary

team meetings.

Additionally - a second project involving implementation of clinical resource has been

completed. This takes the form of Locality Nurse Facilitators to support General Practices

in establishing their multi-disciplinary teams and develop robust case management plans

for those patients who require them. The Locality Nurse Facilitators are senior nurses (at

the request of General Practice colleagues) and two nurses have been appointed and

commence in post in 2016/17. One of the early pieces of work undertaken was working

with the Frequent Attendees Forum to facilitate joint care planning across all agencies

including primary care; secondary care; mental health and London ambulance services.



Integrated Intermediate Care

The successful pilot accessing intermediate care via the hospital in-reach (‘swoop’) team

has been implemented with an integrated multi-agency in-reach team based at St Helier

Hospital to facilitate complex discharges back into the community. The team consists of

community nurses, therapists, healthcare assistants and social workers and acts as a

single point of referral for patients who may require intermediate tier support after their

discharge and has received positive feedback.

Plans for further improvements to ensure coordination amongst the various services is

improved are underway to ensure that duplication is reduced and efficiency increased.

Investigations are also underway to involve transport and pharmacy representatives earlier

in the process.

Integrated Equipment

This service has been commissioned as an Integrated Community Equipment Store. It is

designed to minimise unnecessary spending and maximise the potential of this budget

stream in supporting independence at home. The service is currently available 6 days per

week, in line with safe discharge requirements. The budget was increased for 2016/17 to

reflect the need for additional equipment for a higher number of residents that are expected

to be managed safely at home. We are planning to review the whole service in 2017 to

ensure value for money is maximised.

Seven Day Services

Building on the two successful weekend discharge initiatives held in 2015/16 the Trust has

implemented the findings and operates a 7 day service as per NHSE/NHSI 2016/17 Rapid

Implementation Guidance. For example, the BCF funds an integrated in-reach service to St

Helier hospital. This is a 7 day 2 hour service delivered via the Community Prevention of

Admission Team to patients at home or via the Rapid Response Team based at St Helier

A&E and acute medical unit (AMU), with the objective to prevent unnecessary hospital

admission and facilitate the patient remaining at home where possible.

We are using the key principles of our Out Of Hospital (OOH) work through the urgent care

working group and A&E Delivery Board and striving to ensure that all our services cover a 7

day period where they are required and are affordable. These principles are also being

used in the design phase for our new models of care.

Mental Health

Work continued to focus on reaching the National dementia diagnosis rate of 67% during

2016/17. Sutton has achieved this target from October 2016, having a dementia diagnosis

rate of 68.3% for 2016-17.

To increase this diagnosis rate Sutton CCG previously invested in the following services:

o A dedicated Memory Assessment Service in its Older People’s Community Mental



Health Team to increase capacity for assessment and diagnosis.

o Increased capacity for assessment and diagnosis by the Psychiatric Liaison Service

at St Helier Hospital

o Expansion of the local Admiral Nurse service to enhance capacity to work with

Carers of people living with Dementia

A range of initiatives were and continue to be implemented to ensure that this diagnosis

rate is sustained

o Practice data systems are regularly reviewed to ensure dementia information is

coded and recorded appropriately and systems are up-to-date

o Data harmonisation audits are run regularly to ensure consistency with GP

dementia registers

o Sutton CCG’s Vanguard programme introduced “Dear-GP” in Sutton’s 29 care

homes enabling care home staff to identify dementia among their residents and seek

further assessment.

The Dementia Pathway is progressing and we are planning to provide a Stepped Care

Model of Care for people with dementia, whereby people with dementia and their Carers

can get early support to live well with dementia, as well as on-going support throughout

their dementia journey from both health and voluntary sector partners. We are currently

piloting this with a cohort of patients before extending this across the Borough.

Improved Data Sharing between Health and Social Care based on the NHS Number

An enabler work stream has focused on the creation of an Integrated Digital Care Record

(IDCR). The Sutton IDCR project is a joint initiative between NHS Sutton Clinical

Commissioning Group and LB Sutton and is an innovative secure electronic record that

facilitates smoother flow of information between health and social care.

Data from all 25 GP practices has now been successfully loaded. Currently consent has

been obtained for over 1200 clients and social care records have been uploaded to the

Sutton IDCR.

Access to the system has been provided to all clinicians at St Helier Hospital using single

sign on from their clinical manager system. Having access to important information about a

patient's allergies, existing medical conditions and their current medication, has helped

clinicians provide the best care and advice available. Feedback from clinicians, particularly

in A&E and the Acute Medical Unit, has been very positive with growing recognition of the

positive impact of the new access to clinical records.

Work is underway to provide SELDOC out of hours GP service with access to the system

using single sign on from their patient record system.

During August 2017 a survey took place to measure the impact of the Sutton Integrated



Digital Care Record (SIDCR) to understand how Hospital clinicians having instant access to

patient information 24/7 has reduced activity at practices. Questionnaires were completed

by a number of departments within St Helier Hospital and by Sutton GP Practices.

The purpose of the survey was to understand:

· Who is accessing the SIDCR to look for opportunities to expand number of users

· The impact to having access to SIDCR and how this related to treatment

pathways

· If GP Practices are spending less time on requests for patient information

· Feedback on functionality and data – to develop additional data feeds.

12 questionnaires were received from a number of professionals within St Helier, including

A&E, AMU, Medicines Management, Liaison Psychiatry and Older Peoples Liaison Service.

Summary of feedback from St Helier:

Medicines Management Team (based in AMU) – the SIDCR is a quick and easy way to

access GP information. The medication summary is extremely useful as patients are not

always able to remember details about their medication. The SIDCR is mostly relied on to

perform efficient medication reconciliation.

Senior Pharmacist –SIDCR enables information to be obtained within 5 minutes. No need

to wait on hold or send faxes for information. It is a secure method to which improves

information governance.

A&E Consultant – the SIDCR has excellent drug and contact history as well as allergies’

details. It is accurate, quick and up-to-date. There is no risk of error, linking via the Clinical

Management System and decreases the risk of accessing another patients’ data. It would

be useful that this was also available for Merton patients.

The use of the IDCR by the hospital pharmacists is a good example of how outcomes have

been improved for patients. Pharmacists are using the shared record to access GP patient

information to prescribe more quickly and efficiently and therefore facilitate a quicker

discharge of patients.

Summary of feedback from GP Practices:

16 Sutton Practices completed questionnaires to feedback on the impact of the SIDCR.

14 Practices confirmed there has been a reduction in calls received requesting patient

information. A reduction in time spent on these calls is a positive outcome, however we

recognise GPs are still receiving calls for additional information with 11 Practices

confirming this. 4 Practices reported that they are not receiving calls anymore in relation to

requests from St Helier.

