Appendix 1. Rochdale Borough. Co-operating for better health and wellbeing: A plan for

Transcription

1 Appendix 1 Rochdale Borough Co-operating for better health and wellbeing: A plan for

2 Document Control Document Title: Co-operating for better health and wellbeing: A Plan for Summary Publication Date V4.0 4 th April th 21 st March 2016 Related Policies, Strategies, Guideline Documents Greater Manchester Strategy, HMR CCG 5 Year Plan, Rochdale Borough Sustainable Community Strategy, Rochdale Council s Corporate Plan and the Greater Manchester Plan (Taking charge of our health and social care in Greater Manchester) Replaces Joint Health and Wellbeing Strategy for Rochdale Borough Joint Strategy (Yes/No) Name of Partner(s) if joint Strategy Owners (Name/Position) Strategy Author (Name/Position) Yes Heywood, Middle and Rochdale Clinical Commissioning Group (HMR CCG) and Rochdale Borough Council (RBC) and other partners represented on Rochdale Borough s Health and Wellbeing Board Simon Wootten, Chief Officer of HMR CCG and Sheila Downey, Director of Adult Care, RBC Joanne Platt, Interim Head of Corporate Policy, Performance and Improvement Review of strategy Last Review Date 29 th March 2015 Review undertaken by Joanne Platt, Ian Mello and Sheila Downey Next Review Date June 2016 Page 1

3 Document control Date 11/06/15 17/06/15 18/06/15 24/06/15 25/06/15 29/06/15 Version Comments / author 0.1 First draft based on existing plans /06/ Ian Mello 30/06/ Ian Mello 01/07/ Revisions and additions by Charlotte Booth, Karen Kenton, Jennifer Hopes, Laura Fletcher, Wendy Meston, Michelle Loughlin, Dianne David, Sheila Downey Karen Kenton, Sam Evans, Lea Fothergill, Charlotte Booth, Ian Mello, Dianne David, Sheila Downey, Andrew Fry, Julie Murphy, Phil Burton, Richard Pinkney, Michelle Loughlin, Wendy Meston, Laura Beesley, Kathryn Saunderson, Jeanette Leach Ian Mello, Sheila Downey, Karen Kenton, Charlotte Booth and Sam Evans 30/10/ Joanne Platt, Charlotte Booth, Lesley Mort, Sheila Downey 27/11/ Locality Plan Steering Group 30/11/ Ian Mello and Joanne Platt 02/12/ /12/ Joanne Platt, Wendy Meston 15/12/ Joanne Platt 05/01/ Editorial Group 13/01/ Editorial Group 25/01/ Editorial Group 01/02/ Editorial Group 12/02/ Joanne Platt 24/02/ Editorial Group 29/02/ Joanne Platt, Sheila Downey 11/03/ Editorial Group 14/03/ Editorial Group 18/3/ Editorial Group 21/03/ Health and Wellbeing Board 04/04/ Ian Mello, Joanne Platt, Sheila Downey, Gail Hopper, Andrea Fallon, Pauline Kane, Steve Rumbelow Page 2

4 Document approvals This document requires the following approvals. Name Date Version Number Rochdale Health and Wellbeing Board 15 th December 2015 V2.4 Rochdale Health and Wellbeing Board 16 th February 2016 V3.4 Rochdale Health and Wellbeing Board 29 th March 2016 V3.11 Rochdale Council Cabinet HMR CCG Governing Body Rochdale Council: Full Council TBC TBC TBC Page 3

5 Section Contents Page No. Introduction and executive summary 3 Part 1: Strategic plan Context Strategic context Geographic and demographic context Where we are now The case for change Finance Workforce The existing health and social care system Estate Engagement with local people and other stakeholders Where we want to be Our Vision for health, wellbeing and social care in Improved outcomes A new model of care Part 2: Implementation 2 3. Delivering our plan making it real 2.1 The Strength and unity of the local partnership 2.2 Estate 2.3 Working and investing together to deliver public service reform 2.4 Engaging local people and other stakeholders 2.5 Transforming Primary Care 2.6 Our transformation work programmes 2.7 Workforce 2.8 Information and data sharing 2.9 Contracting and commissioning 2.10 Housing 2.11 Managing change 2.12 Innovation and Learning 2.13 Investment 2.14 Governance and programme management 2.15 Foundation for further transformation Signatures Page 2

