Agenda Item: 14 NHS Norwich CCG Governing Body

Transcription

1 Agenda Item: 14 NHS Norwich CCG Governing Body Tuesday 23 rd May 2017 Subject: Presented By: Submitted To: Purpose of Paper: Commissioning Report James Elliott Director of Clinical Transformation NHS Norwich CCG Governing Body Tuesday 23 rd May 2017 Discussion, Information and Assurance for Commissioning Programmes Summary & Recommendation: To note the update on the Better Care Fund plan and strategy for Norwich 2017/19. The Governing Body is asked to note the update on the following commissioning portfolios: 1. Norwich New Model of Care 2. Norwich Other 3. Central Norfolk 4. Norfolk and Waveney The Governing Body is asked to note the update on the Better Care Fund plan and strategy for Norwich for 2017/19.

2 Introduction The CCG has introduced a revised Programme Management Office (PMO) Process and Work Programme of which Commissioning projects are a central element. The Norwich CCG Work Programme is a repository of all transformational and QIPP projects/schemes that Norwich CCG is leading on or involved in with CCGs in the central and Norfolk and Waveney areas. The Work Programme is structured around four main portfolios: Norwich New Model of Care Norwich Other Central Norfolk Norfolk and Waveney The commissioning report will also be structured around these headings. 1. Norwich New Model of Care Within this portfolio there are 9 programmes of work, each of which has a number of projects identified to progress the development of a New Model of Care for Norwich. Project teams and managers are currently being identified for each of the programmes some of which are already well underway, with the remainder on target to be in place by the end of June. The current status of each programme and individual projects are summarised below:- Care Homes Projects Enhanced Care in Care Homes Project Aim - to improve the quality of care for registered patients who reside in care homes or nursing homes within the Norwich CCG area. The project will develop a new model of care that enhances care in care homes, in line with the Five Year Forward View (FYFV). At present there are areas within this project (such as the evaluation process of the BCV service pilot) which require specific, detailed milestones. Whilst internal CCG decision points are clear, the Project Manager is confirming with all project stakeholders their own processes/milestones regarding the pilot evaluation. The workstream lead for falls prevention & management will finalise 1st draft of evaluation report (Falls workstream at Bowthorpe Care Village) for submission to thecare Homes Programme Board. Digital Projects Digital Clinical communication (secondary care to social care & primary care) E-prescribing E-referrals IG/Data sharing Interoperability & Shared Patient Record 2

3 New Consultation Types Patient On Line Review of BI shared with GP Practices (including referral data & waiting times data) Risk stratification Telemedicine to support self-management Interviews to appoint an IT Manager as a joint post with One Norwich GP Alliance are scheduled for Monday 15 May. A status report for this programme will be included in the July Governing Body report. Estates Projects Estates & Technology Transformation Fund (ETTF) Schemes Workshops are being held this month to agree the areas of responsibility between NHSE and CCGs undertaking delegated commissioning. Strategic Review of Primary Care Estates It is proposed that CCGs will take on the following tasks from NHSE Estates: Regular liaison with local authorities and discussions as required with potential developers Contribute to preparation of and submission of responses to local authority planning consultation documents. Management of estates database baseline provided by NHS England Monitor Community Infrastructure Levy (CIL) applications and submit bids for projects as opportunity arises Negotiate and defend mitigation requests. Attend planning appeal hearings as necessary Management of database to record proposed development growth mapped against affected GP practices baseline provided by NHS England An overall Project Manager for Norwich is currently being identified. A status report for this programme will be included in the July Governing Body report. General Practice at Scale Projects Care Navigation and Active Signposting for Reception Staff Improved Access Both projects are at the Project Initiation Document (PID) stage. A status report for this programme will be included in the July Governing Body report. 3

