Hambleton, Richmondshire and Whitby CCG

Workshop Briefing Paper

Development of proposals for the use of health and social care reserves and establishment of the Integration Transformation Fund

Thursday 19 December 2013

Introduction

Over the past three years, North Yorkshire County Council and the PCT / CCGs have been working together to jointly agree and deliver proposals using Health and Social Care monies for integrated solutions based on reablement that will help to keep people out of hospital and long term social care.

The overall fund available was worth c. £6 million (over 3 years) for this CCG and a range of initiatives were taken forward, including: START free at the point of delivery, integrated overnight fast response service, hospital case management, additional therapy and district nursing capacity and home from hospital services.

2014/15 is the final year of spend using these monies, before the formal Integration Transformation Fund (ITF), a pooled budget of c. £5 million between HRW CCG and NYCC, is established in 2015/16. The H&SC monies have under-spent to-date, so the CCG has an opportunity to utilise the remainder of the fund (£1.4 million) on a non-recurrent basis in 2014/15. From 2014/15, continuation of funding would need to be assured from the ITF.

CCGs need to work with NYCC to create local ITF plans, which will be amalgamated to a single NYCC-wide submission. The CCG needs to agree which proposals to pump-prime as strategic initiatives using the H&SC underspend (which can later receive main-stream funding through the ITF). Proposals will need to be signed off jointly with NYCC before spending is released.

Progress to-date

In October 2013, the Governing Body held a workshop to look at emerging proposals. At the workshop, it was agreed that further work should be undertaken to confirm whether all the key areas which might require investment had been identified, through care pathway mapping workshops. These have now been held and the findings are summarised in Appendix 1.

The CCG has also been undertaking a specific project to create integrated teams in Hambleton and Richmondshire, which has also identified barriers and obstacles to successful integrated working. A summary of this project is included as Appendix 2. Prioritising proposals

Based on the proposals generated for the original GB workshop and based on the outputs since, the CCG management team has developed formal proposals for 18 schemes. These are all listed in Appendix 3.

The proposals have all been scored using the CCG’s prioritisation criteria by the teams involved in creating the templates.

The templates themselves were been circulated with this paper.

Discussion required

The Governing Body is asked to review the list of the proposals against the outputs of the prioritisation criteria and decide:

 Whether the scores reflect the perceived commissioning need

 Which proposals are priority for funding from the H&SC reserves and potential future funding under the ITF

 Whether any adjustments are required to agreed costs for prioritised schemes

 What additional action or information is required to take these proposals forward

Sam Haward 16th December 2013 Appendix 1

Outputs from Care Pathway Mapping “Pinchpoints” Workshop

Introduction

Care pathway mapping workshops were held to enable discussion with partners to help take forward ‘Fit 4 the Future’ and identify priorities as part of the Integration Transformation Fund.

The approach was to bring people from different organisations together (e.g. NYCC, acute trusts, CCG, and voluntary sector) to map the pathways using patient personas, looking at people from their being relatively well through to crisis, and mapping pinch-points and service gaps. The end-point was to start to understand what would keep people at home and what services were missing to help with this, with the overall aim of patients being maintained at home 24/7.

The 4 pathways were:

