MiddlesbroughHealth and Wellbeing Board Better Care Fund Submission Narrative Plan 2017/19

Area / Middlesbrough
Constituent Health and Wellbeing Boards / Middlesbrough
Constituent CCGs / South Tees CCG

Contents

General

Introduction / Foreword

What is the local vision and approach for health and social care integration?

Background, context and evidence base to the plan

Progress to date

Better Care Fund plan

National Conditions

National Conditions (continued)

Overview of funding contributions

Programme Governance

Assessment of Risk and Risk Management

National Metrics

Delayed transfers of care (DTOC) plan

Approval and sign off

Introduction

South Tees CCG covers the two local authorities of Redcar & Cleveland and Middlesbrough. We use the South Tees area as our local integration footprint and our aim is to ensure equity of access and quality of service provision and experience, regardless of postcode. The Middlesbrough plan for integration and use of the Better Care Fund, although separate to Redcar & Cleveland’s, reflects our common approach.

The aim is to shift the emphasis from being a “Better Care Fund programme” to a more ambitious range of work for which the BCF is a key mechanism for delivery but which reflects our comprehensive integration agenda. The plan for 2017/19 therefore sets out a range of work-streams and shows how the specific elements are supported by the BCF, leading to a comprehensive integrated system by 2020.

We have recognised the need to drive the integration agenda at the highest level. The Chief Officers from key organisations across the South Tees health and social care system provide joint leadership and the programme is being progressed through our Integration Executive Group (the IEG) which also serves as the Partnership Board for the BCF section 75 arrangements.

The IEG, which includes partners from South Tees NHS Hospitals Foundation Trust and Tees Esk and Wear Valleys NHS Foundation Trust, have led the development of the Better Care Fund plans. We have also engaged with wider stakeholders, including our voluntary and housing organisations through individual workstreams.

Both Health and Wellbeing Boards were engaged in developing plans in their early stages with special BCF workshops taking place in May 2017.

A review of the work-streams by the Chief Officers resulted in a reconfigured approach to delivery with senior (director level) hands on ownership of work-streams. We have and will continue to explore new models of care which are aligned with the STP objectives.

We have grouped our programme into themes, each with a range of schemes and services being or to be delivered. These are underpinned by 4 crosscutting elements identified by the Chief Officers as priority areas:

a)Discharge Home

b)Out of Hospital Care

c)Admission Avoidance

d)Keeping People Healthy.

The table attached at Appendix 1 sets out our BCF plan and provides a brief description of each of the themes and supporting schemes, their intended impact and how they are aligned to the wider integration programme.

Background, context and evidence base to the plan

This section provides the background to the local health economy and the evidence base for the plan including key issues and challenges around demographics, long term health issues and financial and other challenges in health and social care locally which this plan aims to address in support of delivering the wider integration plan.

About Middlesbrough:

Middlesbrough is the 6th most deprived of 326 local authority districts in England and about one third of children (11,500) grow up in low income families, compared to one fifth nationally. Middlesbrough has the highest proportion of neighbourhoods within the most deprived 10% in England of all local authority areas, with 69,800 residents (50.0%) in those neighbourhoods. Conversely, fewer than 1,400 residents (1.0%) live in areas among England’s 10% least deprived. The number and proportion of residents in the most and least deprived areas have both decreased marginally since 2010, suggesting little change in economic and social gaps within Middlesbrough.

Life expectancy for both men and women is significantly lower than England: men in Middlesbrough can expect to live 3.4 years less than the England average and women 3.3 years less. Similarly, healthy life expectancy for both men and women is lower in Middlesbrough than England, with gaps of 4.6 years and 4.3 years respectively. This indicates that people in Middlesbrough have shorter lives than average and spend a greater proportion of their short lives in ill health. The slope index of inequality (SII) for life expectancy has decreased for men but fluctuated for women in recent years, suggesting a mixed picture of health inequalities within Middlesbrough.

The gap with England for deaths aged under 75 from heart disease and stroke had been reducing up until 2008-10, but remaining significantly above the England rate. Since 2008-10, the rate in Middlesbrough has remained similar whereas the national rate has continued to reduce, widening the gap once more. Deaths from cancer aged under 75 are higher than average and have declined less quickly than for heart disease and stroke. Since 2007-09, the rate in Middlesbrough has reduced more rapidly than the England rate, suggesting a reduction in the gap might be happening, although it is too soon to be confident about this.

Possible indicators of progress

Using the Public Health Outcomes Framework indicators, the following observations might be made:

The proportion of 16-18 year-olds who are not in education, employment or training has reduced from 11.8% in 2011 to 6.4% in 2015. While this is still significantly higher than England, the relative gap as reduced from 93% above England in 2011 to 52% above in 2015.

