NEATH PORT TALBOT LOCAL SERVICE BOARD

BRIEFING PAPER - APPROACHES TO HEALTH AND SOCIAL CARE INTEGRATION

PURPOSE

The purpose of this paper is to provide the Neath Port Talbot Local Service Board with a high level overview of different approaches to integration across health and social care. The overview is drawn primarily from developments in England, however, there is also some reference to structures in Scotland and Northern Ireland. Further, more detailed briefing outlining governance, management arrangements and outcomes, could be provided on some or all of the approaches if required.

It is worth noting that the Department of Health is planning to issue advice on the range of organisational options open to PCTs in the autumn (no further details to date), including implications for governance – so further detail should be available to support this paper fairly shortly.

INTRODUCTION

Whilst collaboration and partnership working are the cornerstone of the Beecham Review, Making the Connections and One Wales – and indeed the raison d’être behind the establishment of Local Service Boards (LSBs), formal integration of services is rarely evident in Wales. There is, however, a great deal of interest in the approaches taken elsewhere in the UK, and England in particular has a variety of models which have, and continue to, develop.

This paper provides a high level overview of different approaches, outlining some of the key aspects and differences, and will also identify localities where the new arrangements have been implemented or are being piloted.

Before making any decisions on progressing integration, organisations must be clear that:

·  They have a common understanding of what integration means – is it management/planning/provision/resources?

·  The purpose of integrating – integration in itself will not necessarily result in improved services for local people.

·  How success or otherwise will be evaluated; and finally

·  What will happen if integration is not deemed to successful?

CARE TRUSTS

Care Trusts (CTs) started to develop in 2002, and are viewed as a way of building on the use of Health Act Flexibilities, enabling closer integration of health and social care, and ensuring that local authorities are able to fulfil their community leadership role. They are viewed as a pragmatic way of broadening the range of possible options for health and social services to deliver integrated care – but are not a takeover of one organisation by another. Neither does the formation of CTs mean that Health Act flexibilities cannot continue to be used in other settings and situations.

The CTs should create a stable organisational framework allowing staff to shape a new organisation and patient and service user needs, and can operate across organisational boundaries. Governance arrangements must ensure that local councils and the NHS are involved in commissioning and providing services in a way that takes a holistic view of the needs of the community. They also allow for:

·  The development of new approaches to the provision of services by a single body

·  A consistent approach to quality improvement by bringing together exiting systems to wok more effectively

·  A single strategic approach, with a single set of aims and targets

·  The potential for financial flexibility and efficiency

·  Better and clearer working arrangements for staff, with more varied career opportunities

·  A single management structure, multi-disciplinary teams managed form one point, co-location of staff, as well as single or streamlined cross-disciplinary assessments; and

·  Better communication between staff about packages of care – they will be in an excellent position to develop a single information system.

CTs may focus on services for specific client groups – eg older people, people with mental health problems, or they cover the breadth of the local population. Different models can be developed which allow:

·  Focused strategic commissioning with primary care teams and partners developing a wide range of service delivery options

·  Integrated health and social care teams providing care management, assessment and service delivery

·  Multi-disciplinary teams with a single budget created from NHS and local government resources, joint priorities, a single management structure and one information system

·  Integrated provision with sheltered housing.

The governance of CTs needs to ensure it can properly reflect its purpose and accountabilities. A governance framework has been developed to reflect the particular focus of this new kind of organisation, with the aim of ensuring:

·  That governance arrangements genuinely reflect the shared responsibilities of the partners in the CT

·  That the organisation is driven by frontline health and social care professionals who are best placed to respond to the needs of the communities that they serve

·  That there is sufficient flexibility within a national model to respond to different local situation such as CTs with delegated social services and housing functions from two different councils

·  That there is a robust and responsive mechanism for leading and monitoring the development of services in the CT.

In establishing CTs, local authority councillors will be members of the Board, and the Board will also have representation from the Patients’ Forum (which were being developed at the time). The LA’s Scrutiny Committee would also have an important role in the strategic monitoring of the CT (CHCs do not exist in England).

CTs are formed by bringing together staff from the NHS and local council. Most staff would be expected to transfer under TUPE, although secondments and new appointments are possible.

Once agreement is reached on establishing a CT, agreement is also required on the level of resources to be transferred, and the basis for reaching agreements about resources – eg managing over and under spends, the year-on-year agreement about levels of resourcing (including approaches to resolving disputes) and treatment of capital assets and expenditure – which may already be covered by Health Act Flexibilities. Where a local authority delegates functions to a CT, it will be on the basis that any charging regime for those services will continue and any policy change will be made by the local authority. A CT may administer the charging function on behalf of the local authority, but NHS services through the CT will continue to remain free at the point of use.

Examples:

Bexley Care Trust http://www.bexley.nhs.uk/ngen_public/home.asp

Bexley Care Trust provides community health, public health, social care and primary care services to a population of 219,000 in London.

Bradford District Care Trust http://www.bdct.nhs.uk/index.php

Established in 2002, Bradford District Care Trust provides mental health and learning disability services to the diverse communities of Bradford, Airedale and Craven.

Camden and Islington NHS Foundation Trust http://www.candi.nhs.uk/

Services include adult mental health, mental health care of older people, substance misuse services and care for people with learning disabilities.

Manchester Mental Health and Social Care Trust http://www.mhsc.nhs.uk

Manchester Mental Health and Social Care Trust brings together social care and health services for adults of working age with severe and enduring mental health problems, and provides NHS services for the elderly mentally ill.

Northumberland Care Trust http://www.northumberlandcaretrust.nhs.uk/

As well as providing health services the Care Trust is also responsible for managing most social care services for older people and adults with physical or learning disabilities on behalf of Northumberland County Council. We also manage some other services on behalf of the Council including day care, home care and residential homes.

