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Rochdale Better Care Fund

Plan 2016/17

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PLAN DETAILS a) Summary of Plan

Local Authority Rochdale

Clinical Commissioning Groups Heywood Middleton and Rochdale

Date agreed at Integrated Commissioning Board:

12th April 2016

Date agreed at Health and Well-Being Board: To be confirmed

Date submitted: 21st March 2016

Total agreed value of pooled budget: 2016/17

£18,096,240

Sign Off and Approval

Signed on behalf of the CCG NHS Heywood Middleton and Rochdale CCG

By Chief Officer Simon Wootton

Signature

Date

Signed on behalf of the Council Rochdale Metropolitan Borough Council

By Director of Adult Social Care Sheila Downey

Signature

Date

Signed on behalf of the Clinical Commissioning Group NHS Heywood Middleton and Rochdale CCG

By Chair of CCG Dr Chris Duffy

Signature

Date

Signed on behalf of the Health and Wellbeing Board Rochdale Health and Well Being Board

By Chair of Health and Wellbeing Board Cllr Janet Elmsby

Signature

Date

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1. The local Vision for Health and Social Care Services

Our vision for health and social care and wellbeing by 2021 is set out in Rochdale GM

Devolution Locality Plan ‘Co-operating for better Health and Wellbeing: A plan for 2016-21.

Section 1.3 Where we want to be.

In order to achieve our vision we will prioritise the following:

1. Extending lifestyle and behaviour change programmes – aiming to have an impact at

the earliest possible time.

2. Strengthening community engagements and ownership of health and wellbeing,

building more opportunities for community and peer support, developing new

solutions and support mechanisms alongside public services.

3. Growing early years and early intervention support, targeting children and adults at

risk before problems take root.

4. Extending local mental health and wellbeing services, with individuals and community

groups becoming a strong part of the support available.

5. Integrated the commissioning of health, care and wellbeing so that services are put in

place to meet the needs of the person.

To achieve this transformation we will pool resources and jointly commission services across

health and social care, concentrating on the needs of the whole person in the design of

services, using co-production as our default way of working.

Our new models of care and support focus investment in new ways of supporting people,

placing greater emphasis on self-care, peer support, prevention, screening and informed and

shared decision making.

By doing the above, we believe this will reduce demand for planned and emergency health

and care services as more people choose more solutions closer to home, or choose to

manage their health care conditions in a different way.

2. An evidence base supporting the case for change

Please refer to Rochdale Borough Locality Plan, Section 1.2 Where we are now and section

1.2.1 -The case for change describes the opportunities to improve quality and reduce costs.

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3. A coordinated and integration plan of action for delivering that change

Rochdale Integrated Commissioning Board was set up in October 2015 as part of the

revised Governance arrangements. This Board received monthly assurance and updates on

the BCF progress and achievement of the targets during 2015/16. The actions and reports

were then submitted to the Health and Wellbeing Board as the statutory board for

responsibility.

There are a number of Better Care Fund work streams that were set up in the first year of

the plan. The Integrated Care Steering Group (meets bi-weekly), BCF performance, finance

and activity and the Integrated Care Record task and finish group that meets monthly. It is

expected that these groups will remain in place in some form to ensure delivery of the

requirements of the BCF and will report within the new governance arrangements proposed

within the Rochdale locality plan.

The Integrated Commissioning Board will oversee the delivery of the GM Rochdale locality

plan as set out in Section 2.1.4 Governance and programme management.

A section 75 agreement is already in place and this will be revised and updated in line with

the BCF budget and plan for 2016/17.

4.0 A clear articulation of how are plan meets each national condition

4.1 Plans to be agreed jointly

The Better Care Fund planning 2016/17 has been presented to the Integrated

Commissioning Board whose membership consists of Local Authority, CCG and Public

Health representation with Governing Body members and Cabinet portfolio holders.

4.2 A demonstration of how the area will maintain the provision of social care services

in 16/17

Local adult social care services will continue to be supported within the same manner as

15/16 via the same allocation £8.217m funded from the CCG minimum allocation.

