c) please provide details of the management and oversight ......stakeholder plan monitored weekly...

c) Please provide details of the management and oversight of the delivery of the Bettercare Fund plan, including management of any remedial actions should plans go off track

We recognise that a programme of this scale is unprecedented and requires tightmanagement and accountability to ensure that financial and wider health and socialbenefits are realised. We have identified 9 projects which sit under the Health and SocialCare Integration Programme.

We will be monitoring progress using a series of tools and metrics to ensure all of thoseinvolved in the programme across health and social care are able to track inputs andoutcomes and to ensure the programme runs on time and to cost and delivers theexpected outcomes at each phase of the programme. This will help us to manage theprogramme effectively and ensure that there is borough-wide buy in to the programme.Outcomes will be tested and reported at each phase to ensure there is a solid basis forbenefits being realised in the next phase of integration.

Project dellvenj monitoring tool Monitoring Reportingfrequency

Reporting documents: Reported Monthly To programme board)‘ Risk and Issue register>‘ Highlight reports> Exception reports

Progress against plan. Accountable Monitored weekly To project board.leads and clear phases/milestonesStakeholder plan Monitored weekly Signed off and monitored by(influence/importance and project/programme boardengagement plans)

communication plan Monitored weekly Project board.Benefits realisation plan with clear Monitored weekly To project manager and programmemilestones (realised vs plan) boardcost monitoring’ Actual spend vs Monitored weekly To project manager and programmeprojected spend board

A risk log has been created that is reviewed and updated on a regular basis by the BCFProgramme and it is reported on a monthly basis to the BCF Operational Group.

Any risks that are identified as Amber or Red are progressed to the Health and SocialCare Integration (HSCI) Board for immediate action and mitigating actions are put intoplace.

Any risks that arise within the reporting periods are documented on the risk log.If any that require immediate action I mitigation then they are communicated to all therelevant people and are resolved accordingly.

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d) List of planned BCF schemes

Please list below the individual projects or changes which you are planning as part of theBetter Care Fund. Please complete the Detailed Scheme Description template (Annex 1)for each of these schemes.

Ref no. Scheme1 Community Offer2 Primary Care3 Prevention4 Integrated Assessment & Reablement5 Intermediate Care Management6 Integrated Care Management7 Acute Bed Based Services8 Timely & Effective Discharge9 Integration Enablers

5) RISKS AND CONTINGENCY

a) Risk logPlease provide details of the most important risks and your plans to mitigate them. Thisshould include risks associated with the impact on NHS service providers and anyfinancial risks for both the NHS and local government.

There is a risk that: How likely Potential Overall risk Mitigatingis the risk impact factor Actionsto Please rate on a scale (likelihood

~ . . of 1-5 with I being a potential impact)materialise? relatively small impactPlease rate on a and 5 being a majorscale of 1-5 with I impact

~ being very unlikely~ and 5 being very And if there is some

likely financial impact~ please specify in

L000s, also specifywho the impact of therisk falls on)

The programme doesn’t 1 5 5 The businessdeliver the level of This may have case is robust,savings required to meet an impact of includes a highthe desired outcomes upto £9.5 level of detail and

million if it does is subject tonot deliver the scrutiny at each

required phase of thesavings, programme

SMBC Adult Social Care 1 5 5 The businessdoes not make the This may have case is robust,required savings in line an impact of includes a highwith budget setting upto £9.5 level of detail andtimescales and the million if it does is subject tointegration programme not deliver the scrutiny at eachfails required phase of the

savings, programme


Sandwell & West 1 5 5 The businessBirmingham COG does This may have case is robust,not make the required an impact of includes a highsavings in line with upto £9.5 level of detail andbudget setting million if it does is subject totimescales and the not deliver the scrutiny at eachintegration programme required phase of thefails savings, programmeIt is believed the 5 1 5 We shall locallyNational calculator agree a targetbaseline used for non when we agreeelective admissions by a the local baseline.3.5% reduction does notaccurately reflect thelocal usage of the nonelective admissions.Health and Social Care 1 5 5 Business caseare unable to commit to This may have includes detailedthe significant an impact of phasedinvestment required to upto £9.5 investment andset up primary care, million if it does resource shiftingcommunity and not deliver the to ensure aprevention services required sustainable

savings, approach

Seed Fundingarrangements areincluded in theprogramme tobolster initialresource

Disruption to service 1 3 3 Detaileddelivery which impacts contingency andon the quality of care transitionsthat patients and service planningusers receive Key scenarios

identified andmitigation plansput in place

There is staff/union 1 3 3 Involve staff andresistance to the providers in theproposed changes development ofincluding new teams the integrationand new ways of programme at anworking early stage

throughconsultation andworkshopsUnions invited tokey workshopsand kept informedth roughconsultation.

The workforce across 1 2 2 Develop robusthealth and social care programme plans


do not have the capacity setting out theto invest time and effort resourceinto the change requirementsprogramme whilstundertaking operational Cross-agency signduties/ no additional up to resourcefunding to commission commitment andexternal resources. build into

operationaldelivery plans

The workforce across 1 3 3 Involve staff andhealth and social care is in thenot adequately development ofdeveloped to support the integrationthe integration programme at anprogramme early stage

throughconsultation andworkshops

A lack of knowledge of 1 2 2 Include detailedavailable services and a service mapping,risk averse culture will communicationscontinue to push low and training in thelevels of need into the initial stages of thesystem meaning the programme toinvestment into bring staff on-prevention and boardmanagement of peoplein the community will nottranslate into thereduction in use of acutecare services and bedsThe Care Act proposes 1 3 3 Estimate thesignificant changes to additional demandhow care and support is in financial termsdelivered, will place an and build into theadditional financial integrationburden on health and programmesocial care with baseline includingincreasing demand for the localservices, community based

resourcesrequired

A change in political 1 4 4 Involve all keycontrol or leadership politicallocally and/or nationally stakeholders atdestabilises the the initial stages ofprogramme and causes the programmedelays to and throughoutimplementation each to ensure

cross-party buy-into the programmethroughoutelections

Build in regular[ILl: PROTECT]

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policy andmanifesto reviewsto the programmeplan to ensureareas at risk ofnational changeare identified asearly as possible

Statutory or regulatory 1 3 3 Potential areas fordifferences between conflict identifiedhealth and social care and formallead to tensions plans/protocols

put in placeJoint commissioning 1 3 3 Continuedapproaches are not Services may understanding ofadopted in order to not be delivered priorities, a jointdeliver services appropriately if approach toeffectively both economies services

are not workingjointly

Winter pressures for 1 3 3 Awareness of2014 could have a The impact will workstreams inimpact on BCE be on current placeimplementation of resources andschemes as priorities could impact onmay change based on support given toactivity, flow and citizens and bereaction to acute detrimental toservices the success of

new winterpressure

schemes suchas the flexi bedmodel and own

bed instead.Both schemeswhich are part

of the BCEprinciples

Legal challenges to the 1 3 3 Engage allprogramme and providers at anchanges regarding early stage andcontracting and ensure all legalcompetition requirements

around noticeperiods andconsultation arefollowed

The proposed 1 3 3 Continue tointegration model will be strengthena threat to the operating engagement withmodel for the Acute the Acute providerprovider to ensure full

understanding ofthe futurerequirements.

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The agreed schemes 1 4 4 More strategic andare not aligned with The impact is operationalother workstreams such processes will approach feedingas intermediate care not align for into overall BCEremodelling, own bed social care agenda forinstead, community hub impacting on change.redesign. the workforce

and delivery tomeet all targets

across thehealth and

social economyThe performance 1 5 5 Ensuring therequirements contained This may have programme boardwithin the BCE funding an impact of monitors theallocations are not met upto £9.5 performance ofand the resulting million if it does the indicators on aadditional funding is not not deliver the regular basis andreceived, required takes appropriate

savings, action to rectifyany underperformance.

The risk sharing 1 2 2 Clear agreementsprotocols between are in place andcommissioners need to all partners arebe understood for all involved inpartners to ensure that decision making.financial implications arefully understood andownership is sharedThe risks associated 1 3 3 Continuedwith the partnership engagement andworking with dialogue withBirmingham City Birmingham CityCouncil, and the Council to ensurepotential impact on activity is coreducing urgent care ordinated andactivity. The COG achievingperformance will be commonmeasured as a whole objectives.thereforeunderperformance byeither Birmingham orSandwell Better CareEunds will directlyimpact on the COGachievement of a 15%reduction in urgent careand its subsequentinvestment decisions.The establishment of the 1 2 2 Clear agreementsintegrated project team are in place andis delayed which slows all partners arethe pace of the involved inprogramme decision making


b) Contingency plan and risk sharing

Please outline the locally agreed plans in the event that the target for reduction inemergency admissions is not met, including what risk sharing arrangements are in placei) between commissioners across heaTth and social care and U) between providers andcommissioners

Risk ShareThe financial risks associated with variations in planned Better Care funded activity willbe managed by revisions to the commissioning plans.

The risk of increases in unscheduled care will be dealt with by the CCG outside of theBetter Care Fund pool.

The proposed application of the funding includes £6.182 million to fund unscheduledcare. Should this activity be reduced these resources will be made available to providefurther protection for Adult Social Care.

If unscheduled care is not reduced sufficiently to support this redirection the partners willreview the BCF Programme to identify other alternatives for redirection of resources.Where it is not possible to redirect from the Better Care Fund Programme the risk of aremaining shortfall between the potential redirection and the actual value will be borne bythe local authority.

The agreed Sandwell health and social care plan for the BCF is outlined in the tablebelow.

