Better Care Fund planningtemplate – Part 1

Please note, there are two parts to the template. Part 2 is in Excel and contains metrics and finance. Both parts must be completed as part of your Better Care Fund Submission.

Plans are to be submitted to the relevant NHS England Area Team and Local government representative, as well as copied to:

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 / Middlesbrough Council
Clinical Commissioning Groups / South Tees Clinical Commissioning Group
Boundary Differences / n/a
Date agreed at Health and Well-Being Board: / <dd/mm/yyyy>
Date submitted: / <dd/mm/yyyy>
Minimum required value of ITF pooled budget: 2014/15 / £6,437,351
2015/16 / £11,609,000
Total agreed value of pooled budget: 2014/15 / £6,737,351
2015/16 / £11,909,000

b)Authorisation and signoff

Signed on behalf of the Clinical Commissioning Group / South Tees CCG
By / <Name of Signatory>
Position / <Job Title>
Date / <date>

<Insert extra rows for additional CCGs as required>

Signed on behalf of the Council / Middlesbrough Council
By / Mike Robinson
Position / Executive director
Date / <date>

<Insert extra rows for additional Councils as required>

Signed on behalf of the Health and Wellbeing Board / <Name of HWB>
By Chair of Health and Wellbeing Board / <Name of Signatory>
Date / <date>

<Insert extra rows for additional Health and Wellbeing Boards as required>

c)Service provider engagement

Please describe how health and social care providers have been involved in the development of this plan, and the extent to which they are party to it

The schemes being proposed through this plan have been developed through a number of work streams such as Urgent Care, IMProVe, Reablement steering group and the Carers Partnership. The key principles of the vision were developed as part of the Transformation Challenge bid, a multi-agency submission seeking funding to support whole-scale transformation across the localities. The Better Care Funds seeks to build on this agreed vision. Key stakeholders were signatories to this vision and a number of key providers have been involved in the various workstrands which have produced the schemes for phase 1.
The Health and Social Care delivery partnership, a sub group to the Health & Well being Board has been briefed throughout the development of this plan.
Dialogue with South Tees Foundation Trust has been undertaken in regard to the key aims and objectives, and the key schemes proposed for the first two years.
Further stakeholder involvement will be achieved following a planned whole system stakeholder event planned for 3rd March.

d)Patient, service user and public engagement

Please describe how patients, service users and the public have been involved in the development of this plan, and the extent to which they are party to it

The schemes proposed in the first two years are centred around the principle of IMProVE, focussing primarily on the elderly.
South Tees CCG are currently consulting on the IMProVE (Integrated management and proactive care for the vulnerable and elderly) programme, which is following the principles of a Call to Action in that it is engaging widely with partners and the public on improvements to elderly care.
In addition a number of the schemes have been included in Middlesbrough Council community wide consultation. As the schemes develop services users and patients will be consulted and key participants in the design of services. In particular a network of carer groups has been mapped to facilitate wide engagement and participation in the strategic planning, redesign and commissioning of services.

e)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
A Clear and Credible Plan for Commissioning Health Services for the Populations of Redcar and Cleveland and Middlesbrough 2012 – 2017
Middlesbrough Council Local Account 2013 / Outlines the service delivery plan for Adult Social Care
Joint Strategic Needs Assessment
Joint Health & Wellbeing strategy / Outlines the core strategy of the Health & Wellbeing board of Improving health and wellbeing of our local population and reduce health inequality
Middlesbrough Council Adult Social care Commissioning Intentions 14/15 / Details the commissioning intentions identify the core work for adult social care in 2014/15
Public Health Commissioning Intentions / Details the commissioning intentions identify the core work for public health in 2014/15, demonstrating particular links with the aims relating to early intervention and prevention
South Tees CCG Commissioning Intentions / Details the commissioning intentions identify the core work for South Tees CCG in 2014/15
Middlesbrough Carers Strategy / Outlines the multi-agency partnership strategy for carers services

2)VISION AND SCHEMES

a)Vision for health and care services

Please describe the vision for health and social care services for this community for 2018/19.