4.3 Delivery of 7 day services across health and social care to prevent unnecessary

admissions

Rochdale has committed to providing 7 day services through its newly commissioned models of care. The new Intermediate Tier of Care service, largest scheme of the Better Care Fund in 2015, mobilised on the 1st September 2015. This has already demonstrated an impact in improved patient outcomes and length of stay.

This new Intermediate tier service is already a fully integrated health and social care service that is delivering demonstrable and significant results, with a single vision, operating model and outcomes. The new model has increased the social care packages of care to allow enhanced support up to 4 times a day enabling discharges late afternoon.

Rochdale has also undertaken a competitive tender process, our community neighbourhood healthcare services known as Integrated Neighbourhood Teams which is due to go live 16th May 2016. This will also be delivered through a provider partnership led by Pennine Acute Hospitals, Integrated Community Division.

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RAID services are commissioned 24/7 in A&E departments and older people inpatients service which also enables 7 day access and discharge arrangements.

7 day extended access to primary care services went live in Rochdale in December 2015. Section 2.5 of the Rochdale Locality Plan, describes the new Primary Care service model which will include the development of integrated health and social care hubs across our Borough. 4.4 Better data sharing between Health and Social Care

During 2015/16 Rochdale Health and Social Care were exploring the implementation of the Integrated Care Record (ICR) locally and as part of the North East Sector Integrated Care Record project. Across Greater Manchester Rochdale, Oldham and Bury were the only local CCGs that haven’t yet established an integrated care record offer. The work on the ICR has been on-going for some 18 months now and a decision has now been reached. This is the only national requirement that Rochdale Health and Wellbeing Board constantly submitted a ‘working towards’ response during BCF 2015/16. Rochdale is 97% complaint in use of the NHS number as the primary identifier. Rochdale has opted for the same model as Wigan CCG and LA which is the Medical Interoperable Gateway (MIG) solution. This is a local and North East Sector project and the solution is fully interoperable with partners across primary care , community, out of hours, hospital, local authority and the ambulance services. The chosen solution is also compatible with any GM solution proposed as part of the Greater Manchester Devolution.

The MIG (Medical Interoperability Gateway) has been decided upon from working across

Greater Manchester and taking learning and best practice from other HWBBs. The support

will be delivered by Healthcare Gateway who will integrate data derived from disparate

Consortium feeder systems and present relevant information in the format of a shared record

view.

There will be 3 stages to this work:

The MIG will allow secure and easy access to other partner organisations going forward to

share care

1) A local focus on collaboration with Rochdale Local Authority – this will involve a Read-

Only view of data being passed between GP and LA systems. Stage 1 will be led by an

Integrated Care project team.

2) A North East Sector focus to consume and share data from Oldham GP’s\LA, Bury

GP’s\LA, Pennine Acute, Pennine Care, BARDOC and Go-To-Doc. Stage 2 is currently in

planning stages.

3) A Greater Manchester collaboration – the MIG will share data into any solution put

forward across GM.

The data sharing agreements have been managed and controlled by the North East Sector IG and IMT working groups and have been signed off by the Local Medical Committee and the Solicitors. Once all these have been completed the anticipated ‘launch date for the MIG is expected June 2016.

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The Greater Manchester Combined Authority and partners (GM) plan to establish a GM wide transformational data sharing capability across public services. In line with the Health and Social Care integration strategy, which has made information sharing its top priority, GM recognises that data sharing is a key pillar to enable the transformation of public services. Data sharing will enable the provision of more integrated, proactive, timely and tailored services to individuals, improving their experience and well-being and supporting more effective and targeted management of GM’s resources: delivering savings, efficiencies, and improved outcomes. GM’s data sharing vision: To create value and insight across GM: supporting improved and more efficient services and improved outcomes for GM and residents, by breaking down information silos and barriers to sharing data, will support GM’s wider vision to be a leading example of efficient integrated public services, establishing GM as a truly connected city and region and a great place to live and work.