4 Mental Health Projects Adult Mental Health Norwich Project Aim - The aim of the project is aligned to the Statement of Intent that was developed in partnership with the wider Norwich system through the Wellbeing and Complex Needs Locality Group. As such, the project aims to transform local service provision to improve outcomes and meet increasing need, demand and expectations by delivering integrated care and support. Local service provision should be evidence-based and focus on prevention, early intervention and recovery, keeping people well in the community, maximising their independence and supporting them to achieve their potential whilst reducing inpatient admissions and out of Trust placements. Current Status The wellbeing & Complex Needs Locality Group (WBCNLG) has been restructured to focus on the deliverables for this project in particular Mental Health Training and Complex Needs. A task and finish group has been set up and chair identified to take forward the training element commencing with a questionnaire to all MH training providers. The Complex needs project is being led with Public Health and is in its early planning stages engaging with stakeholders Dementia Diagnosis Project Aim - The aim of the project is to increase the Dementia Diagnosis rate in Norwich: Jan % Feb % (reduction of 3.4% directly attributed to a coding issue. There are 82 residents with a Dementia Diagnosis that are not included in the figures work is underway to resolve this. Mar % (actual rate when coding issue is resolved (64.3%)) The Dementia component of Enhanced Care in Care Homes Locally Commissioned Service (LCS) has been finalised and offered to the service provider. The previous dementia advice provide to primary care has been reviewed and updated. The LCS specification now includes a more robust approach to screening in care homes, advice on prescribing and advice on dementia diagnosis by GPs. Improvement to discharge letters has been negotiated with Norfolk & Suffolk Foundation Trust (NSFT) which includes clear diagnosis and coding. 12 Practices have been visited to provide specialist support to undertake a Dementia coding exercise. This exercise has focused on those practices that are aligned to Care Homes. The specialist support has been provided by the Dementia UK Regional Admiral Nurse who has completed a desktop review (coding) and provided advice and support on screening and prescribing for this patient cohort Dementia Post Diagnostic Support Project Aim - The aim of the project is to improve the quality and experience of dementia care in Norwich for people with dementia, their family and carer s. The transformation will focus on promoting awareness of dementia, building an integrated approach to dementia, improving managed dementia care pathways, supporting independent living in the community and improving services for those unable to live independently. 4

5 Current status: NCCG have committed to continue with the grant funding to Marion Road Dementia Day Centre which is provided by Age UK Norwich s to support their work with people with Dementia (PWD), their families and carers. NCCG is a founder member of the Norwich Dementia Action Alliance and a member of the Broadland Dementia Action Alliance. As such we have made 3 public pledges the first of which is to ensure that 90% of all staff complete Dementia Awareness and become a Dementia Aware. Following a number of sessions provided by Age UK Norwich we were due to complete this pledge to be published during National Dementia Awareness week (15-19 May 2017) The main focus of this project is the delivery of the Admiral Nurse Service. The focus over the past month has been to identifying providers, agreeing contract, service specification, recruitment and preparing to mobilise the service. Planned Care Demand management within Primary Care Project Aim: The aim of the project is to support the achievement of the 18 week Referral to Treatment (RTT) NHS Constitution standard by managing the demand that flows into the Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH). This will be achieved by addressing variation in GP Practice referrals and ensuring that only the appropriate cases are referred for face-to-face consultation. A PID was approved with the following agreed outcomes: to support GP Practices to make appropriate referrals by addressing variation resulting in nil growth in GP referrals based on 2016/17 M13 outturn. Ensure patients are involved in decisions about their care and are able to make informed choices on treatment and providers. Standardise referral routes into community and secondary care providers. Use innovation and technology to drive quality improvement, patient experience and value for money. Improve business intelligence so that the CCG is making best use of resources. Improve the ability for the CCG to deliver more responsive change including pathway change Included in DMP and QIPP - Impact from Aril 2017 To achieve these outcomes a Local Incentive Scheme (LIS) with GP member practices is currently being finalised. Dermatology redesign Project Aim: The aim of the project is to develop a specification for community dermatology provision underpinned by a cost effective business case with a view to piloting in 2017/18, or including the specification in the New Norwich Model of Care service specification which is due to be finalised March A clinical lead has been identified. Current primary & secondary care providers attended the first project team meeting in May. Discussions have commenced on potential new service model. 5