Sandwell BCF Financial Plan 2015116Total Sub Total

£‘OOO £000Community Development 588Alzheimer’s BlockOSCAR 5Stroke Assoc 37Agewell 414Carers Sandwell 35Carer Network 23Stroke Assoc 74New Vol Offer

2 Primary Care Development -

S Prevention 1,078Telecare 225care Home Quality Team 100Adaptations -

Joint equipment Store 728Carer Services


Wheelchair Service 254 Integrated Assessment & Reablement 2,527

Fast Response 163STAR! OPMH STAR 1,559End of Life 150Reablement FIats 100External Homecare (Proline & Allied) 180Reablement Services (LD)Community Bed Capacity 375

5 Intermediate Care 4,217Stepdown Beds 796IC Henderson 1,242ICLeasowes 1,172BUPA - Ryland View 801Spot Purchase of beds 186GP Support for IC Beds 20

6 Integrated Care Management 0This is not funded as part of the BCE

7 Acute Bed Based services 0The agreed trajectory for the number of beds asper the MMH business case.

8 Discharge Planning ~6627dayworking 322Hospital Team 340

9 Integration Enablers 5,495ENC Administration 85Project Management 72Contingency 156Unscheduled Care 5,182Maintain FACS Eligibility & Manage

10 Demographics 4,000Eligibility! Demographic Issues 4,000Other

11 Protection of Social Care Services 4,625Adaptations 541Joint equipment Store 610Carer Services 460Fast Response 384STAR 1,049Reablement Services (LD) 1,122Community Bed Capacity 459

12 Capital Funded 2,751DFGs 1,722Social Care Capital 1,029Total Planned Spend 25,943 25,943

(ii) Provider Risk SharingAcute ProviderThe CCC has an agreed contract value for 2014 -15 with Sandwell and WestBirmingham Hospitals Trust which includes a transition fund. Should an overperformance occur the transitional fund is required to meet the cost pressure. Should thecost pressure exceed the value of the transitional fund, the CCC and Sandwell and WestBirmingham Hospitals Trust agree to meet the different on a 50/50 basis. Arrangements


for 2015— 16 are yet to be agreed.

Black Country Partnership TrustThe contract is a mixture of block and cost and volume. The services provided by themental health Trust have not been directly included in the BCF. As a Right Care RightHere (RCRH) partner the Trust is supporting the redesign of urgent care pathways forpeople with a mental health illness. This dialogue is being held with Health and SocialCare commissioners.

Adult ServicesAdult Services needs to continue to work with providers to develop the market to meetthe future care needs of Sandwell citizens. The risk is the unknown cost of the Care Actand the implications for managing the market as a result of the potential two tier chargingmodel for self-funders,

6) ALIGNMENT

a) Please describe how these plans align with other initiatives related to care and supportunderway in your area

The BCF Programme has set up 9 workstreams to help deliver the programme.The 9 workstreams are:

• Community Offer• Primary Care• Prevention• Integrated Assessment & Reablement• Intermediate Care Management• Integrated Care Management• Acute Bed Based Services• Timely & Effective Discharge• Integration Enablers

Each of the workstreams have been assigned Project Leads who report on theirworkstreams to the Operational Group on a monthly basis.

Adult Social Care have set up a Programme — Transforming Adult Social Care (TASC),which has been established to bring together a number of projects that will help deliverthe 5 year plan for Adult Social Care. The BCE Programme reports into this programmeon a monthly basis to ensure it is aligned with the delivery of Adult Social Care.

The Care Act Programme has also been established and is closely aligned with the BCEProgramme and reports to the TASC Programme on a monthly basis.

The BCF Programme is also engaged with the wider Council initiatives such asCommunity Operating Groups (COGS), Multi Agency Safeguarding Hub (MASH),Children services and the Neighbourhoods working model. This is to ensure that there isa golden thread approach in the delivery of integrated services.

The BCF Programme is also integrating locally through the GP push sites, MDTs and all


stakeholders to ensure that the services and initiatives that are delivered are aligned andintegrated.

The Better Care Fund programme reports into the Health & Well Being Board. All keystakeholders are represented as part of the Right Care Right Here programme, JointPartnership Board and Strategic Resilience Board.

We are also looking at proposals and making considerations that are in line with thenational crisis concordat for Mental Health. We are committed to working together toimprove the system of care and support so that people in crisis because of mental healthconditions are kept safe and helped to find the support they need. We have made it apriority to work jointly to re-commission urgent care Mental Health services. We arecurrently reviewing proposals for the implementation of a multi-layered pattern ofresponse to people with urgent mental health concerns. Some of the proposals are:

• To work with the joint agencies to extend the Birmingham and Solihull WMAS andPolice Street Triage pilot across Sandwell, Dudley, Walsall and Wolverhampton

• To extend the opening hours and services available at the mental health Oak Unitbased at Sandwell General Hospital

• Support for short stays in supported housing for those not requiring admission tohospital

• Provide emergency assessment and treatment across the whole Sandwell areafrom 5pm to 8:30am.

• Evaluate 7 day working for mental health.

From 1st September The Children and Families Act 2014 places a duty on localauthorities to ensure there is better integration between educational, training, health andsocial care provision where this would promote wellbeing and improve the quality ofprovision for disabled young people and those with Special Educational Needs.Education, Health and Care Plans will replace some of the existing Statements andLearning Disability Assessments and will include Transition Planning to prepare youngpeople for adulthood. In addition, a ‘Local Offer’ is in the process of being developed, inSandwell, which will provide information on services across education, health and socialcare from birth to 25.

We are currently working with all stakeholders to fulfil the duty on the local authority. TheLocal Offer will link with the Better Care Fund and the Community Offer with a focus onuniversal services as well as specialist support to achieve positive life outcomes.

A single definition for ‘Early Help’ has been agreed by partners in Sandwell and testedwith children and families.

We use the term ‘Early Help’• As a single term without distinction between ‘early help’, ‘early intervention’ and

‘prevention’ and ‘integrating services’, used by all staff across all partners;• To define this as services for, and an approach to working with, children and

families who are below the threshold of social care intervention, but require amulti-agency approach that stops problems emerging and supports families toimprove their situation;

• To define the clear link between social care services and our Early Help provisionso as to ensure that access to specialist advice and support is simple and clear,enabling all staff to manage risk appropriately;


• To include all of the partners involved in this strategy.

Currently, emotional wellbeing and mental health services for children and young peopleare being reviewed to better align with changes in the Health and Social Care economy.Redesigned services will have greater emphasis in effective support in the communitypreventing children and young people having to be admitted to acute awards.

Children’s services have already established their locality COGs (Community OperatingGroups) which bring operational multi-agency teams together to deliver the Early helpoffer. These teams include health professionals (school nurses and health visitors) andwork will be undertaken to ensure there is effective working with the MDTs.

b) Please describe how your BCF plan of action aligns with existing 2 year operating and5 year strategic plans, as well as local government planning documents

Sandwell Council have set up a Programme — Facing the Future. The Facing the Futureprogramme has been set up to re-shape Sandwell Council so that it is fit to face thefuture of local government in the period 2015 - 2020.

Sandwell Council has modernised rapidly and radically in the past five years but the nextfive years promise to be even more challenging with greater demands on councilservices and significant reductions in the budgets that are available to provide theseservices.

This programme seeks to deal with the challenges that the Sandwell Borough faces suchas the changing and growing population, especially the increasing numbers of school-age children, elderly and vulnerable people, and the number of people without jobs —

particularly young people.

The programme does not encompass every single change that the council might want tomake between now and 2020, but it is intending to include all of the larger, cross-cuttingprojects on which the overall re-shaping process depends.

The Better Care Fund Programme reports into the Facing the Future Programme as partof the Adult Services programme of works that have been established and are beingdelivered to meet the future challenges Sandwell Council face.

The BCF plan supports the delivery of and is fully aligned to the• Unit of Planning 5 year strategy• CCG two year operational plan• Sandwell and West Birmingham System Resilience Plan 2014/15• Midland Metropolitan Hospital Business Case

The Unit of Planning 5 year strategic vision includes the transformation of primary andcommunity based services through the development of integrated models of care. Theplan includes enhancing existing health and social care integration as outlined in the BCFwork programme to improve the health and wellbeing of our population. The BCF workprogramme will support the delivery of the Unit of Planning vision by:

• Building Community Resilience: residents are informed and supported within theircommunities, enabled to be independent; staff are confident and knowledgeable to


provide or signpost to relevant care• Integrating Care Management: residents have access to joined up care and are

able to exercise choice for care needs; staff provide positive experiences of careof high quality standard to improve outcomes

• Delivering Care Closer to Home: residents have access to care in the communityor own home, and are supported to live independently; staff facilitate theprevention of unnecessary A&E attendance and hospital admission and reducereliance on residential and nursing needs

The BCF enablers will support system transformation by:• Improve data sharing within and across health and social care• Instigating 7 day health and social care services across the economy• Effectively managing demand and enabling timely discharge from acute services• Supporting primary care development and commissioning for hospital alternatives

care• Improving service user experience and satisfaction• Developing trusted single systems, processes, assessments and plans

The CCG 2 Year Operational Plan acknowledges the BCF is not “new” money, the fundis currently committed against existing service provision. The 2 year plan outlines theexpectation that the BCE work programme will deliver system changes which will enablethe release of resources currently spent on unplanned care in order to invest in out ofhospital care and protect social care provision under threat from funding cuts.

The plan recognises that achieving this outcome means significant change across thewhole of our current health and care provider landscape. GP’s are expected to play acentral role as both commissioners of services, providers of primary health services andcare coordination of the most vulnerable patients. The CCG and local authority partnerswill work with the NHS England Area Team to ensure the development and delivery ofthe Primary Care Strategy supports and enables system transformation.

The plan links the BCF to the local Right Care Right Here Programme which hasenduring commitment from local providers and commissioners, to the transformation ofhealth and social care, towards a more community focused model of delivery.

The 2 year plan clearly draws the role of the BCE in delivering an efficient urgent caresystem, effective intermediate care and enablement home care services to ensure therehabilitation and enablement; the reduction of lengths of stay and the elimination ofdelayed transfers of care.

During the next two years and during the transition to the new Midland MetropolitanHospital, the bulk of the Better Care Fund will have been deployed in supporting of acontinued downward trajectory of acute beds and an upward trajectory of primary care,community and voluntary services.

