Written Evidence Submitted by South West England to the Communities and Local Government Select Committee Inquiry Into Adult Social Care August 2016

Home , Plymouth, Poole, South Gloucestershire

Written evidence submitted by South West England to the Communities and Local Government Select Committee Inquiry into Adult Social Care August 2016

About the South West This response is submitted on behalf of South West England. South West England is one of the nine regions of England. It is the largest in area covering 9,200 square miles and includes the counties of Devon, Dorset, Gloucestershire, Somerset, and the unitary authorities of the Isles of Scilly, Bath and North East Somerset, Bristol, South Gloucestershire, Swindon, North Somerset, Bournemouth, Poole, Plymouth, Wiltshire, Torbay and Cornwall.

The South West (SW) has a population of 5.4 million citizens and its population is older than the England average. The dependency ratio in the South West is higher than that seen in England where there are nearly 4 people of working age to every person of retirement age. In the SW there are on average only 3 people of working age per person of retirement age. These numbers mask significant variation across the region with some larger urban areas having younger average populations and conversely certain rural areas with a significantly older population that than the SW average. Sidmouth, for example, is Devon’s oldest town with 37.8 % of its population aged 65 or over and 8% aged 85 or over.1

For 2014-15 our combined Adult Social Care budget was £ 1397.5 million. This represents 22.1% of the 16 councils’ budgets and we collectively supported 287,961 people. Again these numbers mask variations with some Local Authorities (LAs) in the region spending considerably more than the average. Dorset County Council for example has an approved spend on Adult Social Care in 2016/17 which represents 41.8% of its total budget.

The context within which the LAs in the SW are operating is a rapidly changing Health and Social Care landscape where questions around devolution and LAs’ role in Sustainable Transformation Plans are being considered throughout the region.

1. Funding

Implementation of the Care Act and the 2015 Spending Review

The funding current available for Adult Social Care is insufficient. In the SW duties under the Care Act 2014 are being met, however councils across the region are struggling to manage demand within planned budgets. Councils are furthermore finding it difficult to make the necessary investments for a transformative shift to new models of care which will be crucial in terms of managing demand in the future. Demographic pressures are mounting and demand for complex Social Care is increasing. The introduction of the National Living Wage (NLW) and changes to the Deprivation of Liberty Safeguarding (DOLS) assessments have added significant new cost pressures. To give an example of the scale of these new cost pressures the Supreme Court Ruling on DOLS has in Poole resulted in an increase in referrals of 800 % and similarly in Dorset the ruling saw referrals increase from 228 to 3206 referrals in one year.

At present 8 out of the 16 councils in the SW are ‘not very confident’ or ‘not at all confident’ that there is sufficient money within their budget for implementation of the Care Act in 2016- 17. When asked about their confidence in future budget years 80% indicate that they are not confident beyond 2016/172. The experience of the SW councils mirrors the national pessimism around budget sufficiency, which was outlined in the 2016 ADASS Budget Survey.

1 Source: Devon Joint Health & Wellbeing Strategy and 2011 Census 2 LGA Care Act Stocktake 6 Survey, July 2016.

The 2015 Spending Review and Local Government Finance Settlement introduced a possibility for local authorities to levy a Social Care precept and in 2016 all the SW LAs have done so. While this additional funding is welcomed, our experience is that the additional funding from the precept has been less than anticipated by the government as average salaries and council tax bands are relatively low in the SW. Furthermore, the additional funding from the precept has been more than offset by increased cost pressures including those arising from the introduction of the NLW. In Devon for example, the precept has raised £6.5 million in 2016/17 while the cost to the LA of the NLW is estimated to be £ 7.3 million. The announcements made around additional funding through the Better Care Fund (BCF) are likewise welcomed, however, more detail is needed to confirm that it is indeed new money being made available to local authorities. Timing is also an issue as the additional BCF funding is not set to start trickling through to LAs before 2017/18 and the bulk of this new funding will not be available until 2018/19 and 2019/20.