6 Our priorities In order to achieve our vision we will prioritise the following: Co-operating for better health and wellbeing is a joint health and wellbeing strategy and Locality Plan for health and social care in Rochdale Borough (the Plan). The Plan is aligned with the Rochdale Borough Joint Strategic Needs Assessment, NHS England s Five-Year Forward View and the Council s Corporate Plan. It also reflects strategic priorities in the Borough s Sustainable Community Strategy and the Greater Manchester Plan (Taking charge of our health and social care in Greater Manchester). The Plan describes how we will upscale prevention and deliver a new model of care to improve health and wellbeing outcomes and reduce health inequalities for people in the Borough, within a financially sustainable health and social care system. Our Vision By 2021 we want more people to be in control of their own health and wellbeing, managing their long term conditions well and being supported to achieve good health and wellbeing across their life. Implementing this vision will result in more people having increased years of healthy life, as well as increased years of life as evidenced by the measures included within the performance management framework referred to below in section Extending lifestyle and behaviour change programmes aiming to have an impact at the earliest possible time. 2. Strengthening community engagement and ownership of health and wellbeing, building more opportunities for community and peer support, developing new solutions and support mechanisms alongside public services. 3. Increasing early years and early intervention support, targeting children and adults at risk before problems take root. 4. Developing local mental health and wellbeing services, with individuals and community groups becoming a stronger part of the support available. 5. Integrating commissioning of health, care and wellbeing so that services are put in place to meet all the needs of the person. This plan covers people of all ages. We want children in our Borough to have a good start, then as young adults and later as older adults to be able to live well, age well and die well. Improving End of Life care is also an important part of our plan. The new model of health, care and support introduces different support to that currently available for people of all ages. It seeks to fundamentally change the service offer to the public, to enable people to take more control over their own health and wellbeing. It also changes the way we invest public money to achieve good health and Page 3

7 wellbeing, shifting from paying for activity to paying by outcomes. In time, the new model will achieve significant savings as people are able to make different choices and more long term conditions are prevented or better managed. To achieve the transformation, we will pool resources across health and social care, we will concentrate on the needs of the whole person in the design of the services, using coproduction as our default way of working. Service design will be based on what matters most to the people who need that service, and individual care or treatment plans will be based on the outcomes individuals want and what matters most to them. People will be supported to make informed choices and to take responsibility for decision making about their own care and treatment. Our new model of care and support will focus on building resilient people and communities, increasing early help and support and providing joined up care in the right place for those that need it. The new system will reduce demand for intensive and costly care, helping to reduce the predicted funding gap of 26m by 2021, and leading to a more sustainable health and social care system for future generations. The changes we will make will be delivered by six-inter-related work programmes, underpinned by the delivery of our new Primary Care Strategy. Programme 1: Prevention and selfcare will focus on developing the building blocks and early help and support that people need to support themselves to thrive and cope, to stay healthy and to achieve and prosper. Programme 2 - Getting help in the community will support people who have significant and emerging needs. It will provide immediate, more comprehensive, and better coordinated care through multidisciplinary teams working together. The support will be personalised to the person and their families, using personal health and care budgets where relevant. Programme 3 Getting more help will provide more intensive support to people in the community, which may only be required for a short period of time. We will enhance our existing integrated tier of intermediate services as part of this programme. Programmes 1, 2 and 3 are inextricably linked to the delivery of our Primary Care Strategy. Programme 4 Getting specialist help will support people who need to be cared for in a 24 /7 setting or children who need to be looked after. When people do need this level of care, our focus will be on quality and effectiveness, with discharge back to the getting help level services at the earliest point. Programme 5: Mental health and wellbeing is intrinsic to people s motivation, confidence and ultimately success in managing their own needs and taking control over their own health and care. Activities to improve support for people at risk of developing mental health conditions or for those with an existing condition Page 4