 Long Term Conditions  Frail elderly  Dementia  End of life Hambleton and Richmondshire workshop – 2nd December 2013 This was undertaken in four groups, each with a different pathway. Following the initial mapping, group members rotated round to see what the other groups had done. Then the whole room worked together to identify the common similarities and priorities. These were voted on and prioritised at high level as follows: Identified Description Priority priority (votes cast) Coordination (of All groups felt that there was a huge amount of assessment is 9 Care / Team being done but not in a constructive way. However, it wasn’t Working) clear who co-ordinates this and ensure that there is an effective ongoing response to vulnerable patients. Fast Response Capacity of Fast Response Team to respond, particularly in the 8 Capacity (“Tea period 2 – 10 PM. There are deficiencies in the number of staff time to twilight”) available “tea-time to twilight”. Voluntary There was a common feeling in the room that “people don’t 8 Sector know what they don’t know”. This meant that although there Infrastructure were opportunities and services available, they weren’t always accessed. Sustainability was also felt to be a problem, since many of these organisations exist on grants and short term funding which isn’t always very sustainable. Medication This was acknowledged to be a problem. There are limited 6 Compliance services to support patients staying compliant with medication. This can be provided by social care, where it is part of a social care package, and then only in line with the number of social care visits required, but otherwise it can’t be a care package in itself. Single Point Of This was hotly debated amongst the room and on the tables. 6 Access (1 Generally, it was felt better access was important, with one number) telephone number preferable. However, there were also limitations, in terms of whether GPs would accept the current HAS Contact centre as a single point of contact, and also that other points of contact existed, such as NHS 111, and were givens that we would have to live with. Capacity of Capacity within therapy services. There was generally 5 Therapies accepted as a major issue by the attendees. The consensus was current demand outstrips capacity in the community, in physiotherapy and OT particularly. Assessment Assessment needed to take place its most holistic sense. 2 Proactive It was felt that if you could support patients better in their own 2 Management communities, empower them to self-care and get things right at earlier in an earlier stage, then further down the pathway of care pathway everything would work better. Equipment Equipment services were raised by several tables. The current 1 (Access & Set system was not felt to be efficient. Up)

Earlier It was felt that there would soon be greater numbers of patients 1 Information / at a mid-level of care, where support is required, but where Advice / they won’t reach the threshold for social care. These are Signposting patients who may need some concerted action to prevent deterioration. The question is whether and how the voluntary sector can deliver some of this. Access to There was a consensus that when patients arrive at the 1 specialist hospital they need a comprehensive geriatric assessment geriatric input quickly. There was a debate about the role of a community geriatrician and the role of medical speciality support. Specialist Stroke / neurological care – There was also a recognition that 1 Neurological some more specialist therapy support was needed as well as Support more generalist provision, to compliment the additional therapies outlined above. Social Isolation Addressing loneliness – establishing social networks through 1 voluntary services and services in the community. The question was raised about possible match funding. Equity Consistency and equity – There was a shared belief that if you 0 (geography / live in central Northallerton, you will get a different service (for ways of e.g.) to patients in Hawes, both in terms of geography and working) ways of working.

The final key points that emerged from the group discussion were that:

 “This was actually ‘one big project’ that linked many different things together. This included better integration between services, ensuring they had the right capacity, proactive management of patients, enabling them to network effectively, e.g. with the voluntary sector, etc. etc.”

 It was important to sharing information about what’s already there, particularly within the voluntary sector, without reinventing the wheel

Whitby Workshop “Keeping Well @ Home” – 29th November 2013

Frail elderly

The group discussed the current services available and then identified the missing elements/pinch points before ascertaining a range of proposals.

Pinch points included: single point of access, communication, skill mix, carers support and social support.

Proposals highlighted included: Community Agents/ care coordinator model to coordinate care with health, adult social care and voluntary services, Nurse Training to improve skill mix available in the locality and to look at models available currently by third sector Enhance befriending services

Long term conditions (including young adults)

Again, the group discussed the current services available and then identified the missing elements/pinch points before ascertaining a range of proposals.

Pinch points included: single point of access, integration and communication between Community services/Primary Care and Secondary Care, compliance with medications for long-term conditions and support for younger age profile with long- term conditions.

Proposals highlighted included: Community Agents/ care coordinator model to coordinate care with health, adult social care and voluntary services, nurse training to improve skill mix available in the locality, a look at providing something similar to Whitby Trinity Service model for Day rehab service and to scan the third sector for services provided for long-term conditions for younger age profile.

End Of Life Care

Discussed as above. Pinch points included: Social needs, a transport facility for regular chemotherapy appointments and Telecare.

Proposals highlighted included: 25/7 Fast Response nurse led cover, extension of 24/7 nursing staff skills, enhanced Hospice @ Home service for the locality and enhanced Palcall service to cover 24/7.