GM’s vision is to be at the forefront of data innovation and collaborative working across UK public services. The deliverables outlined in section 4 will be transferrable to other councils and in addition, the technology platforms and user/ resident portals which will form the later deliverables of the programme can also be re-used. This work will support the continued development of legislation around data sharing, providing practical guidance and robust data security platforms that enables a more appropriate balance between data privacy and data sharing. 5.0 An agreed approach to financial risk sharing and contingency

The CCG and LA have both agreed that there is no risk share agreement. The risk-share arrangement in 2015/16 related to the successful procurement and mobilisation of the Intermediate Tier service. 6.0 Joint approach to assessments and care planning (accountable professional)

Multi- disciplinary team (MDT) meetings are already in existence across Heywood Middleton & Rochdale GP practices and are the centre of providing local integration with health and social care. The newly commissioned integrated health and social care teams will mobilise 16th May and there will be a process in place to agree a lead professional as part of the joint review and joint planning of identified patients to support the reduction in unnecessary admissions to hospital by improving preventative clinical care and managing complex conditions. In addition to the above, in future all people over 75 will have a named GP, funded through the CCG development programme. This will allocate additional funding for all older people in the borough, and where relevant the GP will take the role as lead professional in coordinating their care. This will particularly be the case where older people have high level needs and/or are identified as being particularly at risk of hospitalisation. The MDT meeting provides a forum in which the integrated teams can engage in the joint process to assess risk and plan care but, as with identifying risk, the team members can initiate a discussion at any time. Patients with a high or escalating risk of admission are reviewed, and an MDT case management plan is developed and mobilised. Patients identified by this process are admitted onto the caseload or virtual ward, with their needs fully assessed and reviewed as part of MDT meetings until they are stepped down to the most appropriate level of care within the wider integrated health and social care team.

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All patients are allocated a named care co-ordinator at MDT meetings, who is accountable for ensuring that the care plan and agreed interventions are delivered by the various team members. This person could be any of the MDT members, depending on the patient’s primary needs. While the GP remains medically accountable for all patients identified in a primary or community care setting, the GP is currently rarely the named care co-ordinator, as it I not always practicable to oversee multiple and complex interventions from a wide range of people. The model of the integrated care team includes a voluntary sector worker to both assess needs for support from the third sector, as well as contributing to holistic care planning and provision of low-level support as appropriate. Team members will liaise with wider community teams, for example with mainstream mental health services, so that the most appropriate specialist support and advice can link with the integrated team care coordinator. The integrated team will allocate a lead professional to ensure that all care planning is patient-centred and co-ordinated with all professionals involved. The integrated care teams, and in particular the mental health nurses in the teams, have established links with hospital-based mental health services as well as community based teams like mental health intermediate care teams and community dementia liaison services to facilitate seamless support for people with mental health problems. Rochdale currently has the Proactive Care programme in place across all GP practices have (Unplanned Admissions Enhanced Service). This enhanced service is designed to help reduce avoidable unplanned admissions by improving services for vulnerable patients and those with complex physical or mental health needs, who are at high risk of hospital admission or re-admission. This programme will be embedded in the new models of primary care in 2016/17 as set out in the locality plan in 2016/17.

6.0 Agreement on the consequential impact on the providers

The lead provider of the Intermediate Tier is the local acute trust community health and

social care division. Through the activity and contract reporting the partnership is able to use

this evidence base internally to influence the commissioning and contracting discussions on

the acute contract activity with the Trust. These discussions have already been factored into

the 16/17 planning round.

7.0 Agreement to invest in NHS Commissioned out of hospital services, or retained

pending release as part of the local risk share

The Intermediate Tier service is commissioned on an outcome based incentivised contract

for 5 years on a 3 + 2 year basis. The new model has already demonstrated a reduction in

admissions in the first quarter September 2015- December 2015. Please refer to the

Rochdale Borough locality plan Section 2.1 page 38 – Case Study, New Integrated

Intermediate Tier services.

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8.0 Agreement on local action plan to reduce DTOC and improve patient flow

High Impact Change Model – Managing Transfers of Care Heywood, Middleton, Rochdale Economy

Impact Change Where are you What do you need to do When will it be done by

How will you know it is successful

Early Discharge Planning

Currently inconsistent application of Expected Date of Discharge, discharge planning a reporting amongst teams across NES

Strengthen training with

colleagues to achieve

consistent approach.