Sandwell Mental Health and Social Care Trust http://www.smhsct.nhs.uk

Provides mental health services to the local population.

Sheffield Care Trust http://www.sct.nhs.uk/

From 1 July 2008, Sheffield Care Trust became Sheffield Health and Social Care NHS Foundation Trust (SHSC), continuing to provide mental health, substance misuse and learning disability services in the city.

Solihull Care Trust http://www.solihull.nhs.uk/default.asp

The Trust provides the full range of health and social care services across Solihull.

Torbay Care Trust http://www.torbaycaretrust.nhs.uk/

The Care Trust provides community healthcare; adult social care and learning disability services, and the council has appointed the Chief Executive of the PCT to fulfil the statutory role of the designated Director of Adult Social Services. A formal Partnership Agreement has been established which sets out how the two organisations will work together and accountability arrangements.

CARE TRUST PLUS

One Care Trust Plus has been established to date in North East Lincolnshire. It was established in September 2007 with responsibility for commissioning health and adult social care services in the area. It also manages community health and adult social care staff who provide the services –enabling a greater degree of integration between health and social care than the Care Trust model.

The council is charged with delivering health improvement – and to support this a jointly appointed Director of Public Health leads a new directorate with former PCT public health staff seconded to it. The council will also become the lead authority for newly modelled children’s services, and health visitors and school nurses will be seconded to realigned multi-disciplinary teams.

Examples:

North East Lincolnshire Care Trust Plus: http://www.nelctp.nhs.uk/

SOCIAL ENTERPRISE

Social Enterprises are organisations run along business lines, but where any profits are reinvested into the community or into service developments. They are seen as having a key role in the reform of how health and community services are developed – by putting people in control of their healthcare. They involve patients and staff in designing and delivering services, improving quality and tailoring services to meet patients’ needs and many feature partnership with third sector organisations. Whole systems working across partnerships are central components if social enterprises are to develop innovative care for individuals. (source: Integrated Care Network)

Examples:

The Department of Health funded 28 pathfinders, for example:

Lorica Learning Difficulties / Based in Pulborough, Sussex
Surrey Community Provider Services (now Central Surrey Health) / Provides community services to total population of 1.1 million
SCA Healthcare / An industrial and provident society, providing long term condition services from Southampton
Milton Keynes Health and Social Care Services / Health and social care including services for older people; children; adults out of hospital services; integrated health and learning disability services
Community Docs for All / Primary care service based in Weston-super-Mare
Devon Healthy Living Community / Multi-disciplinary primary care teams integrated with the voluntary sector
The Bridge / Alcohol and substance misuse programmes in London
Bromley by Bow’s Care Agency / Health and social care services to vulnerable adults
Southend Healthy Living Centre / Developing a health living centre hub for integrated children’s services.

Central Surrey Health, for example, is a not-for-profit, limited liability company under contract to provide community nursing and therapy services on behalf of the East Elmbridge and Mid Surrey Primary Care Trust. The contract is similar to those held by GP surgeries (a specialist medical services contract).

It employs around 650 staff who formerly delivered community nursing and therapy services from within the PCT. They are:

·  district nurses

·  community hospital nurses

·  school nurses

·  specialist nurses

·  health visitors

·  nursery nurses

·  physiotherapists

·  podiatrists

·  dieticians

·  speech and language therapists

·  occupational therapists

·  support and administrative assistants

On transferring to Central Surrey Health all staff were presented with a single share in the company. As co-owners, they are responsible for delivering patient services and shaping the company's future.

Central Surrey Health has been designed to provide flexible, responsive care with an emphasis on streamlining and coordinating clinical services for patients' benefit. Its staff have all the skills needed to care for people in community settings and wherever possible, to allow them to be treated in their own homes.

In Bromley by Bow, healthand wellbeing are at the core of the Centre’s activities. Tackling chronic ill-health is a central objective and many of the Centre’s wider aspirations are underpinned by the need to build a healthier community.

As well as the high levels of chronic physical illnesses there are also significantly high levels of mental health problems which often route back to the social circumstances within which people are living. For this reason the Bromley by Bow Centre’s approach to health and well-being is holistic and continually seeksto innovate and support people toward a healthier lifestyle.

·  At the core is the GP practice and the healthy living centre which offers the wide array of services expected from a modern forward looking primary care facility.

·  The health trainers programme supports people tomanage their own health, which recognises the importance of better nutrition and more exercise on having a major impact on the health of the community.

·  The ‘exercise on prescription’ ideawas pioneered here in1997 and there is now a full healthy lifestylesprogramme with over 300 regular participants.

·  The Working Wonders enterprise offers a full daycare service forvulnerable adults as well as opportunities to take part in creative arts activities to create a community flower garden.

·  A Children's Centre offers a whole range of projects for parents, families and children under 5.

·  The Centre also promotes a holistic approach to wellbeing through its support of Inside Out - a social enterprise which delivers a broad range of complementary therapies in conjunction with the Bromley by Bow Centre.

·  The Centre has also been effective at integrating health promotion into learning programmes. Two examples of this work are the ESOL Health and Humour project and Deciding for Ourselves.

INTEGRATED CARE ORGANISATION PILOTS

Lord Darzi’s next stage review outlined proposals Integrated Care Organisation pilots which would integrate care and organisations at the frontline of delivery to individuals within defined populations. They will operate alongside hospital, community and social care services. They will be based upon personalised and responsive services for care, with the expectation to better health outcomes within a more local population. They are likely to:

·  Focus on patient and public participation at individual and collective levels so as to ensure patient satisfaction and to enhance patient engagement with health improvement measures.

·  Emphasise prevention and reduction of ill health.

·  Support collaboration across primary, community and secondary care boundaries, and across health and social care boundaries too.