The Midland Metropolitan Hospital business case is an output from the Right Care RightHere (RCRH) partnership in Sandwell and West Birmingham. RCRH is a key driveracross the local health and social care system; for delivering improved patient outcomes,care closer to home and reducing demand on hospital services. With the support of thepartnership the local main acute provider, Sandwell and West Birmingham Hospitals hasrecently received approval for the new Midland Metropolitan Hospital scheduled for


completion in 2018/1 9.

The Midland Metropolitan Hospital will have fewer acute beds, advanced technology,efficient care pathways and reduced inpatient lengths of stay. The Trust will continue todevelop its community provision in order to support more patients in the community. Thetransition plan towards the new hospital means over the next two years the Trust will:

• Actively integrate district nursing, community midwifery and health visiting servicesas closely as possible with primary health care teams to ensure that patientsreceive a comprehensive proactive health promoting service

• Work with partners to actively identify and care for patients who are most at risk ofhospital admission, developing services to keep patients out of hospital and toenable swift discharge following an admission

• Work with commissioners to explore new contractual and funding partnerships tocreate a system with clear and comprehensive incentives to keep patients welland out of hospital

• Ensure that pathways focus on prevention, swift rehabilitation and treatment• Relentlessly improve the quality of care provided to patients, achieving ever higher

levels of safety, effectiveness and patient satisfaction• Recruit, engage and develop passionate and committed people

Operational System Resilience Plan will play a significant role in delivering the objectivesof the BCF. The local health and social care system has worked closely together todevelop services and build close links between organisations to assist in improving andsustaining urgent care services across Sandwell and West Birmingham.

The System Resilience Plan short term vision is during the next two years Sandwell andWest Birmingham will see seven-day working across all services embedded and fullyoperational by the end of the 2015/16 financial year.

During winter 2014/15, seven-day services such as social care, rapid home visitingservices, acute on-site mental health psychiatric liaison services and primary careservices will be extended. These expanded services will contribute to the delivery of theBCF objectives and if successful, the BCF will need to consider how these services aremaintained over the following two years.

The plan focuses on A&E capacity, winter beds, mental health, enhanced assessmentbeds and intermediate care beds and the opportunity to get people back to home as adefault position (own bed instead). In addition, there are schemes that support theintroduction of the new discharge pathway across Sandwell and West BirminghamHospitals aimed at reducing Delayed Transfers of Care.

c) Please describe how your BCF plans align with your plans for primary cocommissioning

• For those areas which have not applied for primary co-commissioning status,please confirm that you have discussed the plan with primary care leads.

The CCG has expressed an interest in co-commissioning primary care with the NHSEngland Area Team because it recognises and values the contribution primary caremakes within the health economy.


We plan to strengthen the role of primary care by investing more resources intoimproving the service offer and the quality of care provided. To do this we have set aside£4.2m to invest in primary care during 2014/15, this additional investment will:

• Support primary care to actively contribute to the integration of health and socialcare

• Focus local networks of practices’ attention on developing “placed based”commissioning plans with clear links to the better care fund objectives (communityresilience, integrated care management, managing people in potential crisis andreducing unplanned admissions)

• Set out our aspirations for improving health outcomes• DeliverourQuality Innovation Productivity and Prevention challenge in 2015/16.

The success of the Better Care Fund relies on the quality and performance of primarycare in terms of the lead care co-ordinator role, steering the multidisciplinary team,prevention, patient education/self-care and proactive management of long termconditions.

Our primary care development workstream aims to empower networks of practices todevelop local commissioning plans, based on population health management.We have a dedicated primary care development project involving 35 volunteer practiceswith a registered population of 230,000, who are working together in 10 defined “placedbased” networks across our five local commissioning groups.

Each network is supported by a dedicated team consisting of a clinical lead, seniorcommissioning manager, commissioning manager, quality officer, medicinesmanagement officer and finance officer. The team’s role is to support the network tounderstand their population diversity, their patient risk profile and to identify interventions,which are evidence based, value for money and will support improved health outcomesand patient experience.

This primary care development programme will support primary care to:• Test the concept of community health networks• Support and in some instances start the dialogue about federated/network

partnership working• Think and act locally to address health inequalities• Empower general practice to engage in a proactive rather than reactive way to

improve the health and wellbeing of their local population• Connect partners at a community level to maximise the opportunities for health

and social care (as part of the Better Care Fund work streams)• Connect directly with communities, co-producing solutions to address their health

issues• Embed health and social care integration• Support the development of primary care• Identify and constructively address variations in practice• Deliver increased community capacity in preparation for the new Midland

Metropolitan Hospital in 2018/19• Work with their patients and patient participation groups to define high quality

primary care.

The networks are expected to produce “placed based” commissioning plans by the endof September and detailed business cases by the end of October. The plans will be


robustly analysed and impact assessed to ensure they deliver our strategic objectives,are realistic, deliverable and provide value for money. The outputs from this project willinform the proposed new co-commissioning framework and the future commissioning ofprimary care as part of a whole system.

7) NATIONAL CONDITIONS

Please give a brief description of how the plan meets each of the national conditions forthe BCF, noting that risk-sharing and provider impact will be covered in the followingsections.

a) Protecting social care services

i) Please outline your agreed local definition of protecting adult social care services (notspending)Over the next three years Adult Social Care will need to respond to a number ofchallenges and opportunities that will impact on the range and type of services that itdelivers. These challenges come in the form of difficult savings targets and significantchanges to local and national policy. The scale and pace of change will require a fullscale transformation of Adult Social Care in Sandwell.

It is clear that within this environment we must protect those Adult Social Care serviceswhich focus on the most vulnerable and those in need; ensuring that they continue toreceive the right support at the right time.

Between 2016/17 Adult Social Care will have insufficient funding to meet its statutoryrequirements and deliver the current range of preventative services. The challenge forthe integration partnership is to protect our service model which delivers prevention, earlyintervention and reduces the pressure from demographic growth. We see the future ofthese services being funded from the Better Care Fund.

Local Context

The adult social care budget will reduce by 25% over the period 2014/15 to 201 6/17 andthis will have to be achieved at a time when demand for our services is expected to rise.

Over the period 2010 -2014 Adult Services has undergone significant transformationwhich has delivered cashable savings in excess of £26 million and provided benefits tothe health and social care system:• Adult Services has supported social care service users to have a personalised

budget, 90% of existing social care service users now have a personalised budget.We have strengthened our market relationships with the independent sector to ensurewe are getting value for money.

• There has been further investment in Reablement Services (STAR Team) to supportpeople to regain their level of functioning to remain within or return to their own home.This is alongside investment in Telecare Technology to maximise individuals’independence within their own home. We have also developed additional Extra CareHousing as an alternative to residential care.

• We have established a Joint Hospital Discharge Team to facilitate timely and safedischarges.


• We have also created a Rapid Intervention Team for those at end of life that facilitatesdischarge from hospital or provides an alternative to admission into hospital to enablepeople to die at home.

• We have invested in a Quality Team to improve the support available to providers tosafeguard individuals and improve the quality of services. We have also developed aFriends and Neighbours community project to build community capital and deliver acommunity response.

We have restructured the management model to adopt a more lean approach and focusactivity to priority areas within the business. We have also rationalised administrativesupport to deliver further efficiencies.The funding of~8.4 million currently allocated for social care with a health benefit throughthe section 256 transfer has been used by the council to invest in services such asreablement, telecare and home support. This level of investment will need to besustained and potentially increased, in order to maintain this service level and to deliver 7day services and meet the additional requirements of the Care and Support Bill.

In addition both SMBC and the CCC are committed to investing non-recurrent funding tothe BCF programme for 2014/15 to ensure the identified schemes have an acceleratedstart.

The minimum BCF allocation for 2015/16 is £25.943m — as a health and social careeconomy these minimum resources will be used for prevention and reablement serviceswhich will ultimately reduce demand and improve conditions for service users.

All partners have agreed that a range of prevention services currently provided by AdultSocial Care will be transferred to and re-procured from the Better Care Fund. In 2015/16this equates to £4.6 million rising to £9.5 million in 2016/17 if the predicted efficienciesare realised in 201 5/1 6. These services include Short Term Assessment and ReablementService (STAY), Sandwell Telecare Service (STAY), Joint Equipment Store, Adaptationsand Carers Support Services.

Whilst maintaining eligibility criteria and thresholds are essential and important to asustainable service, our main focus is developing an integrated health and social careservice that will help individuals maintain healthy lives, encourages independence andbuilds community resilience. We have however identified £4million that is being used tomaintain eligibility and manage demographic issues in addition to the monies being usedfor “protecting” adult social care prevention services.

To this end we have committed resources to develop an enhanced “community offer” tofacilitate strong communities to develop local networks and find local solutions to supportlocal people.

The integration plans are fully endorsed by the council, recognising and supporting theimpact of the integration programme, and acknowledging the impact on wider councilservices, e.g. housing, neighbourhoods and public health. This is evidenced by theallocation of resources that has been made available to develop and deliver the jointvision.


ii) Please explain how local schemes and spending plans will support the commitment toprotect social care

We will need to change the way in which we operate in order to meet the manychallenges that lie ahead and deliver a balanced budget. This will mean moving beyondour current methods of commissioning, procurement, purchasing, and service delivery bydeveloping new offers of care.To make this happen we will need to:

Continue to develop opportunities for the integration of Health and Social Care.This will be top priority over the coming years and will lead to significant benefits forlocal people. Our first steps will be to work with our partners to understand needs,demands, functions and pressures and to develop a joint way forward aroundcommon goals. By integrating health and social care services our intended outcomewill be to help enable people to live longer and have healthier lives whilst requiringless formal support from either adult social care or acute services.

• Forge a new relationship with our local communities, empowering people to buildhealthy communities, encouraging people to take responsibility for improving theirown lifestyles and health.

• Shape local communities to support people in non-acute settings (including mentalhealth) helping to keep people healthier for longer, improving health and reducingthe need for high cost treatment and care.