  • What changes will have been delivered in the pattern and configuration of services over the next five years?
  • What difference will this make to patient and service user outcomes?

By 2018/19 we want to achieve our ambitious vision of:
“All care is planned care”.
Improving the “customer experience” throughout the social care and health pathways is central to our work program of integration. In addition, we recognise South Tees CCG cover two local authority boundaries, therefore our aim is to ensure equity of access and quality of service provision and experience, regardless of postcode. Therefore our vision has been agreed across the South of Tees, and whilst this Better Care fund plan refers to Middlesbrough, our key aim is to align and secure joint working not just with key stakeholders within our geographical boundaries but with those in our neighbouring authority.
Key principles underlying our vision:
  • Person centred, promoting preventative approaches, allowing people choice and control in the way they manage health and social care needs
The individual experiences of care and support received are invaluable in shaping our thinking. We want to move towards a system which invests in prevention, not one which is reactive to presenting needs. To achieve this we must involve our patients and service users in the planning and redesigning of services, and consider the benefits of social care and personal health budgets as part of that planning work. Personal budgets in social care has seen people consider innovative options for managing their personal and social care needs, moving away from the more traditional agency model of care. Our vision moving forward will be to develop health budgets, not in isolation to, but in alignment with social care personal budgets, ensuring the funding available is exploited, providing every opportunity for the individual to maximise their health and well being.
  • Integrate pathways across health and social care where appropriate to achieve efficiencies, sustainability and resilience in the system
Currently we recognise that the system across health and social care is fragmented in a number of ways. For example Emma has continuing healthcare (CHC) needs. She was previously assessed by Adult social care who determined a decision support tool (DST) was needed to determine eligibility for continuing healthcare. Whilst this process was ongoing Emma was being charged for the services she was receiving. Nurse assessors undertook the DST with Emma’s current social worker; debate took place with regard to the agreement of the domains within the DST. Eventually the DST was agreed and a slot was booked for panel. One week later Emma’s case is presented by her Social Worker to a panel of senior social care and health staff. Further discussion takes place and the case is accepted as CHC. Emma no longer has to contribute to the care she receives. As a result of the decision, Emma is transferred to a worker in the CHC team who takes over responsibility for Emma’s care. The case is closed to Emma’s social worker and placed in CHC review. One year later Emma’s health social worker determined that her needs had improved and instigates the process again. The case is assigned to a review social worker in adult social care who has never met Emma before. The cycle begins again.
This fictional case is representative of one area of a fragmented system. Integration and joint working could achieve better outcomes for Emma with respect to her experiences of health and social care, and also achieve staffing efficiencies by avoiding duplication of effort. Our vision is to have an integrated service whereby Emma would have one key contact, findings would be shared and the service streamlined.
  • Create consistency in our approach for health and social care assessments which avoids unnecessary duplication, delays and hand-offs, and improves information sharing
Due to current data sharing restrictions and operable processes an individual is likely to have to repeat basic information multiple times. Case tracking has shown that basic details of name, address, date of birth, next of kin may have been asked for on 10 different occasions. This does not foster customer trust in the system.
Currently an individual ready for hospital discharge may receive services from nursing rapid response, along with a separate social care rapid response service to enable them to go home. This results in two separate referrals, two assessments and many professionals all seeking to achieve the common aim of enabling that person to go home. Our vision is to create a single point of contact / access where such referrals can be accepted and appropriate services quickly arranged.
  • Provides adequate safeguarding for people to ensure that their independence is maximised, appropriate risk management processes are in place and duplication of process is minimised.
We are keen to ensure that risk is effectively managed in a balanced and planned way. Safeguarding individuals is a core element of all our work. Now with a legislative footing, the creation of the Tees Safeguarding Board will create consistency in a strategic approach across partners in the Tees area. Managing risk is essential, as being risk averse can have a detrimental impact on individuals quality of life and can create a dependency culture rather than supporting that individual to maximise their potential. Safeguarding encompasses six key concepts: empowerment, protection, prevention, proportionate responses, partnership and accountability. Throughout all the integration and transformation planning these six key concepts must be integral to service design and implementation. For example effective prevention in safeguarding is not about a risk averse practice, preventing abuse should occur in the context of person centred approach and personalisation, empowering individuals to make choices and supporting them to manage risk. This should lead to services that people want to use, with the potential to prevent crisis from developing.
  • Expand joint commissioning of services to meet identified needs and quality standards
Currently lead commissioning arrangements are in place, with demonstrable benefits. In particular nursing and residential care is commissioned and funded through the local authority. As such providers have a single contract and a central point of contact for queries with regard to occupancy. Business relationships have been formed and strengthened with the sector enabling business discussion and developments for health or social care to go through one route. Moving forward our key agenda will be to identify and consider more opportunities for joint commissioning, ensuring services are delivering both value for money and quality of provision.
To achieve our vision we will need to work collaboratively if we are to meet the demands and challenges being placed on the system as a result of demographic and socio-economic changes, in particular an ageing population, increasing diversity in local communities and significant health and social deprivation across our sub region. In addition we have high number of people living in poverty with increased rates of unemployment.
Ultimately we must recognise that a patient may be a service user and a service user may be a patient, above all they are a customer of services, the customer journey and patient experience must be a proactive one in terms of the “customer services “ they receive.
Part of our project plan for the first two years will include the production of detailed project plans and developing longer term plans to cover a five year period and beyond.
We recognise the step changes required to achieve integration and the need to consider the risks and impacts of all activities related to transforming the way we work. Above all is the need to ensure our customers are centric to planning and delivery of services, therefore our plan in the first two years outlines a step change, with the recognition that further work is required during that period to develop a full five year program for transforming the way we work together to achieve the agreed vision and underlying principles.

