SLIC – FINANCE AND CONTRACTING SUB GROUP

FULL IMPLEMENTATION OF HOMEWARD 2013/14

1. Introduction

Homeward is a component of the older people’s pathway and the overall Admissions Avoidance and Supported Discharge model being implemented across Lambeth and Southwark as part of the SLIC/Admissions Avoidance Programme. Homeward is operating as a pilot across two localities, one in each borough. However all parties have committed to the full implementation of Homeward across both boroughs in 2013/14, with a desire to see this completed by early Q3, with the aim of maximising the impact of Homeward on winter pressures.

GSTFT has produced a Business Case for a two borough Homeward. This Business Case has been agreed internally by the Trust’s Executive Management Team. In addition the model of service set out in the Business Case has been discussed with key partners and there is broad support for the model proposed, noting stakeholders have already committed to the full roll out of Homeward.

The Business Case sets out the additional cost associated with full implementation on a full year effect basis. CCG commissioners have requested some further supporting information to enable their endorsement of the FYE costs. CCG commissioners have also reviewed potential funding sources for wider implementation in the context of commitments already made across the system in relation to the current ICP/Admissions Avoidance programme.

This paper sets out:

  • A proposed approach to managing the investment required in 2013/14 to support the implementation of Homeward.
  • A proposed approach to ensuring that the FYE of Homeward can be funded sustainably from 2014/15 onwards.

2. 2013/14 funding proposals

CCG commissioners consider 2013/14 to be a transitional year, recognising the need to fund start up costs associated with implementation plus the additional recurrent part year effect costs of moving from a locality to a borough-wide service.

The following funding mechanisms are proposed for 2013/14:

Additional costs of roll out from two locality to two borough service – funded by the CCGs from the 1% funding set aside in CCG Operating Plans to pump prime the CCGs Community Based Care strategy. The costs of a mid year roll out are being finalised but it is anticipated these will be approximately £1.2m across the two boroughs. Lambeth and Southwark CCGs will split this equally for 2013/14.

Set up costs – these are a combination of capital and revenue set up costs. The total is nearly £0.5m. GST is finalising these costs and the split between capital and revenue. It is proposed that costs are managed through a combination of:

  • Capital expenditure by GST with the costs capitalised over a five-year period, meaning they would be recovered over this period via agreed recurrent Homeward funding streams.
  • Absorption within overall GST budgets as part of the overall 2013/14 agreement.

The exact split of the start up costs across these two categories will be agreed once final costs have been received from GST.

It is proposed that GST be authorised to proceed with implementation of the Business Case with immediate effect, thus enabling the Homeward to open across the two boroughs in early Q3.

In year actual costs will be monitored against the committed level of investment. Commissioners would expect any under spend to be returned to the CCGs, thus providing a source of funds to support acute related emergency admissions pressures over the winter.

3. 2014/15 funding proposals

It is recognised that a sustainable source of income based on actual activity will need to be found for the future. It is proposed that we aim to implement a model of funding that supports this objective for 2014/15 contracts across acute and community services.

Work is needed as part of the 2014/15 contracting round for this toachieve this. A number of key performance metrics will be monitored over Qs 3 and 4 of 2012/13 to support this work, including:

  • Homeward activity - source of referral (GP, community services, acute) and reason for referral (admissions avoidance or supported discharge)
  • Length of stay – Homeward and acute emergency admissions, with Home ward split between admissions avoidance and support discharge activity.
  • Acute tariff - % split between standard and short stay admissions and overall level of admissions compared to plan and Qs 1 and 2.
  • Actual Homeward expenditure versus plan.
  • Homeward occupancy rates.
  • Shadow monitoring of community tariff proposed by GST in the Business Case.

For 2014/15 the following principles are proposed to underpin development of a sustainable funding model:

  • A spell based tariff to be developed and agreed for Homeward and Rapid Response Services for 2014/15.
  • Payment to GST community services to be made on a cost and volume basis.
  • Cessation of the current acute provider top slice model with providers paid for actual activity, which would be expected to reduce, as a result of the ICP/Admissions Avoidance services, from current levels.
  • Development of a contractual framework that incentivises the utilisation of the community based services and a shift from acute to community based care. For community services a spell based model will provide a greater incentive to pull people in to the services than under existing block funding arrangements. For acute services contractual KPIs with financial incentives related to the split of standard and short stay tariffs combined with joint agreements in relation to emergency capacity would be required.
  • A separate assessment of avoidable emergency readmissions for Lambeth and Southwark, with agreement required on the extent to which this source of funds should appropriately be used by commissioners to fund the community based services and the extent to which the funding should be used to support other investment aimed at reducing emergency readmissions for other agreed patient groups.

It is noted that the ICP Business Case makes assumptions about both the overall funding required to support the Frail Elderly Business Case in 2014/15 and the assumed contribution from the Charity and other partners for the year. The above proposal will need to be reviewed in the context of the ICP Business Case to ensure that the overall Business Case proposals are deliverable within the above tariff and cost and volume based model.

4. Recommendations

It is recommended that:

GST be authorised to commence implementation of Homeward implementation as per the Business Case service model.

CCGs to fund the additional recurrent costs of implementation in 2013/14 with start-up costs funded via a combination of capital investment in 2013/14 and recovery via tariffs from 2014/15 onwards (for a five year period) and GST internal absorption.

Monitoring metrics for 2013/14 be finalised and implemented from start date of roll out.

Work commence on the contractual and funding framework for 2014/15 in line the principles set out in this paper, with proposals finalised in Q4 of 2013/14 for implementation from April 2014.