Overall we are therefore of the opinion that the 2015 Spending Review and Local Government Finance Settlement does not deliver enough funding for Adult Social Care and that the additional BCF funding will be made available too late in the Spending Review period given that councils are having to deal with demand and financial pressures at present. Looking further ahead the announcements around the government grant reduction and increased reliance on business rate retention also gives cause for concern, as the scope for generating sufficient funds from the business rate in some parts of the SW will be limited.

Transformation for the future The health and care system in the SW is financially unsustainable without transformational change, and we see it as a key task to reshape our services from encouraging dependence to promoting and enabling independence. We therefore see an increased focus on prevention as the most important way of increasing independence and limiting the need for more expensive ongoing care. However, as budgets reduce it becomes harder for councils to manage the tension between prioritising statutory duties towards those with the greatest needs and investing in services that will prevent and reduce future needs. The ADASS Budget Survey confirms that spend on prevention has reduced greatly in recent years 3. It is crucial that additional resources will be made available to LAs to invest in future service improvements and changed methods of working which over the medium to long term will deliver lower costs.

In addition, in order for us to successfully reshape our services towards new models of care expectations need to shift. Currently the expectations of people, staff and politicians at all levels have not changed, however the funding available to health and care services significantly has. While LAs play an important role in reshaping expectations, the Government needs to set the tone at a national level and show leadership in terms of explaining its vision for the future of Health and Social Care.

Integration of Health and Social Care Health and Adult Social Care are intrinsically linked and must be seen as a totality. There is a risk that under the strain of current cost pressures experienced in the Health and Social Care system attempts are made to “shift the problem” between councils and the NHS as each part of the system tries to deal with immediate budget shortages. This is not a useful approach and issues such as hospital discharge and closure of acute and community hospital beds must be addressed in a whole systems way and with a long term perspective. In order for this to be possible adequate funding needs to be made available for both Health and Social Care, and the current disparate premise upon which funding is allocated to Health (patient based) and Social Care (place based) needs to be aligned and made consistent.

At a local level the NHS and LAs must come together and collectively plan for the future and while the Sustainable Transformation Plans (STPs) are a potential vehicle for this, it is important that LAs are seen as an equal partner in the STP process and not just a stakeholder. In some parts of the region there are concerns that the savings resulting from the STP work will be entirely absorbed by the NHS to offset spending pressures. This does not

3 ADASS Budget Survey 2016

2 add up from a Social Care perspective, as many of the changes introduced through the STP work will have adverse budget implications for Social Care. It is imperative that NHS partners and LAs work collaborate together through the STPs to promote new community resilience models of care. We therefore strongly encourage that LAs be recognised as an equal partner in the STPs across all local areas. Health and Social Care need to be understood as a whole system also in terms of funding and cost saving initiatives.

2. Carers

Carers play a hugely important role in the lives of people needing care and support and in the very functioning of our health and care economy. In the SW we recognise this and support the rights the Care Act 2014 introduced for carers.

Estimates based on the 2011 Census and Carers UK methodology from 2015 calculate that the South West has over 570,000 people providing over 11.5 million hours a week of unpaid care. The actual numbers are likely to be higher given that unpaid carers do not always identify themselves as a carer; therefore there is potentially significant unmet need in the region that we are required to meet as set out in the Care Act.

Across the region there are many good examples of how we work to support carers. In South Gloucestershire the ‘funnel’ for Carers’ assessments has been inverted so that all initial assessments are conducted by the Carers’ Support Centre with referrals into the Council where a full assessment is recommended. In Swindon the Borough Council has invested to fund two extra posts to undertake assessments with the aim of: • identify the carer early on during the ‘hospital episode’ • provide carers with the opportunity to play an active role in discharge planning. • reduce the number of inappropriate discharges and possible re admissions. • ensure carers are aware of their right to a Carers Assessment.

It is vitally important that we are sufficiently funded not only to be able to identify carers across the region but also in order to support them to continue in their caring role and their life beyond caring. We strive to support carers through good quality assessments and care and support planning alongside good quality and accessible prevention, respite and replacement care services that prevent carer burn-out. The consequence of not doing this is more commissioned care for the cared for, increased costs for authorities and services that are reacting in a time of crisis rather than timely and planned prevention and support.