8 have been integrated through each of our programmes of work. However, mental health is also identified as a programme in its own right to reflect the priority which will be attached to it. Programme 6 System transformation will address system and behavioural changes we need to make to ensure we can deliver the outcomes we are seeking. Four new service centres to be developed under this programme will be a critical part of our model. Managing complex dependency Factors that impact on peoples health and wellbeing such as poor housing, education and skills, unemployment, crime and justice, often leading to complex dependency are addressed through the activities within our programmes of work. Many of our challenges are shared by other localities in Greater Manchester and accordingly, we are working together through the wider Greater Manchester Devolution Work Streams to address these. Engagement with stakeholders We have engaged extensively with local people and other stakeholders in developing the new model of care and support described in this plan, including health and social care providers and voluntary and community sector organisations and groups. This gives us confidence that the changes we plan to make reflect local needs and have the support of our communities. Governance and programme management Success will be monitored and managed by our Integrated Commissioning Board on behalf of our Health and Wellbeing Board. We have put a programme management approach in place to manage delivery of our work programmes, to ensure that we stay on track, evaluate the changes we will make and share learning to upscale good practice across Greater Manchester. The Plan is set out in two parts. Part 1 sets out the strategic context (where we are now), our vision, and the outcomes we are seeking to achieve (where we want to be). The key enablers for successful delivery of the plan are set out in Part 2. A separate Appendix to this plan contains more details in relation to the financial gap, the outcome of stakeholder engagement which informed the development of the Plan, how we will measure success, the sixwork programmes, a high-level implementation plan and how our work will link to work streams that are being managed across Greater Manchester as a whole. Page 5

9 Locality Plans for each of the ten Boroughs in Greater Manchester have been developed as part of the overarching Greater Manchester Plan (Taking charge of our health and social care in Greater Manchester). The devolution of health and social care responsibilities to Greater Manchester (GM) provides an opportunity to do things differently with a focus on addressing those issues that will result in the greatest impact in improving health and wellbeing outcomes across the sub-region. The importance of this extends beyond the health and social care economy. Healthier, more resilient and independent communities are better able to take advantage of education, training and employment opportunities, all of which will contribute to economic development and growth in our Borough and across Greater Manchester. In particular, the potential to flex, reduce or remove some of the regulatory and financial barriers, move to fair shares financial settlements across Greater Manchester, and plan finances across multiple years, will significantly aid the development of a sustainable health and social care system, as will the opportunities for invest to save and transition funding that are difficult to enable within the current regime. In response, Greater Manchester has developed a Greater Manchester Strategic Plan for health and social care that is aligned with the NHS 5- Year Forward View (5YFV), which describes how a clinically and financially sustainable landscape of commissioning and provision can be achieved by This is the Locality Plan for Rochdale Borough (encompassing the Heywood, Middleton, Rochdale and Pennines Townships). It summarises the ambition and aspirations for improving health and wellbeing outcomes for local people that have been agreed by all the partners in our Borough with responsibility for health and care (the partnership). It has been developed in line with the principles of the 5YFV as shown below. The Plan has been developed in association with our local provider, communities and general stakeholders. It includes plans for a fundamental shift in our approach to prevention and wellbeing by increasing investment in public health orientated service and developing our community assets. It also contains new radical transformative plans for the identification and management of long-term conditions, through our Test Bed Vanguard Pilot across our Borough GP services. Locally we are pooling adult health and social care budgets and the Locality Plan contains several examples of how we have already jointly commissioned new innovative services spanning traditional health and social care boundaries. Page 6

10 Our new models of care cover elective, non-elective, mental health, learning disabilities and services which support people with complex needs. A new model of Primary Care is being produced which will establish agreed pathways across primary, acute and community services whilst being fully integrated with adult social care. Finally we are working across GM to agree new payment and contractual arrangements to support the transformational change in our services. The priorities identified in this plan are closely aligned to the themes and subthemes of the GM Plan, as shown in the table below, and our implementation plan and programmes of work are also closely aligned to the wider GM vision for health and social care. The table below shows how our six programmes align to the 5 themes identified in the Greater Manchester plan, either as a key component of the programme or as an enabler i.e. the changes we will make will have a positive impact on the GM theme. Our plan is underpinned by our Primary Care Strategy and six bold and ambitious programmes of work that will transform the way that health and social care is commissioned and delivered over the next five years. Our transformational plans are underpinned by the Rochdale Triangle of Change (see Section 2.6 below). The Triangle of Change will support transformation through the establishment of 4 health and social care delivery hubs, a data centre that will allow a single view of citizen to improve both service delivery and service planning and redesign across the public sector and the change cooperative which will harness local talent to deliver innovative service design and sustainable behaviour change. Over time we expect that the changes we are making will result in improved health and wellbeing outcomes for local people, a reduction in health inequalities in our Borough and a more financially sustainable system. Page 7