• Work with colleagues in other parts of the council to build local community capacityand become the first line of prevention. We want communities to reach out to localpeople and offer a range of low level prevention support and to become the firstpoint of contact when people need help. We need to encourage local people todesign and deliver the solution for their local communities.

• Manage demand with initiatives such as public health lifestyle services and ourprevention platform - placing prevention and reablement as our next level ofdiversion from long term Health and Social Care Services.

• Develop risk stratification approaches to maintaining people with long termconditions in the best possible health.

Hi) Please indicate the total amount from the BCF that has been allocated for theprotection of adult social care services. (And please confirm that at least your localproportion of the £135m has been identified from the additional £1.9bn funding from theNHS in 2015/16 for the implementation of the new Care Act duties.)

Within the proposed plan £4.625 million has been allocated for the protection of adultsocial care services with the potential for further redirection depending upon performanceagainst unscheduled care.

The local proportion of the £135 million identified for the implementation of the Care Actduties is £905,000. There is no specific allocation within the proposed BCF Programme,however the local authority has identified one off resources for this value to support CareAct implementation in 2015 /16.


iv) Please explain how the new duties resulting from care and support reform set out inthe Care Act 2014 will be met

We have established a Care Act Programme which meets on a monthly basis andreports into the Adult Social Care Transformation Programme (TASC).

This programme has set up a number of projects that have been assigned project leads.

Each project area has documented what is required from the Care Act and an action planhas been developed that details how the reforms set out in the Care Act shall bedelivered including what resources are required to meet the objectives.The submission takes account of our need to commission preventative services to meetfuture needs. The submission also builds in a commitment to support an integratedapproach to assessments and care plans, as well as accessing independent advocacyservices where deemed appropriate.

The submission recognizes the significant contribution being made by carers to keeppeople away from more intensive and costly health and care interventions. An integratedapproach to support carers, from information and advice, through community services,and to directly supporting them in the continuation of their role will be supported.

v) Please specify the level of resource that will be dedicated to carer-specific support

The Carer specific support has been identified as a project.This project has a lead who has scoped out what is required to deliver the requirements.The current commissioned care and support services are being mapped out to identify towhat extent they meet the requirements and also identifying the gaps in current provisiontogether with the future commissioning needs to meet the carer specific support.

We are currently reviewing the information and advice that is available and scoping therequirements for a new information portal. This will then be translated into a servicespecification and delivery plan for a new integrated information portal that will integrate aself assessment option at the “front end” of the Council website.

Sandwell Council invests over £450k in carers services. This includes a range ofservices such as Cares, Carers Short Breaks and providing an information and servicefor Carers and enables the increased care management capacity to respond to theexpected increased demand for cares assessments.

A proportion of the one off monies identified to support the implementation of the CareAct will be used for Carers.

vi) Please explain to what extent has the local authority’s budget been affected againstwhat was originally forecast with the original BCF plan?

The local authority’s budget strategy for 2015-16 anticipates that allocation for theprotection of adult social care identified in 7W) will be available to support preventativeand re-ablement activity.


b) 7 day services to support discharge

Please describe your agreed local plans for implementing seven day services in healthand social care to support patients being discharged and to prevent unnecessaryadmissions at weekends

The development of the Better Care Fund submission and the work towards theproduction of the business case for whole scale integration has helped us to strengthenour commitment to providing seven-day health and social care services, supportingpatients being discharged and preventing unnecessary admissions at weekends byidentifying high-risk patient groups and introducing rapid response services.

We are currently developing our integration transformation plans for 2014/15 andbeyond. These will set out some of the ways we aim to deliver health and wellbeingpriorities, including integrated working and 7-day services in health and social care tosupport patients being discharged and preventing unnecessary admissions at weekends,and better data sharing between health and social care.

Additional one-off funding has been identified in Sandwell & West Birmingham to enablethe provision of 7 day working. This was operated as a pilot initially to ensure wecaptured the benefits and maximised the efficiencies. We have already started to makethis happen with GP surgeries operating 7 days.

A fully costed plan for 7 day services was developed for sustained provision forimplementation in advance of 2014/15 An amount of £322k has been set aside todeliver 7 day working across STAR, the Joint Discharge Team and the Joint EquipmentService.

Operating 7 day working in this way will allow all parties to monitor the additional capacityrequired to fully develop 7 day working and also crucially evaluate and assess howsuccessful the approach taken is in facilitating the discharge process and avoidingunnecessary admissions.

c) Data sharing

i) Please set out the plans you have in place for using the NHS Number as the primaryidentifier for correspondence across all health and care services

The NHS acute and community health providers already currently use the NHS numberas the primary identifier for patients. This is not currently being used for social care.Over 75% of the SWIFT numbers have been converted to the NHS numbers and theprocess is continuing to ensure all SWIFT numbers have been converted. We expectthis to be completed by quarter 4 of 2014.


ii) Please explain your approach for adopting systems that are based upon Open APIs(Application Programming Interface) and Open Standards (i.e. secure email standards,interoperability standards (ITK))

After the NHS number has been linked with the SWIFT number, Adult Social CareDatabase, for each of our care records, we will employ an Open ApplicationProgramming Interface and Open Standards to create an integrated health and socialcare portal. As a region we are committed to the success of this project which isoperating under the banner of “Shared Care Records”. This portal will enable health andsocial care professionals to view both health and social care information for a givenservice user by inputting their NHS number only.

The establishment of the Central Care Record (CCR) for key stakeholders such as LocalAuthorities and health associates is intended to improve the way patient information isshared.

CCR is an electronic system which is based upon the consent of the patient to make theirdetails available to those who provide them with care across Sandwell, Birmingham andSolihull. Each time a health or social care member of staff accesses CCR the patient willneed to give consent, except in an emergency when staff may need to access the record.In each case health and social care staff will have their details recorded when theyaccess a patient’s record.

Patients have a choice to be included in CCR or to opt-out. If a patient decides to haveCCR, they do not need to do anything, it will happen automatically (subject to GPpractice participation). If a patient chooses to opt-out, they will have to complete an opt-out form (attached to the patient letter) and return it within 12 weeks. Patients canchange their consent after 12 weeks by informing their practice.

Please explain your approach for ensuring that the appropriate IG Controls will be inplace. These will need to cover NHS Standard Contract requirements, IG Toolkitrequirements, professional clinical practice and in particular requirements set out inCaldicott 2.

The proposed data sharing will take place with established Information Governanceframeworks that incorporate the requirements of the IG Toolkit and the Caldicott 2. Weare committed to maintain robust documented processes that uphold the key principles ofConfidentiality, Integrity and Availability, and ensure anyone handling health and socialcare information does so to the same standards. These processes are as follows:

• All staff are aware of the need to determine the confidentiality and security ofinformation

• Adequate security and working procedures are put in place• Systems are in place to monitor all aspects of security• All staff receive training related to information security and that they are aware of all of

their responsibilities with respect to the use of information• Ensure no personal data is inappropriately divulged within and between health and

social care services, and to the wider community• Where health and social care information is shared for the benefit of the community it

is anonymised


d) Joint assessment and accountable lead professional for high risk populations

I) Please specify what proportion of the adult population are identified as at high risk ofhospital admission, and what approach to risk stratification was used to identify them

There is an enhanced service on offer designed by the NHS Commissioning Board (NHSCB) now known as NHS England. This is operated with delegated authority to Sandwelland West Birmingham Clinical Commissioning Group (CCG) and has been designed toencourage practices to identify, manage and co-ordinate with other professionals thosepatients who may benefit from active case management to improve quality of care,reduce avoidable admissions and plan necessary interventions to minimise avoidableadmissions. This enhanced service will be subject to review by the NHS England for2014/15.

The aims of this service are:

• For GP Practices to work as part of a multidisciplinary team (MDT) and work with alocal multidisciplinary approach to identify patients who will benefit from casemanagement and co-ordinate with other professionals the management of thosepatients who may benefit from active case management.

• Undertake risk profiling and stratification of GP Practice registered patients on at leasta quarterly basis.

Working as part of a multidisciplinary team the GP practice will agree with the CCG casemanagement criteria (e.g. percentage of patient’s at most significant risk in the list orfactors such as co-morbidities).

The GP Practice, working as part of the MDT will meet regularly to discuss, share anddevelop an integrated approach to the case management of those identified individuals toimprove the quality of care and support the management of the factors that mightcontribute to reducing avoidable admissions. The community offer will allow collaborativeworking between GP practices and Voluntary hubs and provide an additional supportresource by:

• providing information and advice on self-care, and self management so people areable to look after their own health needs and wellbeing, and can keep fit, safe,healthy and active

• providing access to volunteers who act as good neighbours to support people intheir own homes

• providing signposting to other universal and community services as well andprevention services provided by the SMBC and SWBCCG where appropriate

• to act as the first point of contact within a community for co-ordinating a range ofnon-crisis support options for older and vulnerable persons

Each patient identified for active case management will receive an identified nominatedlead professional who will undertake a care planning discussion and review at a mutuallyagreed time. The CCG is working with the CSU to offer a more sophisticated riskstratification tool based on secondary care and primary care data. In the interim periodthe Local Area Team (of NHS England) is supportive of practices using available toolsuntil a more comprehensive one becomes available.

GP Practices shall have an effective system of clinical governance. The GP Practice will


nominate a person who will have responsibility for ensuring the effective operation of thesystem of clinical governance and will performs and/or manage services under thecontract.

U) Please describe the joint process in place to assess risk, plan care and allocate a leadprofessional for this population

Multi Disciplinary Teams (MDT) have been set up within Sandwell. The MDTs are madeup of key workers from all partners including social workers, GPs, Community Nurses,Therapists where focus can be placed on ensuring that an integrated working model isadopted by all organisations involved. The MDTs assess the risks and plan the carethrough an integrated approach for the individuals identified who have long term healthand social care needs.

There are currently discussions to include additional partners within the MDTs.At present the MDTs are being piloted across 2 GP Push sites but the plan is to rolloutthis out throughout the Borough.

