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Updated July 2014 Better Care Fund planning template – Part 1 Please note, there are two parts to the Better Care Fund planning template. Both parts must be completed as part of your Better Care Fund Submission. Part 2 is in Excel and contains metrics and finance. Both parts of the plans are to be submitted by 12 noon on 19th September 2014. Please send as attachments to bettercarefund@dh.gsi.gov.uk as well as to the relevant NHS England Area Team and Local government representative. To find your relevant Area Team and local government representative, and for additional support, guidance and contact details, please see the Better Care Fund pages on the NHS England or LGA websites.

1) PLAN DETAILS a) Summary of Plan

Local Authority Portsmouth City Council

Clinical Commissioning Groups Portsmouth CCG

Boundary Differences No boundary differences

Date agreed at Health and Well-Being Board:

03/09/2014

Date submitted: 19/09/2014

Minimum required value of BCF pooled budget: 2014/15

£ 6,627m

2015/16 £14,193m

Total agreed value of pooled budget: 2014/15

£15,195m

2015/16 £16,409m

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b) Authorisation and signoff

Signed on behalf of the Clinical Commissioning Group By Dr Jim Hogan

Position CCG Clinical Lead

Date 19/09/2014

Signed on behalf of the Council By Julian Wooster

Position Portsmouth City Council Strategic Director

Date 19/09/2014

Signed on behalf of the Health and Wellbeing Board By Chair of Health and Wellbeing Board Cllr. Frank Jonas

Date 19/09/2014

c) Related documentation Please include information/links to any related documents such as the full project plan for the scheme, and documents related to each national condition.

Document or information title Synopsis and links

20/20 Vision

2020 Vision Brochure Web Version.pdf

Q2 Vision defines CCG vision for 2020

Governance and reporting

Programme governance and reporting draft v4.docx

Q4b Demonstrates governance and reporting structure for the BCF programme.

PIP

BCF Programme Implementation Plan 2014-2015.xlsx

Q4. PIP extract for 2014/15

Co-commissioning Q6c. This strategy is referred to in response to question.

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Co-commissioning Expression of Interest Portsmouth FINAL June 2014.docx

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2) VISION FOR HEALTH AND CARE SERVICES

a) Drawing on your JSNA, JHWS and patient and service user feedback, please describe the vision for health and social care services for this community for 2019/20

VISION Our vision is for everyone in Portsmouth to be supported to live healthy and independent lives, with care and support that is integrated around the needs of the individual at the right time and in the right setting. We will do things because they matter to local people, we know that they work and we know that they will make a measurable difference to their lives. We have a strong belief that commissioning joined-up care improves the health and wellbeing of the whole population. Effective prevention and management of long term conditions such as respiratory and heart disease is best done in the community and by services that are joined up to avoid unnecessary barriers to care. Talking to people who use our services, there is one consistent message we have heard – that we must continue to bring services together in a way that makes sense for the patient but also allows front-line professionals to deliver care in a way that is not restricted by professional, organisational or financial boundaries. Our strategy is thus based on joining up (integrating) services around the care of the person. We will build on the well-known, well-established services that Portsmouth people know and use whilst also seeking to use these in the most efficient way but not be afraid to transform services and pathways when necessary. Primary care is at the core of our strategy. We recognise and values the contribution made by GPs and all primary care to NHS provision and understands they are highly valued by patients. This is reflected in our commitment to work with local GPs and their practices to ensure we have strong primary care providers as a foundation upon which to join-up other services. Our Better Care Fund plan is based on the approach of basing services around the GP and other primary care services. GPs and pharmacists are the main point of contact for the majority of patients and their skills are essential for all aspects of health care, including health education and health promotion. We are committed to building a modern model of integrated care over the next five years. We will do this by creating multi-disciplinary teams based on localities in Portsmouth so that services stay local. Whilst these teams will be based around primary care, they will also include staff and services from community NHS services, secondary care specialists and social care practitioners. We also recognise the role that the voluntary sector can play in being a part of these teams, offering expertise and services for individuals that help them live their lives in the way they think best. By doing so we will be placing more specialist services into community settings, including some acute services, with many services available 7 days per week. This will require a change to the way services are delivered; in particular this will impact on some services that are currently delivered in an acute hospital setting. Our strategy, and the financial strategy that supports it, aims to manage the risks of this transition by, for example, contracting using different payment methods with providers of NHS services and

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agreeing ways of sharing risks between NHS organisations as well as the Local Authority. In doing so we will continue to work with our neighbouring CCGs and NHS England to ensure our delivery is aligned, particularly where we share the same NHS providers. To improve health, the Health and Wellbeing Board recognises it requires more than the provision of high quality healthcare services for local people. The joint strategic needs assessment for Portsmouth has highlighted the significant contribution of lifestyles to the large health inequalities that exist in Portsmouth, which themselves are underpinned by the social, economic and environmental circumstances in which residents live. Partnership working with Portsmouth City Council Public Health services who are working with individuals, families and communities in Portsmouth to build their own self-reliance and resilience. The aim is to enable people to take more control over the adverse social, economic and environmental circumstances in which they live. We will commission a sustainable health and care system that achieves a shift in focus from acute care to community and primary care, early intervention, prevention and maximizes the contribution of the voluntary and community sector. Over the next 5 years, in order to deliver our strategy, improve the quality of services, meet rising demands and costs and ensure safe services at all times we will need to achieve at least £40m of efficiencies across health and social care by 2019.

Improving outcomes through Better Care - Mark's Story Mark is a tall 60 year old man, who has mild learning disabilities, diabetes and who had put on a lot of weight. Life has been difficult for Mark with periods of unemployment and depression. Mark lived with his sister but needed a lot of care at night and unfortunately she no longer felt able to care for him.

Mark was admitted to hospital to improve circulation in his leg. This took 10 hours and he lost 7 litres of blood. Mark was extremely poorly afterwards and despite intensive care to save his leg he had to have an amputation above his knee. Mark continued to be poorly for some time however eventually was transferred to a community hospital rehabilitation bed.

Mark had lost a lot of confidence and wouldn’t come out of his room on the ward or chat with staff or other patients. He needed a lot of support, as he couldn't roll over, sit up in bed, get from bed to chair without a hoist and could no longer use his old wheelchair. Mark and his sister wanted him to go to a nursing home even though he was relatively young and would be isolated in that environment.

Mark was supported on the ward through a whole system approach. The physios got Mark going again... and he could soon get in and out of bed. The OT's got the wheelchair he needed which enabled him to get around. The Doctors managed his medical problems which made sure he didn't go back into acute hospital. The social workers arranged for Mark to go to an assisted living lodge as a transition to give him more time to decide about his future. On the day of Mark's move to assisted living, the community re-ablement team went with Mark to ensure a smooth transition and provide expert advice to the staff in the lodge'

An integrated team response helped Mark to retain his independence but we believe the schemes within our Better Care Plan could make Mark’s story look very different.

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b) What difference will this make to patient and service user outcomes?

Where We Will Be in Five Years’ Time? At the end of 5 years we aim to have achieved:

More people will be able to die in their preferred place of death

An increased proportion of older people who have remained at home 91 days after a discharge from hospital

Further reductions in delays to transfers of care from the acute setting to the community, with increase quality of this discharge process

People with complex needs who need to go into hospital who are known to community, locality teams who are safely and actively managed back into their home

A further reduction in acute bed days for older people who need to go into hospital

Delivery of a truly integrated and locally based teams that include the voluntary sector, social care, primary care, community and acute care

A radically improved offer of early intervention and preventative health and social care services that allow individuals to have more choice and control over their own lives.

People of Portsmouth will:

receive effective services to meet their goals to manage their own health and stay well

spend less time in hospital

receive responsive services which help them to maintain their independence

have access to the right information and support about services available

be empowered to participate in service development and delivery

feel confident that their care is co-ordinated and that they only have to tell their story once

benefit from use of assistive technology through telecare and telehealth to help them stay well

What would be different? In the future increased access to improved community based monitoring and management of disease in primary care will enable Mark to be provided with support sooner to help him and his sister better manage his diabetes. Mark would be referred to the Personalised Independence Co-ordinator to support Mark to access wellbeing services such as the lifestyle hub and carer's services, perhaps being able to access support groups with other people with diabetes, provision of cookery courses to make more healthy meals and carers breaks for his sister. Mark would be supported by his Care Co-ordinator to attend regular monitoring checks for his diabetes so that any problems in circulation could be identified and treated earlier, perhaps with less invasive methods of treatment such as angioplasty. Any required hospital stay would take place in a planned way, with an agreed date to transfer to the community reablement bed or directly home with the integrated rehab team to support Mark get back on his feet.

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be supported in their community, by their community to maintain their independence

c) What changes will have been delivered in the pattern and configuration of services over the next five years, and how will BCF funded work contributes to this?

AIM Our aim is to create a single health and social care system, which puts people and their families in the centre. This will be delivered through a single commissioning vehicle and an integrated delivery vehicle.

People will experience integrated care that is personalised and promotes independence in every setting. The care provided will not duplicate and will be in the right place at the right time by the right staff. Service will be designed to make the best use of resources to support people in the least institutional setting possible.

OBJECTIVES Over the next five years we plan to transform services by;

developing a common set of leadership values and behaviours underpinning integration and collaborative working - all patients/service users and their families will be treated with dignity and respect and receive the same high quality of care and support from all staff. They will know what they can expect from everyone involved

streamlining processes so that there will be a single point of access for all health and social care services with no duplication taking place - patients/service users and their families will find it easier to understand, access and contact services and will be enabled to manage their own support. They will have access to information and advice and only tell their story once

using personal budgets routinely and widely across health and social care - patients/services users and their families will have more control, choice and flexibility over the support they receive

creating multi-disciplinary integrated locality teams, consisting of primary, social and secondary care medical with one trusted assessor and a common assessment framework - patients/service users and their families will receive well-co-ordinated, seamless services, with closer working relationships between professionals resulting in better health outcomes

placing more specialist services in the community, maximising use of ambulatory pathways, with many services available 7 days a week - patients/service users will receive support close to home, will have more flexibility around when they receive support, and will remain independent for longer. Patients/service users will have quicker discharges from hospital and there will be fewer unnecessary admissions at weekends

increasing involvement and provision from a flexible and responsive third sector -

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patients/service users and their families will have increased choice of provider and support from within their local community

establishing IT system(s) and processes that can work across all health and social care providers - with referral forms populated from patient/service user records and results and discharge information electronic and at speed - patients/service users will have access to their records, be able to use direct booking and experience less delays and a higher quality of service

agreeing clear and transparent information sharing protocols and governance arrangements will be in place - patients/service users will only need to give permission to share once and will benefit from everyone involved in their care having rapid access to the information they need to provide the best support

Through our engagement strategy we will assess qualitative patient experience and seek active patient participation in service design development and improvement.

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3) CASE FOR CHANGE Please set out a clear, analytically driven understanding of how care can be improved by integration in your area, explaining the risk stratification exercises you have undertaken as part of this.

PORTSMOUTH - DEMOGRAPHIC PROFILE There are 208,900 people living in Portsmouth and 217,562 people registered with a

Portsmouth GP. In the last ten years the biggest growth in our population has been in

the over 85 yrs. age group with an increase of 12%. By 2021, this age group will grow by

19.5% and the 75 to 84 yr. age group increasing by 13.3%. We are living longer and so

more people will need healthcare. As the population ages and lives longer so the

number of people living with dementia and other long term conditions is likely to increase.

We know there significant health challenges in Portsmouth. Too many people have poorer health and wellbeing than in other similar cities. Portsmouth is ranked 84th of 324 local authorities (excluding counties and where 1 is the

0

5000

10000

15000Projected population growth over 65's

65-69

70-74

75-79

80-84

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most deprived). Deprivation is not just about lack of money. The dimensions of deprivation include income, employment, health, education and skills, barriers to housing and services, living environment and crime.

Health & social needs1

Men, in particular, have a shorter life expectancy caused by high levels of smoking, alcohol misuse and obesity. The causes of comparatively poor male health are complex and affected as much by culture and the broader determinants of health as by access to services. Alcohol misuse, domestic abuse, young people at risk, drug misuse and adult re-offending all impact on health and health services.

Almost half of all the deaths in Portsmouth are caused by heart disease, stroke, cancers

and respiratory conditions. Heart disease is the most common cause of all early deaths.

Many of these conditions could be prevented by adopting healthier lifestyles. For

example smoking, diet, being overweight or obese and drinking alcohol to excess

account for 34% of cancers. Early death from cancer for Portsmouth residents is

significantly above the England rate.

24% of children live in poverty. In some areas this is even higher (Charles Dickens ward). We have a high number of women who smoke during their pregnancy and more women need to breastfeed their babies for longer. Obesity rates for children (in school year 6) are declining but still much higher than they should be. Over half of older people in most deprived areas in Portsmouth live in poverty and this is likely to contribute to a higher level of deaths in the winter than would be expected. Local analysis has found that the main local causes of excess winter death are respiratory diseases (especially influenza and chronic obstructive pulmonary disease). In Portsmouth, the level of Chronic Obstructive Pulmonary Disease (COPD) is comparable to England (1.6%) but COPD early death is significantly worse than the England average. The highest COPD emergency admission rates are from our most deprived areas. Over 17,000 residents are unpaid carers looking after family or friends with about 4,100

providing 50+ hours of care per week. We know that caring for a loved one can a

detrimental effect on the carer's health and wellbeing.

Compared to the South East or England, Portsmouth has significantly higher rates of:

People claiming incapacity benefit or severe disability allowance due to alcoholism

Alcohol-attributable crime, violent crime and sexual crimes

Alcohol-attributable hospital admissions – and the male trend is increasing

Alcohol-specific mortality rate for males

Liver disease in under 75s mortality improved between 2011 and 2012 but

1 http://www.portsmouth.gov.uk/living/19059.html

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remains in the 2nd worse quintile when compared with other CCGs

Portsmouth is significantly worse than England average for amputations with

diabetes and ranks 9/11 for patients with diabetes in whom the last IFCC-HbA1c is

64 mmol/mol or less.