11 ALIGNMENT WITH GREATER MANCHESTER PLAN GM Theme Programme 1: Prevention and self-care Programme 2: Getting help in the community Programme 3: Getting more Programme 4: Getting specialist help Programme 5: Mental health Programme 6: System transformation Locality Plan Programme Radical upgrade in population health prevention Transforming community based care and support Standardising acute and specialist care Standardising clinical support and back office services Enabling better care Page 8

12 The Borough of Rochdale lies to the north east of Greater Manchester. It is made up of four Townships, each having its own diverse and distinct identity. We are bordered by Bury, Manchester and Oldham (within Greater Manchester) and Lancashire and Calderdale to the north and east of our Borough. elderly local people compared to those of working age as people are living longer. The population aged 65 or over in Rochdale Borough is expected to increase by 18.8% over the next 5-years. This is already putting pressure on both health and social care services, and this will increase further in future years. Deprivation The Borough is one of the most deprived in England, being ranked between 16th and 46th most deprived 2. A proxy measure for deprivation used to segment the Borough into 5 categories from the most (Group 1) to the least (Group 5) deprived shows an increase in the Borough s population living in our two most deprived population segments compared to Our most deprived communities have a younger age profile compared to the Borough average and our more affluent areas. Population Rochdale Borough s population is 212, Future population growth is expected to be modest across most age groups (3% over the next 10 years), but with a predicted larger increase in the over 65s age group. Age The population is relatively young, with 19.7% of the population being under 15, compared with 18.8% across Greater Manchester and 17.8% in England. In future there is an expectation that there will be a greater proportion of 1 Mid-Year Estimates 2014 Ethnicity Our population is ethnically diverse. People from black and minority ethnic communities (BME groups) account for over 21% of the Borough s population 3 and the rate of increase since 2001 and other evidence, such as the schools census, suggests that it may be higher than this. The socio-economic profile of our BME groups is often vastly different to that of our White British residents with consequent effects on their quality of life and health outcomes. Language 91.7% of the Borough identified English (or Welsh) as their main language in the 2011 Census. South Asian was the 2 Indices of Deprivation 2015 district level measures Census Page 9

13 second most common language (5.6%) with 4% of households having no occupant with English as their main language. This can impact on people s ability to access help and support when they need it. Housing We know that, alongside the wider impact of deprivation, poor or unsuitable housing or homelessness also causes ill health and additional cost to health and social care budgets. Poor housing is concentrated in certain areas and forms of tenure. In our Borough: 61% of homes are owner occupied, 23% housing association and 13% private rented 11.3% of all households in our Borough are in fuel poverty The number of inquiries received by Homelessness services has increased significantly over the last 2 years, from 3,864 in to 8,599 in The last House Condition Survey was carried out in At that time, 5.05% of homes were unfit for human habitation and a further 16.24% were seriously defective and borderline unfit. There has been a 25% increase in calls to the Council regarding the condition of private rented homes While the majority of unhealthy homes are in private ownership (home ownership and private rented), the bulk of housing association properties are in the areas of highest health inequalities. We know that health outcomes in Rochdale Borough are generally worse than regional and national averages 4, and there are significant variations between people living in the Borough s most and least deprived areas and between ethnic groups 5. Although life expectancy in the Borough is increasing, it is below national levels for both males and females The Borough ranks 140th out 150 local authorities for overall premature deaths (under 75-years of age) A large proportion of the Borough s early deaths are caused by heart disease, cancers, digestive disease (including liver cirrhosis) and lung disease (including lung cancer) High numbers of local people in our Borough have long-term conditions Emergency hospital admissions for Dementia and Schizophrenia are high Suicide rates are high in our Borough Our Borough has high numbers of adults with learning disabilities The wider determinants of health make a significant impact on these outcomes. In our Borough: Smoking prevalence is higher than national averages and under-18 hospital admissions for asthma are also higher than regional and national rates Levels of childhood and adult obesity are higher than national averages data 5 JSNA 2015 Page 10