Hi) Please state what proportion of individuals at high risk already have a joint care plan inplace

At present the answer there are no any joint care plans in place, each organisationcomplete their own care plan.

Plans are being developed that shall look at individuals that are high risk and establishingways in which joint care plans can be put in place and shared between all the relevantorganisations that require this information.

8) ENGAGEMENT

a) Patient, service user and public engagement

Please describe how patients, service users and the public have been involved in thedevelopment of this plan to date and will be involved in the future

Sandwell Metropolitan Borough Council (SMBC) and Sandwell and West BirminghamCCC (the CCC) are committed to ensuring that health and social care providers,including the voluntary and community sector, are all working in partnership to developour integration programme.

We are committed to promoting a diverse, sustainable and high quality market for health,care and support services and ensuring there is a range of providers offering servicesthat meet the needs of individuals, families and carers. Our Market Position Statementrecognises the diverse range of providers within Sandwell and the surrounding areas,which ensures real choice for people as well as supporting value for money andsustainable robust markets.

To achieve our goal of ensuring the provision of appropriate services with long term,[ILl: PROTECT]

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sustainable, collaborative relationships with service providers and wider partners acrossthe health and social care economy, we will utilise improved market knowledge andongoing provider engagement to ensure there is diverse, appropriate and affordableprovision to meet needs and deliver effective outcomes both now and in the future.

We formed The Right Care Right Here” programme (RCRH) to lead the development ofintegrated local services for local people. Key partners include SMBC, the CCC,Sandwell and West Birmingham Hospital NHS Trust, Black Country PartnershipFoundation Trust, Birmingham and Solihull Mental Health Trust, Birmingham CityCouncil, and Birmingham Community Health Services which encompasses the wholehealth and social care economy.

RCRH has championed the development and integration of local services throughextensive engagement with providers. There are numerous examples of successful coproduction between providers including;

• The “Shrink to Fit — Acute Care in the New World Order” event was attended by118 consultants and GPs who provide health services in Sandwell and WestB i rm i ng ham

• The Sandwell Health and Wellbeing Board Stakeholder Event that was attendedby the Local Authority, CCG, NHS and voluntary sector service providers, andlocal community stakeholder networks such as the Local Involvement Network

• Sustained engagement forums focusing on the integration agenda with> the Acute provider and the Black County Mental Health Trust> locality Commissioning Groups and clinical leads (CCC and SWBH)> the third Sector through the Sandwell Council of Voluntary Organisations

(SCVO)> social care provider forums

This effective collaboration enables SMBC and the CCC the opportunity to influence localmarkets to offer affordable services that promote community resilience, enabling andachieving better outcomes. Re-shaping the market will deliver improved universalservices, information, advice and guidance which will enable people to make belierinformed choices.

Since our last submission in February we have taken a number of opportunities to workfurther with key stakeholders in shaping the future delivery model. We have alsoengaged with the Joint Health Overview Scrutiny Committee and the CCC Patientadvisory group.

A workshop was held with over 120 voluntary and independent sector providers to coproduce the new community offer.

Following the workshop over 90% of people who attended commented on how useful andinformative they found the event with many positive comments including:

• A good opportunity for joint working across a large number of organisations• Really positive to see the LA ‘stepping out’ to meet with us• Continue to work closely with the VCS & share good practice• Great to see a ‘person centred’ approach, taking the community’s views on board


The CCC has an extensive programme of engagement with service users, the public andother stakeholders. It has embedded patient representatives throughout theorganisations governance structure and a patient advisory group which informs andprovides constructive challenge to commissioning decisions.

The CCC works closely with the local voluntary sector network who acts both asadvocates and as conduits to engaging with vulnerable adults and their carers. Throughthis network we engaged with over 200 adults and carers to co-design the model for themanagement of people with long term conditions.

Over the last 8 months we have conducted an extensive structured programme ofengagement with service users, carers and the voluntary sector (as providers andadvocates for patients) to understand the experience of our population when accessinglocal services. The outputs from this ‘experience” based commissioning approach hasinformed the CCGs contribution to the development of the BCF plan with regards tobuilding community resilience, improving primary care, care management, intermediatecare, long term conditions management and the integration of health and social care.

The Patient Advisory Group has received and commented on the BCF plan. They havealso actively participated in review panels, which have provided constructive challenge tothe emerging planning assumptions of the primary care workstream.

We have also engaged with our Ambassador Forum and a number of ambassadors arenow part of the customer journey workstream, as well as a number of other workstreams.

b) Service provider engagement

Please describe how the following groups of providers have been engaged in thedevelopment of the plan and the extent to which it is aligned with their operational plans

i) NHS Foundation Trusts and NHS Trusts

The Better Care Fund programme, draws together key system programmes of redesignwhich support the delivery of the Right Care Right Here objectives and the effectivenessof the local health and social care systems.

We are committed to ensuring greater engagement with all NHS providers in comingmonths.

The local providers have been engaged in the development of system solutions toaddress non elective demand, delays in care pathways and improving service quality. Amultidisciplinary group consisting of GP leads, health commissioners, adult social carecommissioners, social workers, nurses/matrons, therapists and case managers havereviewed the local issues, co-designed solutions and agreed the phased implementation.

We have 33 MDTs all have had development meetings and standard operatingprocedures agreed. Engagement from clinical lead and commissioning managersaround the role and development of the MDTs. Operational managers at the providershave been fully engaged through the Pacesetting Board and an operational group.

Working with the local mental health providers we have co-designed the mental health


urgent care response to Sandwell and City Hospitals, to provide timely assessment anddischarge to the most appropriate. This work has included close liaison with NHS 111,the ambulance service and the police to treat people at home and avoid unnecessaryhospital attendance.

U) primary care providers

The CCG is a primary care provider membership organisation, with a strong embeddednetwork of clinical leadership. The engagement of our primary care providers has beenprimarily through our governance structure which has clinical leaders from each of ourlocal commissioning groups in attendance:

• Partnership Committee — receives regular updates on the BCF and gives thePrimary Care representatives opportunity to comment and steer the direction oftravel

• Strategic Commissioning Committee — receives the proposals for servicereconfiguration and agrees the direction of travel.

• Contracting and Performance Groups — all the contracts are overseen by a clinicallead, they are aware of any proposed changes

• Local Commissioning Groups (LCGs) — are the forums where primary caremembers are engaged in the dialogue about service change. All LCGs havereceived presentations about the purpose of the BCF and some have hadpresentations from local authority colleagues on the impacts of the Care Bill.

Individual work programmes — each of the CCG work programmes including the BCF hasan appointed clinical lead who represents the organisation but also contributes byproviding a primary care perspective.

In addition, the primary care development work steam has engaged and is currently codesigning solutions with primary care to support the reduction in non elective admissionsand proactive support in the community.

Ui) social care and providers from the voluntary and community sector

We believe that successful health and social care integration must be patient and serviceuser led. Patient and service user views are integral to the vision for integrated care inSandwell & West Birmingham and will serve as a benchmark to measure our success indelivering plans that truly impact on areas that are important to our residents.

We asked local people what they wanted from their health care services - they told usthat they wanted faster and more convenient access to services within better facilities,and to be treated with dignity and respect. These are the founding principles of the RightCare Right Here programme. Key to delivering our purpose and objectives will bedeveloping and maintaining relationships with our patients and service users. By doingthis we will be able to respond to needs more effectively and provide relevant supportand challenge.

Our residents and the wider community are at the heart of everything we do, and arepivotal to driving the integration agenda. Listening and responding to the public is


achieved in a variety of ways including formal consultation, direct patient and serviceuser contributions, focus groups, seminars, presentations and informal feedback fromclinicians, officers and Members.

A good example of how this process works is the “Long Term Conditions” group whichco-ordinates events to bring together patients, carers, service users, and professionals toco-design solutions.

Officers from both the Local Authority and CCG have presented at the SandwellHealthwatch Board meeting on our plans for the Better Care Fund and received positiveendorsements, critical challenge and ongoing support to deliver this agenda.

We have facilitated community Roadshows and Help4U events which have strengthenedour relationship with residents. This engagement continues to increase and is essential toshape the integration agenda. Managing patient and service user expectations andexperiences well is critical to the delivery of our priorities.

Some of the key groups that we collaborate with include:• Community Ambassadors Forum that is attended by older people, people with

mental health needs, learning disabilities, sensory and hearing impairment,physical disabilities, as well as carers and 3rd sector volunteer agencies.

• CARES, Changing our Lives, Ideal for All, Sandwell Visually Impaired, Agewell• Service User Network Forums that are open to current or ex mental health service

users and mental health service user carers• Patient networks and user groups

We also recognise and value the contribution made by the 33,500 unpaid carers withinSandwell and the increasing number of older carers providing 50 hours or more of formalcare per week. Through CARES we ensure their voice is represented on the differentforums we hold within Sandwell and they have a real opportunity to positively impact andshape the future.

We have continued to engage with patients, service users and the wider public indeveloping future plans and realising our integrated vision. We have aligned ourselveswith Healthwatch to make sure our plans for integration reflect the views and experienceof people who use and access services.

c) Implications for acute providers

Please clearly quantify the impact on NHS acute service delivery targets. The details ofthis response must be developed with the relevant NHS providers, and include:

- What is the impact of the proposed BCF schemes on activity, income andspending for local acute providers?

- Are local providers’ plans for 2015/16 consistent with the BCF plan set out here?

In our BCE submission there is a working assumption that we shall deliver a minimum of3.5% reduction in unplanned emergency admissions. We acknowledge that the BCF NELchallenge exceeds the originally envisaged reduction in the MMH business case and willwork with partners to address this issue.


The schemes in the submission require the ongoing support of Sandwell and WestBirmingham’s clinical staff, i.e. District Nurses, Case managers, Therapists who currentlywork with primary care and provide care in the community. There may be future potentialwith regards to new models of care for intermediate care.