Demand for Services Providers in the South of England have experienced 8-9% growth in emergency admissions between June 2008 and June 2012. As has been the case for a number of years this is significantly in excess of the rate that can be explained by population changes. (Kings Fund). Between September 11 and August 12 there were an average of 250,000 A&E attendances and 100,000 emergency admissions. In Portsmouth, in the last year, there were:

42,000 attendances at A & E

23,500 emergency admissions to hospital

16,000 planned admissions to hospital

122,000 hospital appointments

7,000 GP appointments and 1,350 hours of Practice Nurse time each week

108,128 appointments with community nurses

49,715 appointments for adults with mental health problems

32,729 appointments for older people with mental health problems and dementia

There are significant variations in performance between providers:

Emergency length of stay – 4.8 days average,

Readmission: average 13.8%

A&E conversion rate: average 22%, range: 14-46%

A&E patients arriving by ambulance: average 28%, range: 11-39%

95% in four hours: average: 93.5%, 67-97%

Discharge to nursing homes and other important variable show similarly wide variation

Locally, we are performing well on a number of indicators

non-elective admissions at Portsmouth Hospitals NHS Trust (PHT) grew by just 3% between 2007 and 2012. In addition for 2013/14 they are currently 3.8% lower than last year, against 0.5% growth nationally.

the average emergency length of stay for 2011/12 was 4.4 days; 0-1 days 55.5% average and 15.2% staying longer than 7 days. The ED conversion rate was 18%, with 30.2% arriving by ambulance.

08.8% of emergency patients were discharged to a nursing home compared with

the south of England average of 1.6%The admission rate for assessed patients

with a high risk condition (e.g. heart failure, respiratory disease, and dementia is

20% compared to a national rate of around 30%.

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The Case for Change

30% of the population have a long term condition (LTC) and consequently use 50%

of GP appointments and 70% of hospital beds. The 30% of people with one or

more LTC account for £7 out of every £10 spent on healthcare.

Reducing the prevalence of heart failure, respiratory conditions, diabetes, cancer and dementia is therefore a key priority for the City; as is supporting people to better manage their existing conditions to prevent further deterioration and helping people to maintain their independence. The Better Care Plan, aligned with other key strategies and plans is focused on achieving these aims. An integrated approach Whilst the case for the development of integrated services is far from proven, evidence nationally and internationally suggests that delivering effective community based integrated health and social care support can reduce emergency admissions, reduce length of stay in hospital and avoid long term care admissions. In Portsmouth through our Health and Social Care Partnership (HASP) Programme we have achieved a significant proportion of this already:

The establishment of an integrated health and social care intermediate care team with full 7 day working and community geriatrician support - thereby contributing to a 3% reduction in emergency admissions to Portsmouth Hospital.

Implementation of an integrated pathway for rehab and reablement, including the creation of a new community inpatient rehab unit. This, along with strengthening the intermediate care team has increased the number of people supported at home and significantly reduced length of stay in acute care, as well as achieving demonstrable savings of £750,000 to the healthcare system.

Within 6 months the section 75 agreement supporting integrated CHC assessment

50 115

243

121 146

521

301

195

40 46

0

100

200

300

400

500

600

Projected increase in number LTC cases 2014-2020

Growth

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and contracting has led to a reduction in delays and less assessments taking place in acute hospital. Review of the top 5 high cost placements has improved quality of life for those involved and reduced the costs of long term care. In addition, we have reduced management costs and achieved a budget under spend position for re-investment.

The central cluster pilot has shown that integrated working with those with the most complex needs is likely to result in better outcomes and experience for patients and their families. Despite an increase in the older population, hospital admissions fell slightly. People tended to require less intensive types of support and treatment and less residential and nursing care packages were agreed. In addition, the amount of domiciliary care was reduced over the life of the pilot and there was a reducing trend in the amount of CHC eligibility.

We have invested in new forms of reablement, piloting 8 community schemes mainly provided by voluntary organisations but also including additional reablement beds and 24 hour support.

Understanding demand, patient needs and risk stratification Our approach to service redesign and further improving integrated care support will continue to be delivered through an evidenced based approach, based on meeting and managing demand on services where appropriate and underpinned where possible through risk stratification. We have achieved this in a number of ways.

As part of the system wide Kings Fund Leadership Programme a simulation exercise was undertaken to model the existing system and test the hypothesis of how integrated care may be able to improve system performance. The model showed that improving integration of care within a coordinated system approach can increase the effectiveness of care planning, improve efficiency of administrative processes and enable a more managed, flexible approach to utilising resources, leading to increased capacity and reduced costs. This approach has enabled us to recognise that current delivery models will not deliver sustainability or improve people’s wellbeing.

We have undertaken a full review of older people’s services in Portsmouth using falls an exemplar. This review highlighted multiple referral and assessment processes, duplication across health and social care pathways, confusion about boundaries and ‘exclusion’ criteria, resulting in disjointed planning. This review and the stakeholder engagement that supported it has underpinned our philosophy and approach to deliver a different model of integrated care.

Our model of care is in line with national policy and intermediate care guidance.

For any service changes we have undertaken full business planning approach ensuring the costs and benefits are fully taken account of.

We are committed to evaluating service changes and understand the need for longitudinal study to understand the impact over time. Examples of where we are doing this include: Adopting an overarching evaluation process to the reablement pilots; Central Pilot 6 month evaluation, Spinnaker Evaluation from 1st year of

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Dom care package, social worker, day care services, OT, falls prevention, district nursing

operating and a 2 year evaluation , review of PRRT to enable us to understand value for money and cost and clinical effectiveness of the service.

Risk Stratification Risk stratification at GP practice level, using current and predicted utilisation of health and social care services and sharing this information with the integrated community teams has been a long held aim which we have made some progress towards. Through the National DES programme the vast majority of GP practices in the City are using the ACG tool to undertake risk stratification at practice level. There have been a number of issues identified through this process, including issues in rolling out the tools to all practices, maintenance of the reporting system to practices and reliability of the data, have all meant that progress has not been as good as we would have like. The following has been achieved however:

In 2013/14 through the risk profiling DES Portsmouth practices identified 0.25% of their registered population requiring pro-active case management either by the GP or in partnership with the community teams. This work continues to form the basis of the integrated virtual ward discussions.

In 2014/15 through the Avoiding Unplanned Admissions DES practices are identifying 2% of their registered population requiring a care plan.

Through this work we have identified approx. 4000 individuals across the City requiring some level of case management and support in order to prevent future admissions.

Through delivery of the Better Care Programme we will be able to ensure all of these

Equipment VCS, self-care, family care, primary care

VCS, community alarms meals on wheels, equipment, primary care

Intensive dom care package, case managed by community nursing or PRRT

PHT/ Virtual ward/Spinnaker/Jubilee/Grove/case management (PRRT)

Total 4,000 people

PRRT = 1,000 people

Health = 100 people Social Care = 150 people (overlap)

Social Care = 1,500 people

District Nursing = 1,000 people

Target?

(Greatest Impact)

Need links to primary

care - Prevention

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patients receive care co-ordination and pro-active management at the level that best suits them. This could be via the GP, through Personal Independence Coordinator being developed through the Age UK Care Navigation Scheme or by another member of the integrated locality team. SUMMARY - The Better Care Programme will drive the integration agenda in Portsmouth The health of people in Portsmouth is generally worse than the England average and there is a real need to tackle health inequalities and life expectancy. Our focus now must be on prevention and supporting people to stay well. We realise that to do this we must radically change the way services are currently being provided. The artificial, historical barriers that exist within the system need to be broken down, with the aim of providing a single, co-ordinated service. We must identify and respond to patient’s needs in a seamless way, offering a rapid response at the most appropriate care setting and provide high quality and consistent community support for those with multiple pathologies, particularly dementia. Our Better Care Plan is aligned to the Health and Well Being Strategy, the CCG’s Operating and Strategic plan to ensure delivery of our ambitious 5 year Plan. The priorities and aims have been developed by local GPs through discussion with other clinicians and practitioners and by listening to the views of local people, particularly those who legitimately rely on our NHS services regularly. As a unitary city, which already enjoys close partnership working between health and social care (coterminous), we have great opportunities for genuine partnership to achieve integration through delivery of the Better Care Plan at scale and pace. We have the right relationships to enable a significant and fast moving expansion to deliver high quality, joined-up services to meet the health and social care needs of Portsmouth people and deliver long term financial efficiencies. This means co-ordinating the full range of public service investments and support, including not just NHS and adult social services but also housing, public health, the voluntary, community and private sectors. Importantly, it means working with individuals, their carers and families to ensure that people are enabled to manage their own health and wellbeing insofar as possible, and in doing so live healthy and well lives. We have a strong track record of success and have already integrated community health, Mental Health and social care services to a great extent. There is a great foundation to build upon, but still much more to be done.

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4) PLAN OF ACTION a) Please map out the key milestones associated with the delivery of the Better Care Fund plan and any key interdependencies

BCF Programme Plan

Scheme 14/15 milestones 15/16 milestones 16/17 milestones

Scheme 1 – Integrated locality teams

Age UK Care Navigation Scheme mobilisation in the central cluster.

Integrated Care Team(ICT) pilot launched in the North cluster

Extension of Clinical Directors pilot in all 3 clusters to provide clinical leadership within the localities and support implementation of the schemes

Increased capacity provided within community nursing to strengthen ability to prevent emergency admissions

AGE UK Care Navigation scheme fully operational

ICT roll out to other 2 localities

ICT clinical leadership model developed

Single assessment and care planning process in place

Single care record in place

New workforce structure in place and supporting training programme

Robust 7 day access to primary and community services

Scheme 2 – Review of bed based services

Community bed audit completed

Review and redesign of OPMH beds and the Grove complete and new bed model in place

Scheme to enhance GP and community health input into care home beds up and implemented to reduce

2nd phase demand and capacity work complete

Re-specified, simpler access to all relevant beds within the system

Strengthened integrated hospital discharge model, better aligned with PRRT and community locality working in place.

Expanded bed capability across the system

Bed based services better fit to match needs operating 7 days per week

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admissions

First phase of demand and capacity work completed

Short term social care bed based and step up bed based capability increased to further avoid long term care admission

Scheme 3 – Increase reablement services

Evaluation of the reablement pilots complete

Increased capacity within PRRT

24 hr support in the home pilot complete and evaluated

Pilot SPA for voluntary sector services for GPs underway

Strengthened relationship between PRRT and the wider reablement community, development of a hub and spoke model of support within localities

Increased capacity within voluntary sector reablement services following pilots

Robust 24 hour support in home model in place to enable more people to remain at home

Comprehensive network of reablement services across the system working on 7 day basis and integrated with locality teams and PRRT.

Scheme 4 – Prevention

Mapping exercise of LTC pathway services complete

Lifestyle hubs mobilisation

First phase roll out of improved self-management strategies within localities

Locality based self-management support groups up and running and utilisation of personalised self-care management plans well established

Re-commissioning of LTC pathways to improve early presentation / diagnosis

More ambulatory care and community based service models in place to support people with long term conditions in their community.

Effective commissioning of integrated LTC pathways linked to prevention and self-management strategies

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Key Interdependencies: The schemes are all interdependent and are supported by a number of underpinning work streams. These are; Workforce development There is a pressing need to accelerate the pace at which we transform clinical pathways and in order to do this we need to specify and train a new style of workforce so that the next generation of clinicians have the skills and mind set to provide ever greater elements of care in the home and/or community environment. Workforce planning for transformed community services has begun through the establishment of a working group to pilot a novel, system wide approach, to ensure an adequate supply of highly skilled (non-medical) staff to meet service needs, improve patient care and support the move of care out of hospital settings into primary and community settings across Portsmouth, South East Hampshire and Fareham & Gosport CCG areas It is important that we work with partners on this agenda to enable consistency and minimise organisational and staff impact. Information technology: It is widely recognised that information sharing across health and social care providers is critical to improved patient care and system sustainability. In addition, whilst technology is now becoming available to support large scale interoperability across a system of care, successful delivery of benefits to patients and carers can only be achieved through a good description of requirements, effective procurement and implementation. This will require clear governance, stakeholder engagement and a review of supporting business processes to achieve maximum benefit. However, whilst technology and standards supporting interoperability have come a long way in the last couple of years, the local technical landscape remains challenging with health and care systems not designed to connect with each other. A two stage approach may therefore be necessary with the development of interim tactical solutions to bridge the gap between supporting immediate (short term) needs and the longer term strategic solutions. NHS Portsmouth CCG has developed an Informatics Strategy with its Compact CCGs, which has integrating health and care records as its number one priority focusing on:

Driving Integrated Care – through integration of health and care records

Providing information to support patients, carers and the public - supporting to make available on-line services.

Helping staff (clinicians and social care professionals) support patients through introduction county wide use of shared electronic care plans and End of Life Care register

Information to support the Commissioner ensuring all Information required to enable informed business decisions will be easy to access.

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Estates A separate enabling work stream has been established to identify, evaluate and agree solutions estates requirements. These solutions will need to be provided in accordance with the needs of the BCF schemes' delivery plans in terms of cost, quality and timescale. The interdependencies with other asset strategies and the One Public Estate agenda will be fully considered in the decision making process. Again, this needs to be developed at whole system level. A collaborative approach to estates management will enable

Efficient and effective use of estates assets to enable project schemes achieve the deliverables

The use of property assets will be coordinated between the organisations, taking into account their own strategies and the implications of the government's One Public Estate agenda.

Through joint working the financial benefits of estates rationalisation will be maximised.

Service users and providers will be consulted in the suitability of estates to ensure that they are accessible and fit for purpose.

b) Please articulate the overarching governance arrangements for integrated care locally

At whole system level: The Portsmouth and South East Hants System Transformation and Resilience Board is well established and works to secure whole system sustainability, understand and manage the impact of the transformational change required on partner organisations across the system. Focused working groups, including the Integrated and Urgent Care Delivery Board and IT Enablement Board report into the System Transformation and Resilience Board to ensure progress is being made and blockages resolved.