14 Alcohol related mortality and admissions to hospital are higher than national averages Substance misuse is higher than national average Our Borough has some poor housing School readiness and educational attainment rates and adult skill levels are lower than national averages High rates of unemployment in the Borough also lead to poverty and poor mental health System pressures Pressures on existing health and social care systems are made worse by lack of alternative provision, custom and practice, and public expectations. Long Term Conditions are known to take up 50% of GP appointments, 70% of Primary Care budgets and 70% of hospital inpatient bed days Rates of attendance at Accident and Emergency departments are high Hospital admission rates for both falls and hip fractures in over 65s are above the England averages Mental health services are too heavily weighted towards secondary level care with too little prevention and recovery Too many people access hospital care for conditions that could be managed in the community Once in hospital many people stay too long Emergency hospital admissions for people over 85 years are continuing to grow and our nursing care home capacity is potentially inadequate for the future 22.2% of the population have some sort of carer role, putting them at increased risk of developing ill-health themselves Vulnerable groups Black and minority ethnic groups generally have worse health than the overall population. Language or cultural barriers may prevent these groups from accessing mainstream services Both physical and mental health conditions can lead to health inequalities due to the barriers they can present to accessing treatment There is an adverse impact on the health, future employment opportunities and social and leisure activities of those providing unpaid care, particularly in young carers The majority of asylum households that are in accommodation in the borough are families with children and many will have experienced significant instability. Shortages in mental health services for asylum seekers remain a national issue, particularly for children Lesbian, Gay, Bisexual & Transgender (LGBT) people experience significant health inequalities, which impact both on their health outcomes and their experiences of the healthcare system Although the majority of ex-armed forces can adapt to civilian life without any problems, the veteran population are at increased risk of developing certain physical or mental health conditions in later life The 2011 Census estimated that there were 186 travellers in Rochdale Borough. Further local data from August 2014 estimates the combined traveller community in the Borough to be around 250 people. Page 11

15 Homeless people are an extremely vulnerable group with very complex health and social care needs Mental health and wellbeing The Borough s mental health needs are high. Although existing services are available at both primary and secondary care level, they are too heavily weighted towards secondary level care with a focus on people who already have a severe and enduring mental illness, too much use of inpatient and residential care and limited recovery and movement through services. Good mental health is vital to ensuring good physical health. It is also important for ensuring the development and maintenance of family relationships and friendships, education, training and the ability to fulfil potential in employment. Many of our young people live in areas of high poverty and deprivation, factors often associated with poor mental health, while the projected increase in older people will likely see an increase in the prevalence of Dementia. Further data can be found in the most recent Joint Strategic Needs Assessment. Getting a good start Thriving children who get the support and nourishment they need to develop and excel The health and well-being of the Borough s children is generally worse than the England average. There are also significant variances in outcomes within the Borough itself. This may increase the risk of children and young people achieving poor outcomes, and of their needs escalating and impacting on their adult lives, which in turn impacts on the resources required to support them. We understand that by supporting our children and young people now, we will be turning off the tap of future demand. A significantly high number of children who have an early help assessment (Common Assessment Framework) or are in the child protection system have parents who are affected by the toxic trio of poor mental health, drug or alcohol misuse, or who experience domestic abuse. Over 60% of children on child protection plans are there as a consequence of neglect, and this emphasises the need to work across organisational boundaries to provide wrap around support to whole families to address need. Too many vulnerable children and young people go on to become vulnerable adults. Lifetime outcomes are determined very early in a child s life. More effective intervention early in a child s life and earlier in the onset of problems will improve their outcomes whilst also reducing long term demand on acute services. Living well Resilient adults who are willing and able to take care of both themselves and their families We know that lifestyle choices can have a significant impact on health outcomes. Eating a healthy diet, being physically active, not smoking and not drinking too much alcohol can all help us stay healthy and enjoy a longer life. Page 12