b)Aims and objectives

Please describe your overall aims and objectives for integrated care and provide information on how the fund will secure improved outcomes in health and care in your area. Suggested points to cover:

  • What are the aims and objectives of your integrated system?
  • How will you measure these aims and objectives?
  • What measures of health gain will you apply to your population?

As part of the integrated planning work, we must initially acknowledge the problem we are attempting to solve across the South of Tees. The demographic data and statistical analysis below seek to portray the issues which assist in prioritising the work plan for the first two years.
The Health Picture of South Tees
South Tees comprises two local authorities and one clinical commissioning group covering a total population of 273,742 (138,744 in Middlesbrough and 134,998 in Redcar and Cleveland).
The area has an above average rate of deprivation and child poverty. Life expectancy is significantly lower than the national average and the gap is even more marked for those aged over 75. Deaths from heart disease and stroke, whilst improving are still higher than the national average. Early death rates from cancer remain fairly static and again, higher than the national average.
Economic, social and health gaps have widened between those who have benefited from available jobs and opportunities and those who have not, with 25% of the population living in the most deprived 10% of wards nationally and less than 4% living in the most affluent 10% of wards nationally.
Historically, the local area has been highly dependent on heavy industry for employment and this has left a legacy of industrial illness and long term conditions. This, coupled with a more recent history of high unemployment as the traditional industries have retracted, has led to significant levels of health deprivation and inequalities that rank amongst the highest in the country.
Figure 1.
The area faces new challenges around the major causes of death and the gap in life expectancy with statistics poorer than England average across a number of disease groups and conditions, often as a result of obesity, smoking and binge drinking, as illustrated in figure 1. [1]
South Tees ranks higher than the England average for almost all disease prevalence