The Medicines Management department at St Helier was the department making the

highest number of calls to Practices, with the request for detail in relation to medication.

Patient summary detail was feedback as being the 2nd highest request.



We will continue to seek feedback to further enhance and promote the benefits of the IDCR

to colleagues, patients, service users and partners over the coming year.

Sutton CCG has recently submitted a business case to the Estates and Technology

Transformation Fund (ETTF) for funding for Phase 2 of the IDCR. Sutton CCG and Sutton

Council’s bid is to further develop the IDCR to incorporate mental health information in

addition to acute, primary care, community health and social services information in Sutton

and Kingston as well as to facilitate integrated care planning. The plan to include work to

improve operational efficiency through mobile working, link to Richmond and a patient

portal will now be taken forward as part of the wider interoperability plans for SW London.

This will promote better sharing of information between health and care organisations to

provide safer, more-timely care to residents across the South West London boroughs.

Disabled Facility Grant

In 2016 Sutton Staying Put and the Kingston Home Improvement Agency become a

Shared Home Improvement Agency as part of the Sutton and Kingston Shared

Environment Service. The Disabled Facilities Grant is administered by the HIA. The HIA

supports vulnerable residents to remain independent by providing advice, access to funding

(including the DFG) and the surveying for property improvements or adaptations.

Improved homes reduce the likelihood of a hospital admission and the need for costly and

unnecessary residential care and can help reduce delays when a patient is ready to be

discharged. The HIA can also assist vulnerable residents to self-fund works not eligible for

a DFG. The HIA is seen as a trusted service that provides person centred advice and

delivers home improvements that aid safety, independence and have a significant positive

impact on emotional health and wellbeing.

In 2014 the council commissioned the Building Research Establishment (BRE) to carry out

a Health Impact Assessment of the private sector housing within the borough. This

estimated that cost to the National Health Service of treating accidents and ill-health

caused by the hazards due to poor housing is £1.3 million each year and if the wider costs

to society are considered the total costs are estimated to be £3.4 million.

Sutton’s Joint Strategic Needs Assessment (JSNA) has been developed by the council and

the Clinical Commissioning Group (CCG) and uses data on health and wellbeing to form

the Health and Wellbeing Strategy. The Council's JSNA identifies injuries including

hospitalisation and deaths from falls and excess cold as being higher than the national

average in Sutton. Assistance in the form of handrails, ramps, and provision of adequate

affordable heating can help reduce the risk.

Our Housing Assistance policy sets out the discretionary assistance policy to support wider

social care needs of residents living in the private rented sector. This flexibility in providing



assistance links to wider strategic aims to keep people safe and well at home, speed up

discharge from hospital and to reduce bureaucracy and waiting times in the grant’s

administration. We are currently in the process of revising the Housing Assistance policy

and have planned for this to be approved by October 2017.

The new policy has been developed after consultation with Adult Social Care, Public Health

and Occupational Therapist at Epsom and St Helier Hospital and is part of the our

approach to develop preventative services to keep residents safe in their homes.

Converting rooms downstairs into bedrooms, house clearance and small security

enhancements are just some examples of how we propose to widen the services provided

through the DFG. The HIA works closely with Occupational Therapists (OT) and Adult

Social Service and the majority of clients are referred via these routes. Work is also

undertaken for private clients who pay for the works and the HIA fees. It is proposed to

extend the referral pathway to enable residents to be referred via alternative routes, for

example Hospital Discharge Teams or GP’s.

Progress against National Performance Metrics 2016/17

Although there was a reduction in NEL’s for 2016-17 of 849, the targeted 3.5% reduction in

non-elective admissions (NEL) was not achieved in. Year-end actual NEL were 19,847

against a plan of 19,063 (2.2% above plan). Despite all schemes performing well and

meeting their contractual KPIs the anticipated reduction has not been achieved. This is due

to a number of contributing factors including a period of increased acuity particularly in July

and August.

Figure 1: Non-elective admissions (G&A), all-age (2016/17)

Admissions to residential and care homes (Figure 2)



The permanent admissions of older people (65+) to residential homes, per 100,000

populations target was met during the 2016/17 with a rate of 186.6 against a target of

282.7.

Figure 2: Permanent admissions of older people (65+) to residential homes, per 100,000 pop. (2016-17)

Effectiveness of Reablement (patients still at home 91 days after discharge)

(Figure 3)

Sutton CCG and the London Borough of Sutton both contribute funding to our highly

successful START (Short Term Assessment and Reablement Team). The number of

clients still at home 91 days after a discharge from hospital after their period of reablement

was consistently above 95% for the year, against a target of 90%. Performance was 96.2%

overall for the year.

Figure 3: Proportion of older people who were still at home 91 days after discharge into Reablement (2016-17)



Delayed Transfers of Care (Figure 4)

Following development of our local action plan for escalating Delayed Transfers of Care

(DTOC) issues, we have seen a significant improvement in DTOCs. Delayed Transfers of

Care (delayed days) from hospital per 100,000 population have been sustained below the

198.9 target, with the year-end performance at 170.4

Figure 4: Delayed Transfers of Care (delayed days) from hospital per 100,000 population (2016-17)

Local metric – Dementia Diagnosis

Sutton has undertaken significant work over the past year to improve dementia diagnosis

rate compared to estimated prevalence moving to above the 66.7% diagnosis rate to 68.3%

for the year. Whilst there is no longer a national requirement to report on local measures,

dementia will continue to be a priority for Sutton.

Metrics for 2017-19 The metrics for 2017-19 are set out in the Planning template. There are four national

metrics for 2017-19 and these are:

1. Non-elective admissions (G&A), all-age

2. Permanent admissions of older people (65+) to residential homes, per

100,000 population

3. Proportion of older people who were still at home 91 days after discharge

into Reablement

4. Delayed Transfers of Care (delayed days) from hospital per 100,000

population

The table below shows what the targets for Sutton are for the period 2017-19.



Metric

Q1 17/18

Q2 17/18

Q3 17/18

Q4 17/18

Q1 18/19

Q2 18/19

Q3 18/19

Q4 18/19

Non-Elective Admissions per 100k pop

5,012 5,229 5,164 5,151 5,234 5,231 5,297 5,186

Permanent Admissions to Residential Homes/100k pop

21 21 21 21 21 21 21 21

91 Days (Reablement)

92.5% 92.5% 92.5% 92.5% 92.5% 92.5% 92.5% 92.5%

Delayed Transfers of Care per 100k pop

675 656 656 642 656 656 656 642

Non-elective admissions (G&A), all-age

For the Non Elective activity plan, we have aligned the BCF target with the CCG

operational plan and are not intending to make further reductions to the NEL target this

year.