16 High numbers of local people in our Borough have long-term conditions, many resulting in emergency admissions to hospital. We also have higher than average rates of people living on disability related benefits, which is indicative of the prevalence of long-term conditions, especially mental health. In 2013, 48% of people claiming incapacity benefit or employment support allowance in our Borough were claiming for mental health or behavioural disorders. Ageing well Older people who can live a fulfilling and independent life Our population is ageing. We expect an average annual rise in people over 65 of 1.8% and people over 80 of 2.4% over the life of this plan. By 2025, nearly one in five people in our Borough will be aged 65 or over. People over 65 have a significant contribution to make, and our focus is therefore on prevention, early intervention and personalisation to help people to stay healthy and able to live independently. Older people should expect a good quality of life with high-quality care and support for those with complex needs. Locally, rates of depression and dementia rates are highest in more affluent areas, where there is a higher proportion of older residents, and we expect an increase in dementia as our much older population (age 80 plus) continues to grow. Over the past 5-years fewer people, especially older people, have been able to access lower level social care support to help them to stay well and independent at home. Along with other Boroughs, more people have been signposted to community and voluntary sector support that has been significantly financially challenged. This is exacerbated by changes in family patterns. Instead of supporting more people with a low or moderate level of need, on-going adult social care support is now concentred on people who have the very highest levels of need. Dying well People supported to die in their place of choice with dignity and appropriate integrated care We know that most people would prefer to die at home, or closer to home with the support of their family and friends. Although the number of people able to do so has increased in recent years, it is still the case that over half of local people die in an acute hospital ward. We will extend and develop new alternatives for people at or very near the end of their lives, so that fewer people die in a hospital ward. This will include ensuring that end of life planning helps the person to understand their prognosis and timescales, so that people can make informed choices about their care at the very end of life, and can die well with the support of their family, friends and planned care. The financial gap facing the CCG and the Council between 2016 and 2021 is an annual deficit of 26m by the end of March Further details can be Page 13

17 found in the Appendix to this document (Appendix 1) This figure reflects the position without large scale transformation i.e. if the CCG and the Council continue to commission and provide current services. Transitional investment will be needed to support new services and ways of delivery shown in the Programmes of work shown in the Appendix to this document (Appendix 4). This figure only reflects the CCG and the Council s position and does not include the financial challenges of our main NHS providers. Health Providers are expected to address the GM provider gap of 1.4bn separately, ( 736m to be delivered as provider reform reflecting 2.5% efficiency in and 2% thereafter). NHS England is also expected to address its plans for Specialist Commissioning and Primary Care for the Borough directly with the GM Devolution Team. Rochdale Council The Council s current financial projections through to suggests a total overall budget gap of 58.8m of which 49.8m relates to adult social care, public health and children s services. Impact of Locality and Sector Plans Whilst the locality and sector will look to address the predicted 26m gap by , there will be a requirement for additional funding and upfront investment for a number of areas such as parallel running, public engagement, workforce training and culture change activity, changes to the estate and ICT, recruitment drives for GPs and data sharing. Impact of Greater Manchester transformation Greater Manchester modelling has confirmed the legitimacy of the inclusion of Greater Manchester s share of the national 8bn additional Health funding equating to 450m over the next 5 years across Greater Manchester. The GM Devolution Team has confirmed 60m is available for However this money is also to fund the two Vanguard Sites in Greater Manchester, these being Stockport and Salford. Access to the remainder of the fund will be from joint Local Authority and CCG bids. Bids need to be in line with locality plans and deliver financial sustainability for the locality. We have also assumed an increase in Council Tax of 2% in relation to the Social Care Precept, totalling 7.3m by , and have allocated savings arising from healthcare schemes within the plan ( 9.2m) and from Council schemes ( 3.8m). In total, the gap anticipated by 2021 is therefore 26.0m, as shown in the tables in the Appendix to this document (Appendix 1). The local modelling reflects early budget planning from the CCG and the Council s developing medium term financial strategy relating to social care. For the Council, this includes savings from transformation initiatives in the Locality Plan and efficiencies from social care budgets in scope that the Council would seem to achieve without integration. Page 14