We would also encourage the Government to support carers more pro-actively by working with employers to enable carers to have flexible arrangements when required, and, through the Department for Work and Pensions (DWP), do more to enable former carers to get back into the workforce, after a period of what in some instances is a full time role as carer over many years. This would support the overall economy by maximising the potential labour force and ensure carers are less isolated.

3. Commissioning and market oversight

The Care Act 2014 introduced new duties on local authorities to facilitate a vibrant, diverse and sustainable market for high quality care and support in their area of the benefit of their whole local population, regardless of how the services are funded.

Workforce A key challenge in terms of market oversight is the sufficiency and quality of the care workforce. As a region it is a challenge to attract and retain a sufficiently qualified and sufficient workforce to the area. This is particularly the case with independent and voluntary sector care staff. It is increasingly difficult for providers to recruit care assistants, even with the national living wage offering greater remuneration than in previous years. High housing costs compared to average earnings in the SW as well as relatively low levels of unemployment in the region are factors negatively impacting this. Labour market cost and

3 sufficiency issues, including a shortage of frontline care workers, qualified nurses and social workers, as well as the inflationary effect of the National Living Wage are driving up costs in the SW and putting the viability of a number of providers under pressure. Our previous comments about seeing Health and Social Care as intrinsically linked very much apply here too because much of the labour force is shared across Health and Social Care.

We would welcome national initiatives to raise the profile of the health and social profession. This would enable local areas to devise and co-ordinate recruitment pathways within the framework of such a national workforce strategy.

An example of these workforce challenges can be found in Devon where there have been a number of closures or re-registrations of nursing homes, partly in response to the difficulty of securing qualified nurses but also as a result of the more demanding regulatory environment and cost pressures. The prices paid for nursing home placements has been on an upward trajectory beyond inflation rises for some time and this is placing severe stress on local authority and NHS budgets. In Devon the Proud to Care campaign has been launched over the last 18 months to attract people into the care sector.

Market sufficiency Another key challenge experienced in the SW is sufficiency. This is widespread – in cities and towns as well as in rural areas, where it is often especially difficult. The workforce issues mentioned above contribute to this as does the availability of the right accommodation and support. In the SW inflated house prises and affordability of accommodation within the rental sector are issues of concern.

Sufficiency is an issue for specialised markets such as the Dementia, Mental Health and Learning Disability markets. These are examples of markets that still need to be shaped as they are risk averse and meeting the needs of individuals can be difficult and expensive. It is crucial that a consistent focus on choice, control and independence for the individual is embedded at a national and local level, and in the region we are committed to working with providers to shift the culture in these markets to a strength-based approach that focuses on promoting independence for individuals. One future approach to specialised provider markets may be, through devolution, to consider commissioning for a bigger footprint than the current LA footprints.

Within the SW region we are addressing market sufficiency issues and we are working to develop new models of commissioning to strengthen integrated commissioning between the NHS and LAs. Across the SW we have a positive relationship with CQC and work with them in a spirit of no surprises to improve quality with providers. We also see an increased use of outcome-based commissioning as part of the solution so that we can free providers to meet need as flexibly as possible. In Dorset a radical approach to market-shaping has been introduced by setting up a Dynamic Purchasing System (DPS) to produce services for people with learning disabilities and long-term mental health problems. The DPS is essentially an electronic framework and brokerage portal. The system is based upon a pure outcome based commissioning model rather than a traditional “time and task” approach.

We seek to continue to drive improvements for the people we serve in the SW in spite of the challenges described above. In this respect we would like to stress the importance of a consistent commitment and narrative at the national level to shifting to progressive models of care that focus on promoting independence, choice and control for the individual. It is crucial that we at a local level are supported in our endeavours to shift to new models of care by a consistent national policy framework.

4. New ways of working

The LAs within the SW region have put forward a number of examples of innovative approaches that we would like to share with the Committee. These examples are listed in annexe 1. From these examples it is clear that one size does not fit all and that there is a great variety of solutions being tested across the SW region. Going forward it will be important that flexibility to innovate locally is retained. LAs play a key role in terms of producing local solutions which work in their particular place context. While innovation historically has taken place both within LAs and NHS partners, going forward, as we seek to increasingly integrate Health and Social Care, it will be important to ensure that innovation doesn’t happen in organisational silos but rather happens across the whole system.