In Portsmouth: The Joint Health and Wellbeing Strategy and oversight by the Joint Health and Wellbeing Board drive our strategic direction in relation to closer integration between partners to improve the health and wellbeing of Portsmouth residents. The Health and Wellbeing Board is fully engaged in and supportive of the work being done to join up services across health and social care. Delivery of the Better Care Plan is therefore a key priority. The Board is supported in the delivery of this through the following:

Integrated Commissioning Board – Long standing and effective board which governs the S75 integrated commissioning arrangements and provides strategic oversight and direction for health, public health and social care. This Board reports into the CCG & LA governance structures

Health and Social Care Partnership (HASP) Delivery Board; delivering Better Care. includes The HASP board continues to oversee delivery of our integrated model of care bringing together Adult Social Care, health provider partners from community and acute care; Solent NHS Trust, Portsmouth Hospitals and GPs, together with commissioners and elected members. As we move forward we are looking to continue to strengthen the partnership agreement which is already in place and invite

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greater representation from the wider community

The diagram demonstrates the governance and reporting structure to support delivery of the programme. This is an established structure which has been fortunate to have consistent representation to drive the progress of the Better Care Plan.

The programme governance and reporting documents define the structure and management principles for decision making.

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

The diagram below provides an overview of accountability of functions for the Better Care Fund. Portsmouth has been working to this structure which has successfully delivered service improvements. We are confident the framework provides robust governance controls to implement, deliver and review results and milestones required to drive through the programme.

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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 the Better Care Fund. Please complete the Detailed Scheme Description template (Annex 1) for each of these schemes.

Ref no. Scheme

1 Integrated locality health and social care teams

2 Bed based service provision review

3 Reablement

4 Well Being and Prevention - Early intervention

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5) RISKS AND CONTINGENCY a) Risk log Please provide details of the most important risks and your plans to mitigate them. This should include risks associated with the impact on NHS service providers and any financial risks for both the NHS and local government.

There is a risk that:

Outcome Owner How likely is the risk to materialise? Please rate on a scale of 1-5 with 1 being very unlikely and 5 being very likely

Potential impact Please rate on a scale of 1-5 with 1 being a relatively small impact and 5 being a major impact And if there is some financial impact please specify in £000s, also specify who the impact of the risk falls on)

Overall risk factor (likelihood *potential impact)

Mitigating Actions

Risk 1: Stakeholder resistance

The ability to re-design services will be impacted

JY/VG 3 4 12 Comprehensive communication and engagement plan Specialist PCC Comms resource allocated with links to CCG Comms Consultation process

Risk 2: Financial risk of KPIs not being achieved

Financial pressure if PbR met.

MS/JY 3 3 9 Contingency plan in place (see above) Robust programme management and strong governance in place

Risk 3: Increased need/

Increase cost implications. Fuelling demand on services

JY/PL 2 4 8 Needs analysis/demand profile to be carried out and a dedicated underpinning work stream to be

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demand for services

created. Behaviour change of service users and providers

Risk 4: Capacity planning and the acute sector

Inaccurate planning potential destabilisation of the acute section causing additional financial burden

JY/PL 2 3 6 Linking with system wide sustainability plan to ensure estates and finance implications of the transformational change programme do not de-stabilise the local health system

Risk 5: Provision of accurate data / Information Sharing

Insufficient data/ shared resource will impact on accurate need and demand planning

2 2 4 Enabling work stream / project established to support the collation and dissemination of information across the programme.

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b) Contingency plan and risk sharing Please outline the locally agreed plans in the event that the target for reduction in emergency admissions is not met, including what risk sharing arrangements are in place i) between commissioners across health and social care and ii) between providers and commissioners

Portsmouth City has established formal integrated commissioning arrangements through Integrated Commissioning Unit (ICU), supported by a S75 agreement and the Integrated Commissioning Board. The ICU will manage the commissioning risk across health and social care on behalf of the partners through its lead delegated role for joint health and social care commissioning. There will be a pooled budget for delivering Better Care; this will include detailed risk sharing agreement between commissioners across health and social care. The Payment for Performance element of the pooled fund has been split into:

Payment for performance on total emergency admissions (general and acute non-elective admissions)

NHS commissioned out of hospital services. The financial value of the Non elective saving / performance fund for the Portsmouth BCF is £816,520.00. This money will be released from the CCG into the pooled budget on a quarterly basis, depending on performance. These payments start in May 2015 based on Quarter 4 performance in 2013/14. If the locally set target is achieved then all of the funding linked to performance will be released to the Health and Wellbeing Board to spend on BCF activities. If the target is not achieved, then the CCG will retain the money proportional to performance, to be spent by the CCG in consultation with the Health and Wellbeing Board. An annual target of 548 reductions is NEL activity has been set from Q4 2014/15 until end of Q3 2015/16), with quarterly milestones, outlined in the finance and activity plan template. Portsmouth CCG is also intending to develop alternative forms of contracting with providers such as risk and reward sharing approach. This would particularly apply to specific services provided by The Acute Trust, Community Health Provider and Adult Social Care which are working together to reduce emergency admissions through the Better Care. Portsmouth CCG is intending to use the NHS Contract in 15/16 to minimise conflicting incentives and create a system to incentivise collaborative working to achieve the target of reduced emergency admissions.

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6) ALIGNMENT a) Please describe how these plans align with other initiatives related to care and support underway in your area

Implementation With recognition that we already have a number of projects underway that directly or indirectly relate to/potentially impact on our plans for BCF and with a number of emerging developments (e.g. special educational needs reforms, MOPRS older persons pathway development) we will focus our work broadly around the following areas of care and support Older people and Long Term Conditions Older people, many who are vulnerable and have long term conditions including people with dementia and carers are the focus of 2014-15 and 2015-16 priorities. We have narrated our plans for four schemes initiating in 2014-15 with further development of these in 2015-16. In relation to other care groups we will start applying the principles of Better Care to them through the work of the Integrated Commissioning Board, the Health and Wellbeing Board and the Children's Trust Board. We have already started, and reflected through revisions in this submission, to think about how work within other care groups relates to the principles of prevention, early intervention, integration and the Better Care Fund Delivery Plan. Whilst there are some clear priorities to develop better and more integrated care across our systems, we will focus on testing some activity at a locality level in 2014-15. Work within the City across other care group that have the underpinning principles of integration and better care coordination, is already in progress and is outlined below. Mental Health Integrated community adult mental health services in Portsmouth are provided jointly by Solent NHS Trust and Adult Social Care with a supporting section 75 agreement in place. The service has been redesigned in the last eighteen months and now offers an enhanced gateway model of service which includes an Assessment to Intervention Team (A2i) and Recovery & Intensive Engagement Teams. A2i offer focussed preventative interventions within primary care reducing the necessity for referral to secondary care. The team provide initial assessment, appropriate signposting and short-term work (up to six months) where IAPT interventions are not appropriate or effective. We also commission voluntary sector providers to deliver various support services to people in secondary adult mental health care. We are currently reviewing these services in order to develop a more recovery orientated, sustainable model of service with a greater emphasis on service user involvement and peer support. Learning Disabilities Since April 2013 Portsmouth has been developing its integrated care offer for people with learning disabilities and the development of a S75 agreement was approved on the 1st April 2014. An integrated health and social care team are co-located on one site with a team of clinical nurse specialists and qualified social workers supporting people in the community by providing an intensive outreach support role to prevent unnecessary admission to acute care. When there is a necessary admission the learning disability team provide specialist support within the acute hospital setting in order to support the patient's care needs during the admission and throughout the discharge process. The

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integrated care team also monitor those who are placed outside of the City for inpatient care for forensic and criminal reasons. Continuing Healthcare (CHC) for Adults Establishing an integrated team for adults continuing health care assessment and supporting S75 agreements for this and for the CHC contracting function has ensured that a consistent approach is now being taken on all cases dealt with by the team where service users are assessed as eligible. Integrating the CHC team has helped to break down organisational barriers caused by financial and professional pressures by creating a single health and social care commissioning system which puts patients in the centre. The model is reducing bureaucracy by bringing health and social care together, merging cultures, eliminating duplication and streamlining processes to work more effectively and efficiently. The remodelled team has resulted in a considerably less adversarial approach to supporting individuals and practically eliminated the use of lengthy panel processes and funding disputes between the LA and NHS. The integrated approach has also enabled the team to proactively manage the local market, tackling the two tier pricing structure imposed by providers, and introduce a single LA/NHS contract and commissioner assurance process. Additionally, work is being done to strengthen the rehabilitation pathway for people with long term conditions and complex disabilities. The purpose of this is so that people accessing the pathway achieve their maximum rehabilitation potential prior to any decision about meeting continuing care criteria. Long term slow-stream rehabilitation work has been piloted and we want to develop this further within the reablement project and links Childrens The vision for our health in Portsmouth is reinforced and supported through the vision for children and family services which aim to improve the lives of the children and families in Portsmouth City, through the delivery of high quality care pathways that ensures equity of access for all who need those services. The Childrens Trust Board agreed priorities for 2014-2017 are:

Integrated support for children and parents families from pre-birth to age five

Families with Multiple Problems

Effective Learning for Every Pupil

Preventing poor outcomes for young people at risk

Early Help, Safeguarding and Workforce Development

Improving outcomes for looked after children and care leavers

Improving outcomes for children with special educational needs and disabilities Partnerships with the local authority, provider organisations, the Clinical Commissioning Group and voluntary organisations to provide an integrated approach to children and families continues to be a key driver nationally and locally during 2014/15 to 2016/17. This will enable a child and young person centric approach to be created across pathways of care and organisational boundaries to improve outcomes and experiences for children, young people and their families.

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In 2014-15 there will be two key priorities in relation to integration:

1) The impact of implementation of special education, health and social care plans with effect from April 2014 will need to be monitored; particularly in respect of transition and that services are modelled in such a way as to support young adults up to the age of 25

2) The transfer of Public Health services for ‘under 5s’ from NHS England to Portsmouth City Council from October 2015 provides an opportunity to review service delivery in the context of moving towards a fully integrated and seamless care pathway. We will work closely with the National Commissioning Board to enable the safe and timely transition of the health visiting and family nurse partnership programmes back to the local authority during 2015.

b) Please describe how your BCF plan of action aligns with existing 2 year operating and 5 year strategic plans, as well as local government planning documents

In developing our Better Care plan, we have discussed and agreed our priorities with the Portsmouth Health & Wellbeing Board. This ensures the Better Care plan:

Aligns with and supports delivery of the Joint Health& Wellbeing Strategy (JHWS)

Gives a focus for the work of established integrated commissioning arrangements

between Portsmouth City Council and the CCG.

Reflects the Joint Strategic Needs Assessment for Portsmouth

Contributes to the wider vision for communities shared with partner commissioners

in Portsmouth City Council

Shapes other local commissioning plans to enable integration of services/

pathways

Integrates local planning with Portsmouth City Council to use local resources to

better effect

Develops a shared vision and consensus with Portsmouth City Council and local

communities about the priorities for local services including integrated services

The Joint Health and Wellbeing Strategy comprises of 5 Priorities and 15 Workstreams

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Key to the development of the Better Care plan has been the alignment to the CCG operating Plan and the JSNA and alongside the Joint Health & Wellbeing Strategy. The CCG has ensured that the Operational Plan, MAR Plan and the Financial Plan all link together and support the Better Care strategy, HWBB strategy and CCG strategic plan. The CCG is working closely with public health, maximising capacity and reaping the benefits of a more aligned and comprehensive approach to early intervention and prevention. Capacity and benefits will be boosted further by partnership working with the voluntary and community sector using a community asset based approach delivered through the Third Sector and Service Delivery Strategy. We will ensure maximum utilisation of the JSNA to support this. Further work is planned to develop a process for systematically delivering health impact assessments.

c) Please describe how your BCF plans align with your plans for primary co-commissioning

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

NHS Portsmouth CCG’s 5 year Strategic Plan clearly articulates the need to do things differently if we are to meet the needs of everyone who needs care. The Better Care is aligned to this. As a CCG we want to use co-commissioning as a vehicle to support delivery of our 5 year Strategic Plan which identifies 4 key priorities all of which require the full involvement of GP practices as providers. As co-commissioners we will be able to

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facilitate general practice to work differently and to play a full part in the delivery of new models of care. Priority 3 and 4 of the CCG strategic plan will be delivered through BCF. Co-commissioning will support this in the following ways: Priority 3: We want health and social care services to be joined up so that people only

have to tell their story once. People should not have unnecessary assessment of their needs , or go to hospital when they can be safely cared for at home or stay in hospital longer than they need to

Priority 4: With our partners, we will tackle the biggest causes of ill health and early

death and promote wellbeing and positive mental health. As a CCG we already co-commission many of our community services with Portsmouth City Council (the Local Authority) with whom we are coterminous. By co-commissioning primary care we will be able to drive and encourage transformation of primary care locally so that health and social care services can be joined together effectively, in line with our Better Care Fund Plans. We will do this by encouraging practices to think about future configuration and models of delivery of practices which can bring efficiencies and economy of scale. Primary care is at the core of the CCG’s strategy for integrated care. GPs and pharmacists are the main point of contact for the majority of patients and their skills are essential for all aspects of health care; including health education/ill health prevention/early diagnosis/treatment/prevention/follow up care/management of long term conditions and effective response to urgent/acute care conditions. We will be piloting a Care Navigator Programme in partnership with Age UK which will link with multidisciplinary teams including GPs. By co-commissioning primary care we will have greater opportunities to work with partners to reduce the harm caused by alcohol, smoking and obesity and greater influence over unacceptable levels of variation between practices. The CCG recognises that key to maintaining capacity in the future is ensuring practices retain the flexibility to respond to increasing demand, ageing population and additional pressures and will look to support practices to share resource and pooled responses to new initiatives and core requirements. The CCG will also be looking to extend the role that community pharmacy plays in improving access, particularly around urgent care and management of minor ailments.

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7) NATIONAL CONDITIONS Please give a brief description of how the plan meets each of the national conditions for the BCF, noting that risk-sharing and provider impact will be covered in the following sections. a) Protecting social care services i) Please outline your agreed local definition of protecting adult social care services (not spending)

The DH guidance on Funding Transfer has indicated that the H&WB Board may use the funding transfer to support both existing services or transformation programmes, where such services or programmes are of benefit to the wider health and care system, provide good outcomes for service users, and would be reduced due to budget pressures in local authorities without this investment.

Protecting Social Care Services therefore means understanding the services we currently have, provided by statutory and third sector organisations that deliver the right outcomes building on these and supporting new services and transformation programmes which can be demonstrated to offer real improvement and positive outcomes for service users.