6 Prevention & Wellbeing Community Assets Project Project Aim: This project aims to develop the voluntary and community sector supporting people in Norwich to improve their health, wellbeing and wider determinants of health. The Project's key deliverables are to: Promote, award and manage grants that support voluntary sector development in relation to key health outcomes that reduce inequalities for people in Norwich Develop activities that support self-care for populations or condition groups who experience the greatest health inequalities Expand the use of Personal Health budgets for wheelchair users and people with learning disabilities to meet statutory minimum targets Promote, award and manage grants that deliver direct support to carers Support district councils to improve the use of the Disabled Facilities Grant (DFG) and other property-related grants, with a particular focus on improving key health outcomes - The new Head of Integrated Commissioning has now taken over the lead of Community Assets and is gathering necessary information to progress the Project. A detailed update report will be provided in the July Governing Body report. Further information The CCG has been running a website for three years in June, which helps members of the public find voluntary services to help improve their health and wellbeing. It is called Our data shows the number of hits for each organisation on the website ranges from a few hundred to 12,000. There is a comprehensive falls section which has received more than 3,000 visits. People are accessing the site at all hours of the day and night, suggesting they are searching our site to find help, as and when issues are occurring. Healthy Norwich Project Project Aim: The aim of Healthy Norwich is to improve the health and wellbeing of the people living in Norwich and the surrounding area. It will do so by delivering ill health prevention and wellbeing activities. Healthy Norwich has three identified themes for 2017/18 aimed specifically at tackling health inequalities in the city and to promote health and wellbeing messages to the whole population. These three themes will focus the Healthy Norwich project deliverables. They are: Promoting healthy weight and lifestyles Smoking cessation and prevention Affordable warmth The Daily Mile - Activity this month includes the resources booklet sent to all primary schools with a cover letter from Tracy Williams to encourage engagement. Healthy Norwich webpages has been updated and this includes a short link to the Daily Mile promo video. Breastfeeding Friendly GP Surgeries - 10 Practices have signed up to the scheme so far. Smoke-free side-lines. Project - continued engagement with county wide partners has 6

7 resulted in all 7 districts have committed to this project and contributed 500 Sugar Awareness the promotional film is ready and engagement with schools is planned for June. 2 clinicians to support the programme roll-out to Norwich high schools have been identified. An application made to the Children's Health Fund for a Healthy Norwich water fountain. Outcome of submission is expected by end of May. Social Prescribing Pilot there has been a drop-off in referral rates from one of the pilot practices discussions are underway with Practice Manager to re-engage GP's support Excess Winter Deaths - the Norwich steering group meeting will be held in early June to learn from previous activity and develop plan for winter Primary, Community & Social Care Projects Homeward Plus (HW+) Project Aim: The aim this service is to provide high quality, personalised, patient-centred care for people experiencing a health care crisis which can be managed safely in the community (i.e. is not assessed as needing an emergency (999) response and/or acute hospital care) or who require support to return home following an inpatient stay in an acute hospital, community unit or procured/spot-purchased bed. It is designed to improve patients functional ability and independence enabling them to remain in, or return to, their usual place of residence, and/or receive dignified end of life care. The key deliverables are to: Maintain emergency short and long stay admissions at or below 16/17 activity levels for the agreed HW patient cohort (aged 70 and over and specific specialties) Minimise the number/cost of excess bed days for agreed patient cohort (aged 70 and over and specific specialties) A PID and project team has been approved for this project. Over a series of meetings in April the HW+ establishment and budget has been approved and the provider has been advised to commence recruitment. Neighbourhood Care (including unplanned/planned Hub) It is anticipated that the PID for this project will be completed and approved in June. More details on the aim and deliverables of this project will be included in the July Governing Body report. Norwich Escalation Avoidance Team (NEAT) (incl. Integrated Case Management and Admission Avoidance & Supported Discharge response) Project Aim: The aim of this project is to deliver integrated urgent and unplanned care to: Manage people safely in the community through a period of crisis with an appropriate, coordinated response using the lowest level of intervention. Facilitate fast-track early supported discharge from an in-patient setting. The NEAT model adopts an every contact counts approach which addresses the urgent and unplanned need and incorporates a navigator function to identify the additional support required to promote independence and keep people safe and well at home for as long as possible. It is a mechanism for multi-agency referral management, resulting in the coordination and deployment of existing services as effectively as possible to optimise capacity in the system without generating increased activity. 7