Progress has been made in reducing the proportion of women smoking in pregnancy. In 2010/11, 27.2% of infants were born to mothers who smoked, more the twice the England rate (13.5%). In 2015/16, this had reduced to 19.8% in Middlesbrough compared with 10.6% in England, reducing both the absolute and relative gap.

There has been continued reduction in teenage pregnancies, falling from 196 in 2007 to 84 in 2015. While the rate remains significantly higher than England, the relative gap has fallen from being 71% higher than England in 2007 to 62% higher in 2014.

The gap between Middlesbrough and England for hospital admissions due to injury has been declining for children aged 0-14 years and young people aged 15-24 years.

Emergency hospital admissions for intentional self-harm have reduced significantly in Middlesbrough, but remain higher than regional and national rates.

Middlesbrough has seen reducing numbers of first time entrants to the youth justice system. In 2010, the rate was more the twice the England average. In 2014 & 2015, the rate was similar to England and there has been an 80% reduction in numbers, from 284 in 2010 to 53 in 2015.

Key Challenges

The picture of health, deprivation and the growth in the ageing population has a significant impact on health and social care services locally:

  • The number of people who are elderly, vulnerable and living with a long term condition in our area is increasing with impact on primary care, hospital services and social care.
  • Analysis of admission activity information shows that many of our elderly and vulnerable residents have a hospital admission that could have been avoided.
  • Significant rates of non-elective admissions across the locality coupled with the demographic factors described earlier present a very real challenge in terms of our collective ability to plan the future health and social care requirements of our population.
  • Residential Care admission rates in Middlesbrough are high in relation to our comparator authorities.
  • Care at Home services regularly reach full capacity and are unable to meet demand within timescales required. Retention of staff has been identified as a key factor with competing markets (NHS, Council, independent providers, other businesses eg supermarkets) drawing from the same workforce pool.
  • The demand for social care services, costs and expectations are rising and are predicted to continue to do so, at a time when the funding is decreasing. To continue to try to meet service demand in the current way will have a significant impact on the sustainability of local authorities who will not be able to meet the needs of those requiring social care services. Local Authorities will also need to redirect resources for other universal services.

What is the local vision and approach for health and social care integration?

Our Vision:

“South Tees working together to promote health and wellbeing, reducing dependency and minimising the need for ongoing care. Ensuring our citizens are well informed and can access the right services at the right time, in the right place.

This will be achieved through maximising integration opportunities, great partnership working and a real focus on prevention and sustainable outcomes.”

To achieve our vision we need to successfully meet the demands and challenges being placed on the system as a result of demographic and socio-economic changes, in particular an ageing population, significant health and social deprivation across our sub region and reducing financial resources. Whilst acknowledging the above challenges, it is important that we recognise that the people and places in our Boroughs are assets and offer skills, resilience and opportunities which will be at the heart of our delivery of improvement.

Providers and commissioners across health and social care are working together to further develop the common purpose, trust and level of shared accountability required to respond to the challenges faced.

Our local model of care provides the basis for our approach to implement the STP at a local level and focuses on the development of community based hubs providing a range of health and care services that will support improved access, increased continuity of care, better coordination between and across service providers (and sectors), in line with the shared commissioning vision of the health and care partners across our system.

The 5YFV provided the national policy context of the reshaping of care in England over the next 5 years and beyond. It presented two emerging care models: Primary and Acute Care Systems (PACS) and Multispecialty Community Providers (MCPs). Work has commenced across the South of Tees to engage with all partners to further develop our local model of care in light of these emerging models.

The overarching model of provision will be one based on Clusters/Hubs of population and need where individuals access services and support through Practices and the Single Point of Access. Care will be designed around these clusters and delivered through coordinated multi-disciplinary teams. Prevention and Social Prescribing will underpin our approach with active case seeking as well as traditional referral mechanisms to identify the most vulnerable people and work with them on solutions.

Integration Objectives

We aim by 2020 to create a health and social care support system where:

  • services and pathways are designed around people’s needs;
  • traditional boundaries between primary, acute, community and social care are broken down and better coordinated care is provided;
  • barriers around accountability, information, incentives and time are removed;
  • care is brought closer to home;
  • information technology is used to its best effect to integrate systems, records and information;
  • capacity is increased by extending access, eliminating waste by reducing hand offs, duplication and making the best use of all health and social care resources - i.e. the best use of the South Tees Pound (£);
  • there is cohesive, whole system planning and commissioning through aligned teams and pooled budget arrangements;
  • a whole system workforce is developed in an integrated way from inception, to include a joint approach to recruitment, training, development and retention to underpin future models. New roles will emerge which bridge organisational boundaries and drive further innovation; and
  • there is a more holistic, lifelong and seamless people centric approach to health and well-being, rather than illness.