Similarly, it is important to stress that adequate funding is needed if local innovation is to continue. In making this submission we wanted to show the diverse ways that LA are using to make current funding go further. However, innovation alone will not be the solution to the current funding shortfall. While some innovative solutions over a period of time may be able to generate efficiency savings (invest to save), there needs to be funds available for initial investments in order for this to be feasible. The comments we have made elsewhere in this document re. funding available for prevention is a particular case in point.

Annexe 1: Best Practise Examples from the South West

Regionally

Whilst at an early stage there is a formative approach to a regional campaign ‘Proud to Care’ which will raise the profile of care across social and health care roles; public, private and volunteering roles. Born out of a programme in Devon and now working with a wide range of partners through ADASS SW this collaborative initiative will lead to increased efficiencies in recruitment with improved and sustainable spending creating a positive change in the perception and culture of care in the South West. Care as a career will be considered by new cohorts of the population, young and older, with the rewards of self-esteem and career progression through innovative contracts and services and transferrable skills which will support the demand for care in its many forms.

Torbay

Torbay has long been committed to enablement and independent living.

Building on the reablement work of the likes of Dorset and the outcomes based approach of Wiltshire as well as the community sector work in Plymouth and Cornwall, Torbay developed the Living Well@Home programme.

The underlying principle is Wellbeing developed through a sense of purpose for both the cared for and the carers, informal and paid. The coordination of domiciliary care and expanding it to include care and support has enabled an approach which has increased care capacity with people joining the care workforce that have not previously considered it as employment or a career option. With an increasingly skilled workforce and improved data gathering prevention and a wider range of tasks can be undertaken in the community in a cost efficient way. Through this approach of care delivered closer to home, care wages can be increased and overall system costs reduced.

The principles of the successful Buurtzog model are being piloted to contribute to the development of the programme, community networks and outcomes based contracting.

Devon

Devon is committed to ensuring that Health and Social Care is increasingly integrated, and is using joint commissioning as a way forward.

The Living Well at Home contract for regulated personal care Regulated personal care is crucial to the most vulnerable people, 4100 of whom are supported in their own homes in Devon every week. This is over 2 million hours of care delivered every year. The two NHS Clinical Commissioning Groups operating in Devon and Devon County Council have jointly commissioned a new contract for regulated personal care in order to address some of the challenges facing this market.

Across the county, Social Care providers are finding it extremely difficult to recruit and retain a skilled workforce and the Proud to Care advertising campaign together with our new contract aims to resolve that. The new contract has secured three Primary Contractors to work with the commissioners as strategic partners and to manage the supply chain. The contract has had significant additional investment, not least to increase the rewards and other training and support to paid care workers.

Demand pressures continue to grow, especially in the personal care sector where we have experienced a growth of 10.5% in the last two years and 6.5% in the last year. The market has responded to meet this need but is unable to meet it all. The challenge for our Living Well

6 at Home contract is to secure as much efficiency from the extant labour force as well as to attract new entrants.

Our ambition is that the new contract will:

 deliver personalised care with dignity and respect, in which the service user and their families and informal carers take an active part in shaping how that service is delivered to them.  secure and retain a high quality workforce, which is well rewarded and is paid not just for contact time but for time spent travelling and for any other non - contact time - at least to the level of the National Minimum Wage (NMW)/ National Living Wage (NLW)  To build a career structure for that paid workforce which is attractive to enter as a career of choice in the context of a competitive labour market.

South Gloucestershire

South Gloucestershire is committed to working across boundaries to promote quality, independence and consistency.