8 The key deliverables are: Run NEAT pilot in June (adopting a phased approach) Promote prevention, independence, self-management and behaviour change through the NEAT model Facilitate fast track early supported discharge from an inpatient setting to support system flow Improve the coordination of unplanned care, manage demand and optimise the use of existing resources (including community assets) A core group of providers met at the end of April to review progress with the various work streams and develop the work packages to support delivery. The next meeting in May will focus on what success looks like and how to measure and evidence the impact of NEAT. This discussion will inform the identification/calculation of the significant financial savings linked to this project which are due to be realised in Quarters 3/4 of In order to appropriately address potential constraints (for example telephony issues and IG/Data sharing) the original pilot start date of has now been postponed until Workforce Develop Existing Workforce Expand Capacity in System Maximise Existing Funding Schemes Current Status The volume of workforce initiatives with multiple stakeholders and organisations involved results in a complex picture, with some initiatives led by Health Education England (HEE), some by NHSE and some at a more local level. Work is underway to identify what need to be done at National, STP and local level to enable PID to be drafted and project resources identified. 2. Norwich Other Norwich CCG Clinical Reference Group Recommendation: The Governing Body is asked to note the update of key discussion items from the Clinical Reference Group in April & May At the April and May meetings of the CRG the following agenda items were discussed and recommendations made where appropriate: Dr Sara Lear, Consultant Immunologist, NNUH attended and provided a summary of the allergy and autoimmune tests available at the NNNUH. Actions were agreed that should lead to appropriate request of tests. CRG discussed the ongoing Community Clinic pilot and supported that North Norfolk CCCG proceed to full business case to expand the Clinic. CRG supported the continuation of the existing IV iron community clinic beyond the agreed 4 month pilot (if the time required to develop the business case extended beyond the 19th May) subject to there being clear evidence that the trial had been evaluated and proven to be cost effective. CRG supported in principle a proposal for a Self Care campaign in partnership with the other Norfolk & Waveney and offered suggestions regarding content and implementation. Dr Richard Reading (Consultant Paediatrician, NCH&C) and Sudeep Dhillon (Project Manager, NCH&C) presented a proposed Community Paediatric Service Pathway specifying criteria for new referrals to address the waiting list of over 600 children waiting to 8

9 be seen. There was support from the CRG for the proposed criteria and actions agreed regarding implementation. CRG considered and gave support to an engagement plan for Care & Nursing home residents, their loved ones and professionals. The work plan is for 12 months and an evaluation report will be shared with CRG. Demand Management Norwich CCG projects Next Steps Five Year Forward View (FYFV) highlights that in 2017/18, CCGs and trusts will need to step up their work to get more value out of the NHS growing, multi-billion pound investment in elective care. This will mean tackling clinical practice variation in referrals to ensure appropriate referrals are made to the NNUH and that we meet and maintain the 18 week referral to treatment target. The CCG has been required to submit an updated Demand Management Plan (DMP) to NHS England for 2017/18. The DMP aligns to the 2017/18 QIPP plan. The DMP includes some Norwich CCG only projects but most are projects being undertaken through the Central Norfolk work programme (see below). Work is ongoing to integrate the three individual central Norfolk CCG plans into one where appropriate. Monthly updates on achievement will be submitted to NHS England and there will be follow up monthly assurance telephone calls. With regards, Norwich CCG-only projects:- Executive Committee in March 2017 approved a business case for a GP Practice incentive scheme to address variation in GP referrals. Peer review of referrals within GP Practice will identify opportunities to address the variation. The Next Steps FYFV requires attention on the upper quartile higher referring GP practices and CCGs to benchmark clinical appropriateness of hospital referrals using CCG dashboards and a new tool from NHS Digital, and then deploy clinical peer review. The CCG is also encouraging adoption of the Academy of Medical Royal Colleges Choosing Wisely initiative through the Incentive Scheme. On 8 th May 2017, the CCG held its first meeting with current dermatology providers to identify the potential scope of an enhanced integrated community service. This was a positive meeting and clinical representatives have agreed to meet soon to review. 3. Central Norfolk CCGs Work Programme Please see Appendix 1 for detail on the current projects within the central work programme including project description, SRO, Project lead and whether a Project Initiation Document has been approved. Most projects are on a central Norfolk footprint but some include West Norfolk and Great Yarmouth & Waveney CCGs also. 4. Norfolk & Waveney Commissioning Work Programme The following is an update from the joint commissioning networks:- Planned/Unplanned Network Feedback from the meeting on 9 th May 2017:- Presentation and discussion with NNUH clinical and management team, Dr Martin Patel and Chris Cobb, on the frailty pathway. The Trust is reviewing current internal pathways and bed 9