Permanent Admissions to Residential Care Homes

Sutton already performs very well in this area. Almost all requests for placements emanate

from the hospital and locality teams, and these requests are now approved by one Head of

Service. This has helped manage placements so that suitable alternative to a residential

placements are considered, where appropriate. We will continue to fund the Admiral

Nurses so that more people are able to continue to live in their home for as long as

possible. We have therefore kept the target in line with 2016-17.

Proportion of older people who were still at home 91 days after discharge into Reablement

We performed well against this target for 2016-17, with 96.2% of clients still at home after

91 days, following a period of reablement. We have therefore proposed that this target is

raised to 92.5% for 2017-19.

Delayed Transfers of Care (delayed days) from hospital per 100,000 population

Sutton CCG and London Borough of Sutton have submitted targets in line with the

nationally set requirement. However, we have questioned the principles being applied to

the methodology for setting the DToC targets.

In Sutton we have a record of maintaining very low levels of DToCs and yet have been set

a further substantial reduction (of 17%), which is going to be extremely challenging given

the low historical level of DToCs. Also some areas with far higher DToC baseline levels

(i.e. rate per 100,000) seem to have been set a target of no reduction at all. It is therefore

not clear whether any reasonable principle has been applied to these targets.



However, in line with the guidance we have been given by NHS England, we have set the

DToC target to align with the provisional targets submitted in July 2017.

Evidence base and local priorities to support plan for

integration

Drivers for Change The demographic pressures of an ageing population combined with budgetary pressures

and increasing costs exacerbates an already challenging environment. At present, care is

fragmented across the health and social care provision and the approach to managing

long-term conditions is outdated. 3

The Sutton health and care economy is unsustainable in its present form. Providers and

commissioners need to respond collectively to a range of challenges which; taken together,

require a significant re-think of the way in which care is provided.

Key challenges include:

5. Increased demand from a growing and ageing population: The population of

Sutton is projected to grow by approximately 10% over the next 7 years34. This

translates into 20,000 additional residents, all of whom will make use of services to

33 Triborough ASC Vision

4 Sutton JSNA 2016



varying degrees. The population is also ageing. Life expectancy in Sutton is higher

than the London and national averages for both men (84.3 years) and women (86.1

years), and continues to rise. In 2011, 14% of Sutton’s population was aged 65 or over,

with the 60-64 year old cohort registering the largest growth of any age cohort over the

preceding ten years (38% increase). As a result, the proportion of Sutton residents

aged over 65 is forecast to rise by 18.7% by 2021. This should be celebrated, but

places a steadily increasing pressure on many elements of the health and care

economy as older people are typically most at risk of admission to hospital. For

example, I in 10 people aged over 65 are “frail” (rising to 1 in 4 people aged over 85)

and most people aged over 70 have one or more long term condition (LTC)

Figure 6 Percentage change in population, 2014-2024 by age band, Sutton 6

2. Increased prevalence of long term conditions: linked in part to an ageing

population, LTC prevalence is also increasing. For example, it is projected that the

number of people suffering from diabetes aged over 65 will increase by 5% over the

next two years, a pattern reflected for other long-term conditions such as COPD. The

additional burden on health and care services is considerable – as well as more

frequent trips to hospital, LTC sufferers require ongoing support from community and

primary care services for the management of their condition. This is particularly true for

individuals with multi-morbidities or complex health and social care needs. Whilst the

diagnosed incidence of the main LTCs is lower in Sutton than the national average,

there is strong evidence to suggest that LTCs are underdiagnosed in the borough,

implying that many people in Sutton are not receiving the support they need to manage

their condition. Though not ‘long term conditions’ in the clinical sense, social

pathologies such as loneliness and isolation are also becoming more widespread as

the population ages. For example, over half of people aged over 75 live alone and 40%

of older people in the UK report that television is their main company .The link between

loneliness and ill health has been demonstrated by numerous studies, for example, the

ONS reports that 59% of adults aged over 52 who report poor health say they feel

lonely some of the time or often, compared to 21% who say they are in excellent



health.

3. Opportunity to improve outcomes for service-users: Sutton health and care

services are of good quality. Both the CCG and the Council perform well against most

national quality metrics and continue to improve year on year. However, there are

opportunities to improve outcomes for service-users still further. Health and well

being inequality remains a significant problem. For example, two Sutton wards,

Wandle Valley and Sutton South, had a significantly higher mortality rate than the

average for England, whilst six had a significantly lower rate (Beddington North,

Belmont, Carshalton South, Worcester Park, Carshalton Central and Nonsuch, based

on data for 2008-12). This translates into marked differences in life expectancy

between residents in different wards (6 years for men and 8 years for women).

4. Opportunity to improve service-user experience of care: Sutton residents are

broadly satisfied with the health and care services they receive, with both health and

social care services scoring well for service-user satisfaction. For example, 86% of

patients are satisfied with their GP (compared to the national average of 69%) in

2015. Similarly, Epsom and St. Helier Hospitals Trust achieved a Friends and Family

Test score of 93.7% for the same period. Research undertaken by Sutton Council

indicates high levels of satisfaction the Council’s approach to customer interaction

(88-90%) and an overall satisfaction with Adult Social Care services in excess of 60%

However, there are still opportunities to improve. Feedback from service-users

indicates that, too often, care is orientated around organisational boundaries rather

than built around the needs and aspirations of the individual. Specifically, there are

opportunities to:

■ Empower service-users to manage their own care through emphasising self-

management, providing choice and working with patients as equal partners in the

co-design of care plans.

■ providing a seamless experience of care across organisational boundaries and

settings of care. In practice, this means improved information sharing between

professionals such that service-users only have to tell their story once and the

number of assessments each person needs is kept to a minimum.

■ improving continuity of care such that a meaningful relationship of trust can

develop between a service-user and their support team.

5. Significant financial challenges: Against a backdrop of rising demand and complexity,

providers and commissioners across health and care are under sustained financial

pressure. Sutton CCG and Sutton Council are under pressure to deliver cost

reductions in 2017/18. This has a knock-on effect for providers, who are being asked

to agree reduced funding despite increases in demand. Cumulatively, the result is a

health and care economy that is financially unsustainable without significant change.