We need to look at services that require continuing or increased investment, disinvestment in other areas that are not seen to provide the outcomes required as well as investing in new ways of working, in particular investment in prevention that keeps people independent and healthy. That will mean utilising information from the JSNA as well other sources of intelligence and work programmes that can inform the approach we should be taking.

The Health and Wellbeing Board as well as local governance arrangements for integrated commissioning will agree and monitor protection of social care services.

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

There is an obvious area of overlap between health and social care provision represented by a cohort of service users / patients who are in touch regularly with both health and social care practitioners. A huge amount of work has been done already in Portsmouth to integrate services for this group of people i.e. PRRT, community beds and joint community cluster teams. However we have yet to understand the size of this cohort.

We also know that there will be a distinct cohort who will only receive social care services, many of whom will have complex needs relating to safeguarding, social situations, mental capacity etc. and correspondingly a distinct cohort who will have complex health needs and limited interaction with social care professionals even though some may have packages of care (many of these may be self-funders). Before we can decide how best to design community health and social care pathways, effectively utilise our resources and the scale of integration we need to meet need, we first need a better

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understanding of the profile of service users / patients across the health & social care continuum of need and the size of the overlapping areas as opposed to single agency core business and responsibilities.

In addition, there needs to be a shift to prevention and early intervention services reflecting the public health agenda to add to the traditional “gatekeeping” of statutory services so that professionals from all disciplines can deliver or allocate the resource of early intervention and prevention to meet the whole spectrum of need. To define prevention and early intervention we have used the Department of Health's resource pack Making a strategic shift towards prevention and early intervention, Oct 2008. The pack contains a framework with three broad categories- Primary prevention/promoting wellbeing (universal): This is aimed at people who have little or no particular social care needs or symptoms of illness. The focus is therefore on maintaining independence and good health and promoting wellbeing. Interventions include combatting ageism, providing universal access to good quality information, supporting safer neighbourhoods, promoting health and active lifestyles, delivering practical services etc. Secondary prevention/early intervention (targeted):This aims to identify people at risk and to halt or slow down any deterioration, and actively seek to improve their situation. Interventions include screening and case finding to identify individuals at risk of specific health conditions or events (such as strokes, or falls) or those who have existing low level social care needs. Tertiary prevention (specialist): This is aimed at minimising disability or deterioration from established health conditions or complex social care needs. The focus here is on maximising people’s functioning and independence through interventions such as rehabilitation/enablement services and joint case management of people with complex needs.

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The BCF will be set up to cover the totality of this need once it has been clearly identified by the work stream below. While recognising that we are likely to maintain some elements of existing services, we will not be limited to what is currently provided. There will be three key areas to our work -

1. Understanding the services needed, not just supplied, and how joint resources can be shifted/joined to supply these

2. Spotting where immediate improvements can be made to existing services in the short term

3. Commissioning new services or significantly changing existing ones to meet what is identified in 1 above.

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

The total amount allocated from the BCF to protect social care in 2015/16 is £8.4 million. This includes the health transfer money allocated to the CCG as part of the minimum CCG contribution; local authority minimum contribution and £2.1 million new investment from the CCG to adult social are services. Included within this figure is the £500k for the implementation of the new Care Act duties.

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We believe all of this funding is required to protect social care services in the way outlined above. However we also recognise that budget pressures within the Council and the local NHS will still require further savings to be made. We anticipate that these savings will be delivered through continued development and implementation of the Portsmouth Better Care Plan.

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

The new Care Bill consolidates and modernises existing law as well as bringing about new provisions that enshrine in legislation the role that local authorities have in ensuring people are able to live independent lives. The many sections include working to a principle of wellbeing, ensuring the provision of preventative services, and carrying out care and support functions in an integrated way with health related and other services. It covers how we should be undertaking assessments, supporting carers, using personal budgets and direct payments and safeguarding vulnerable adults. All of the sections contained within the Act will be considered alongside the local Better Care Fund Plan to ensure they complement each other. In this sense funds contained within the BCF will be used to achieve the Act's aims of enhancing support for carers, ensuring we have good universal information systems setting up of Safeguarding Boards, delivery of national eligibility criteria, training and workforce development across the system. We have already made good progress in many of the areas highlighted by the Care Act, as is demonstrated by the high level of integrated service delivery and commissioning we already have within the city and has been set out in the BCF plan. We are currently using a tracker developed within the region to assess our readiness for implementation of the Act and its many sections. A second stocktake will be submitted before end September 2014. We are also linking with ADASS and other colleagues regionally in order to keep abreast of the 's progress and implications for current practice in readiness for the implementation in April 2015.. Care Act requirements mean changes for Carers, in the Care Act are said to give carers the same recognition, respect and parity as those they support. In summary these changes include -

A responsibility to the local authority to assess carers needs, and only if the carer

and the cared for agree can a joint assessment be undertaken.

The authority must decide once assessment is completed if the carer meets

eligibility and is entitled to support. Eligibility regulations are currently being

considered by the Department of Health, PCC contributed to discussions

regarding the new regulations on the 12th August 2014 and the new regulations

come in in October 2014.

The local authority and carer will agree a support plan which sets out how the

carers needs will be met.

Charging for services can now apply but a financial assessment must be

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undertaken if a local authority decides to charge carers for services. The

department of health are indicating a lack of appetite for this and it may be

addressed in eligibility guidance later in the year.

If financial support is assessed a personal budget must be provided and a direct

payment issued giving them control over how support is provided.

The Children and Family Act gives young carers (and parent carers) similar rights

to assessments as adult carers have under the carer act.

Regulations under the Care Act 2014 sets out how assessments must be carried

out to ensure the needs of the whole family are considered.

Adults caring for children with disabilities are entitled to ask for an assessment of

need prior to the child reaching the age of 18 years and if support is identified they

can receive that support via an adult carer's service.

Adult care and support needs to be involved in planning support to young carers

transitioning through from children's services to adult service prior to them

becoming 18 years.

In February 2014 Portsmouth City Council RAG rated carer's actions in the care act stocktake as green or amber on the majority of the actions, as work undertaken in previous years through the local strategy addressed most of the required changes in the act. Areas that will require work or changes in delivery are -

It is anticipated, based on Lincolnshire Model that 2400 more carers will come

forward requesting assessment because of the Care Act in 2015/16; Because of

the work undertaken via the strategy since 2011 we have this year seen an

increase in carer identification which will therefore mean there will be a pressure

on resources and commissioning due to the requirement to provide assessments.

The implications are that there will be a funding pressure on the joint breaks

service for the provision of breaks to an increased numbers of carers and pressure

on the team undertaking assessments.

The Children and Family Act gives young carers (and parent carers) similar rights

to assessments as adult carers have under the carer act. Currently no specific

young carer's assessment is offered. This is likely to create a commissioning

pressure which may require a review of all funding currently allocated to young

carers services, a review of model of delivery and the development of a new

assessment for young carers as possibly new staff to be able to undertake the

assessments.

Regulations under the Care Act set out how assessments must be carried out to

ensure the needs of the whole family are considered. This will be possible to

implement via the adults joint assessment service, there is however likely to be a

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gap in adults and Children social care workforce and a programme of training is

likely to be required. As with Adult carers there has been an increase in

identification of young carers, this is due to increased identification via schools,

colleges and as a result of young carers within families that have been identified

via adults being identified.

Our plans will continue to be developed and revised as further guidance becomes

available form autumn 2014.

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

The joint assessment service identifies carers, specifically in health settings. Identification of carers has been a national conundrum, carers don’t like to identify themselves as carers and can therefore miss out on support. We have tested various ways of identification over the last few years and our efforts are now successfully increasing identification. This annual period we are reporting via our MOU with the CCG a 75.5% increase in carer identification (new carers) for the same period last year. Early identification means we can provide assessment and support earlier to reduce the risk of carers going into crisis with the need for more expensive health or social care solutions. Identification has increase by the implementation of CCG funded pre-paid card/short break initiative. Pre-loaded cards were provided to new carers in health setting to incentivise them undertaking a full supported assessment via the carers assessment team based at the carers centre. The initial amount was £50 which has recently been reduced to £25, agreed by the ICB, (to be implement when the ICB mins are public), because of the increase in new carers being identified. This offer is now part of the joint assessment service. We provide access to a supported self-assessment which will determine the level of support required and provide an opportunity for the carer to contingency plan for the future. The assessment can provide a wide range of support, including access to -

Breaks (these are wide a varying depending on need)

Sitting service

Counselling

Advice and information about a wide range of subjects including statutory and community based provision

Benefits and entitlements advice

Direct payments

Access to a range of peer support groups

Training opportunities either to support the carer in their caring role, training as a break or to support maintain employment while continuing caring role

Health checks and information about health lifestyles Outcomes for carers are improved by -

Increased identification

Improve the quality of life for carers (and patients)

Support carers to continue in their caring role

Reduce and prevent hospital admissions of both carer and cared for

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Improvements to be measured in performance in national carers survey (due for dissemination October 2014)

Evidencing joint health and social care to carers Carer commissioning includes access to sitting services from the zoned care agencies. These are paid for via direct payments or can be directly arranged. Counselling is also offered on a spot purchase arrangement if Talking Change is not appropriate. Carers Council is also commissioned and forms part of the governance structure of the carers strategy and carers service development and delivery. Carers Together currently support current carers to meet and input. We are currently retendering this contract to build on the last 3 years, the successful organisation will be expected to develop the council further, hopefully into a User Led Organisation (ULO). Adult and Children social care are required to be involved in planning support to young

carers who are in transitioning from children's services to adult service prior to them

becoming 18 years, an agreement is in place but protocol processes will need to be

developed and implemented. This will require a review of what is already in place and the

development of processes between Adults and Children services to meet the

requirement of the act.

vi) Please explain to what extent has the local authority’s budget been affected against

what was originally forecast with the original BCF plan?

Since the original submission pressure on the Local Authority budgets has increased, meaning that £4-5 million savings are required from the PCC Adult Social Care Department each year for the next three years. This is £600k more than was originally anticipated at the time of the original BCF submission. This means that despite the £8.4 million commitment to protect adult social care services in 2015/16 through the BCF, significant savings of £4-5million will still need to be made, resulting in cuts to services and consequently increasing the pressure on the local health and care system. We anticipate that these savings will be planned jointly across health and social care and will be delivered through continued development and implementation of the Portsmouth Better Care Plan.

b) 7 day services to support discharge Please describe your agreed local plans for implementing seven day services in health and social care to support patients being discharged and to prevent unnecessary admissions at weekends

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There is commitment at a strategic level across all system partners to see in place 7 day working that enables people to live independently and ensure the sustainability of our local health and social care system. This is promoted through the Portsmouth and South East System Transformation and Resilience Board (STAR), the Portsmouth integrated commissioning arrangements between Health and Social Care, as well as the local Health and Wellbeing Board. The Health and Social Care Partnership (HaSP) has developed a range of integrated services and has an on-going programme of work that is consistent with the outcomes expected of the Better Care Fund, and which, as part of agreed local plans, have in place 7 day working in health and social care. There are many working examples of this already including;

Portsmouth Rehabilitation and Reablement Team (PRRT). This service is part of an integrated strategy for intermediate care aligned with community beds. PRRT provides a joint approach across four disciplines (OT, Physiotherapy, Social Work, and Nursing) to assessment and care management with data sharing between clinical systems facilitated by the use of NHS numbers and common assessment tools. There is 7 day working across all disciplines with the ability to support acute hospital discharge, put in place packages of care and prevent admission over weekends.

Community beds. Provided over three sites each with a different focus, these offer admission over 7 days when clinically safe to do so, including access to therapy support. In addition social care residential units also take admissions 7 days per week.

The Hospital Social Work team also offer a 7 day service and are able to facilitate discharge with packages of care as appropriate, with some hospital based health staff also able to restart packages of care in addition there is a 7 day service offered by the integrated mental health teams and the 24/7 AMHP service.

In addition the integrated Continuing Health Care Team working across community teams allows for quicker decision making and assessment on CHC referrals. The hospital discharge team, PRRT and the Community Nursing Teams all have access to fast tracks eligibility and commencing/amending POC's. There is also Jubilee House which provides CHC assessment beds and currently we have access to The Grove if required for CHC assessment also. This means we have a robust 7 day CHC service across Portsmouth City.

To further enable contractual obligations to develop 7 day working there is inclusion within PHT contract in the schedule for Service Development Improvement Plan. The plans include the following planning requirements:

7 day working group formed and lead clinician identified.

Conduct Trust audit against Keogh 7 day standards applicable.

Gap analysis presented to the trust Publish draft action plan to address gaps with costs identified

Agree management of costs with Commissioners

Include agreed objectives within 15/16 business plans

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c) Data sharing i) Please set out the plans you have in place for using the NHS Number as the primary identifier for correspondence across all health and care services

Yes, the NHS number is being used within the adult social care client recording system, Adult information System (AIS). Although not the primary identifier within the system itself (a unique AIS number is generated), it is available to practitioners as a means of ensuring client details are correct within each system as used as a matter of course when corresponding with colleagues in health. Adult social care have met the required 95% Department of Health 'compliance' for rate data quality and, once final protocols are agreed, will be able to connect directly to the NHS Spine. The NHS number is currently collected and held within the client 'passport' details. An audit of current practice will be undertaken to establish that this number is used routinely for correspondence between health and social care. If it is found not to be the norm, communication will be made with all staff to ensure that this practice is adopted and embedded as usual practice.

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))

Yes, we are happy to confirm that this is the case. Portsmouth City Council has worked in partnership with Portsmouth CCG and Solent Healthcare NHS Trust to develop a memorandum of understanding for the purposes of information sharing. Each organisation is committed to adopting relevant systems and has secure email (via a N3 connection) that is used to send and receive client / patient sensitive information. Patient Transfer List Social care has worked with community health, PHT and Newton to develop a joint patient Transfer data base to enable all parties to input patient discharge progress into one IT system, this enables a robust method of sharing relevant information across the boundaries of health and social care making the PTL meetings more affective by only reviewing these patients that need to be escalated as opposed to just those who are medically fit which saves time for all partners and allows the meeting to be more action focused. VitalPac Work is continuing for social care staff to have access to VitalPac which would permit access to nominated adult social care staff to be able to view acute hospital clinical records and track patient referrals by ward in order to establish the following:

a) Is the patient currently clinically stable i.e. do they have an Early Warning Score of <3

b) Which ward is currently managing the patient (which may not be the same as detailed on the referral)

c) Access to the draft version of the electronic discharge summary – what are the clinical needs of the patient on discharge including anticipated destination

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d) Saving valuable social work time attending wards to patients who are/become medically unstable and unable to assess.