The table below sets out how our overall Integration plan (supported by the BCF programme) will achieve the fundamental changes in the characteristics of provision between 2015 and 2020:

2015 / 2020
Range of access points for assessment and services
Duplication in referral mechanisms and recording, fragmented and complex communication mechanisms / Single point of access underpinned by shared information and records.
Streamlined access through assessment and into appropriate provision.
Increased patient/service user and carer experience
Reduced duplication for staff
Limited options for independence focussed approaches and step up/down intermediate care type services to prevent hospital and residential care.
“Best fit” solutions with identified service gaps / A range of recovery and enabling focussed services across different settings delivering the right care, right time, right place approach.
Services in silos with fixed provision / An integrated model of care with flexible services enabling continuity of care.

The Better Care Fund programme supports the delivery of the wider integration agenda and its themes are:

  • Carer Support – Maintaining and developing robust assessment and support for Carers to sustain resilience.
  • Operational Integration – a structural theme focussing on bringing together services, systems and pathways
  • Promoting Prevention and Independence – Models of navigation, early intervention and social prescribing
  • Recovery & reablement: Step Up/Down – Whole system design for Intermediate/interim care across settings to maximise independence and provide timely assessment and recovery
  • Support to Care Homes – A range of initiatives to prevent admission to hospital, improve discharge pathways and maximise client experience
  • Proactive Health Care to Avoid Admissions – Primary and Community based initiatives to provide health care and assessment before crisis/urgent need develops.
  • Urgent Care and Admission Avoidance – Active admission avoidance in urgent care situations focussed on ensuring robust assessment, decision making and diversion to more appropriate services and support when needed.

The overview of the integration plan (see introduction) shows the alignment of the BCF schemes with the wider integration programme.

This could include

  • a high level summary of the BCF plan.
  • outcomes you are trying to achieve.
  • a summary of funding contributions and schemes

Use this page to confirm the signatories to the plan and wider partners involved – for instance providers, voluntary sector partners etc.

Describe the progress that has been made to integrate health and social care and support more people to be supported closer to home.

This section should set out:

  • the existing approach to integration and the main points of the current BCF plan;
  • review progress to date through the BCF;
  • current performance on national metrics, and;
  • successes
  • Use this section to set out the background to the local health economy.

This should include:

  • Local demography and future demographic challenges
  • Current state of the health and adult social care market
  • Key issues and challenges that the plan will aim to address

Progress to date

The South Tees IEG oversees a number of schemes and developments which contribute to the overall delivery of the 4 priority outcome areas. In addition there are now a range of services in place as “business as usual” which are subject to ongoing monitoring and evaluation under the integration programme to ensure continued effectiveness.

The BCF programme initially saw key metrics achieved but this was not sustained in 2016/17 as activity rose significantly for non-elective admissions and permanent admissions to residential care.

Despite this, evaluations have shown most schemes to be effective and further new schemes in development are expected to support demand management. Reasons for the increases have been out-with the parameters of the BCF current programme (which is focussed on adults, particularly older people) eg a significant increase in Children’s admissions and these need further analysis. Activity in relation to older people increased only slightly. This trend was identified early in the year, managed and covered by contingency funding.

The programme moving forward will continue to re-evaluate what has gone before and build on successes through evidence based developments.

Update on 2016/17 plans:

The following shows key work-streams as set out in the 2016/17 submission and provides a summary of progress to date.

Work-stream / Plan / Progress
Single Point of Access / Phase 1 – Co-location of key access points and relevant personnel including the two LA Access points, Community Health Teams and Single Point of Referral (hospital discharge). / Phase 1 of the South Tees Single Point of Access (SPA) project was implemented on 30th January 2017.
It brought together key partners from existing teams within health and social care services from across Redcar & Cleveland and Middlesbrough. This included the initial contact staff from the Adult Access Teams from both Middlesbrough and Redcar & Cleveland as well as the initial contact staff from the Community Nursing/Community Matron Team and the Integrated Community Therapy Team.
The SPA also has triage staff including the Duty Social Worker for both Local Authorities, a District Nurse, a Duty Occupational Therapist from Middlesbrough Council, a Duty Integrated Community Therapist covering South Tees, a SPOR (Hospital Discharge Team) Officer and a Mental Health Nurse. These teams share one building and a single contact phone number and information is shared between these partners where appropriate.