6. Alignment with local and national strategies: The challenges outlined above are well

known. In response to a number of large-scale national, regional programmes, local

strategies have been developed that will shape service provision in Sutton over the

next 5 years. In particular, the South West London Sustainability and Transformation

Plan (STP), summarised in Figure 7 below, will be a key driver for service

transformation in Sutton. Furthermore, the programme will seek to align with and

learn from the Sutton Homes of Care Vanguard. The vanguard programme works

towards a parallel aim of reducing non-elective admissions and length of stay in

hospital for people living in care homes. Sutton Health and Care will learn from their

experience and align to their plans for supporting older people in Sutton. For

example, in relation to culture change, staff training and achieving change in the

hospital transfer pathway (including red bag initiative). To enable this, people from

the vanguard team have been involved in the development of this business case, and

during the implementation phase further work will be undertaken to ensure that

pathways and interventions will complement each other in order to prevent

duplication.

Figure 7: Summary of the SWL Sustainability and Transformation Plan, 2016



Current provision of services

Sutton Commissioners and local providers are well aware of the challenges facing the local

health economy. They have responded with a range of interventions, including a the BCF

programme orientated around supporting people to stay well and out of hospital.

Whilst, as is set out below, there are opportunities to do more, it is essential that further

transformation builds on existing local good practice. Therefore, this section provides an

overview of current intermediate care service provision for people with LTCs and complex

needs.

To gain a thorough understanding of what is currently provided for Sutton residents and key

opportunities for improvement, we undertook extensive engagement with local service users,

providers and commissioners (see appendix 3 in the Sutton Health and Care Outline

Business Case for further detail) via a series of one to one interviews and a whole systems

workshop.

Sutton CCG currently commissions:

● Acute services from Epsom and St. Helier University Hospitals NHS Trust and St.

George's University Hospital NHS Foundation Trust;

● Community services from Royal Marsden NHS Foundation Trust and Age UK; and

● Mental health services from South West London and St. George’s NHS Trust.

The London Borough of Sutton commissions adult social care services. It provides

Reablement services via the Short-Term Assessment and Reablement Team (START),

through the BCF which is jointly commissioned by Sutton CCG and the council. The figure

below, maps these services at a high level. The map shows clearly that there is significant

overlap between services and, conversely, some gaps in provision.

Figure 8: Targeted Services in Sutton for people at risk of hospital (re-)admission



For people who require equipment to support them to maintain their independence at

home, the Integrated Community Equipment Services (ICES), a partnership between

Sutton Council and Sutton CCG, provides community medical equipment to patients being

cared for at home. It aims to provide easy access to equipment, adaptation services and

timely advice and information to help with improving and supporting independence,

mobility, personal, or end of life care. Examples of equipment loaned might be a hoist,

walking frame, raised toilet seat, or minor adaptations such as grab rails.

Opportunities for improvement

The conversations with staff and service users show that there is a good set of services

available and there is a strong consensus around the long-term direction of travel for

Sutton. Equally, it is also recognised that services are experiencing increasing pressure

due to the growing and ageing population.

Stakeholders identified a number of key opportunities to improve pathways and practice

that will enable Sutton providers and commissioners to build on the BCF existing schemes

and achieve lower rates of unplanned admission and a better experience of care for

patients and service users. The three key themes were:

● Further joining up working to support consistent patient experience;

● Shifting system capacity to out of hospital services to make sure that people receive care as close to home as possible; and

● Further coordination to ensure resources are deployed to best effect.

Further integration across teams

We want to build on the success of previous BCF plans to further integrate our teams.

Currently, there is still considerable variation between the quality and coordination of care

that people receive depending on through which service and at what time they enter the

system. Moreover, people frequently cited that they have experienced a disjointed system.

For example, people progressing through different services may experience multiple

handoffs, delays in decision making, having to repeat themselves and other duplication

between the services and teams that help them.

For example, in-patients are often assessed as medically fit for discharge, but remain in

hospital longer than necessary due to:

● There remains a lack of capacity in teams providing assessments and care packages, meaning people need to wait until time is available;

● Delays due to lack of capacity in the market creating waiting times to hand over to care agencies and bottlenecks in processes;

● The need for multiple assessments from different professionals, all acting independently; and



● Delays due to family choice and in putting appropriate care packages in place such that it is safe for the individual to return home.

Taken together, these many small delays can easily add up to days of delayed transfer of

care.

These challenges centre on the coordination of care and can partly be explained by the

lack of a clear owner of the whole journey for the person. Instead, social workers work

separately to physios or OTs, and there are separate assessments for OT, physio and

intermediate care. These all need to be completed on the ward before the person is able to

leave hospital.

Additionally, opportunities are being missed that could promote self-management and

make best use of available voluntary support, such as Age UK Home from Hospital, or

‘Caring Neighbour’, which provide additional support to enable people to return home safely

and prevent people from experiencing a ‘cliff-edge’ with care reducing slowly rather than

abruptly.

Shifting care out of hospital

The other key opportunity is around shifting care away from acute settings. Though a

number of high quality targeted interventions have been put in place and ESTH has a good

record of meeting the 4 hour A&E target, feedback indicates that there still is a heavy

reliance on hospitals to manage complex cases, and for many people A&E is still the

default destinations in times of urgency. There is considerable evidence to suggest that

hospital is not always the most appropriate setting to meet people’s needs, both because it

can be disruptive for those taken out of their familiar home environment and because a stay

in hospital presents potential dangers, particularly for older patients.

As an example, a vulnerable person’s experience of care in an out of hospital setting can

vary significantly depending on the time and day of the incident. If they are assessed on

weekdays or weekends before 7am, they are likely to be able to stay at home and be

supported by the START or CPAT team (if alerted by the patient's GP or LAS), who will

follow a management plan, treat them and update their care package.

However, if this happens outside 7am-7pm or there is a ‘barrier’ somewhere in the pathway

it is likely that the only alternative for this person is a visit to A&E for assessment. In some

cases, SWOOP can support a patient, and if a care package is readily available they could

return home quickly again. However, even this is contingent upon the availability of

appropriate assessors (START team capacity and assistive equipment which can

sometimes take up to a week to arrange).

If capacity is unavailable in the community, an admission is highly likely, with implications

for cost, acute capacity and the long-term wellbeing of the patient. On occasion, if a patient

presents later in the evening then it may well be deemed inappropriate to transfer them

anywhere until the following day irrespective of capacity. Here there is an opportunity to

review the threshold for admission to intermediate care beds and improve occupation and



impactful use of the beds, so that the most dependent can be cared for in the place best

suited to supporting their needs.

As a system there is an opportunity to make better use of existing resources through

realigning the pathways and interfaces for urgent and crisis care. For example, there is

potential to streamline pathways for multi-disciplinary assessment and rapid intervention,

as well as to increase uptake of the existing intermediate care beds and to improve

discharge planning. Currently, all discharge assessments take place on the ward. However,

it is commonly recognised that this is not the best place to assess a person’s capability to

manage at home. If assessments were to take place in the person’s home, this is likely to

lead to more appropriately targeted and smaller care packages.