We will establish a robust mechanism of metric data measurement and plan to build upon existing data measurement tools. From September 2013 Kitbag was introduced as healthcare performance improvement specialists. Working as a whole system the aim is to take a different approach to improving patient services by using and interpreting data to proactively deliver capacity & demand management to identify surges in demand and allow the system to make pre-emptive operational decisions with greater confidence.

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

Data sharing arrangements between organisations which adhere to IG controls and Caldicott requirements are in place with a high level information sharing protocol (ISP) agreed at NHS and ASC Director level. The NHS number is used and there are shared arrangements for a Patient Transfer List) which all health and social care professionals will be feeding into.

Information Management and Technology to support the integration of care services is at the core of Portsmouth and South East and PCC strategies. Both the LA and the CCGs recognise the complexity and technical challenge involved in integrating information across care services provided by different care providers but have already made significant steps toward sharing care information across health and social care through the joint support of the Hampshire Health Record and the extensive use of the NHS number as a key identifier across all care systems.

Both the CCG and LA are keen to move forward to the next stage of the strategy which will concentrate on the development of shared care plans across all provider care services supporting patients with long term conditions and complex care needs.

The development of shared care plans will in the first instance explore solutions based on existing and readily available technologies including the Hampshire Health Record, primary, community and social care systems an messaging solutions to bring information together into a virtual care record.

Looking forward our strategy sets out a vision for an inter-operable approach to integrating care information for the longer term. Unfortunately existing systems and information standards are not mature enough for us to achieve this at the moment. However much work has been and continues to be done through the combined efforts of the HSCIC and the health care system industry in the on-going development of the Interoperability Toolkit (ITK). It is our intention therefore to use as much as we can from the ITK to ensure that system developments supporting an integrated care environment can be used as a foundation for future longer term care system interoperability.

This work is overseen and directed by a whole systems IT Enabled Change Board, comprising healthcare providers, commissioners and Social Care representatives.

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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 of hospital admission, and what approach to risk stratification was used to identify them

Current approaches to integrated care have focused on those 0.5% - 1% at the top of the long term conditions (Kaiser Permanent) triangle, with the most complex needs. GP's have been working towards identifying those most at risk within the local population and will be supported to further risk stratify the population. Over the next 5 years, we plan to shift our focus to ensure we are providing adequate support for vulnerable people and those at risk across all 3 levels of the triangle. If successful, this will enable us to operate more proactively and anticipate crisis in order to truly prevent ill health decline and improve outcomes for service users. We envisage broadening this to 5% initially and then to 20-30%, by the end of the 5 years.

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

Case Management and Care Co-ordination Routine treatment and pro-active monitoring in primary care and review of those most at risk of admission to acute care or long term placement will be undertaken. Risk stratification is used to ensure those at the highest risk of avoidable admission are prioritised for case management discussions between primary care and Integrated Community Care Service. One of the key principles of Scheme 1 will be to secure effective case coordination. Named care co-ordinators (case managers) will ensure effective liaison and continuity of care for people who need the service and their carers and will work with the individual and their carer to develop the care plan and signpost to other relevant services. The identification of the care co-ordinator or manager will be on the basis of a lead professional model. The care co-ordinator and / or the patient’s GP will be the first point of contact for any changes in a person’s need or concerns. Trusted assessors and information sharing will support this approach to ensure there is no duplication, delays or unnecessary hand-offs between professionals. Where a service user is known and has a care co-ordinator, that professional will continue to operate as the case manager and lead professional, co-ordinating the crisis elements of the service as appropriate and ensuring that decision making is in line with the care plan. Where changes are required these should be made in collaboration with the professionals that best know the individual. If the person is not being actively case managed or is not known to the Integrated Community Care Service the crisis management element of the service will work closely with colleagues to ensure that the individual’s long term needs are taken into account and that the care plan in place is in line with the risk stratification approach.

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Where are we now?

The Virtual Ward (VW) enables an integrated approach to the case management of those patients stratified (0.5% of a GP's practice population filtered to 0.1%) to be at highest risk to achieve improved health and well-being outcomes. The Virtual Ward is supported by a range of health and social care practitioners from primary, secondary and community care, including,

GP

Community geriatrician

Community nurses

Adult Social Care Social Workers

Occupational therapists

Physiotherapists

Older Persons Mental Health Weekly meetings of the VW team and discussion about individual cases, ensures accurate diagnosis and access to appropriate investigations and onward referral/signposting to specialist services as well as providing a forum for integrated care planning that supports people to remain in their home and when clinically safe to do so and avoiding acute hospital or care home admission Where we want to be

Achieving effective joint assessment and assuring a key lead professional is a key and underpinning component integral to our approach. There is recognised success in the approach taken to date but there is further work to be undertaken to ensure that all people at high risk of hospital admission have an accountable lead professional. The mechanism for this delivery will be through the schemes, principally scheme 1.

iii) Please state what proportion of individuals at high risk already have a joint care plan in place

Approximately 1000 people deemed to be at high risk have a joint care plan. This will include patients on the co-ordinating future care record in the last year of life.

8) ENGAGEMENT a) Patient, service user and public engagement Please describe how patients, service users and the public have been involved in the development of this plan to date and will be involved in the future

Involving patients, service users, their families, friends and carers, and the wider public, is central to our approach to the development of our BCF plan. Consultation and engagement in everything from the development of services to procurement of service providers is part of business as usual for us and our plan priorities mirror what we already know local people want.

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We have well-established structures and strategies in place for both bespoke and on-going patient/service user and carer consultation and involvement, e.g. Service User and Carer Involvement Charter, Carers Council, Dementia Cafes & Network, Portsmouth Disability Forum, General Practice Patient Participation Forum, Healthy Discussions online forum, membership bodies of local NHS Trusts etc. We have been using these, alongside other existing groups and channels such as Healthwatch Portsmouth to further refine and support our communication and engagement strategy. Communication and engagement strategy The initial focus of the communications and engagement strategy was to effectively identify, map and prioritise Better Care Fund stakeholders. Subsequently the strategy has focussed on developing and delivering an on-going programme of communication to support a programme of consultation and engagement on the options within Portsmouth's Better Care Fund Plan. Going forward we will continue to deliver against coordinated consultation plans, targeted to the specific stakeholders (staff, patients/service users, media, health/social care committees, councillors) and tailored to the ongoing needs of each scheme to enable options to be effectively consulted on. We will deliver a marketing campaign, developed with stakeholder input, to promote the benefits of the change for and patients, service users, carers and staff. The development of a communications and engagement strategy has been informed by the establishment of a project group with representation from the CCG patient champion, and communication and engagement leads for Portsmouth City Council, Solent NHS and Portsmouth Hospital Trust and Portsmouth Clinical Commissioning Group. This strategy has been developed to build understanding and facilitate consultation by:

identifying and developing targeted communications channels/tools for each main stakeholder group (service users and carers, NHS/council staff, councillors, providers of health and social care services, committees/boards)

creating a clear and concise communications for a range of audiences, introducing the scheme and explaining what will happen and when

regularly communicating with all stakeholders, maintaining interest, support and momentum

designing a programme of consultation for key stakeholder groups: o to capture views on how services should develop o to contribute to/secure support for a shared vision of the future o to identify potential issues o to ensure targeted communications channels/tools meet the needs of specific

stakeholder groups

designing a communications campaign to ensure key target audiences (service users, patients, carers/family/friends, NHS and council staff, other professionals and providers) are well-informed about changes to services and are aware of where their input into consultation have been used to shape local service

scoping a targeted marketing communications campaign to promote the benefits of the change for patients, service users, carers and staff and evolving to support behaviour change around choosing the right NHS and social care services to meet needs, and encourage take-up of early intervention/preventative services

The delivery of this work is expected to run until at least July 2015.

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We are engaging with the University of Portsmouth Ageing Network (UPAN) to consider how we can maximise our reach in terms of consultation regarding some of the projects we are prioritising during 2014-15. UPAN have offered to help facilitate targeted stakeholder consultation in relation to projects which may impact upon this population. We have established a stakeholder reference group meeting approximately every eight weeks, chaired by the Head of Better Care and reporting through its own representative to our Health and Social Care Partnership Board. The structure for this group was developed in liaison with the Portsmouth Voluntary and Community Sector Network (PVCN). The membership includes service users and carers, frontline staff from carers services, social care and NHS teams, clinical leaders, representatives of the care home sector, Healthwatch Portsmouth, and members of the voluntary and community sector including Pompey Pensioners, and the British Red Cross and Age UK Portsmouth who are both providers and representatives of PVCN.

The responsibility of the group is to act as an independent voice for Providers Service Users and connected Stakeholders to challenge and influence how the Better Care programme and associated schemes are delivered. The elected SRG representative will have membership on the HaSP Board. The SRG representative will share the group's views and concerns through evidence based feedback with a direct reporting structure to to HaSP and will act as a conduit to disseminate progress or engagement required by the HaSP Board to the SRG.

This group works alongside leaders from our Better Care projects to give insight and challenge on the development of their work, including communication and engagement elements.

Various activities have been used to reach the full range of stakeholders. This has included integrating engagement activity for Better Care with a range of existing NHS, city council, and voluntary and community sector channels such as publications; short and in-depth engagement exercises at NHS public meetings; and bespoke activity such as a stakeholder launch event to mark the six month countdown to the Better Care fund. Two consultation events with key stakeholders were held on the 17 March and 1 April. The first of these was to consult with key representatives in regard to the implementation planning of schemes one and two and this has helpfully informed our thinking about timescales, milestones and interdependencies. The second event on 1 April focussed on key project initiatives and deliverables in 2014-15 and plans to enable progress to be made in the shadow year towards realisation of full integration of health social and primary care in one locality. A further stakeholder event is planned in October. There has been a series of visits to discuss Better Care plans with established forums such as the Portsmouth Older Person's network and the patient experience, public & service information forum for people working with BME communities. These will continue, and a programme of visits to community and service user groups is being planned. When designing workshops and presentations such as the Reablement Stakeholder Event, we ensure that members of the public who have used the services we are talking about are present and involved throughout. We often have members of the public as key speakers at events - since sharing their personal stories is one of the most powerful tools we have to ensure a wider understanding of the impact these services and problems within the system have on individuals.

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Feedback from our patients and the public

Feedback from our stakeholders, patients and the public tells us that:

Services need to more joined up and communicate better with each other;

Access to all services must be timely and appropriate

We need to optimize the contribution of the voluntary and community sector

We need to empower and encourage individuals to take control of their own health

through healthy community programmes, education and raising awareness

We need to work with GP practices to improve access, including providing

alternatives such as telephone consultations and seven day working, whilst

ensuring they maintain quality

Access to secondary care services needs improving including introducing 24 hour,

seven day working

We must focus on quality

We need to reduce the number of inappropriate attendances at the Emergency

Department and inappropriate admissions and improve the Out of hours service

We need more support for those with long term conditions, such as dementia,

rheumatology, pain management and mental health conditions

We need to support GPs to use other local services as alternatives to acute

admissions

We need more services that are closer to home

IT solutions need to be developed quickly to enable information sharing

b) Service provider engagement Please describe how the following groups of providers have been engaged in the development of the plan and the extent to which it is aligned with their operational plans i) NHS Foundation Trusts and NHS Trusts

We recognise a collaborative approach between Portsmouth City, the South East Hampshire Clinical Commissioning Groups and Hampshire County Council is essential. Hampshire and Portsmouth have a shared aim for the Portsmouth and South East Hampshire System so that local people are not disadvantaged by any border system issues.

The Portsmouth and South East Hampshire system is complex, with three Clinical Commissioning Groups, two Local Authorities and two community and mental health NHS trusts working together with a single acute NHS trust. All partners are committed to working collaboratively, putting the person at the centre. The 3 CCGs have committed to commission collaboratively and ensure a consistency of provision across Portsmouth and South East Hampshire. A whole system Integrated and Urgent Care Strategy was developed in 2012 with the engagement of all providers and delivery of the local BCF plans in both Portsmouth and South East Hampshire will enable delivery of this shared

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strategy. This is integral to the system wide sustainability plan, which all partners are signed up to. This Better Care Fund Plan is the collaborative work of Portsmouth City Council, Portsmouth CCG. Both Solent NHS Trust and Portsmouth Hospitals NHS Trust have been long standing partners in the development of this work and have both had representation on the HaSP Board since the start of the programme. A BCF plan consultation event for providers was held in November 2013 which was well attended with representation from all statutory organisations (Portsmouth City Council, Solent NHS Trust and Portsmouth Hospitals NHS Trust and key voluntary and community sector providers, including Age UK Portsmouth and the British Red Cross. The event included workshops which tested the hypothesis of integrated delivery using the BCF planning format, reviewed progress towards meeting the national conditions and revisited and confirmed local priorities. The themes and ideas developed inform the plan and its central tenets. Overall the event demonstrated that there is a strong and united drive to work towards an integrated, preventative model and the presiding consensus is towards overcoming any anticipated challenges and risks. The event also identified that organisational flexibility, strong leadership, trusted relationships and a common goal were key to underpinning success. There was a strong consensus that there should be gravitation towards prevention, supported by a greater utilisation of the voluntary & community sector. This Plan has been shared with the STAR Board, which brings together local CCGs, the NHS acute trust and 2 local NHS Community and Mental Health providers, as well as Portsmouth City Council and Hampshire County Council. The group is supportive of the delivery of the plan. In the first phase of the programme, service providers will continue to be involved in the development of the plan, through the programme management and governance arrangements supporting implementation via the HaSP Board. In the second phase, service providers will be part of the co-design and production, along with other key stakeholders, in the development of the services that will deliver our BCF plan and ensure local services meet the needs of patients and users. In phase three, service providers will be actively engaged to ensure effective collaborative working during implementation of new services. NHS providers are also represented on the stakeholder reference group.

ii) primary care providers -

The CCG is led by five local GPs who are elected to represent all the GP surgeries in Portsmouth. The CCG as one of the key partners for delivering Portsmouth's Better Care agenda has a strong record of engagement with primary care as evidenced by receiving the HFMA Efficiency and Innovation Award for its work with member practices in commissioning, as well as being recognised by the Thames Valley and Wessex

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Leadership Academy as Governing Body/Board of the Year. The CCGs Clinical Leader Dr. Hogan also won the top national prize in the NHS Leadership Awards 2014 in the community leader category. Alongside the overall close links that the CCG executive team maintain with primary care providers, there have also been a series of engagement sessions with GPs looking at the projects within Better Care. A number of our underlying work streams have Primary Care representatives as the Executive Sponsors as well as ensuring that GPs are included in project teams throughout. During 13/14 the CCG funded a pilot which is ongoing to support the creation of a new post within general practice in the city - that of GP Clinical Director. The GP Clinical Director’s role was designed to act as a conduit for information sharing between localities and the CCG and to consider how resources might be better deployed to improve outcomes. In addition to this information sharing role these individuals have also acted as key contacts for reviewing support within care homes to facilitate clinical risk management and to better understand how links can be created between the acute and primary care teams. The four individuals appointed over the three clusters of health teams have provided an invaluable tool to facilitate discussions with primary care professionals and have used their cluster forums to discuss ideas and bring back feedback to the Health & Social Care Partnership Board which is overseeing Better Care for Portsmouth. Primary care teams are also represented on the stakeholder reference group.

iii) social care and providers from the voluntary and community sector -

The Local Authority & CCG engage with the Voluntary, Community & Social Enterprise sector in Portsmouth through a range of established and new mechanisms. Regular monthly updates are provided to the wider sector via the Integrated Commissioning Team's Voluntary & Community Sector Information Update. The update is sent to just under 800 organisations and individuals involved with the voluntary and community sector in the city to keep them in touch with local and national developments. Better Care has been the subject of numerous feature pieces in the update and regular space has been set aside for further communications.