In spite of the evidence to the contrary, 72% of residents in the Tees Valley believe that they lead a healthy lifestyle. This provides an additional challenge in our work to further shift the focus of our health and social care provision to improving health outcomes and reducing inequalities, in order to improve the overall health of the local population within the available resources.
The challenge that we face is further exacerbated by the predicted increase in the number of elderly people living in the area, see figure 2. This will have a major impact on health care services, requiring a wide range of services to be readily available in convenient, accessible and user friendly settings, with an increased emphasis on treating people with long-term conditions. In turn it is anticipated that this will significantly increase the burden on social care services as both health and social care continue to work to meet the increasing demands of this ageing population.
Figure 2
Authority / Mid-2012 population estimate / 2021 population projection
Number / No. (%) aged 65 + / No.(%) aged 85 + / Number / % aged 65 + / % aged 85 +
Middlesbrough / 138,744 / 21,293 (15.35%) / 2,591 (1.87%) / 144,275 / 24,997 (17.33%) / 3,911 (2.71%)
Redcar & Cleveland / 134,998 / 27,396 (20.29%) / 3,259 (2.41%) / 135,466 / 31,782 (23.46%) / 4,540 (3.35%)
Total / 273,742 / 48,689 (17.7%) / 5,850 (2.1%) / 279,741 / 56,779 (20.2%) / 8,451 (3.2%)
Source: ONS mid-2012 population estimates and interim mid-2011 based population projections
The Health Picture in South Tees – its impact on services
The picture of health, deprivation and the growth in the ageing population has a significant impact on health and social care services locally:
  • The number of people who are elderly, vulnerable and living with a long term condition in our area is increasing. This is already having an impact on primary care (eg GPs), hospital services and social care.
  • Too many of our elderly and vulnerable residents end up very poorly, resulting in a hospital admission that could have been avoided.
  • Rates of non-elective admissions experienced across the locality, are amongst the highest in the country and are growing. This growth, coupled with the demographic factors described earlier present a very real challenge in terms of our collective ability to plan the future health and social care requirements of our population.
  • Middlesbrough remains significantly above national average in terms of the number of permanent admissions for both 18-65 and over 65 to care homes.
  • It isn’t always necessary to be treated in a hospital. For many people who are frail, elderly or have long-term conditions, a community or home-based service is more appropriate. Improving and enhancing the range and type of healthcare available close to home can help people to live independently for longer.
  • The demand for social care services, costs and expectations are rising and are predicted to continue to do so, at a time when the funding is decreasing. To continue to try to meet service demand in the current way will have a significant impact on the sustainability of local authorities who will not be able to meet the needs of those requiring social care services. Local Authorities will also need to redirect resources for other universal services.
  • Traditionally there is a local culture of dependency on health and public services and a tendency that people usually seek support when they are in crisis. This adds additional pressure on the most costly acute services. This is further exacerbated by the lifestyle choices of many people.
We need to improve the health of the population in our area and tackle the legacy of ill health and deprivation, whilst meeting the increasing demands of an ageing population. To achieve this ambition, the shape, type and form of health and social care provision available to our population, needs to be different to that available today.
The health and social care system across Tees is currently operating at capacity, the present configuration of commissioned services, and the commissioning models in place, will require significant rethinking and redesign if they are to cope with the future demand evidenced by the factors detailed above.
Current health and social care service delivery is very fragmented and there is significant variation in service models, capacity and capability. This poses risks to the continuation of care pathways if individual organisations become unsustainable as they find themselves under increasing pressure both financially and through increasing demand. Combined operations and resource allocation will increase resilience and sustainability.
We recognise and acknowledge the challenges we face and have developed four key aims and objectives to underpin the transformation of the system. Our aims are both reflective and supportive of the Unit of Planning Strategy:
  • Early intervention and promotion of prevention – using evidenced based practice, promoting and supporting screening and vaccination programmes, further developing community based programmes such as the “deep-end” and building capacity within the local authority and NHS workforce to support patient / service user education. Linkages with public health delivery programmes are critical to achieving this aim.
  • Right care, right place, right time – Improving access across the range of health and social care service provided, including where those services are delivered from and ensuring pathways of care and support are evidence based
  • Facilitation of hospital discharge – reducing and eliminating waste and delays in the system, supporting individuals to return home safely with the necessary support to reduce the risk of readmission
  • Working better together- to ensure services are integrated around the needs of the individual, recognising the specialisms and maximising the skills of all stakeholders, minimising duplication to realise the full potential across the system.

c)Description of planned changes