Please note that CCGs are asked to share their non-elective admissions planned figures(general and acute only) from two operational year plans with local acute providers. Eachlocal acute provider is then asked to complete a template providing their commentary —

see Annex 2 — Provider Commentary.


ANNEX I — Detailed Scheme Description

For more detail on how to complete this template, please refer to the Technical Guidance

Scheme ref no.Scheme 1Scheme nameCommunity OfferWhat is the strategic objective of this scheme?

This scheme is aimed to deliver more effective management of people in the communitywhich will require refocusing and realigning of existing community services.Overview of the schemePlease provide a brief description of what you are proposing to do including:

- What is the model of care and support?- Which patient cohorts are being targeted?

This scheme will deliver a new community offer working within defined localities toestablish clear networks, targeted development to build up community resilience andclearly defined outcomes. By creating local services through the coordination ofvolunteers, local carers and commissioned services, it will enable the development of asupport structure required to manage peoples’ diverse needs in the community. Thecentral role of the local GP is crucial to this - our people tell us that the GP is their mosttrusted health professional. Establishing GP’s at the heart of the community offer willensure that the support delivered is joined up and connected through local primary care.For children the role of the GP is also critical but schools also play an important part insupporting families and are often the first port of call for parents who need help. Workingwell with schools will strengthen local networks of support.The delivery chainPlease provide evidence of a coherent delivery chain, naming the commissioners andproviders involved

There are a number of stakeholders involved in delivering this scheme.These have been detailed in the Project Initiation Document which is available.The evidence basePlease reference the evidence base which you have drawn on

- to support the selection and design of this scheme- to drive assumptions about impact and outcomes

The scheme is based on the Prevention and Self Help Agenda and a local approach tothe delivering this Agenda. It will focus on ensuring the individual can maintain theirindependence and stay at home for long as possible.Investment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure PlanThis scheme is funded external to the BCE Programme to evaluate the success.The Local Authority shall be adding two injections of £600,000 (total £1.2 million) of nonrecurrent monies over the next 2 years to establish and develop the new communityoffer.


Impact of schemePlease enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics belowThe outcomes for the scheme are:

• Total non elective admissions into hospital• A reduction in permanent admissions of older people (aged 65 and over) to

residential and nursing care homes, per 100,000 population.• An increase in the proportion of older people (65 and over) who were still at home

91 days after discharge from hospital into reablementl rehabilitation stay• A reduction in delayed transfers of care from hospital, per 100,000 population

which are attributable to adult social care• An increase in the estimated diagnosis rate for people with dementia• An increase in overall satisfaction of people who use services with their care and

support• A reduction in the number of requests for support in Adult Social Care• An increase in population vaccination coverage

The local outcomes are:• Reduction in calls to ASSIST as low level interventions are managed by the

community• Delivery of efficient, good quality and cost effective local services that also help to

prevent avoidable demand on traditional SMBC and SWBCCG services• Individuals are directed towards existing provision of community based services• Increased use of voluntary sector provision to empower local communities• Increased use of volunteers through a more co-ordinated approach that targets those

most in need of support• Support to Primary Care to facilitate a reduction in demand on Acute services.Feedback loopWhat is your approach to measuring the outcomes of this scheme, in order to understandwhat is and is not working in terms of integrated care in your area?This workstream will report back on a monthly basis to the BCF Programme Board. Thisworkstream shall also be monitored against the deliverables and this will be built into thereporting templates provided by the workstream,What are the key success factors for implementation of this scheme?

The workstream has a number of key objectives that shall be the key success factors.These objectives are being drafted at present with the organisations that have beenselected as part of the community offer model.


Scheme ref no.Scheme 2Scheme namePrimary CareWhat is the strategic objective of this scheme?

This scheme will require an enhanced user-led primary care offer which will focus onearly identification and prevention, early targeted interventions, self-care, education,effective proactive management of vulnerable groups and 7 days working. ______

Overview of the schemePlease provide a brief description of what you are proposing to do including:


Establishing the link between primary care and social care is essential to making thiswork. Ensuring timely, up-to-date and effective information is communicated when it isrequired will enable the proactive management of people and keep them in their ownhomes and communities.The delivery chainPlease provide evidence of a coherent delivery chain, naming the commissioners andproviders involved

The GP has the role as accountable lead for over 75s and this will be a pivotal link in themanagement of vulnerable people.The evidence basePlease reference the evidence base which you have drawn on


The workstreams have been modelled on the work that was conducted as part of theoriginal submission.The whole system approach was modelled and identified 9 workstreams which deliverbenefits across all the health and social care economy.A business case model was produced by Ernst & Young that supported the rationale forthe 9 workstreams. The business case detailed the assumptions that were made as partof the model.Investment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure PlanThe CCG investment is £4.2 million in Primary Care.Impact of schemePlease enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics belowThe intended outcomes from this scheme are:• Detailed analysis of the health needs of the population — risk stratified to identify those

requiring early Intervention• Detailed commissioning plans• Improved patient experience• Improved continuity of care• Increased usage of selfcare programmesThe impact of this scheme will be evaluated after go-live in March 2015.


Feedback loopWhat is your approach to measuring the outcomes of this scheme, in order to understandwhat is and is not working in terms of integrated care in your area?The workstream will feed back into the BCF Programme and report on progress on amonthly basis. This will be tracked and monitored through this programme.What are the key success factors for implementation of this scheme?

• Reduced admissions amenable to Primary Care intervention• Reduced secondary care Out Patients activity• Reduced variation in clinical outcomes• Short-medium term increase in the number of people recorded as having an LTC, but

with more effective management in Primary Care• Long-term reduction in LTC• Improve health outcomes and impact on health inequalities

Scheme ref no.Scheme 3Scheme namePreventionWhat is the strategic objective of this scheme?

This scheme is built upon the principles developed under the Multi-Agency PreventionPlatform (MAPP). This piece of work is to build a prevention4ocused service deliverymodel aimed at ensuring the preventative offer for Sandwell is well focused and rapidlytargeting all those who could benefit from early intervention - both younger adults andhigh risk older groups.Overview of the schemePlease provide a brief description of what you are proposing to do including:


MAPP is a prevention-focused service delivery model aimed at ensuring the preventativeoffer for Sandwell is well focused and rapidly targeting all those who could benefit fromearly intervention - both younger adults and high risk older groups.

Embracing new technology such as telehealth and telecare are fundamental to thesuccess of this scheme alongside a radical redesign of existing pathways and supportingcarers to ensure as many people as possible are managed outside the traditional healthand social care system, their needs being met via the community. The role of Housingbeing integrated within the prevention platform will ensure that the range of needs can bemet within a single point of access.

This will be achieved through a refocused community development strategy, supportingand building on the existing local infrastructure — including up-skilling professionalsalready in the community - and signposting the community to advice services, localservices and clear points of access to 24/7 prevention services. Ensuring advice andmessages are consistent no matter which professional gives them is key to theprevention offer.

There will be a range of commissioned services in place that are specifically intended totarget those people who are able to remain independent within the community enabling


self-care.The delivery chain -

Please provide evidence of a coherent delivery chain, naming the commissioners andproviders involved

There are a number of key stakeholders within MAPP.MAPP will include all the preventative services within Adult Services, such as STAR,Telecare, STAY, Home Loans and the Joint Equipment Store.It will also include partners within the MDTs and other voluntary organisations andorganisations involved in the community offer.

The workstreams have been modelled on the work that was conducted as part of theoriginal submission.The whole system approach was modelled and identified 9 workstreams which deliverbenefits across all the health and social care economy.A business case model was produced by Ernst & Young that supported the rationale forthe 9 workstreams. The business case detailed the assumptions that were made as partof the model.The evidence basePlease reference the evidence base which you have drawn on


The evidence base for MAPP has been through consultation and design workshops thatdetailed an integrated approach to delivering services and meeting the increaseddemands for services within reducing budgets.

Investment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure PlanThe investment is Prevention is £1 .078 million.The re-alignment of the current service delivery model and the management servicesshall be absorbed in the existing budgets within the Local Authority.Impact of schemePlease enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics belowThe intended outcomes from this scheme are:• 20% reduction in ASSIST contact. This is based on an activity study that was carried

out by Adult Social Care.• Reduction in hospital admissions• Reduction in prevalence rates of preventable illness (linked to lifestyle)• Increase in use of telecare.• Development of the voluntary sector via a commissioned service to provide the advice

/signposting/info.• Removing the ‘council’ as the information conduit• Opportunity to align CCG and acute prevention services within the MAPP• Nursing input within MAPP services offering a more integrated approach to service

usersFeedback loopWhat is your approach to measuring the outcomes of this scheme, in order to understandwhat is and is not working in terms of integrated care in your area?


[ILl: PROTECT]

The workstream will feed back into the BCF Programme and report on progress on amonthly basis. This will be tracked and monitored through this programme.

What are the key success factors for implementation of this scheme?

The scheme is based on a joined up whole system approach. The scheme is basedaround providing the support system to allow people to stay at home for longer.

• 20% reduction in calls to the ASSIST contact centre. ASSIST is the Adult Social CareContact Centre.

• Reduction in hospital admissions• Reduction in prevalence rates of preventable illness (linked to lifestyle)• Increase in use of telecare.• Development of the voluntary sector via a commissioned service to provide the advice

/sig n posting/info.

Scheme ref no. — - _____________________________________________Scheme 4 _________________________________Scheme nameIntegrated Assessment & Reablement / Own Bed Instead ___________

What is the strategic objective of this scheme?

The Local Health Economy strategy for intermediate care and reablement is for patientsto be in their “own bed Instead” rather than a commissioned bed, unless absolutelynecessary. We know that patients, with the right level of support and input will thrive inthis environment and less patients require long term care if they are not“institutionalised”. The strategy is to commission 7 day “wrap around” services to keeppatients living independently within their own homes.

The objective is to enhance the current offer to support people at home over a 24 hourperiod __________________________________Overview of the schemePlease provide a brief description of what you are proposing to do including:

- What is the model of care and support?Which patient cohorts are being targeted?