Common issues

A number of missing elements/pinch points were consistently discussed for several or all of the pathways and these will need to be addressed –

 Single point of access

 Integration of services and communication between services

 Staff skill mix

 Personalised care

 Social support/befriending services

 Improved transport links Appendix 2

Integrated Teams Project Progress Report as at December 2013

Project objective South Tees Hospital NHS Foundation Trust, North Yorkshire County Council and Hambleton, Richmondshire and Whitby Clinical Commissioning Group agreed that services in the community were poorly integrated and didn’t work effectively together. All partners believed there were inefficiencies in ways of working and a more integrated approach could lead to a reduction in emergency admissions, the size of ongoing social care packages and long-term care home placements. The jointly agreed objective was to create six functionally integrated health and social care teams for Hambleton and Richmondshire, geographically aligned, and built around groups of GP practices. Funding of £80K was allocated for a programme of organisational development from health and social care monies.

Project design The Centre for Innovation in Health Management (part of Leeds University) was engaged to facilitate the programme to help bring the teams together. Each team would go through 2 workshops, 6 weeks apart, with further support provided through mid-point coaching sessions and two Community of Practice events. A ‘prototyping’ approach would be used where staff would work together in teams and identify problems and solutions in a bottom-up way. Ideas would be tested on a small scale over a short timescale, with the aim of achieving rapid improvement. Patients, service users and voluntary sector organisations would help facilitate a person- centred approach. Teams were also asked to consider what integration meant to them and how they wanted to work as a result. An ‘Unlocking Group’ was established to unlock or escalate any problems arising at team level.

Progress to date Four teams have currently gone through the workshop process: Wensleydale, Richmond and the Dales, Northallerton, and Hambleton North. Two Community of Practice events have been held. The final two teams (Thirsk and Bedale) will go through the process between January and March 2014. The workshops to-date included good representation from: social care assessment, START (Short Term Assessment and Reablement Team), district nursing, fast response services, and intermediate care. There has also been more limited attendance from older people’s mental health teams, GP practices, and housing.

Achievements to date The four teams so far have responded very positively in an energised, pro-active way. A range of prototypes have been identified and tested and some early successes have been achieved both generally and in individual localities.

 Multi Agency Meetings have been re-energised with a fresh approach to managing minutes, improved attendance, extending the invitation list to wider agencies, and identified priority patients for discussion and advice.  Generic Working opportunities between START and FRT have been identified, supported by training, so that a more flexible approach can be adopted for who can attend in more remote locations.  Teams have actively embraced the idea of using the NHS number as a common identifier, and liaised with the HAS customer contact centre to start to collect this on assessment documentation on an ad-hoc basis.  Teams have compiled ‘Who’s Who’ guides, better telephone contact lists so they know who people are and can more quickly get hold of each other  Improved telephone answering at the Friary Hospital has been put in place  Hot-desking for social care staff at some GP practices has been agreed, as have suitable drop-in times for social care to discuss patients with GPs  A ‘patient passport’ to leave with the patient listing key information about what services they are receiving is being tested  A patient consent form has been developed that seeks consent to share information across GP practices, acute and community services and social care, which is currently going through official approval channels  Better communication has been established as part of acute trust discharges, with a pathway direct to the social care locality team for suitable patients

Recommendations to address identified obstacles and barriers Despite the good progress at the workshops, most teams are still scoring themselves as only 4 out of 10, when asked to assess how integrated they really are. There are a number of key problems which are preventing full integration and the delivery of the full benefits and expectations of the programme.

The following recommendations would address the identified problems and need to be escalated further for more senior agreement.

 Properly aligning the district nursing and social care locality teams – This would prevent staff having to liaise and form relationships across multiple teams, improve effective team-working and reduce inefficiencies.  Establishing an enabling IM&T infrastructure to ensure there is access to both health and social care electronic systems at the same sites where staff hot-desk and hold multi-agency meetings, establish processes for sharing information using safe and secure e-mails and systematically collect and quality-assure the NHS number through the Contact Centre.  Preventing duplication of assessment by leading from the top a culture of trusted assessment and giving permissions to better co-ordinate assessments through multi-intervention planning and mechanisms for sharing and feeding back on the assessments that have already been undertaken.  Establishing better links with GP practices through implementing the Directed Enhanced Service for risk profiling to refer vulnerable at-risk patients into the integrated community teams  Improving equipment delivery and fitting services to reduce the overall number of unnecessary journeys undertaken by health and social care staff  Addressing identified service gaps, such as medication support to aid compliance where patients don’t have an existing social care package, and therapy support within the community, either through additional capacity or agreement to skill-mix more flexibly.