Adopt consistent reporting

mechanisms across all site

including MH trusts

Quick Word approach – Social

worker face to face screening

on wards to assess situation

before referral – pilot at FGH

indicated reduction in referrals

and thus reduction in delays

through increased capacity in

team

March 2017 Reduced Length of Stay

Improvement against 4 hour target

Systems to Monitor Patient flow

Inconsistent across PAHT Sites, although Patient Tracker being piloted at Fairfield General Site.

standardised patient tracker

systems across all sites and

ideally the wider system

Ambulatory Care development

across all sites

Develop transitional pathway

March 2017 Improvement against 4 hour target

Reduced Data errors in reporting and wasted capacity resulting from this

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for patients to get out of acute

beds into community resource

(not rehab potential type

patients ie IMC) just ready to

go home but waiting in acute

beds

Acute – review of key policies

at PAHT including;

bed management,

site management and

escalation

Multi-Disciplinary Multi-Agency Discharge Teams (Including Voluntary and Community sector)

Co-location of health and

social care teams at

Rochdale Infirmary.

Variable levels of resource

between hospital site and

often impacted by varying

levels of demand at each

site.

Increased level of trust in

system between teams

regarding transfer of care

and social work and re-

ablement services

Voluntary and community

sector engage in integrated

capacity and demand analysis

of current state and future

state models

Enhance governance and

engagement of locality

meetings to engage wider

system and more robustly

mange SRG schemes

Single line management of

MDT discharge teams – in

progress through current

developments 1st June 2016

March 2017 1st June 2016

Improvement against 4 hour target

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care collaborative

Weekly operational group

meetings to monitor system

pressure and take remedial

action

Home First Discharge to Assess

Not very well established in

Rochdale Borough – the

nearest is STARS

Integrated Intermediate Tier of Services improving patient flow out of hospital in a timely manner

Develop transitional pathway

to enable discharge to assess

from acute site. Recent work

highlights need for this in our

locality

March 2017 Reduced Length of Stay

Reduced delays

Seven-Day Services

7 day services in place

across the system, although

not all 24 hours a day but

covered through extended

hours to 8pm

Integrated neighbourhood teams to go live in July 2016 to improve system wide support over 7 days and link into already extended integrated intermediate care offer

July 2016 Weekend discharges

Reduced delays at weekends

Trusted Assessors

Rapid Process for

Improvement work includes

project to develop Trusted

Assessor pilot with NES

Colleagues – currently

piloting on ROI site.

Resources still an issue to

Engage and support the development of this work to ensure our locality need is reflected in final definition of trusted assessor.

March 2017 Reduced delays

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deliver

Focus on Choice

Locally we have limited choice of provider in MH care market and high number of providers seeking financial top up to accept packages, which reduces choice for cohort of patients requiring residential nursing home care.

work with commissioners to develop market in order to reduce local challenges

March 2017 An increase in available providers in the market

Enhancing Health in Care homes

Nursing and GP teams

aligned to care home and all

have community matrons

linked

Quality and safeguarding –

Leg ulcer pathway in place

and nationally recognised as

reducing prevalence and

admissions resulting from

leg ulcers

Yellow Care Plans in place

for patients with long term

conditions to enable quick

understanding for

ambulance crews and

clinical teams on patient’s

status.

Carers night sitting service in development Partnership work to be developed with CAU at Rochdale infirmary to have timed visits for patients in a move to more managed care of conditions rather than reacting through Emergency Clinics A review of contracts for care

homes to include criteria to

accept weekend referrals

Review top up arrangements

with providers

Develop market as part of

integrated offer

March 2017 Reduction in admissions from care homes

Updated contracts to include weekend acceptance criteria

Reduced Length of Stay

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Explore possible shared care

management of staff with care

homes

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During 2016, an Analysis of the volume of patients with a Heywood Middleton and Rochdale

address declared medically fit for discharge (MFFD) across the 4 Pennine Acute Hospitals

sites was completed for a 4 week period.

Rochdale Health and Social Care system has experienced unprecedented pressures on

service demand since November 2014. This has resulted in a failure to achieve the

Emergency Access target of 95% for all patients to be seen, treated and discharged from

Accident and Emergency (A&E) within four hours, both across the country and within the

Pennine Acute footprint.