South Gloucestershire has

i) A Joint procurement of Extra Care Housing across LA Boundaries - we have worked with Bristol to commission a 261 Extra Care Housing Scheme, predominantly leasehold but with 41 affordable rent properties for South Glos and 40 for Bristol. The site abuts the LAs’ common boundary. Extra Care delivers a better quality housing conditions where care and support can be delivered more cost effectively and reduce the prevalence of admissions into care homes. ii) Discharge to Assess – Together with NHS partners have changed from Assess to Discharge to Discharge to Assess in hospitals. Patients leave hospital into one of 3 pathways – 1. home with appropriate intensive community health support whilst assessments are completed and services put in place; 2. To a Community Rehabilitation/Reablement bed for up to 6 weeks – with the intent of returning home and decision on permanency is taken then; and 3. Those needing CHC funded care home support and/or not suited to rehabilitation/ reablement. Since Q3 2015/16 implementation had seen reductions in assessment delays, with very few now being experienced for Pathway 1 and Pathway 2 delays almost entirely due to supply and demand of care home beds. iii) Integrated Discharge Service- forming a single virtual team in acute hospital of acute, community Health and Social Care staff to manage discharge planning process. The organisational impact is to what we now have staff from different organisations in a single team working to a set of common/shared objectives. iv) Use of ‘Just Checking’ to monitor actual activity of service users, especially those with a learning difficulty, in supported living setting to enable objective analysis of the level/frequency of care and support to be commissioned. v) Intended Pilot of Myhomehelp, an iPad-based interactive aid to enable those with dementia to remain at home for longer by providing information, prompts for activities such as medication administration or appointments, messaging facilities and a diary so the person can see where they and other are at any one time.

Bristol

Bristol is committed to working across boundaries to transform services and provide better care.

Bristol have invested in capacity across ASC in partnership with health to focus on diverting admissions away from acute services and assist with early supported discharge to reduce DToCs and excess bed days.

Better Care Other Projects 2014/15 and 2015/16

This investment covers a range of 10 projects at the front door and in the community that reduce emergency admissions by 532, with the intent of saving £1.6 million – these projects form the Performance for Pay element of better care and include schemes such as:

 Introducing a Social Care practitioner to work in ED.

 Social Care working at weekends.

 Early OT intervention to focus on preventing admissions in ED.

 Dementia support to support people to stay at home.

Preparing for Better Care 2015/16 projects

This investment of £1.4 million supports 4 projects and primarily focus on discharge:

 Expanding brokerage to work weekends and support self-funders to source care homes effectively and efficiently.

 Develop a single, trusted assessment which is a Better Care national condition.

 Training for home care providers to maximise independence, minimise care packages to free up capacity to get more people discharged.

 Increase Reablement capacity by 20%.

In October 2015, NHS England undertook a deep dive of the Better Care Transformation Programme and its links to Urgent Care which highlighted that few projects have KPIs in place to demonstrate impact. Also emergency admissions are increasing across Bristol and it was considered important to understand if the projects are effective.

The projects are monitored by the Health and Wellbeing Board and the Better Care Transformation Board.

Gloucestershire

Gloucestershire is committed to working with partners to deliver better outcomes.

Telecare Responder Service

Following a short pilot in North Cotswolds between July and September 2015, Gloucestershire Fire and Rescue (GFRS) have become the first responders to all telecare across the county using retained fire fighters.

Previously, people who were unable to offer a number of responders were declined from the service and to mitigate risk would have been placed either short or long term in a residential care home setting. Additionally, if responders were unavailable other emergency services such as ambulance or police were called out, usually resulting in an admission to hospital and longer than necessary length of stay, all avoidable costs to the public purse.

The pilot provides significant social return on investment with care home placements, ambulance, emergency admissions and hospital stays, police and fire brigade call outs avoided.

GFRS are responding to all calls, including dementia wandering, faulty telecare and other equipment, supported self-assessment and are working alongside the voluntary sector in supported hospital discharge. All contacts also result in Safe and Well visits, encompassing the top 2% risk stratification of vulnerable people.

The initiative was shortlisted for Innovation in the national Excellence in Fire and Emergency Services Awards 2015 in London.

GFRS are also one of three pilots with PHE working on reducing social isolation, falls prevention, falls and flu vaccinations.

This collaborative working across Health and Social Care has meant that the most vulnerable people are being identified and supported in their communities.

In 2016 plans are to implement multi-agency Community Risk Intervention Teams, e.g. utilising fire station facilities for mobile clinics, community equipment pick up and drop off facilities.

Bournemouth, Dorset and Poole

Bournemouth, Dorset and Poole are behind the creation of first tripartite ASC trading company Tricuro that works across the three counties. The company was created jointly by Dorset County Council and the two of Unitary Authorities of Bournemouth and Poole. This bold step has prepared the way for increased joint working and local government re- organisation.