This is not just about changing processes and pathways - a collective shift in mindset

regarding the joint management of clinical risk by different professionals will also be

required, necessitating a renewed focus on joint decision-making, clinical accountability

and trust between professionals.

In summary, feedback indicates that the system needs to move away from:

● Duplication of assessment and planning as people move between services and teams

● Inconsistent experience of care depending on where people enter the system

● Focus of resource on acute setting and associated capacity and coverage challenges in the community

● Separate teams, working in silos of different procedures, incentives and processes

● A&E being the default destination in times of escalated need

and begin to work toward delivering:

● Pro-active community based care, with sufficient capacity to support people out of

hospital - including timely review, signposting and liaising with appropriate services

● Truly person-centred care, with care and resources following the patient

● Expanded, responsive crisis care with access to assessment and short term services,

irrespective of place

● Single integrated multi-disciplinary team with flexible use of resources and joint

decision making around the patient's’ needs

● Single point of coordination to deliver true person centred care that is informed by individuals’ ambitions, and ability to self-manage and stay at home

Local Needs To design an effective model of care for Sutton, it is important to understand the needs of

different segments of the population, as individuals will require different types and

intensities of service provision to ensure their needs are met proactively, preventatively and

effectively.



Using the Sollis system, the CCG’s risk stratification platform, GP data for individuals in the

Sutton locality was analysed. The platform uses the Johns Hopkins Adjusted Clinical Group

(ACG) methodology to classify people’ past medical needs and future predicted medical

needs including: resource utilisation, chronic conditions, frailty, predicted 6 month, 12

month and overall hospital admission risk, the number of GP attendances and hospital

admissions, and total costs associated with each patient

The age and practice filtered population was then stratified by using four main indicators:

1. Resource Utilisation Band

2. Chronic conditions

3. Probability of Emergency Hospital Admissions

4. Frailty

It should be noted that the Sollis system includes health data only, meaning cohorts have

been defined without reference to social care or mental health service risk stratification

data. Work is underway to incorporate social care and mental health data into the analysis,

meaning the cohort sizes may need to be revised. This issue highlights the importance of

the creation of an integrated health and social care data-set for service design and

performance management.

Using risk stratification, we have created a snapshot of the Sutton population, allowing us

to map interventions to different population groups and identify opportunities to reduce

admissions. The intention is to target the tier 3 cohort in order to deliver the largest possible

NEL reduction. The insight has also allowed us to map other inflight interventions and

projects, such as the establishment of Localities team in the BCF, to the tier 2 and to some

extent tier 1 cohorts, in order to more clearly articulate where Sutton Health and Care will fit

into the service landscape.

Intended outcomes

Providers and commissioners in Sutton have committed to a set of outcomes for people,

staff and the wider health and care system. These are:

■ Improved outcomes for people – in terms of wellbeing, clinical quality and patient

experience of care

■ Improved outcomes for health and care professionals – providing new ways of working

that support staff well-being, personal development and satisfaction.

■ Improved outcomes for the Sutton Health and Social economy – reducing and re-

balancing spending to support the financial sustainability of both commissioners and

provider organisations;

A snapshot of outcomes for Sutton Residents and Health and Care professionals is illustrated below.

Figure 9 Outcomes ‘I statements’ for Sutton residents and staff, developed from local engagement



Proposed future model

The following diagram sets out the proposed model of care, with one team moving patients from assessment to care planning to delivery, based on a trusted assessor principle, a single point of coordination, and signposting to services within Sutton Health and Care and beyond.

This builds on the trusted assessor work that is already underway through the

implementation of the 8 High Impact Changes.

By putting the patient at the centre of what we do through the BCF and the Sutton Health

and Care plan, we will ensure that they receive a broader package of care based on their

needs.



Figure 10 the proposed model of care and pathways for Sutton Health and Care

There are four key elements for our plans to deliver integration in Sutton for 2017-19

through the Sutton Health and Care plan:

1. Rapid Response service – providing support to people with long term conditions, who

have had an exacerbation and are either still at home or have arrived to A&E / AMU.

The service provides a multi-disciplinary assessment and delivers support for people

to return home rather than be admitted to hospital.

2. Multi-disciplinary care service – delivering targeted packages of multi-disciplinary

care at varying levels of intensity for a period of up to 6 weeks. The aim here is to

smooth the transition from acute/ high-intensity support back into long-term care,

reducing the frequency of readmission. Care will be provided primarily in the home,

but also in community step-down beds if required. These are not currently included

in the business case and are assumed to be commissioned and utilised as before. In

time, a ‘step up’ function may also be included; however, experience suggests that

demand management/ appropriate referral challenges mean it is better to start with a

limited ‘step down’ service in the first instance.

3. Discharge to Assess – supporting in-patients to be discharged as quickly as

possible and receive their full assessment at home or usual place of residence.

4. Single point of coordination – providing a single point of communication and

coordination for the service elements within Sutton Health and Care, providing an

integral point of access for service users, staff and information sharing. The function

will be responsible for conducting triage, the administrative co-ordination of care,

including the scheduling, and sharing care plans/ integrated patient records. Care

Coordination will be put in place to ensure that service users experience a smooth

and well thought-through pathway.

A further element of the model - Localities teams will continue to be progressed through the

BCF. These will provide preventative care for people in tier 1 and 2 of the ‘risk triangle’ and

will include social care, mental health, community services and care coordinators in a

single team. The links and dependencies between the proposed Localities service and the

services covered in the Sutton Health and Care business case are clear:

● They target the same cohort of people;

● The interventions are similar (multi-disciplinary assessment, care planning and delivery);

● The staffing model and skills-mix required is nearly identical.

We will continue to work with IPC Oxford Brookes, to ensure that there is no duplication in

effort and that the services outlined build upon the work started in the Localities service.

It is anticipated that Localities teams will ultimately be incorporated into Sutton Health and

Care, to create a single integrated team and suite of services dedicated to keeping people

well in their own homes and getting them home quickly when an admission is unavoidable.



All of these service elements could be provided independently, however, bringing them

together as one integrated service, staffed by a single team, has a number of advantages:

● Seamless experience of care for service-users as they move between service elements and settings;

● Reduced service duplication;

● Ability to map capacity to demand more effectively and use workforce more efficiently;

● All services working together to deliver shared outcomes, reducing perverse incentivisation and unintended impacts of one service on others; and

● A more satisfying, comprehensive career for staff.