This summer, following a consultation with both Voluntary Community and Social Enterprise (VCSE) and Statutory colleagues, the Portsmouth Compact was revised and re-launched. The compact outlines how the relationship between the local statutory sector and the VCSE sector can work more effectively to strengthen communities and improve people’s lives. While there are many differences between the statutory and voluntary sectors, which must be acknowledged and respected, the sectors have much in common. The ownership of the revised Portsmouth Compact sits with the Portsmouth Voluntary and Community Network, an established group of VCSE representatives with a mandate to provide a voice for the VCSE sector in Portsmouth. The City Council has signed up to the Compact and Clinical Commissioning Group is due to sign early Autumn up to the compact, committing to support the principles and undertakings therein.

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Following the revision and re-launch of the Portsmouth Compact a Providers Network has been set up to maintain and develop the commissioning relationship with voluntary sector existing or potential new providers of services. This Network is facilitated by the Integrated Commissioning Unit and feeds into the Compact review group. The first meeting of the Network was held 10th July 2014, when the focus of the meeting was the Better Care Fund. Ongoing meetings have been scheduled to cover other topics including Prevention and Early Intervention. Social care providers and the voluntary and community sector are included as stakeholder groups in the communications and engagement strategy, and a range of targeted communications and consultation approaches will be used to ensure these groups are engaged in and consulted on Better Care. See section 8a for more detail.

Social care and providers from the voluntary and community sector are also represented on the stakeholder reference group.

c) Implications for acute providers

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

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

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

We recognise that realising the shared vision for PSEH will mean significant change across the whole of our current health and care provider landscape. All providers of health and care services will need to change how they work, and particularly how they interact with patients and each other. The CCG and local authority commissioners are committed to working together to create a marketplace, and to effect the required behavioural and attitudinal change in the acute sector, to ensure that this happens at scale and at pace. The volume of emergency activity in hospitals will be reduced and the planned care activity in hospitals will also reduce through alternative community-based services. A managed admissions and discharge process, fully integrated with locality based specialist provision will mean we will minimise delays in transfers of care, reduce pressures in A&E and wards, and ensure that people are helped to regain their independence after episodes of ill health as quickly as possible. The approach will reduce the non-elective admissions and re-admissions and will necessitate a shrinking but more clearly focused acute sector which, in partnership with other providers in the health and care system, is more effective at managing patients better in the community. A more developed understanding of hospital data, admissions and discharges will be required and the financial effects modelled. Our ambition is to ensure that:

Robust admission avoidance and early supported discharge mechanisms and

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pathways are in place to ensure that only acute interventions are undertaken within the acute setting.

long term assessments / decisions about long term care needs are not undertaken within the acute environment and that these assessments and therapeutic interventions should wherever possible be undertaken in the individual’s own home or in a community based environment where this is not possible.

Maximising the use of community based specialist services, providing support and advice to GPs, as well as utilisation of a range of ambulatory emergency care pathways.

bed based service provision enables any deterioration in the patient’s health to be managed in a community environment, thus ensuring services are wrapped around patient need and choice with a focus on the national agenda of community based care.

there is a shift of current bed based services away from acute and community ‘step-down’ beds towards an increase of step up beds in a community environment

the cohort of people using bed based provision may have complex needs and services must be appropriate to meet this level of acuity

Given the complexity of the system the need to work closely at system level with all partners to ensure key acute services are not destabilised is crucial. The System Transformation and Resilience Board, where all Chief Executive Officers are represented, will oversee this process. In addition the 3 local CCGs, through this group, are aiming to develop an alliance contracting framework for 15/16, with a risk and reward mechanism. The financial details of this are being worked through and this new contracting arrangement will support delivery of this plan across all main existing NHS providers. Portsmouth CCG has therefore worked closely with partner CCGs in Hampshire to ensure there is consistency of approach. For both the Hampshire and Portsmouth area, the non-elective activity reductions across the Clinical Commissioning Groups that are set out in the Better Care Fund equal the planning assumptions that we have already made for our 2015/16 QIPP plans. Once local assumptions about growth have been taken into account, these plans equate to a 3.5% reduction across Hampshire and 3% across Portsmouth. It should be noted that:

The actual percentage varies by Trust and commissioner (Hampshire CCGs only).

All current plans for non-elective activity reduction for 2015/16, are as set out in

CCG strategic and operational plans.

The reduction will be measured against Monthly Activity Reporting for non-elective

admissions and as such will not equate directly to contract activity for non-elective

spells.

The cut of activity is by Health and Well-being Board and therefore is also not

reconcilable to individual CCG contracts with providers.

The figures in the Portsmouth operating plan are part of a 5 year trajectory to achieve a 15% reduction in NEL admissions from a baseline of 20384 (1314 FOT) to 17277 in 2018/19.

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The information on this basis (MAR plans, adjusted for QIPP, by Health and Well-being Board) is set out in the attached templates. PHT response is included in BCF template annex 2.

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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance

Scheme ref no.

Scheme 1.

Scheme name

Integrated Health and Social Care community teams

What is the strategic objective of this scheme?

The strategic objective of this scheme is a fully integrated locality team based approach to ensure that individuals are empowered to self-manage to maximise their independence, health and wellbeing.

Overview of the scheme Please 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?

The model of care proposed is:

The team will operate under a single line management structure with strong clinical and social care leadership. The multi-disciplinary team will be co-located to ensure seamless use of systems and enable short communication

The team will consist of GP, social care staff, community nursing, community geriatrician, allied professionals and the voluntary sector working in a joined up way to deliver a single assessment and lead professional approach.

Care co-ordination will range from intensive case management requiring a multi-disciplinary approach to welfare checks, light touch monitoring and support similar to that provided by dementia adviser model. Care co-ordination will be provided through a named worker

A single personalised care plan approach will be required which is owned and understood by the individual and reflects their changing needs including supporting them through end of life decisions

The team will recognise and value the specialist knowledge, skills and legal framework of each discipline whilst maximising opportunities to streamline delivery to avoid duplication of effort

There should be an appropriate and rapid community response across 24/7 to avoid unnecessary admission to hospital or residential care

The patient cohort to be supported are: Care co-ordination, appropriate to need, irrespective of Fair Access to Care eligibility will be available for;

People with Long term conditions

People with diagnosis of dementia

People requiring end of life care

People with health and social care circumstances adversely affecting their physical and mental wellbeing

People over 75 year who will have a GP check and will receive care co-ordination

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and intervention as appropriate. People will be identified using risk stratification based on current and predicted use of health and care services.

Milestones for delivery Delivery of this scheme requires significant organisational change across the current health and social care system to be achieved over 5 years. The delivery milestones for the next three years are outlined below:

2014/15 Milestones

Age UK Care Navigation Scheme mobilisation in the central cluster.

Integrated Care Team(ICT) pilot launched in the North cluster

Extension of Clinical Directors pilot in all 3 clusters to provide clinical leadership within the localities and support implementation of the schemes

Increased capacity provided within community nursing to strengthen ability to prevent emergency admissions

2015/16 Milestones

AGE UK Care Navigation scheme fully operational

ICT roll out to other 2 localities

ICT clinical leadership model developed

Single assessment and care planning process in place 2016/17 Milestones

Single care record in place

New workforce structure in place and supporting training programme

Robust, appropriate 7 day access to primary and community services

The delivery chain Please provide evidence of a coherent delivery chain, naming the commissioners and providers involved

The work stream requires a multi-disciplinary team approach to integration between primary care, community health and social care and the voluntary sector that will need to be to co-designed and produced with commissioners. As identified previously the Integrated Commissioning Unit (ICU) in Portsmouth, operating under a section 75 agreement between the CCG and local authority, enables joined up commissioning decisions to be taken around developing services within the city, including in relation to the Integrated locality team development. Whilst currently there is no defined delivery chain the providers and stakeholders identified as needed to be involved in the design and production of the integrated locality teams are as follows.

Organisation name Rationale for involvement

Solent NHS - PRRT Community health provider of services including community nursing, therapies, OPMH, re-ablement and rehabilitation services

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Primary care 24 GP practices in the City, the Locality Clinical Directors and the Portsmouth GP Alliance

PHT Acute provider including provider of community geriatrician services

ASC Commissioner of social care services, nursing homes, extra care and residential.

Voluntary Community Sector Age UK, Alzheimer's Society

The evidence base Please 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

In consideration of the design of this work stream, the evidence provided within the technical guidance and nationally including Kings Fund and Nuffield reports on Integrated Care, the Torbay care trust work and early results from Cornwall pathfinder project have been considered. We have also reviewed local evidence following the virtual ward pilot scheme developed by field staff to explore integration of multi-disciplinary work which started in September 2012, as well as learning from integration of existing teams such as PRRT and CHC. The Portsmouth pilot provided a compounding evidence to develop the scheme. While it was acknowledged that the numbers of patient cases analysed represented a relatively small cohort of the GP's practice populations there was in addition evidence that;

hospital stays have been avoided;

information about hospital admissions was collected; both for a group of specified Health Resource Group's (HRG's) and also for all HRG's. Although the information collected showed a small

decrease in admissions, given the rapid increase of the older population in Portsmouth City this was seen as a positive outcome of the pilot.

The study demonstrated a decrease in re-admissions for both pilot and non-pilot sites, but by significantly more in the pilot site. This would indicate that the pilot was one of a number of system wide factors contributing to admission reduction When people are admitted to hospital, data showed length of stays were much shorter in general for people at the pilot practices. Only a very minor number of stays exceeded the trim point for their HRG, under 1% for both the pilot and non-pilot areas, changing little between the years. There is still further data collection required to evidence the effect on readmissions as absolute figures are very low here. This evidence has informed the on-going development of the model.

Investment requirements Please enter the amount of funding required for this scheme in Part 2, Tab 3. HWB Expenditure Plan

.

Impact of scheme Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan

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Please provide any further information about anticipated outcomes that is not captured in headline metrics below

Patient and service user impact

Improved health & wellbeing

Maintaining independence for longer

Reducing social isolation

Improved access to services

Continuity of care

Shortened time between identification of need and delivery of service

Say it once Organisational impact

Reduction in numbers of emergency admissions to acute care

Reduction in the length of stay in acute care, particularly for those of 14 days and over

Reduction in the number of people transferred to into long term care - Nursing home or residential care

Increase in the number of people accessing and utilising personal care budgets

Reduction in number of multi-disciplinary assessments

Increase satisfaction in provision of service users care

Feedback loop What 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?

In analysis of the scheme a system of both qualitative and quantitative measures will be applied, as per the virtual ward pilot which will include:

Emergency admission activity

ED attendances of known case managed patients

Domiciliary and residential care package rate and cost

Patient satisfaction feedback

Service providers positive feedback

Peer Review with comparator organisations

Benchmarking

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

Achievement of significant cultural change in the way that organisations manage the delivery of care and allocate resources that will need to be reflected in workforce strategies and staff development

Organisational change to existing staffing establishments and line management structures for all organisations

Utilisation of health flexibilities, pooled funds and delegated budget management to support commissioning and operational delivery

Alignment of IT strategy & potential investment to support an integrated approach and enable effective information sharing across the team.

Early intervention of Health and Social Care (with people who are likely to have low to moderate needs) to prevent escalation and exacerbation of needs and facilitate health and social gains

Secondary care resource delivered through a more ambulatory care approach

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and community based pathways, providing specialist advice and support to GPs e.g. community diabetes pathway

A more significant role for the voluntary and community sector and work collaboratively across the whole sector to limit duplication of service delivery and prevent referral to statutory services

Partnership working with GPs so they can access the whole range of social care and voluntary and community support services

Workforce development to enable greater flexibility around provision. A specific work stream has been developed to review this. Joint working is already in place in several locations in the city and this will be further developed.

Need and demand profiling: any plans around re-commissioning services needs to be future proof as far as possible. A work stream is in place to develop cohort stratification alongside mapping service demands and pressures against demographic changes.

Scheme ref no.

Scheme 2.

Scheme name

Review of Bed Based provision

What is the strategic objective of this scheme?

Bed based services should promote independence and empower self-management wherever possible. The strategic objective of this work is to ensure that people are supported in the right place, at the right time, and with the right services. Furthermore, this work stream will provide certainty that right capacity of beds is available to meet demand. Key objectives will be to ensure:

Robust admission avoidance and early supported discharge mechanisms and pathways are in place to ensure that only acute interventions are undertaken within the acute setting.