Services provided by Tricuro services include:-

Residential services – including residential care homes and care homes with nursing Reablement services – intensive short-term home care to help people get back on their feet after illness or hospital stays Day services – support, rehabilitation and skills training for independent living, plus opportunities to socialise Shared lives – providing adult placements with self-employed host carers Care catering services – providing nutritional care advice, support, training and relief staff Oh Crumbs! – people with a disability can develop work skills and experience.

Support time and recovery – supports a recovery approach that promotes wellness, builds resilience and improves quality of life for people who experience mental health problems Training projects – employment related skills training (catering and horticulture) for people with a disability Community employment services and Coast – offering support to disabled people and people with long term health conditions to identify, obtain, and sustain employment (paid and/or voluntary).

Swindon

The Bridging Service is a dedicated service to support rapid discharge from hospital. People receive care and support within three hours of returning home from hospital. The provider is there to ‘meet and greet’ the client, and provides a continuous assessment of their needs over a six week period. During this period they enable the client to re-gain skills and independence. The service has delivered positive outcomes with some providers demonstrating 60% of the clients no longer needing a service or needing a much reduced service following their input.

Poole

The Borough of Poole has established an integrated team approach for people with long term conditions in partnership with the local NHS community trust. The teams have introduced a case-finding methodology and case co-ordinators in order to target services to those people who would benefit most from a multi-disciplinary approach. The work is underpinned by some pooled budget arrangements, an information sharing charter to support better data sharing and the emergence of a joint digital care record.

To better support early intervention and prevention, the Borough has integrated re-ablement, brokerage and intake teams into a single service. This new approach to managing Adult Social Care enquiries at the point of first contact is anticipated to reduce demand for long term services and assist with the reduction of unplanned admissions to hospital and care homes. To improve discharge performance, Borough of Poole is also working with the local acute hospital trust to develop an integrated discharge bureau which will provide health and Social Care support to people across three local authority areas. Also supporting timely discharge, Borough of Poole operates a small specialist social work team for people who fund their care and may not otherwise receive Social Care support.

Plymouth

The Plymouth Integrated Fund (Section 75 Agreement with NHS N.E.W. Devon CCG)

From 2015/16 the Council and NHS N.E.W. Devon Clinical Commissioning Group (CCG), as part of their overall transformation programme, have taken the innovative decision to create the Plymouth Integrated Fund by pooling or aligning the vast majority of the People Directorate budget and the Public Health commissioned services budget to form a fully integrated Health and Social Care commissioning budget. This has been implemented via a Section 75 Agreement under the NHS Act 2006.

The Plymouth Integrated Fund has a combined net budget of circa £482m in 2016/17 and has been established to create an integrated population based system of health and wellbeing for the city of Plymouth. Four new integrated commissioning strategies have been developed in conjunction with the NEW Devon CCG based on the 2014 Joint Strategic Needs Assessment for the city.

These strategies address the whole of the Health and Social Care system in Plymouth and therefore identify how the Plymouth Integrated Fund will be used to improve outcomes and maximise efficiency.

The two partners to the Plymouth Integrated Fund are contributing funding to these arrangements as follows:

. NHS N.E.W. Devon Clinical Commissioning Group: £346m . Plymouth City Council: £136m

The Plymouth Integrated Fund also incorporates the Better Care Fund, which is an ambitious national programme aimed at driving forwards integration between the NHS and Local Government. It creates a local single integrated budget to incentivise the NHS and Local Government to work more closely together placing wellbeing as the focus of the Health and Social Care services. For 2016/17 the funding we receive from the Better Care Fund has been confirmed as £19.351m for the two partners.

The Plymouth Integrated Fund which was created by the Section 75 Agreement is also supported by a detailed financial framework which in defines how the integrated arrangements are intended to work. The fund is further underpinned by an innovative risk capping agreement on the basis of a 77% CCG: 23% Council share of both financial benefits

and risks. This agreement limits the transfer of any over or under spends between the partners to a defined prudent maximum.