10 management, with a view to better utilising existing bed capacity to address increasing demand. There was clinical agreement in principle to support NNUH proposal however it was recognised that there will be financial and contract implications which need to be picked up through coordinating commissioner (NNCCG). It was agreed that any proposed development within the NNUH would benefit from close alignment with the community/primary care based service models for the older people cohort, to ensure most effective care pathway implemented. In particular, the opportunity to better utilise electronic communication, especially Systm One was highlighted. Current plans are to implement by October 2017 to help prepare for winter demands. Presentation from Roberta Fuller Chief Operating Officer at NNUH, on the redesign of emergency pathways, including the development of the Urgent Care Centre. This is a major programme of re-design, coordinated through the A&E Delivery Board. It was recognised by GPs that much of the change programme is not clear to the wider primary care community, and that an effective communication process will be important to help the wider system utilise the new arrangements effectively. An open day is being arranged by the Emergency Department, to which GPs and wider primary care will be invited. No date as yet confirmed, but it will be the opportunity for primary care to see, meet and discuss the new model. This will be communicated to One Norwich, for consideration of how Norwich primary care can best optimise this opportunity for collective learning. There was an update on the Right Care work programme, which included confirmation of Norwich CCG s arrangements for coordination of the respiratory pathway project. Mental Health & Learning Disabilities Network Network meetings have changed their structure so that the content aligns to STP Mental Health priority areas which are:- Primary/Secondary MH Care Variation in Model - Variation in care cannot be explained by demographics and so work will commence to standardise clinical quality eg people in Norwich are twice as likely to be admitted to a mental health bed as from North Norfolk. Crisis Hub Development - Project has commenced with target of implementation by end of IAPT Expansion SNCCG producing a scoping document and PID. CORE 24 Development in crisis response A bid to expand the Mental Health liaison team at NNUH has been successful however the bid was for 1.5m but 480k was awarded. The expectation is to achieve 24 hour coverage by Q4 2017/18. Step down beds development - NSFT is leading on this development which should address Delayed Transfer of Care (DTOCs). Perinatal Implementation - Norfolk & Waveney has received a 3 year funding allocation, with 980k available per annum by 2019/20. The target is to see 350 women in 2016/17, rising to 540 in 2019/20. Early Intervention in Psychosis (EIP) Expansion - the specification is being adapted based on the agreed changes to expand the service model. National expectations have changed and now require an all-age (previously years) service and 50% of new patients being assessed within two weeks of referral. Child Health & Maternity Commissioning Network The Network is currently not meeting. Great Yarmouth & Waveney CCG has agreed to become the lead CCG for children s commissioning. Discussions ongoing on infrastructure and work programme. 10

11 Right Care The overall Right Care approach has been agreed by the STP Demand Management Board with support from the STP Delivery Board. The aim of the programme is to produce population focused service designs that make best use of the resources available to deliver the best outcomes for patients. Five pathways have been identified to address they are below and the coordinating CCG is noted in brackets:- People living and at risk of respiratory conditions (Norwich CCG) People living with or at risk of diabetes (West Norfolk CCG) People lining with or at risk of chronic heart disease (Great Yarmouth & Waveney CCG) People living with or at risk of skin cancer (North Norfolk CCG) People living with a mental health condition (South Norfolk CCG) With regards respiratory, Norwich CCG has identified the membership of the working group and confirmed approach, plan and timescales which will now feed into the development of a project plan. Better Care Fund plan and strategy for Norwich for 17/19 1. Background / History: Within Norwich Clinical Commissioning Group there are several schemes/interventions that are enabling health and social care to move forward on its integration journey. It is important to note that this integration ambition and subsequent delivery plan will need to deliver the following; an ambitious plan that by 2020 health and social care is integrated across the country 1 an expectation set by NHS England that any BCF Plan should set out local vision for closer integration by 2020 This paper details the vision, principles and approach which will drive forward the integration agenda within the Norwich area. This will need to be discussed and agreed by the Senior Management Team. 2. Proposal: The integration of services to deliver person-centred care and support should not be restricted by organisational boundaries, and should build on the successful partnerships that exist across Health, Social care and District Council s to deliver those services. The integration will meet the strategic levers in place which include; Sustainability and Transformation Plans - Enabling delivery of the STP outcomes and system priorities Pooled Funds - The expectations set within the Better Care Fund concerning pooled fund and going beyond the minimum contributions and funding requirements. Instead focus should be on developing pooled funds that enable the delivery of an integrated offer of services to people who require health and social care, supported through appropriate risk sharing arrangements. 1 Spending Review