A pilot over winter 2014/15 will offer 10 “virtual own beds” across Sandwell that willenable patients to go home to their “own bed” with an enhanced service offer. Toinclude:-Domiciliary careNight sittingCommunity alarmsTelecareNursingCase managementTherapiesGeneral Practice

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This service offer will be applicable for both step down and step up support to ensure theoffer is wrapped around the needs of the service user with an increased focus onpreventing admission to achieve better outcomes for individuals outside of acute hospitalsettings. This can only be achieved through an integrated assessment process that candeliver significant assessment savings to health and social care and ensure that peopleare discharged for assessment to ensure as many assessments as possible aredelivered out of the acute environment.The delivery chainPlease provide evidence of a coherent delivery chain, naming the commissioners andproviders involved

The key stakeholders are:CommissionersSWBCCGSMBC

ProvidersDomiciliary Care — STAR and othersSandwell and West Birmingham Hospital Community ServicesLocal GPsTelecareCommunity AlarmsThe evidence basePlease reference the evidence base which you have drawn on


Local audits of length of stay, appropriate/inappropriate admissions to all commissionedintermediate care beds has given us the local evidence to show that 26% of patients atany one time could have been discharged to their “own home” with support.The intention is to “pilot 10 virtual beds” over the winter of 2014/15 with extracommissioned services with a full evaluation.

This model will impact upon DTOCs and lengths of stay by releasing intermediate carebed capacity by providing an alternative pathway.Investment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure Plan£250,000 has been accounted for in the Sandwell and West Birmingham Resilience Planto fund “own bed instead” to cover 20 virtual beds over winter over Sandwell and WestBirmingham footprint

The whole of Sandwell and how many “virtual beds” required will be modelled followingthe evaluation of the winter pilot.Impact of schemePlease enter details of outcomes anticipated in Part 2, Tab 4 HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics belowThere is an opportunity to achieve savings through diversion from high cost packages ofcare, long term services and savings in Health aligned to the identified QIPP targets.The outcomes of this scheme will be:


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• Rapid response to discharge and crisis in community through personalised careplanning

• Avoidance of duplication between health and Social Care• Right care in the right place — “the patients own bed first every time”• Using our acute and community facilities to ensure patient has the fastest route homeFeedback loopWhat is your approach to measuring the outcomes of this scheme, in order to understandwhat is and is not working in terms of integrated care in your area?The workstream will feed back into the BCF Programme and report on progress on amonthly basis. This will be tracked and monitored through this programme.What are the key success factors for implementation of this scheme?

• Rapid response to discharge and crisis in community through personalised careplanning

• Avoidance of duplication between health and Social Care• Right care in the right place — “the patients own bed first every time”• Reduction in DTOCs and Lengths of stay in intermediate care service.

Scheme ref no.Scheme 5 _____________________________Scheme nameIntermediate Care ManagementWhat is the strategic objective of this scheme?

This scheme will deliver a single point of access and nurse-led triage services designedto streamline the assessment and referrals within the service releasing capacity andimproving flows between services and improving outcomes for individuals.Overview of the schemePlease provide a brief description of what you are proposing to do including:


We will use existing capacity within intermediate care beds to ensure we optimise theiruse. Beds in the system will be managed through a joint community hub, as a whole withclear access criteria and rolling joint audits to ensure that admissions are appropriate,well managed and effective.This is linked to the own bed instead scheme — scheme 4, which will free up capacity inour existing intermediate care provision.The delivery chainPlease provide evidence of a coherent delivery chain, naming the commissioners andproviders involvedExisting joint commissioners within health and social care.

CommissionersSWBCCGSMBC

ProvidersCurrent commissioned IC bed provision

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Sandwell and West Birmingham Hospital Community Services.Local GPsThe evidence basePlease reference the evidence base which you have drawn on


The current provision for intermediate care beds is commissioned separately by SMBCand SWBCCG. A joint approach would manage this more effectively. Indicative savingsare yet to be estimated, based on bed occupancy being maximised and excess supplydecommissioned.All Intermediate Care bed services have been audited reviewing lengths of stay, qualityof care and effective reablement. The work undertaken by the National Audit forIntermediate care shows that an average length of stay in any Intermediate careprovision should be 26.9 days. The lengths of stay in provider units all exceed thisnumber. We are therefore working with providers to reduce length of stay and haveintroduced new key performance indicators as a measure. Furthermore, the work beingled in relation to developing 7 day services as required by the Sir Bruce Keogh report(Transforming Urgent Care Services; Department of Health, 2014) identifies that we mustensure 7 day admissions and discharges are being undertaken as routine and this is notnecessarily the case at this present time.

Over winter System resilience monies is funding a 20 bedded flexible bed model whichenables health and social care patients (with re-ablement needs) to be in one unit insteadof separate units as per the commissioned stance at present. This model has health andsocial care staff running the unit and will be fully evaluated as a model going forward forfuture joint commissioning under the BCF.Investment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure PlanImpact of schemePlease enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics belowThe intended outcomes from this scheme are:• To maximise the effectiveness of appropriate reablement care, which will ensure

hospital beds are not blocked• A reduction in the number of people who remain dependent in the beds and then

transfer to bed based care• Mix of beds for dementia with commissioned GP and clinical support to enable timely

diagnosis of dementia within Intermediate Care• Providers and Social Care to be more responsive and held to timescales• Joint commissioning will establish full picture of need, rather than health and Social

Care competing for the same beds• Jointly agreed performance framework to ensure no transfer of care delays in

intermediate services and reablement servicesFeedback loopWhat is your approach to measuring the outcomes of this scheme, in order to understandwhat is and is not working in terms of integrated care in your area?The workstream will feed back into the BCF Programme and report on progress on amonthly basis. This will be tracked and monitored through this programme.What are the key success factors for implementation of this scheme?


Scheme_ref no. - ________________________________________Scheme 6Scheme nameIntegrated Care ManagementWhat is the strategic objective of this scheme?

This scheme will deliver a carefully focused, multi-disciplinary care management processthat will significantly reduce both attendances and admissions.Overview of the schemePlease provide a brief description of what you are proposing to do including:


The single biggest opportunity for saving is the reduction in emergency admissions fromthe acute sector and the release of the associated bed day savings. The reduction inadmissions will also reduce social care assessment costs and promotes better dischargeplanning and reduced residential and nursing care bed costs.

This will be supported through the establishment of Multi-Disciplinary Teams, basedaround defined populations with clear links to the community support offer (the effectiveutilisation of community support networks through people management and ongoingsupport within their communities). Feedback from patients and service users themselveswill be used to optimise the services offered.The delivery chainPlease provide evidence of a coherent delivery chain, naming the commissioners andproviders involved

GPs, Social workers, Practice and District Nurses, Community Matrons, Palliative Careand the organisations involved in the community offer.The evidence basePlease reference the evidence base which you have drawn on


We are piloting the MDTs and some initial findings are and the indications are• Increasing the staff knowledge and improving communication• Gaining access to other professionals• Easier and quicker access for appropriate support for service users• Improving the data sharing amongst organisations• Reducing avoidable referrals

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Potential savings and commissioned beds that are value for moneyAn integrated health and social care culture to holistic assessment and well being.Shorter lengths of stayImproved flow through systemReduced Delayed Transfer of Care

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Investment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure PlanImpact of schemePlease enter details of outcomes antidpated in Part 2, Tab 4. HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics below• Improved patients experience• Improved continuity of care• Reduced admissions amenable to community intervention• Better signposting for preventative services• Following risk stratification (short medium term), reduce numbers of people requiring

assessment/review• Collaboration across Social Care and health teams offering enhanced workforce

development• Sharing of information across organisations

Feedback ioopWhat is your approach to measuring the outcomes of this scheme, in order to understandwhat is and is not working in terms of integrated care in your area?The workstream will feed back into the BCF Programme and report on progress on amonthly basis. This will be tracked and monitored through this programme.What are the key success factors for implementation of this scheme?

• Reduced variations in health and Social Care outcomes• Effective integrated teams• Improve patient experience — “only telling the story onc&’• Increased number of people being managed in the community and not admitted to an

Acute Emergency admission.• Collaboration across Social Care and health teams offering enhanced workforce

development• Reduced Delayed Transfer of Care

Scheme ref no.Scheme 7Scheme nameAcute Bed Based Services — Midland Metropolitan Hospital (MMH)What is the strategic objective of this scheme?

The development and build of a new hospital with reduced bed capacity by 2019.



The Trust will develop a new model of patient care in line with the vision agreed by ourlocal health economy under the Right Care, Right Here Programme. Within this servicemodel they will deliver clinical services in multiple locations including:


• Patient’s own homes• Primary care and health centre settings• The Trust’s own Community Facilities i.e.: Rowley Regis Hospital (RRH), Sandwell

Treatment Centre (STC), Birmingham Treatment Centre (BTC), Birmingham andMidlands Eye Centre (BMEC) and the adjacent Sheldon Block and Leasowesintermediate care facility.

• The new MMH.In summary this vision requires a major step change in service provision across thehealth economy through service redesign and investment with a re-balancing of capacityto reflect a greater focus on delivering care in community and primary care settings andMMH (the new single site acute hospital) operating at maximum productivity.The delivery chainPlease provide evidence of a coherent delivery chain, naming the commissioners andproviders involvedMain commissioners involved are Sandwell and West Birmingham CCG and SandwellMetropolitan Borough Council. The two Birmingham CCGs, Cross City and SouthCentral also commission services from the provider, they are covered in the BirminghamBCF.The Trust will commission the contractors to build the new hospital.The evidence basePlease reference the evidence base which you have drawn on


This has been documented in the business case for the new hospital within Sandwell,Metropolitan Hospital.Investment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure PlanImpact of schemePlease enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics belowThe new hospital business case outlines have been agreed by the Treasury.