Case Study Examples

The case studies below set out how people's’ experience of care will be different as a result

of moving to the new model of care by comparing the experience now and once the new

model of care is fully implemented:

Better Care Fund plan Funding Contributions

Funding contributions from the CCG and Local Authority are agreed at the Sutton



Integration and Transformation Board and the Sutton Health and Wellbeing Board. The

2017/18 BCF budget totals £18.538m, £ 17.034m revenue funding and £1.505m capital

funding (DFG). There is a risk share arrangement currently in the S75 agreement between

the London Borough of Sutton and the CCG in the event of an overspend on the 2017/18

budget. The budget will be closely monitored during 2017/18 and reported through the

Sutton Integration and Transformation Finance Board and Health and Wellbeing Board.

Impact assessment

The details of the risk share and contingency agreement, and the overarching S75 agreement that governs the risk share can be found in the appendices. The non-financial risks associated with not meeting the 2017/18 BCF targets can be found in the risk log at the end of this document.

National Conditions National condition 1: A jointly agreed plan

The 2017/19 Better Care Fund plan is a continuation of the programme of work

commenced in 2015/16 and continued throughout 2016/17. The plan articulates our long-

term vision for integrated health and social care services for Sutton and is supported by our

joint approach to governance and performance through the Sutton Integration and

Transformation Board which reports directly to the Health and Wellbeing Board. The plan

has been discussed at the Urgent Care Board in August 2017 and the Sutton Integration

and Transformation Board; which includes membership from partner organisations

including acute Trust; community provider; mental health provider and voluntary sector

providers before final sign off by Sutton Health and Wellbeing Board.

The BCF plan is driven by the Joint Strategy for Health and Social Care in Sutton and

supports implementation of the SWL STP. The approach taken to reducing non-elective

admissions and supporting out of hospital care is aligned to the Sutton CCG Operating

Plan and SWL STP. It reflects work undertaken with the other South West London CCGs

and local authorities on the STP requirements. Elements of the schemes that are focused

on reducing non-elective admissions align with QIPP plans and the Systems Resilience

work plan agreed with the acute Trust.

National Condition 2: NHS contribution to social care is maintained in line with

inflation

Social services funding is ‘protected’ through the use of a ring-fenced amount of funding

which is ‘passed through’ from the CCG to the Local Authority. For 2017/18, this figure is

£4.731M. This funding allows Sutton to retain services such as the Short Term Assessment

and Reablement Team (START) who have a significant impact on improving the

independence of residents to allow them to remain in their own home, or to provide short

term care following a period of hospitalization or poor health.



The amount of DFG funding for the 2017/18 pooled budget is £1.355M. DFG requirements

in Sutton are managed through the in-house home improvement agency ‘Staying Put’. The

agency is well placed to deliver the requirements of the DFG given their structure with

caseworkers and a process which follows the mandatory guidance in place. The focus of

the DFG team is a more long-term solution given their need to be bound by procurement

rules and regulations and the need to manage expectations between those who have been

waiting a significant period of time and cases deemed to be ‘urgent’. However, the same

team also manages the ‘Care and Home Assistance Fund’ (CHAF) which is utilized for

assistance on discharge, for example deep cleaning or minor electrical works.

National Condition 3: Agreement to invest in NHS-commissioned out-of-

hospital services

The plan includes £4.558M ring-fenced Sutton CCG funding for community nursing

services delivered via the wider Sutton Community Health Services contract to provide out

of hospital care with consequent reduction in avoidable emergency admissions to hospital

and reduced delay in discharge home from hospital. The service is delivered through 3

integrated locality teams with the objective to support patients in the community;

maintaining and improving health outcomes and avoiding unnecessary hospital admission.

In addition there is £0.764M SCCG funding for prevention of admission services delivered

via the wider Sutton Community Health Services contract. The service is a 7 day, 2-hour

rapid response service (8am-8pm) delivered via the Community Prevention of Admission

Team to patients at home or via the Rapid Response Team based in St Helier A&E and

AMU (acute medical unit) with the objective to prevent unnecessary hospital admission and

facilitate the patient remaining at home.

National Condition 4: Implementation of the High Impact Change Model for Managing

Transfers of Care

High Impact Change Model (HICM) / DToC Plan

In 2016/17, the Sutton system was identified as 5th best in London and 14th best in the

country in relation to DToC. We continuously monitor and analyse our delays to learn

lesson and adopt actions to reduce these delays as much as possible.

The Local Authority analysis of ‘social care delays’ has identified 88% relating to care of

which 57% of these attributed delays are due to the inability to source homecare packages.

The IBCF monies therefore will seek to address this and our action plan, approved by the

Integration Board (SITB) in June, is attached in the appendices. The IBCF is expanded

upon later in this section. A further 31% relates to residential/nursing care. Thereafter, 8%

of delays relate to a person awaiting an assessment.



Sutton has aligned the BCF DToC metric with the provisional targets submitted in July and

will make every effort to meet the stretching DToC targets for 2017-18 and continue to work

with St Helier to maintain the existing excellent performance. This is a challenging target

due to the low base in Q4 (2016-17) used to calculate 2017-18 targets and there is a risk

that the target will not be met.

During 16/17 there were 1277 hospital delayed discharge events. Of those 850 discharge events (relating to 775 unique individuals) involved either reablement care or further assessment of eligibility for services. Of those 775 clients, 208 new people went on to receive a service funded by LBS. Of the 208 people, 13 of the clients were placed in nursing/residential care following their discharge during 16/17. The remaining 195 clients received either Home care or a Direct Payment.

Year No. Discharges

Involving service/ assessment

Dom Care/DP

Costs directly relating to transfers

Nursing Costing

16/17 1277 850 195 £661,038 13 £155,834

17/18 1309 871 200 £781,576 13 £159,729

Diff 32 21 5 £120,538 13 £3,895

Throughout 2016-17, there has been a sustained focus on managing and reducing DToC’s.

Significant progress has been made and the actions are in place to ensure DTOCs are

monitored and total numbers reduced where possible.

A task and finish group has been set up, reporting to the A&E Delivery Board to focus on

the links to the D2A model and how the system as a whole, including the London

Ambulance Service (111 and OOH), can contribute to reducing delayed transfers of care.

This group will also conduct a focussed piece of work to analyse the “current state” prior to

winter and resolve any issues.

Progress is being made implementing the High Impact Change Model and an action plan

has been developed to ensure the 8 changes are delivered. The plan is attached in the

appendices for information. We also have agreements in place to fund the proposed

changes in the HICM. The entire new Model of Care for Sutton will be delivered through

Sutton Health and Care. This ring fences savings from Non Elective Admissions spend

agreed with our local provider, Epsom and St Helier Hospital Trust, allowing us to reinvest

in our new model which incorporates changes through the HICM e.g. Discharge to Assess.