Whilst the development of the Plymouth Integrated Fund will create new opportunities to deliver improved outcomes and financial savings, it is important to recognise the existing budget pressures that exist in both separate organisations. Both organisations have developed plans to address underlying overspends in relation to the funding in the Plymouth Integrated Fund.

As part of the planned integration of Health and Social Care 171 Adult Social Care delivery staff transferred from the Council to Livewell Southwest on the 1st April 2015. Livewell Southwest is a community interest company (CIC) set up in 2011 to deliver community, physical and mental healthcare to people living in Plymouth, South Hams and West Devon. The transfer of the Adult Social Care delivery staff will, for the first time, enable a fully integrated approach to both Health and Social Care assessments for the people of Plymouth.

Integrated Health and Wellbeing

The programme has engaged with commissioning and delivery partners to establish a more collaborative, integrated and strategic approach to how the organisations commission and deliver services, with the aim of reducing costs, improving patient/service user experience and improving outcomes for residents in Plymouth. As part of this, the programme recognises the importance of investing in preventative and early intervention services in order to reduce demand on higher cost community and bed based services, particularly acute services.

Services that are in scope of the Integrated Health & Wellbeing Programme have been grouped into four strategic areas, which correspond to differing levels of need and complexity, and allow a focus on the aim of ‘investing to save’ as noted above. These four strategies are:

 Wellbeing - Universal & preventative focused services.  Community - Targeted services for those who may be at risk in the future, and services for people who need support in the community.  Enhanced & Specialist - Services people with complex needs, who cannot be supported in the community.  Children Young People & Families- Services aimed at ensuring children and young people get the best start to

The programme currently comprises three main complementary projects, which in turn comprise myriad work streams. The projects are: Integrated Commissioning, Children and Young People Services and System Enablers.

Key achievements to date:

 Launched four Integrated Commissioning Strategies and whole system action plans which are agreed with all partners to ensure the right outcomes for the city are achieved  Begun operating jointly as an integrated Commissioning Function, with a single budget co- located at Windsor House  Ensured that the new Integrated Commissioning Board is responsible for driving forward the strategies and governing the way the joined up Commissioning Function operates  Developed an integrated outcomes framework to support system monitoring  Launched our System Design Groups to implement the strategies across the whole system  Transferred our Adult Social Care Teams across to Plymouth Community Health Care (Livewell) to deliver integrated Health & Social Care provision  Launched an Integrated Hospital Discharge Team to ensure individuals get the right support to go home  Co-located Health & Social Care staff in 2 localities across the city with 2 further moves to be completed by the summer

 Set up our Local Authority Trading Company, CaterEd working to cooperative principles which will bring together local schools to provide healthy food to children across Plymouth through a sustainable and affordable service  Created On Course South West CJVC in partnership with Shekinah Mission and Plymouth YMCA to deliver adult community based learning for all residents across the City and help those seeking assistance with skills development, whatever their interest or requirements.  Redesigned our Early Help offer and launched a new Gateway Team to provide joined up access to services  Redesigned our Online Directory pages for Children, Young People and Families to deliver improved information and advice  Launched our Permanency Team to support young people in care  Redesigned our Family Support offer to ensure targeted and timely assistance is available  Worked with secondary schools to develop a consistent approach to Emotional Wellbeing support for children across the city  Begun the roll out of mobile working for frontline staff in Children’s Social Care to ensure individuals have access to real time information  Co-located staff from Douglass House to Windsor House, releasing this facility to support the One Public Estate agenda to deliver Health & Wellbeing Hubs across the city

So what is next?

 Development of the integrated commissioning structure.  Delivery of 2016/17 Commissioning Plans including the development of Health and Wellbeing Hubs  Extension of Gateway offer to widen the support for Children, Young People and Families  Remodelling of SEND services across the system to deliver a joined up approach making use of mobile working technology  Redesign of targeted support to ensure children and young people get the right help at the right time to ensure services provide early help and support during crisis  Extension of the Permanency team to widen the support for Children in Care  Work with Firmstep team to embed our digital advice and information offer currently delivered through the on line directory  Development of an improved quality assurance response for children’s services  Launch of a new multi-agency hub with partners to safeguard children across the city  Implementation of new ways of working across Children’s Social Care, which will make use of mobile working to deliver timely assessments and support for children in need  Review and remodelling of the services for Education, Learning and Skills to improve our offer to students, parents and schools across the city  Launch of a new Community Operations offer which will join together Housing, Community Youth and Community Safety services to work with partners to support the delivery of the Community Engagement Framework for the city  Review of governance arrangements to support the One System One Aim work programme