Long term assessments / decisions about long term care needs are not undertaken within the acute environment. These assessments and therapeutic interventions should wherever possible be undertaken in the individual’s own home or in a community based environment where this is not possible.

Bed based service provision will enable deterioration in the patient’s health to be managed in a community environment, thus ensuring services are wrapped around patient need and choice with a focus on the national agenda of community based care.

Shift of current bed based services away from acute and community ‘step-down’ beds towards an increase of step up beds in a community environment

Overview of the scheme Please 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?

The project will review the model of care offered in the different bed settings and evaluate

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the effectiveness of these before recommissioning services to apply these models of care to maximise the outcome for the individual in the most efficient way. Model of care

The bed service provision will work with the integrated health & social care community teams, as part of an integrated community delivery model, preventing avoidable acute hospital admissions and supporting appropriate early discharge. by providing assessment of patients, short term support and interventions

Where admission to bed based services is required, every effort should be made to ensure a minimum length of stay as possible. Where patients are receiving care co-ordination the decision making should be in line with the personalised care plan. In all cases, discharge planning should begin at the point of admission and should be in partnership between the bed based provision and the integrated health & social care community team.

There should be an appropriate and rapid response across 24/7 to access bed based provision in order to avoid unnecessary admission to hospital or residential care

Bed based services need to be able to accommodate people with challenging behaviour

Primary care, in partnership with community health and social care through the integrated locality based services will be required to provide increased medical cover and responsibility to support bed based provision, supported by secondary care colleagues.

Independent bed based providers may be required to change existing service models to support shorter term placements, possibly for assessment. In addition care homes may also be required to cope with frailer, more complex patients and those requiring end of life care. Additional support from primary and community health services is likely to be required to support this.

The patient cohort to be supported are:

Bed based services will be required to support adults who are medically stable and require assessment, treatment and rehabilitation including, personal care, OT and physiotherapy, as an alternative to an acute hospital environment, where these cannot be provided for in the individuals own home.

The cohort of people using bed based provision may have complex needs and services must be appropriate to meet this level of acuity

Milestones for delivery Delivery of this scheme requires significant organisational change across the current health and social care system to be achieved over 5 years. The delivery milestones for the next three years are outlined below: 2014/15 Milestones

Community bed audit completed

Review and redesign of OPMH beds and the Grove complete and new bed model established

Scheme to enhance GP and community health input into care home beds implemented to reduce admissions

First phase of demand and capacity work completed

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2015/16 Milestones

2nd phase demand and capacity work complete

Re-specified, simpler access to all relevant beds within the system

Strengthened integrated hospital discharge model, better aligned with PRRT and community locality working in place.

Short term social care bed based and step up bed based capability increased to further avoid long term care admission

2016/17 Milestones

Expanded bed capability across the system

Bed based services better fit to match needs operating 7 days per week

The delivery chain Please provide evidence of a coherent delivery chain, naming the commissioners and providers involved

As identified above the Integrated Commissioning Unit in Portsmouth, operating under a section 75 agreement between the CCG and local authority, enables joined up commissioning decisions to be taken around developing services within the city. This integrated team will be the lead commissioning entity for community bed based services and residential/nursing care homes and extra care homes within Portsmouth.

Community bed based provision in Portsmouth is delivered through the local authority and through Solent NHS Trust, with one of the four units being jointly operated. It is anticipated that there should be closer integration between the community bed units in the future and this will include exploring opportunities for flexing the staff teams between the units to ensure that the service can adjust to meet the needs of the population. The community bed units in the city already have close links with consultant geriatrician and GP support commissioned in addition to the standard acute and primary care provision. Social work input is provided at all of the units to enable increased flow through the beds and many people using the services go on to be supported by the third sector commissioned through the reablement work stream (see scheme 3). One of the additional elements we will be looking to develop through this work is closer integration with housing services. The delivery chain will therefore include:

Solent NHS Trust: as provider of bed based services and through its community services such as community nursing, therapy, OPMH and its specialist teams such as the palliative nursing team.

Portsmouth City Council - Adult Social Care and Housing teams - as provider of bed based services and through its services such as the Independence & Wellbeing Team, social work and housing provision.

Integrated services such as Portsmouth Rehabilitation and Reablement Team (a joint multi-disciplinary team of Solent NHS Trust and Portsmouth City Council).

Portsmouth Hospital Trust

GPs

Third sector organisations

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Care home providers (residential and nursing)

Rowan's Hospice

The evidence base Please 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

Across Portsmouth we have 71 community beds available over 4 units in 3 sites; this is above the national average number of beds per 100,000 weighted population, and equates to a maximum capacity of 25,915 community bed days per annum. Each of the four locations in Portsmouth provide very different models of care for a different mix of patient needs, therefore it is not practical to make comparisons directly between all of the units however certain key themes can be looked at. Comparisons are also being made against community bed facilities across South East Hampshire and Fareham & Gosport CCG localities, as well as making use of the 2011 NHS Benchmarking review.

Virtually all patients in community beds are elderly, with the average age being just under 80 years old. Nationally seven patient profiles have been identified as using community beds: 1. Sub-acute e.g. UTI or flu 2. Intensive rehabilitation e.g. following fractured neck of femur, major surgery 3. Specialist e.g. stroke rehabilitation

4. Complex elderly with co‐morbidity 5. End of life care 6. Neuro rehabilitation e.g. Multiple Sclerosis or Parkinson’s Disease 7. Respite A local audit has shown the most common profiles within the 71 Portsmouth beds are Intensive Rehabilitation and Sub Acute, although the mix varies across sites as does the average patient dependency. Alongside the community beds sit the Medicines for Older People, Rehabilitation & Stroke (MOPRS) wards at QA. A 2013 review showed that there are two quite separate patient types being treated on these wards:

51% stay less than 3 days and are essentially MAU + patients

The remaining 49% stay considerably longer The project will review the impact and availability of community services for these two cohorts.

Our current system for community beds is heavily based on step down care (91%) rather than step up (9%). The original project scope identified that transformational change would be required to develop more of a step up culture and this is supported by the data received so far. A managed admissions and discharge process, fully integrated into local specialist provision will mean we will reduce length of stay and ensure that people are helped to regain their independence after episodes of ill health as quickly as possible.

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The approach will reduce the non-elective admissions and re-admissions and will necessitate a shrinking but more clearly focused acute sector which, in partnership with other providers, is more effective at managing patients better in the community. A more developed understanding of hospital data, admissions and discharges will be required and the financial effects modelled.

A key area which impacts on hospital activity is the link between age and hospital stay - an example of this is in relation to the MOPRS wards projected bed need should no changes be made to the system.

The information team within the acute trust is currently working to produce data which will demonstrate the variability of LoS for individuals within the MOPRS wards based on CCG residence. Anecdotal evidence supports that those residents within the Portsmouth system experience shorter LoS and smoother discharge pathways to services such as community beds - however at this point we do not have a clear evidential base for this position.

Ensuring effective community bed based services will deliver greater flow through the system and shorter LoS so that additional capacity does not need to be develop din terms of bed volumes in line with the population shift (an example of which is demonstrated at 1.3 above). Although the services have been experiencing demographic pressures and higher complexity of cases the LoS to date has remained stable or improved in many services and the project will look to improve this further.

Alongside measuring LoS we are measuring outcomes for individuals in terms of achieving their stated goals, returning to their usual place of residence, and avoiding readmissions. Evidence has been gathered from all of the existing services and is being mapped against best practice examples, neighbouring areas, and the NHS benchmarking studies. The findings from the community bed audit has further evidenced the appropriateness in the use of the community bed.

Spinnaker Ward (Solent NHS Trust for Portsmouth City residents) - Average LOS by month

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Investment requirements Please enter the amount of funding required for this scheme in Part 2, Tab 3. HWB Expenditure Plan

Impact of scheme Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan Please provide any further information about anticipated outcomes that is not captured in headline metrics below

Patient and service user impact

Improved health & wellbeing

Maintaining independence for longer

Improved access to services

Continuity of care

Reduced duplication of assessment

Improved patient experience

Less time spent in hospital Organisational impact

Reduction in numbers of emergency admissions and readmissions to acute care

Reduction in the length of stay in acute care,, particularly for those of 14 days and over

Reduction in the number of people transferred to into long term care - Nursing home or residential care

Reduction in number of multi-disciplinary assessments

Increase satisfaction in provision of service users care

Potential efficiency savings to be achieved

Feedback loop What 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?

In analysis of the scheme a system of both qualitative and quantitative measures will be applied, which will include:

Emergency admission activity

ED attendances of known case managed patients

Length of stay in acute hospital

Acute occupied bed days rates

Discharge to usual place of residence

Appropriateness of access to bed based services

Timeliness of access to bed based services

Domiciliary and residential care package rate and cost

Patient satisfaction feedback

Service providers positive feedback

Peer Review with comparator organisations

Benchmarking

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

Achievement of significant cultural change in the way that organisations manage the delivery of bed based provision and allocates resources that will need to be

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reflected in workforce strategies and staff development.

This will be reflected by organisations operating an integrated approach to delivery of bed-based provision, including partnership working with the independent sector.

Organisational change to existing bed numbers and bed based services provided by all organisations to manage operational capacity of bed based services and budgets across organisations.

Aligned estates strategy to optimise use of all capacity available.

Utilisation of health flexibilities, pooled funds and delegated budget management to support commissioning and operational delivery

Alignment of IT strategy & potential investment to support an integrated approach and enable effective information sharing across services.

Secondary care resources delivered through a more ambulatory care approach and community based pathways

A reduction in acute occupied bed days and a move towards more step up provision to avoid acute hospital admissions

Workforce development to enable greater flexibility around provision. A specific work stream has been developed to review this. Joint working is already in place in several locations in the city and this will be further developed.

Need and demand profiling: any plans around re-commissioning services needs to be future proof as far as possible. A work stream is in place to develop cohort stratification alongside mapping service demands and pressures against demographic changes.

Scheme ref no.

Scheme 3

Scheme name

Increasing Reablement provision What is the strategic objective of this scheme?

The strategic objective is to increase the provision of re-ablement based services 'which provide a personalised and responsive approach to deliver a range of service and interventions which enable people to maximise their potential and quality of life and live as independently as possible for as long as possible.

Overview of the scheme Please 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?

Model of care

Reablement services support people to “do things for themselves, rather than having things done for them.” improving wellbeing with an independent and confident recovery for people after hospitalisation avoiding readmission.

Reablement services must uphold this approach, working collaboratively with stakeholders and as part of the integrated care delivery model.

Service Users will be entitled to a period of up to six weeks of intermediate care, based on assessed need, in line with National Intermediate Care Guidance (DH 2010). This should be free at the point of delivery and not subject to social care

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financial assessment.

Reablement services must ensure consistency of response, effectively manage the workforce, recognising the need to respond to peaks and troughs in demand and seasonal pressures.

There should be an appropriate and rapid access to reablement services to avoid unnecessary admission to hospital or residential care.

Services will be provided in an integrated way with other elements of the integrated locality based model of care and seen as an integral part of the pathway and aligned with the wider rehabilitation pathways and bed based provision.

Cohort of patients to be supported:

Reablement services must be able to respond to and provide support for people with dementia and older people with functional mental health problems, where needs are stable and do not require secondary psychiatric support on an inpatient basis.

Reablement services will support the learning or relearning of the skills necessary for daily living which some people may have lost through deterioration in health and/or increased support needs. A focus on regaining physical ability is central with an emphasis on regaining independence and better functioning.

Support will be for people whose health and independence is in long term decline, but who are unlikely to get health or social care support until reaching a crisis

People with long term care needs also need ot be able to access the 'reablement offer'

Milestones for delivery Delivery of this scheme requires significant organisational change across the current health and social care system to be achieved over 5 years. The delivery milestones for the next three years are outlined below:

2014/15 Milestones

Evaluation of the reablement pilots complete

Increased capacity within PRRT

24 hr support in the home pilot complete and evaluated

Pilot SPA for voluntary sector services for GPs underway 2015/16 Milestones

Strengthened relationship between PRRT and the wider re-ablement community, development of a hub and spoke model of support within localities

Increased capacity within voluntary sector reablement services following pilots

Robust 24 hour support in home model in place to enable more people to remain at home

Community neuro-rehab pathway review completed

Reablement services across the pathway re-specified to ensure appropriate access and improved outcomes

Training programme up and running to support reablement provision within domiciliary care agencies

2016/17 Milestones

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Comprehensive network of reablement services across the system working on 7 day basis and integrated with locality teams and PRRT.

Training programme up and running to support reablement provision within domiciliary care agencies

The delivery chain Please provide evidence of a coherent delivery chain, naming the commissioners and providers involved

The work stream requires an increase in provision of 'up-front’ reablement services to prevent admission, increase in package of care or following discharge from hospital. Reablement services are likely to be provided by a greater extent by the voluntary sector and must be seen as an integral part of the pathway. multi-disciplinary approach to achieving this between the voluntary sector social care, primary care and community health partners will need to be to co-designed and produced with commissioners. As identified previously the Integrated Commissioning Unit (ICU) in Portsmouth, operating under a section 75 agreement between the CCG and local authority, enables joined up commissioning decisions to be taken around developing community based services within the city, including in relation to the development of reablement services.

Whilst currently there is no defined delivery chain the providers and stakeholders identified as follows as needed to be involved in the design and production of reablement services

Organisation name Rationale for involvement

Voluntary Community Sector A range of voluntary and community groups across the City

Solent NHS - PRRT Community health provider of services including community nursing, therapies, OPMH, re-ablement and rehabilitation services

Primary care 24 GP practices in the City, the Locality Clinical Directors and the Portsmouth GP Alliance

PHT Acute provider including provider of community geriatrician services

ASC Commissioner of social care services, nursing homes, extra care and residential.

The evidence base Please 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

In consideration of the design of this workstream and the development of the current rehabilitation and reablement services, evidence has been considered from a range of

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national guidance and studies. This has included Intermediate Care Guidance the “Care Services Efficiency Delivery (CSED) Homecare Reablement Prospective Longitudinal Study Final Report Summary (DH November 2010)1”.

Locally we continually review and monitor the successful outcomes of the services developed. Studies from the CSED project have been used throughout to as examples of best practice and to support development of local services, as well as benchmarks to establish confidence in services developed and outcomes being delivered.