There is, however, a much larger group of patients who also occupy acute hospital beds and

are described as Medically Fit for Discharge (MFFD). It is thought that, across the Pennine

Acute footprint, there are up to 150 patients per day who are MFFD. What became clear

was that the sites across the Pennine Acute footprint do not have a consistent approach to

the recording of MFFD patients.

For example, The Royal Oldham Hospital only reported a very small number of MFFD

patients in the following three categories only:

1.1. CHC

1.2. Residential Care

1.3. Family Choice

MFFD cases are reported daily and the analysis completed was a midweek point of

Wednesday over four consecutive weeks from 27th January 2016 to 17th February 2016.

HMR Patients with an MFFD Status

The following graphs show the position across all for sites (FGH – Fairfield General Hospital,

ROH – Royal Oldham Hospital, NMGH – North Manchester General Hospital, RI – Rochdale

Infirmary), across a four week period. The final graph shows totals for all four sites for the

period.

27th January 2016:

0123456789

FGH

ROH

NMGH

RI

Trend

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3rd February 2016:

10th February 2016

17th February 2016

0

2

4

6

8

10

12

FGH

ROH

NMGH

RI

Trend

0

2

4

6

8

10

FGH

ROH

NMGH

RI

Trend

0

2

4

6

8

10

FGH

ROH

NMGH

RI

Trend

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Totals for the Four Week Period:

The breakdown was as

- Continuing Health Care Process (CHC) (38)

- Family Choice (18)

- Social Work Assessment (11)

- Residential Care (10)

- Occupational Therapy/Physiotherapy (10)

- Care Packages (9).

- MCA/Best Interest (10)

- Equipment (5)

- Mental Health Specialist Assessments (RAID Team) (3)

- Intermediate Care (3)

- Learning Disability Funding (1).

There is a co-ordinated effort to reduce the number of medically optimised patients waiting

for discharge across the 4 Pennine Acute Trust hospital sites. This work has been driven by

a rapid process for improvement programme of work which was initiated and supported by

the Trust Development Agency (TDA). This has executive agreement from all partners and

has already set ambitious targets. This work is a key priority during 2016/17 for the North

East Sector.

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10152025303540

FGH

ROH

NMGH

RI

TOTALS

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Scheme Level Spending Plan

2016/17 Schemes Summary Description Investment £000

Intermediate Tier Service

- Year 2

The ITS mobilised 1st September 2015. This was a lead provider collaborative model

commissioned on an outcomes based model.

£5,933,500

Re-ablement including

Telecare, Dementia and

Equipment

Co-produce with patients, service users, public and voluntary and community sector

improvements in self-care. Including care navigators, advanced assistive technology,

patient held records and the development of Dementia Friendly Communities.

£783,233

Carers

The Carers re-commissioning commenced in September 2015 with a patient

satisfaction survey. The findings have identified the top 5 areas of concern for Carers

and their families. This work will be modelled into the Carer’s service specification

2016/17 and procurement process due to be completed in summer 2016. This is

aligned to the ‘Living well with Dementia’ pathway redesign work that is also in

progress as part of the Rochdale Locality Plan.

Continue to develop carer specific support – including carers breaks.

£478,767

Disabled Facilities Grant Disabled Facilities Grant Equipment and adaptations are a key enabler to maintaining

independence we will work with Districts to consider future actions required in

delivering DFG.

£2,046,740

Implementation of the

Care Act

Carers assessments and support services; Safeguarding Adults Boards; and national

eligibility.

£637,000

Protecting Social Care

Services

Ensure existing services commissioned under 256 agreements are aligned to the

objectives of transforming integrated working and continue to protect social care.

£8,217,000

TOTAL £18,096,240

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National Metrics

Metrics Definitions

Permanent admissions to residential and care homes

Reduction in admissions based on rate of Effectiveness of reablement – those 65+ still at home 91 days after discharge.

Delayed transfers of care

Agreed 3% decrease on 14/15 baseline. This is still challenging

Emergency admissions 3.8% reduction. Aligned with CCG planning submission 17th March 2016.

Patient / service user experience

No of Carers who receive a service or information advice and guidance as a minimum per 100,000 population (aged 18+)

Local Metric

Now the ITS model is in its second quarter of delivery, this performance metric will be one of the outcome measures that is incentivised in the contract.