MMH will be a single site acute hospital in a modern purpose built facility and will allowus to centraiise emergency and specialist inpatient care on one site with a critical mass ofpatients and staff that will enable development of skills and a greater level of senior onsite cover throughout the day and seven days a week. This will facilitate delivery of:

• High quality care 24/7 and 365 days per year.• Continuity of care through multidisciplinary teams working to pathways and protocols

agreed by expert led teams.• Initial assessment and treatment of patients requiring emergency care by experienced

clinicians with consultant presence on site 24/7 in our most acute specialities, and onsite 12 hours, 7 days a week for a number of others. Sub-specialty expertise acrossthe entire range of non-acute specialties will be available to in-patients in a timelyfashion.

• High-level diagnostic support, including imaging and pathology, immediately available24/7.

• Separation of acute unplanned and elective patient flows with individuals responsiblefor elective care of patients not being simultaneously responsible for the delivery of


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emergency care.• Leadership at the point of care delivery e.g. wards, departments and theatres will be

provided by experienced clinicians with sufficient time to lead and supervise staff andstandards.

This will also mean:• A greater proportion of patients attending MMH will be acutely unwell, have complex

conditions or require specialist assessment;• The smooth transfer of patients to a community location or primary care once this

level of acute care is no longer required will be essential;• Clear patient pathways that cross organisations and professional groups will be

essential to ensure seamless patient care without duplication or gaps and to ensurepatients receive the right service in the right place at the right time;

• Smooth, timely flow of information, ideally in the form of an integrated health carerecord, between professionals and across locations and providers will be important;

• Changes to the workforce will be required to ensure staff with the right competenciesare available at the right time in the right place; and

• It will continue to provide and develop a range of more specialist services to our localpopulation

Feedback loopWhat is your approach to measuring the outcomes of this scheme, in order to understandwhat is and is not working in terms of integrated care in your area?This workstream will be reported into the RCRH Programme and the SMBC and CCCrepresentatives will report back to the BCF Board.What are the key success factors for implementation of this scheme’The delivery of the new hospital within Sandwell and community infrastructure which cansupport people within the community.

Scheme ref no.Scheme 8Scheme nameTimely and Effective Discharge PlanningWhat is the strategic objective of this scheme?

The timely and effective discharge planning scheme will provide an integrated and wholesystems approach that ensures that people get access to appropriate health and socialcare support at the right time. This approach will contribute to reduced assessments insocial care, and reduce admissions/re-admissions back into the acute services.

The new approach to discharge planning will support and maintain people in thecommunity for longer, without impacting on acute services. It will manage demand andreduce pressure in the system, by taking early steps to prevent the need for those whorequire acute services and by supporting people who need social care to liveindependently in their own homes for as long as possible.Overview of the schemePlease provide a brief description of what you are proposing to do including

- What is the model of care and support’- Which patient cohorts are being targeted’

This scheme will support the following objectives to maintain people in the community forlonger and will result in less admission/readmission to hospital.

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Discharge processes will be aligned back to the appropriate casemanagementicommunity teams to complete the pathway and to ensure that people aredischarged to the right environment, with the information and support necessary achievethe above objectives. This process sits with the new hospital pathway (ADaPT) designedwith acute services to ensure that the future pathway of all patients are defined within 36hours of admission.

Options such as Intermediate Care, Enhanced assessment and Own bed instead, will beconsidered as pathways to support the discharge planning within that first 36 hour period.Additionally, the early use of technology in conjunction with the use of reablement/rehabilitation will allow community based support options to be shaped I tested I tailoredto meet the individual’s needs during and after the intervention.The delivery chainPlease provide evidence of a coherent delivery chain, naming the commissioners andproviders involved

GPs, Social workers, Joint Hospital Discharge Teams, Practice and District Nurses,Community Matrons, Palliative Care and the organisations involved in the communityoffer.The evidence basePlease reference the evidence base which you have drawn on


The evidence base for this scheme is a:• Reduction in the delayed transfer of care• Shorter lengths of stay• Increased throughput in intermediate care• Reduction in re-admissionsInvestment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure PlanImpact of schemePlease enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics below• 12% decrease in delayed discharges by Oct 2015 (based on comparing current

baseline of 337 against target of 300)• Subsequent decrease in readmissions• MDT discharge planning from day one admission to Intermediate Care• Early management of patient expectations and psychological preparation of patients

for discharge• Reduced delays, enhanced flow, optimum bed usage,• Reduced duplication between health and Social Care through joined up approach to

discharge planning• Better overall patient experience through timely communication and effective

management of expectations• Increased reablement numbers and improved outcomes for people — ASCOF 2b Part

IFeedback loopWhat is your approach to measuring the outcomes of this scheme, in order to understand


what is and is not working in terms of integrated care in your area?This workstream will report into the BCE Programme on a monthly basis.


• 12% decrease in delayed discharges by Oct 2015 (based on comparing currentbaseline of 337 against target of 300)

Scheme ref no.Scheme 9Scheme nameIntegration EnablersWhat is the strategic objective of this scheme?

We recognise that the infrastructure required to wrap around the schemes identified isfundamental to the success of the vision. There is a clear need to use a single carerecord through NHS numbers that will facilitate the data-sharing that is required forsuccessful integration.The scheme will look at ensuring the IT infrastructure is available to support the schemein delivering and meeting their outcomes. It will develop an information portal to provideinformation and advice for the public.There is a central care records system and the ability for organisations to share data asrequired.The risk stratification of the population will be completed as part of this scheme.



The scheme will look to identify patients through risk stratification and modelling. Thiswill then be used to allow the other scheme to target people and support patients beingdischarged and preventing unnecessary admissions at weekends by identifying high-riskpatient groups and introducing rapid response services consistently across a 7 dayperiod.

Underpinning this infrastructure will be 24/7 access to diagnostics and clinical expertise,and the associated workforce development essential for the delivery of the integratedvision. Integration requires a whole scale change to workforce culture that will befundamental to the success of the project.

The scheme will also look at providing an information advice system that is available tothe public that is supported by all partners.

The NHS number and SWIFT numbers shall be aligned within both organisations.The delivery chainPlease provide evidence of a coherent delivery chain, naming the commissioners andproviders involved

There are a number of different people who shall be involved in delivering this scheme.


GPs, Social workers and MDTs will need to be involved in the risk stratification.IT will need to be involved in the development of the information portal.The information and performance team shall need to provide the risk stratificationinformation that can be analysed. ________________

The evidence basePlease reference the evidence base which you have drawn on


This workstream is fundamental to help enable the delivery of the other workstreamswithin this programme.The workstreams have been modelled on the work that was conducted as part of theoriginal submission.Investment requirementsPlease enter the amount of funding required for this scheme in Part 2, Tab 3. HWBExpenditure PlanThe investment for this scheme is £5,495 million.This includes £5,182 unscheduled care.Impact of schemePlease enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits PlanPlease provide any further information about anticipated outcomes that is not captured inheadline metrics below• Single record number. The NHS number and the SWIFT ID will be aligned.• 7 Day working to support the integration schemes• Integrated patient held record and care plan• Sharing of information across organisational boundaries.• Risk stratification of the population• A public information system that is supported by all• A skilled and developed workforce to meet the challenges of the new approach.Feedback loopWhat is your approach to measuring the outcomes of this scheme, in order to understandwhat is and is not working in terms of integrated care in your area?This workstream shall report into the BCF Programme on a monthly basis.


• Single record number. The NHS number and the SWIFT ID will be aligned.• 7 Day working to support the integration schemes• Integrated patient held record and care plan• Sharing of information across organisational boundaries.• Risk stratification of the population• A public information system that is supported by all


ANNEX 2— Provider commentary

For further detail on how to use this Annex to obtain commentary from local, acuteproviders, please refer to the Technical Guidance.

Name of Health & Wellbeing Sandwell Health and WellBeing BoardBoardName of Provider organisation Sandwell and West BirminghamName of Provider CEO Toby LewisSignature (electronic or typed) Toby Lewis

For HWB to populate:Total number of 2013114 Outturn 37,137non-elective 2014115 Plan 36,416FFCEs in general 2015116 Plan 34 709& acute 14/15 Change compared to 13/14 751

outturn -

15/16 Change compared to planned 170714115 outturn -

How many non-elective admissionsis the BCF planned to prevent in 14- 015?How many non-elective admissionsis the BCF planned to prevent in 15- 170716?

For Provider to populate:

Question ResponseDo you agree with the data The Trust is committed to reducing the scale ofabove relating to the impact of hospital provision. The figures above are new tothe BCF in terms of a reduction us in the last few days and are different to thosein non-elective (general and agreed by local partners in the Midland

1~ acute) admissions in 15116 Metropolitan Business Case and embedded incompared to planned 14/15 five year plans. We are committed to working asoutturn? a partnership to achieve the reduction and will

work through the projects suggested in this planto_understand_their_likely_impact_timeline.

If you answered ‘no’ to Q.2 We strongly suspect that the additional changesabove, please explain why you set out above would take to late summer 2015do not agree with the projected to implement. We will work with partners as weimpact? prepare the ABC for Midland Metropolitan and

the downside case requested to ensure revised

2. but continued congruence.

We think that the intermediate care positionoutlined in the document merits restatement.The Midland Met Business Case to which areparties are signatories envisages a quadruplingof Trust_provided_intermediate_care_from_the


3.

Can you confirm that you haveconsidered the resultantimplications on servicesprovided by your organisation?

current base. This is not inconsistent with thehealth and social care rationalisation describedbut could become so unless a managedtransition path is agreed between stakeholders.The Trust has just successfully bid to providewinter intermediate care for the partners.We are happy to work through with partners how

this change can be accomplished and how we canensure that we do not end up with a double bill forcommissioners. This will need to be based oncommissioning non-acute care throughpartnerships including the Trust and its staff if weare not to waste redundancy resources or createstranded costs.

We believe that the significantly revisedgovernance model for RCRH and BCE outlinedherein would assist with that, as would a singleapproach across the natural geography of SWB,aided by a distinct section 75 agreement forLadywood and Perry Barr.


c) please provide details of the management and oversight ......stakeholder plan monitored weekly...

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