In particular we have reviewed the PRRT service against this model. The CSED study looked at intermediate care services directly analogous to PRRT examining the financial impact, clinical and user led outcomes for four intermediate care services and observed significant reduction in costs for health and social care services for up to two years after providing reablement services similar to those provided by PRRT.

The focus of the CSED report in 2010 is on financial benefits to commissioners, however improved patient experience was also considered in some detail and links established between the two areas. In the CSED report, benefits to the service user are considered in terms of the Adult Social Care Outcomes Toolkit (ASCOT) framework. The report looked to demonstrate cost effective services correlated with better patient experience. Furthermore, in the CSED report lower care costs were said to indicate better outcomes for the individual. We used the same approach to analyse effectiveness of PRRT. The Portsmouth Rehabilitation and Reablement Team (PRRT) provides outcomes similar to the four schemes considered by the Department of Health Care Services Efficiency Delivery in the Retrospective Longitudinal Study2. In 3 of the schemes considered by the CSED report, 53% to 68% of service users left reablement requiring no immediate homecare package - in Portsmouth3 this figure was 64% for the 2011 cohort and 72% for 2012. In the CSED schemes 36% to 48% of service users continued to require no package for 2 years after reablement, in Portsmouth this figure is 48% for 2011 and 62% for 2012 (for one year after reablement). In the CSED schemes, of those service users that required a homecare package within 2 years after reablement, 34% to 54% had maintained or reduced their homecare package 2 years after reablement. In Portsmouth 2011, 37% had maintained or reduced their homecare package 2 years after reablement and in 2012, 60% (at 1 year after reablement). In addition to this we have piloted a number of local reablement based schemes provided by 16 local voluntary and community groups. Similar methodology is being used to evaluate these services and provide evidence of their success.

Investment requirements Please enter the amount of funding required for this scheme in Part 2, Tab 3. HWB Expenditure Plan

Impact of scheme Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan Please provide any further information about anticipated outcomes that is not captured in

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headline metrics below

Patient and service user impact

Improved health & wellbeing

Maintaining independence for longer

Reducing social isolation

Improved access to services

Increased support within their community

Continuity of care

Shortened time between identification of need and delivery of service

Less time spent in hospital

Able to stay in their own home for longer Organisational impact

Reduction in numbers of emergency admissions and readmissions to acute care

Increase in numbers of people remaining in their own home 91 days after discharge

Reduction in the length of stay in acute care,

Reduction in the number of people transferred to into long term care - Nursing home or residential care

Increase in the number of people accessing and utilising personal care budgets

Reduction in number of multi-disciplinary assessments

Increase satisfaction in provision of service users care

Reduced reliance on statutory provision

Long term package costs for individuals should be reduced due to achievement of greater independence and reduced requirement for more intensive long term support

Improved cost effectiveness across the system, achieved through reduction in care packages that are not ‘right sized’ and therefore not reflective of reduced need. This will enable reductions in domiciliary care levels for individuals and delays in requirement of long term residential care

Feedback loop What 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?

In analysis of the scheme a system of both qualitative and quantitative measures will be applied, which will include:

Emergency admission activity

ED attendances of known case managed patients

Length of stay in acute hospital

Acute occupied bed days rates

Discharge to usual place of residence

No of people remaining at home 91 days after discharge

Appropriateness of access to reablement services

Timeliness of access to reablement services

Domiciliary and residential care package rate and cost

Patient satisfaction feedback

Service providers positive feedback

Peer Review with comparator organisations

Benchmarking

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

Achievement of significant cultural change in the way that organisations deliver a reablement approach consistently throughout the pathway. This will be reflected by organisations operating an integrated approach to delivery of reablement services

A more significant role for the voluntary and community sector and work collaboratively across the whole sector to limit duplication of service delivery and prevent referral to statutory services

Effective information and risk sharing from a variety of sources eg the voluntary, community about potential deterioration of individuals to enable earlier intervention and support to be provided.

Partnership working with GPs so they access the whole range of social care and voluntary and community support services

Workforce development to enable greater flexibility around provision. This will include a reablement focused approach to the provision of domiciliary care. A specific work stream has been developed to review this. Joint working is already in place in several locations in the city and this will be further developed.

Need and demand profiling: any plans around re-commissioning services needs to be future proof as far as possible. A work stream is in place to develop cohort stratification alongside mapping service demands and pressures against demographic changes.

Early intervention of Health and Social Care (with people who are likely to have low to moderate needs) to prevent escalation and exacerbation of needs and facilitate health and social gains

Scheme ref no.

Scheme 4

Scheme name

Prevention

What is the strategic objective of this scheme?

To work with individuals, communities and organisations to tackle the underlying causes of ill health and reduced wellbeing (primary prevention) and improve the identification and treatment of individuals with early stages of disease (secondary prevention).

Overview of the scheme Please 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?

Portsmouth City is a densely populated urban area, with areas of marked deprivation. There are correspondingly high levels of smoking, obesity and alcohol use by residents. As a result the City has high levels of respiratory (chronic lung disease and cancer), cardiovascular (heart attacks and strokes) and gastrointestinal diseases (alcoholic liver disease). The effects of this are made worse by late presentation to care services. This is demonstrated by the high level of premature mortality and low life expectancy for residents, which is statistically significant from the England average for men.

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This scheme is focused on tackling the upstream causes of poor health and is underpinned by Portsmouth City's Health and Wellbeing Strategy. There are three key elements:

1. Working across organisations to tackle the underlying causes of ill health including poverty, education and crime. Portsmouth City's Health and Wellbeing Strategy has just been refreshed using the Joint Strategic Needs Assessment to identify the key issues facing the City. There are 5 themes: best start, promoting prevention, supporting independence, intervening earlier and reducing inequalities. Each has three work streams and an action plan is now in the process of being developed by all stakeholders. These work streams are essential to improving the wider determinants of health and many of the actions are directly linked to the overall aims of the Better Care Fund.

2. Work with individuals, communities and the community and voluntary sector to prevent disease and improve quality of life by focusing preventative services on those most at risk of developing illness. The City Council, with partners, is redesigning preventative services to target those individuals most at need and is a work stream within the Health and Wellbeing Strategy. A number of the current public health services, including health trainers, smoking cessation, and alcohol, are being integrated in to a single service and based in the community; this integrated wellbeing service will also provide advice around the wider determinants that affect health and wellbeing, including housing and income maximisation. A key role of the hubs will be to work with communities to identify needs and aspirations. Relevant outcome measures are described under other work streams but tackling inequalities will necessarily mean improving the health and wellbeing of males of all ages, of Black and Minority Ethnic groups etc. Over time, different hubs are likely to have different outcomes reflecting the needs of their local communities, local assets etc. The key intelligence need is to conduct the health and lifestyle survey of adults. The anonymised results will provide baseline information about current health and lifestyle issues, trend information when compared to the previous surveys in 1999 and 2005, and help us identify areas for direct action by the new lifestyle service.

As well as providing one to one help and advice there will be a strong emphasis on adopting an asset based approach, working with the local community and voluntary sector. The development of this will be closely linked with the integrated care pilot. It will work with the Independence and Wellbeing team of adult social care that provides support to older people and carers. This service will initially be for adults but this will become more closely integrated with children's services as these are reviewed and redesigned. There has been extensive stakeholder engagement and the service is currently being piloted in Somerstown. This work will be underpinned by a comprehensive social marketing campaign, which will be based around both national and local initiatives. This will also be closely linked with the work to increase identification of individuals with early stage of disease, maximising the effects of the NHS Health Check programme. Two other important initiatives within this element are the continued roll out of the local Making Every Contact Count programme across the City and the implementation of a City wide workplace health strategy.

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3. Working with primary care services to increase the identification of individuals with early stages of disease and streamline their management. Late presentation is a factor in the poor health outcomes experienced by residents. Local health data shows that there are lower than expected numbers of residents with many long term conditions. This element will be looking to maximise every opportunity for early identification and will be closely linked to schemes within the previous element (e.g. Making Every Contact Count, work place health, social marketing and the development of the integrated wellbeing service). It will also learn from other successful schemes such as the local Breathe Easy Campaign, which was run in partnership with primary care, to identify people with chronic lung disease. A systematic programme is also being developed to review the long term conditions pathways in primary care building on the success of the redesign of the local community diabetes service, musculoskeletal service and ongoing work with chronic respiratory disease pathway. Opportunities for streamlining services will be identified and there will be an emphasis on ensuring that opportunities for modification of lifestyle risk factors and self-care are embedded throughout pathways; this will also include the feasibility of using novel technology such as telehealth. This will be closely linked to the development of the integrated wellbeing service and the integrated care pilot scheme, focusing on the management of individuals with co-morbidity and multiple long term conditions.

Secondary prevention and support will be factored into this work stream Milestones for delivery Delivery of this scheme requires significant organisational change across the current health and social care system to be achieved over 5 years. The delivery milestones for the next three years are outlined below: 2014/15 milestones

Mapping exercise of LTC pathway services complete

Lifestyle hubs mobilisation

First phase roll out of improved self management strategies within localities

2015/16 milestones

Locality based self management support groups up and running and utilisation of personalised self care management plans well established

Re-commissioning of LTC pathways to improve early presentation / diagnosis

More ambulatory care and community based service models in place to support people with long term

2016/17 milestones

Effective commissioning of integrated LTC pathways linked to prevention and self management strategies

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The delivery chain Please provide evidence of a coherent delivery chain, naming the commissioners and providers involved

The Integrated Commissioning Unit (ICU) in Portsmouth, operating under a section 75 agreement between the CCG and local authority, enables joined up commissioning decisions to be taken around developing services within the city, including in relation to the commissioning of the prevention agenda. Whilst currently there is no defined delivery chain the providers and stakeholders identified as needed to be involved in the design and production of the prevention workstream are as follows.

Organisation name Rationale for involvement

Portsmouth City Council Through Adult Social Care and Health, Licensing and Safety departments and public health

Primary care The CCG, 24 GP practices in the City, the Locality Clinical Directors and the Portsmouth GP Alliance

Voluntary Community Sector A range of voluntary and community groups across the City

Solent NHS Trust Community health provider of services including community nursing, therapies, OPMH, re-ablement and rehabilitation services

Portsmouth Hospitals NHS Trust Acute provider including provider of community geriatrician services

The evidence base Please 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

National evidence such as NICE guidelines (e.g. smoking, healthy weight, behaviour change and community development), the Marmot Report, Department of Health, Public Health England and the King's Fund. Learning from other areas e.g. Derby integrated lifestyle service and BT Cornwall telehealth. Local learning e.g. LAEDI campaigns, Breath Easy initiative, Healthy Pompey, Chances for Change, the European Integration Fund and the Age UK care navigator programme.

Investment requirements Please enter the amount of funding required for this scheme in Part 2, Tab 3. HWB Expenditure Plan

Impact of scheme Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan

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Please provide any further information about anticipated outcomes that is not captured in headline metrics below

Improvement in the markers of the wider determinants of health (e.g. education, poverty and crime) - the action plans and metrics to be included within the health and wellbeing strategy for the City are in the process of being finalised.

Life style risk factors: o Reduce the prevalence of overweight and obese individuals in the City o Reduce the prevalence of residents smoking in the City o A reduction in the rate of alcohol related hospital admissions to at or below

the England average by 2018 o An increase in the number of people completing alcohol treatment

successfully

Continue to increase the number of NHS Health Checks undertaken in line with national aspirations

Increase the ratio of identified to expected individuals with LTC

Improvement in life expectancy for all residents, males and females

Reduction in mortality rates from cardiovascular disease, cancer and liver disease

Feedback loop What 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?

The performance monitoring will be undertaken by the individual organisations involved but the scheme will have oversight of the different elements.

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

In addition to the success factors outlined for the other schemes. There are four factors that will be imperative for the success of this scheme:

Continued prioritisation of funding for the prevention agenda;

Co-ordination of pathway redesign achieved through alignment of commissioning approach across Portsmouth and South East Hampshire

Support for frontline staff involvement in the redesign of services and work across organisational boundaries;

Strong stakeholder engagement: the local communities, primary care and the community and voluntary sector.

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ANNEX 2 – Provider commentary For further detail on how to use this Annex to obtain commentary from local, acute providers, please refer to the Technical Guidance.

Name of Health & Wellbeing Board Hampshire

Name of Provider organisation Portsmouth Hospital NHS Trust

Name of Provider CEO Ursula Ward

Signature (electronic or typed) Ursula Ward

For HWB to populate:

Total number of non-elective FFCEs in general & acute

2013/14 Outturn 31,955

2014/15 Plan 30,617

2015/16 Plan 30,111

14/15 Change compared to 13/14 outturn -4.2%

15/16 Change compared to planned 14/15 outturn

-1.7% (taking into account growth)

How many non-elective admissions is the BCF planned to prevent in 14-15? 647

How many non-elective admissions is the BCF planned to prevent in 15-16? 557

For Provider to populate:

Question Response

1.

Do you agree with the data above relating to the impact of the BCF in terms of a reduction in non-elective (general and acute) admissions in 15/16 compared to planned 14/15 outturn?

PHT agree with the methodology in principle but are unable to agree with the detailed FFCE data and reductions due to the reasons explained in the response to question 2.

2.

If you answered 'no' to Q.2 above, please explain why you do not agree with the projected impact?

PHT contract and manage internally using the currency of HRG spells. Conversion of this to FFCE is problematical. Any reconciliation is further complicated by boundary issues between the local authority and registered populations with GP practices. CCG plans for 2014/15 appear to assume a low level of growth and high QIPP delivery. Their growth assumption does not appear to align with the growth in the agreed contract. CCG plans for 2015/16 in contrast, appear to assume a much higher level of growth (we estimate at 1.8%) and lower QIPP delivery of 3.5%, which taken together plans to reduce non-elective admissions by 1.7%.

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3.

Can you confirm that you have considered the resultant implications on services provided by your organisation?

PHT continues to work closely with its Commissioners on their QIPP agenda to ensure PHT capacity is aligned with realistic future plans. Caution is required when interpreting changes in activity levels, for example non-elective activity is marginally under plan for the first 4 months of 2014/15 but the casemix has increased and this is reflected in over performance in financial terms. In addition, non-FFCE activity such as ambulatory case attendances have increased in both volume and complexity.

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