12 High Impact Change Model (Managing Transfers of Care) This model has been endorsed in a joint meeting between local government leaders and Secretaries of State for Health and for Communities and Local Government. It is based on ensuring that people do not stay in hospital for longer than they need to, through maintaining patient flow, having access to responsive health and care services and supporting families. This paper highlights some significant areas to agree and focus on, this includes; 1. The Norwich vision for integration of services. That by 2020 health and social care is integrated across the Norwich area, and delivered to best meet the needs of the local population. It is important to recognise when this is achieved and the measurement against this should include; Leadership and Governance arrangements in place that foster and encourage Norwich Health and Social Care integration Systems and structures established that drive forward integration including, where appropriate, one decision process to agree how funding should be spent Delivery of a seamless person-centred rather than a service focused approach including a holistic assessment to understand both a person s health and social care needs. 2. Principles which will underpin the integration of services that meet the needs of the local population. Conversations will need to take place with stakeholders from across the Health and Social care system, along with a review of best practice information and research available on integration, has informed the following set of principles. These are detailed below and are being proposed for Norwich CCG to adopt and champion across the system; Clear and strong leadership A collective leadership which drives culture change, accepts responsibility for achieving the vision and ensures commissioning for and provision of better outcomes Trust and control A culture that extends trust and control across organisations that enables effective and integrated delivery of services Transparency and sharing A joint understanding of the resources available locally, and agreement to direct them to the most effective interventions. These principles have been developed using the best practice document Stepping up to the place The key to successful health and care integration, which is supported by the Directors of Adult Social Services, Local Government Association, NHS Clinical Commissioners and NHS Confederation. 3. Identified enablers to deliver the integration vision. Key enablers to the successful delivery of this plan have been identified as critical success factors and include; 12

13 Workforce - A workforce development programme that equips the workforce to deliver holistic proactive and integrated care Support functions - Ensuring functions that exist in organisations to support delivery of services are working together in an integrated environment. This should include the contracting, commissioning and quality functions. Governance - Clear governance structures in place for the Norwich system, which provides robust challenge and support to enable the vision to be achieved. Pooled Fund(s) - There will be opportunities where pooled funds are key to unlocking the barriers between Health and Social care. We are clear that system partners need to understand the outcomes they wish to achieve for the local population and whether a pooled fund help achieve this rather than seeing pooled funds as a panacea. To date the existing pooled fund arrangement is administered and reported to NHS England and is robustly monitored through the CCGs internal finance function. 3. Barriers to Progress / Key Risks: It is important to note the following risks which have been detailed below; The difference that exists for people to have access to health or social care services. Healthcare services which are free at point of delivery and Social Care which is means tested. Funding for Health and Social Care services are through different routes which affects how decisions are made and who is accountable for those decisions and delivery of services. In addition, financial pressures could undermine shared planning and use of resources. Availability of good data and Information Technology (IT) systems to support integration. Ensuring commitment and engagement from across the local system to deliver integrated health and social care delivery for Norwich. At the time of writing this paper, we still await the final guidance on the Better Care Fund for 17-19, which will allow for plans to be developed and formally signed off by the key partners as directed by NHS England. 13

14 4. Key successes from 16/17: In 2016/17 Norwich CCG with support from its partners have delivered on some key milestones on the integration journey, with these successes being driven through the Better Care Fund. The BCF Annual report 2016/17 provides an update on progress on key milestones so far and is attached below; Attached as a supporting document The BCF Annual report 2016/17 5. Future delivery: We will continue to will build on the success of 2016/17 as we drive forward greater health and social care integration. This will include meeting the ambitious plan that by 2020 health and social care is integrated across the country. It is important to note that this plan will be developed further when the Better Care Fund guidance has been released and this will provide further information on the following areas; How the additional 2 billion funding, recently announced in the spring budget for social care should be used Delivery of the High Impact Change model. In the meantime we will complete a selfassessment against the 8 change areas identified with CCG colleagues, to establish the local health and social care system position and begin to identify any additional system response needed to deliver this model. A detailed plan will need to be formally signed off by Norwich CCG and both local authorities once this guidance is available. This paper does outline the strategic direction to enable detailed planning to happen, when this information is available. 14

15 6. High Impact change Model The following is a summary of the 8 high impact changes detailed in the High Impact Change Model, this is supported by a document called High Impact Change Model Managing Transfers of Care. 15