This is about refocusing existing funding streams on these new areas and is not new

money.



Communication with partners in the system and close monitoring of delays is essential to

ensuring our performance is maintained. The table below illustrates how this

communication and patient tracking, helps to reduce delays in Sutton and is a key

component of the HICM.

Action No.

Description Ongoing actions/mitigations

Responsible Owner

Timeframe Comments/update

1

1a

Joint agreement of DTOCs and attributable organisation

Weekly meeting between St Helier Acute Trust and LBS to determine and jointly agree

Hilary Bennett, Head of Capacity Management, ESH Lynne Brown, Team Manager, Hospital Pathway, LBS

Weekly Friday 10am

Attended by senior staff, for example Director of Performance & Delivery Sutton CCG, if required or numbers higher than expected

1b

Agreement of DTOCs and attributable organisation with trusts other than St Helier

Weekly phone calls with St Georges, Kingston and Croydon acute trusts

Lynne Brown, Team Manager, Hospital Pathway, LBS

Weekly, various times

2

Daily tracking of DTOCs and other clients who may become delayed

Daily email instigated by St Helier capacity management team. Distribution list includes senior staff

Hilary Bennett, Head of Capacity Management, ESH

Mon-Fri before 5pm

Tracking list is RAG rated depending on numbers of inpatients present on the list. Red or Black RAG status actions include escalation of weekly whole system conference calls to daily (see below) Escalation process is being reviewed by end Sept 2017

3

Weekly whole system conference calls

Twice weekly calls chaired by Director of Performance & Delivery. Participation from acute trust, community and social services. Calls are escalated to daily once the daily tracker reaches black status, or at the request of the acute trust.

Director of Performance & Delivery SCCG

Mon/Thurs 10.45am

4

Weekly Care Pathway meetings for Mental Health Delays

Weekly meetings with Local Authority and SWL St Georges MH Trust to agree and monitor delays to ensure quick decisive action is taken

Colin Grant MH Team Leader

Tuesdays Audit trail kept of decisions for learning

5

Sutton health and social care economy demand and capacity plan

Jointly agreed plan, RAG rated and containing actions for all providers and the CCG at each status level. Also linked to the SW London Pressure Surge Hub, with agreed status levels for DTOCs.

Director Performance & Delivery SCCG

Agreed annually

At escalation levels Red and Black, senior members from all parties will participate in daily calls or on site crisis meetings based at St Helier hospital to agree necessary actions for



patients experiencing delays

6

5a

Winter Resilience schemes – Swoop Team

Complex Discharge Team comprising community, social services and voluntary sector staff. Team hours 8am – 8pm 7 days per week. Coordinates all discharges from Acute Medical Unit, Surgical Assessment Unit and escalation wards. Senior social work staff are ensuring patients with complex needs are managed via an MDT approach with community services.

Debbie Lyndon-Taylor, Clinical Nurse Director, Royal Marsden

Fortnightly meeting Monday’s 9.30am

As in previous years, fortnightly meetings will continue.

5b

Winter Resilience schemes – Additional Social Workers

As above – the two additional social workers funded through winter resilience are members of the Swoop team

Sandra Roche, HOS Hospital and Integrated Locality Teams, LBS

Commenced 1st Nov 2015

Will continue this winter

5c

Winter Resilience schemes – Additional brokerage post

The additional brokerage post is supporting the transfer of clients from the START team to longer term providers of care. This in turn frees space within START to accept discharges more quickly.

Sandra Roche, Head of Service Hospital and Integrated Locality Teams, LBS

Commenced 1st Nov 2015

Will continue this winter

7

‘Choice’ policy and patient/carer information

A ‘choice’ policy is in development across health and social care partners. This will need to be ratified by the OSCC once completed

Deputy MD Sutton CCG

Signed off at Epsom Hospital

One of the areas of focus in for Sutton in 2016-17 was in improving Mental Health delays.

The performance in the first two quarters of 16-17 was not on target and analysis identified

Mental Health delays as a major source of these delays. Our performance since June 2017

has been much improved and we would expect Mental Health delays to be very low for July

and August. Sutton compares very well against its neighbouring 5 Local Authorities and are

the lowest for Mental Health DToC’s.

Borough – specific weekly pathway meetings were instigated, with all partners represented

to ensure quick and decisive action could be taken to minimise delays and allocated agreed

delays to the appropriate organisation. An audit trail is now available to assist with any

further analysis needed. This approach led to a significant reduction in the number of

delays in quarters 3 and 4 and has continued into 2017-18.

Sutton already have a funding panel in place, meeting monthly, to review all mental health

discharges potentially requiring section 117 funding.



The Local Authority and CCG jointly commission residential placements in the community,

which will include placements for mental health clients.

We also intend to review and refresh the joint Mental Health strategy in 2017-18 to further

improve and enhance the service we provide for our residents.

Across the 5 Boroughs, work is on-going, led by Wandsworth LA, to identify a consistent

approach to monitoring and recording of DToC’s relating to Mental Health. Sutton will

contribute to this review. We are investigating the feasibility of establishing a DToC team,

with an allocated Social Worker from each of the Boroughs as part of this team. This team

would be based at SWL St Georges Hospital to coordinate MH discharges and will work

closely with the discharge coordinator.

Improved Better Care Fund (iBCF)

Sutton faces significant pressures, as demands for services increase, people live longer

with more complex needs that need supporting. Pressures in the Homecare market in

Sutton have had a significant impact on the Council's financial position. Homecare rates

had been maintained at a historically low level for a number of years, but to ensure that the

market was sustainable; rates were increased by £1, from £13.30 to £14.30 in 2017. We

are in the process of implementing an outcomes based Home care commissioning strategy,

but to deliver this and provide resilience to the system, it is expected that hourly rates will

increase by a further £2-3.50 (DEC 2017) adding further to the pressure on budgets.

Changes to homecare and the increases in hourly rates to pay a sustainable price for care

will have further impact on the rates for Direct Payments. Between 55 and 65 percent of all

spend on Direct payments is linked to services that are impacted by Home Care rates.

Once the new commissioning strategy is implemented, the council will need to review

Direct Payment rates across all services and expect them to increase by £3-4 per hour.

Through this work we will aim to stabilise the market within Sutton, to ensure we are able to

meet the current needs and growing demographic pressures faced within ASC. This in turn

will support transfers of care from hospital to avoid DToC’s and focus on improving

outcomes that reduce the need for longer term care packages.