Dorset – Innovative Approaches

Market-Shaping

The Council has introduced a radical approach to market-shaping by setting up a Dynamic Purchasing System (DPS) to procure services for people with learning disabilities and long- term mental health problems. The DPS is essentially an electronic framework and brokerage portal. The system is based upon a pure outcome based commissioning model rather than a traditional “time and task“ approach.

There are three tiers, Gold, Silver and Bronze, within the DPS, representing the order of purchase. To achieve Gold status providers have to be outcomes focussed and organisational leadership has to be provided by people with lived experience and family

12 carers. Providers stay in the Gold band only if they can evidence continual improvement. The tiering system is used to shape the market by rewarding excellence and setting out a quality framework for providers to work towards.

Providers on the DPS are able to offer Individual service funds which puts the person in control of their personal budget and allows support to be more creatively designed (and can reduce the cost of support over time).

In the future all support will be delivered via a Direct Payment, Individual Service Fund or commissioned via the DPS.

The Council and its district and borough and health partners have commissioned the Dorset Accessible Homes Service which is provided by Millbrook Healthcare. This collaborative model brings together a number of services, historically operating as standalone services, such as: OT assessments, two independent living centres, telecare services, HIA and handyperson services, retail offering (self-assessment and e-commerce), Warm Homes initiatives, DFGs etc.

Holistic in design and combining a number of key preventative services, this approach creates a joined-up delivery, offering greater benefit to the community such as one assessment, one referral route and one footfall across the door. Working from a single client record, they can support needs from low level telecare right through to major adaptations and the HIA’s services are accessible and used by partners and prescribers across all three sectors.

A unique benefit realisations study has demonstrated that these interventions have already saved over £150,000 in year one, therefore reducing pressure on budgets, hospitals and acute care interventions.

Community Channel

Dorset County Council joined a consortium of private sector companies in a successful bid to InnovateUK to explore how the concept of hyperlocal information could be used to tackle social isolation amongst older people by connecting them to community resources close to them.

Participation in a InnovateUK funded project has been beneficial to Dorset County Council: it has provided great opportunities to engage with our community, to be seen to make a difference to people’s lives, for example through the project’s legacy of digital skills gained by participants and the connections made using social media with family and friends.

Nourish

Nourish replaces the old care book in the home. It is a dynamic digital care book accessible online showing all interactions and interventions with a vulnerable person.

It does this by making use of new technology already in most homes as input sources for information about a person’s wellbeing either via sensors (Telecare and telehealth) or by someone entering information using mobile phones, tablets, pc etc. The functions are as unique as the needs of the Service User it could be hydration support, night needs, living independently, risk management, a care diary, all of those or anything else a person requires support with. Nourish supports community cohesion and activates circles of care, as it is live it is proactive and can be used preventatively, engaging community support for low level needs by texting a personal network for support if early risk indicators are detected. Nourish can use sensors in the home to monitor a person’s activity levels, fluid or nutritional intake, if this is decreasing it can send a ‘nudge’ via a text to a member of the circle of care to pop in

13 and make that person a drink or take around a treat. Sensors can also be used to recognise carers phones/tablets.

A couple of other things that might be worth mentioning are the:

1) New Hospital Transitions Role:

https://sharepoint.dorsetcc.gov.uk/news/Pages/New-Hospital-Transitions-OT- Role.aspx 2) The New “Pan Dorset Health and Social Care Academy”. This is a collaboration between Dorset County Council, Poole Borough Council, Bournemouth Borough Council, Dorset Healthcare University Foundation Trust and Bournemouth University. The aim of the Academy is to work together on the recruitment and retention issues across the wider Health and Social Care workforce. The academy has made an funding application to become a Social Work Teaching Partnership that will specifically look at improving the recruitment and retention of qualified social workers across Pan Dorset.