Around 1 in 4 of the population of Sutton (50,187) are aged 55 or over. The proportion of

the population aged 55+ in Sutton is slightly higher than the average for outer London, and

London as a whole. There are growing demographic pressures amongst young people with

more complex need. The over 75 and over 85 population are growing, with these cohorts

living longer and becoming more complex, with projected population increases of 2-2.5%

annually. In March 2015 Adult Social Services were supporting 1526 (long term support),

and now we are supporting 1650 (long term support), an 8% increase which is set to

continue into 2017/18. A recent independent report of Sutton Adult Social Services by

iMPOWER has identified that where reviews take place, ASC are spending an extra £1m

per annum on care packages post reviews adding additional burden to the already

stretched ASC budget.



In 2016 the council commissioned an independent report by iMPOWER to analyse the

council's structure and activity, making recommendations as to how the council could

reduce expenditure and be fit for the future in light of growing demographics and increasing

needs. The report highlighted that ASC has a lean management and staffing structure and

that without additional capacity, the ability of the current workforce to respond to growing

demand would be compromised whilst mobilisation of transformation initiatives would be

severely challenged also. The council has agreed additional investment to support the

transformation program.

We intend therefore to use the additional Government funding to address the market

pressures. This will support transfers of care to avoid DToC’s and support the management

of pressure on NHS beds in local acute hospitals. In order for Sutton to sustain the current

DToC performance, we will need to continue to improve, in light of the growing

demographic / demand pressures across the borough.

Action Plan Table

CONDITIONS of how the iBCF monies must be used

How the monies will be used iBCF Sum

Outcomes

Meeting Social Care Needs through Market Stabilisation

Contribute to £1 Increase in Home Care hrly rates. Contribute to new hrly rates for Home care Under new contract. Contribute to increases in Direct Payment rates. Building capacity in local market. The new Home Care model will support the delivery of integrated locality hubs.

£1,291m Supporting transfers of care to avoid DToC. Residents receive the right support at the right time Market stabilisation and resilience

Meeting Social Care Needs

Contribute to costs of supporting more people through growing demographic changes. Supporting the growing number of residents with Complex Needs

£774k Residents receive the right support at the right time.



Meeting Social Care Needs: Transfer of Care

Contribute to costs of supporting more people with higher needs. Support the Transformation agenda across ASC Support the sustainment of DToC Provider greater assessment capacity. Ensure the Right support at right time.

Please note figures above and £340k

Residents receive the right support at the right time. Supporting transfers of care to avoid DToC. FIt for purpose ASC operating model

Overview of Funding Contributions

Partners in Sutton, The Local Authority, CCG and other key stakeholders have agreed that

the monies in the Better Care Fund will be allocated from the CCG minimum contributions:

● Care Act 2014

● Reablement

● Carer’s breaks

● Social Care

● iBCF

Care Act

We will continue to embed the Care Act and are planning further training and development

for our staff to ensure we continue to provide the best possible service to our residents.

Reablement

We are using the £650k to support additional staff in the community to provide an extra 400

hours per week of reablement and support 10 beds in an extra care housing scheme for

residents who cannot access reablement at home. We continue to focus on efficiency and

by improving flow have been able to provide increased capacity. Last year we were able to

offer 1500 (approximately 120/125pm) people through reablement services. This year to

date, we are projecting this to increase to 140/150pm.

Carers funding and Carers breaks

We continue to fund carers breaks though our Carers Centre and through commissioned

care. This forms a key part of the carers commissioning strategy which we are revising this

year. We will also continue to fund the post of a Joint Carers Commissioner, between the

CCG and the Local Authority.



Programme Governance With the development of the STP, the governance of the BCF will evolve during 2017 to

ensure consistency and congruity with other programmes that are delivering Sutton’s

vision.

Integration of health and social care services will be delivered through a number of

programmes outside of the BCF, for example, Sutton Health and Care. The governance

structure will therefore ensure that any dependencies with the BCF initiatives are identified

and managed and that reporting will be consistent.

The programme will shortly be recruiting a permanent BCF Manager, whose role will be to

ensure the successful delivery the outcomes and benefits of the schemes in the BCF

programme. The governance arrangements outlined above will ensure the effective

management and control of the schemes and identify and address any schemes that are

underperforming.

A Programme plan has been developed, identifying the key milestones for the schemes,



which will be reviewed regularly at the Sutton Health and Care Executive. The BCF

Manager’s participation in the London BCF leads meeting and other organised events e.g.

the recent DToC road show organised by ADASS, will ensure that learning is captured and

shared both regionally and nationally.

Assessment of Risk and Risk Management In line with our agreed 2016-17 BCF risks we have refreshed our risk plan, a detailed BCF

Risk Log is shown below. We continue to manage these in line with ensuring that all risks

are identified and plans are in place to help mitigate these to support delivery against our

BCF Plan 16/17.

In summary our BCF plan will continue to be developed with providers and is based on the

principles of achieving a reduction of acute admissions and effectively manage transfers of

care across the system.

The same core principles of risk sharing have been agreed within the BCF programme:



• Organisations take responsibility for the services they sign-up to deliver

• Organisations take responsibility for the benefits that are expected to be realised

in their organisation

• Effective monitoring arrangements to identify where there are variances and to

reconcile back to the original budget (similar to s.75 arrangement). This is

achieved through the Sutton Integration Finance Group, which meets monthly to

ensure that the BCF is on track. The terms of reference for this group is attached

in the Appendices.(add in MH)

• Commitment to a shared approach to resolving variances and amending service

model and share of costs if required.

The BCF is based on an agreement to share the financial risks and rewards of new out-of-

hospital services between CCGs and Local Authorities. The agreement is based on

estimates of activity, costs and benefits of those services and the previous year’s activity

has supported us to develop plans that reflect actual activity. There is of course the risk

that, if the planned net benefits are not delivered, there will have to be a call on existing

resources in the CCGs and Local Authorities. A risk share has been agreed to clearly

identify accountability in the event that benefits are not realised?

Comprehensive risk logs are in place at scheme and Programme level to manage or mitigate our known risks and any emerging risks associated with the plan. The Programme Risk Log will be reviewed regularly and the scheme risks at the relevant steering group. Any scheme risks deemed as “high risk” will be escalated to the Board for action. A copy of the risk log is included in the Appendices.

All partners, including providers have had the opportunity to contribute to identifying the risks, both for their organisations as well as the BCF as a programme. The Local Transformation Board will provide the forum for discussing and mitigating these risks at a system wide level.



Appendices

1. Sutton Improved Better Care Plan (IBCF)

2. Section 75 2016-17

3. Sutton Programme Risk Log

4. Sutton Health and Care Draft Outline Business Case v2.0

5. Sutton IIA Market Position Statement

6. London Borough of Sutton Housing Assistance Renewal

Policy


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