18 Given the scale of pressures and reductions, savings are being considered from non-statutory services where this could lead to a consequential financial risk for the CCG, providers and the Council from additional demand for services. However, the need to meet savings targets means that the Council cannot afford to continue to fund without protection of social care and / or movement of funding from health. To support delivery of Plans, additional investment (both capital and revenue), and transitional funding will be required. The financial modelling described above will estimate the investment and phasing required to deliver this and will be subject to further refinement as transformational initiatives are developed. In common with other areas, there are a number of workforce challenges that exist now and in the future. It is becoming increasingly difficult to recruit and retain skilled clinicians to work in areas of the greatest demand such as in Accident and Emergency and Medical Wards in our hospitals, and in Primary Care which struggles to recruit both GPs and Practice Nurses. A significant number of GPs are nearing retirement age, with fewer trainees choosing General Practice as their specialty. We also need to address the shortage of consultant psychiatrists, geriatricians and nurses within community and mental health services and to change and expand these roles so that they are able to support more people outside of a hospital setting. Locally, social care faces similar workforce challenges. Most adult social care is provided by independent and third sector organisations. The low pay that is common across the social care sector nationally is also prevalent in our Borough. The adult social care workforce in the independent sector is paid at, or close to the current minimum wage. Whilst the new national living wage will improve this to some extent, there are considerable risks associated with the ongoing sustainability of social care providers if increased employer costs are not reflected in increased fee levels. Recruitment of nurses is also a particular challenge in the independent care sector. In this sector fee levels are restrained and not sufficient for the sector to compete with NHS terms and conditions for qualified nursing staff. This is a critical challenge for the Borough and the sub-region as the provision of high quality personal care at home and in care homes is dependent on being able to recruit and retain high-quality staff. There are also recruitment and retention challenges for professionally qualified social workers and occupational therapists. Both adult and children s social care services in the Borough are working locally to support recruitment and retention, but this remains an issue at both Borough and Greater Manchester level. The tendency for other non-care sector low wage employers to raise their pay and terms and conditions as a result of the new national living wage is already leading to even greater pressure and turnover in the social care sector with a turnover of up to 30% per annum in some areas. This affects the availability of care workers and impacts on the consistency and quality of care. Page 15

19 At the present time, the social care providers in our Borough are able to meet current demand but their ability to recruit and retain staff must remain a priority now and in the future. Similar issues have been raised by childcare partners both nationally and locally who have traditionally experienced high turnover of staff and similarly need to retain staff to meet Government pledges to increase the availability of childcare for 3-year olds. Currently the Borough has an Urgent Care Centre based at Rochdale Infirmary, 37 GP surgeries, 42 care / residential homes (60 including homes for people with learning disabilities) and a number of intermediate care facilities. In addition the Borough has 17 children s centres operating on a hub and spoke model seven lead centres and 10 satellites, four residential children s homes (one being a short-break unit for children with disabilities and complex needs) and 43 private children s homes, as well as a range of community assets, for example community centres, libraries and community day support centres. The independent, voluntary and community sector also provides services, some but not all of these being commissioned by the CCG or the Council. 94% of all adult social care is provided by independent or third sector care organisations. In other service areas, much of the work of the third sector is focused on prevention and self-care. The social care market functions effectively in that it is usually able to meet current demands, however there are significant points of weakness. There are too few providers able to deliver care at home for people with high level needs, and nursing level care capacity is severely compromised. Both of these factors impact on the number of people who can be supported outside of hospital. Bury and Rochdale Doctors on Call (BARDOC) and the national NHS 111 number provide GP out of hour s services across Rochdale and Bury. Pennine Care Foundation Trust (PCFT) provides mental health inpatient and community services. Pennine Acute Hospital NHS Trust (PAHT) provides a range of hospital, specialist, integrated and community services in the Borough. GM Integrated Programme for Health and Social Care Reform The Healthier Together programme is part of the Greater Manchester Programme for Health and Social Care Reform, and is the largest and most ambitious health and care reconfiguration programme in the country. The programme s focus has been to identify opportunities for services to be shared across a number of defined hospital sites within the sub-region, with clinicians working across those sites to provide seamless care, and the teams delivering the once-in-a-lifetime specialist care on a designated site. The changes will lead to improved outcomes for local people as well as system efficiencies across the subregion. Under Healthier Together, the Royal Oldham has been designated as a specialist hospital, supported by North Manchester and Fairfield General Page 16

20 Hospital as local hospitals. Healthier Together changes enhance the current single service model with Acute Surgery and Acute Medicine at the Royal Oldham. Building on Healthier Together and working in partnership with commissioners, PAHT has commenced a clinical service transformation programme (including a full transformation programme being developed for Rochdale Infirmary) that covers its full range of services and delivers clinical and financial sustainability by The Trusts plans are set out in its Transformation Map Property and the built environment is an important part of delivering high quality public services in the communities we serve. It also represents a significant cost and therefore it is more important than ever that as much as possible of the public services budgets is spent on front line service delivery. 1 saved from property running costs is an additional 1 available to spend directly on frontline services. There are continually growing demands and expectations placed on the public sector and current models are considered to be no longer sustainable in the long term. As such there is a need and an opportunity for public services to work more collaboratively to reduce duplicated overhead costs and to deliver more joined up services at a local level. We routinely engage with local people, service users and other stakeholders through a number of different mechanisms and this helps us to develop priorities, and to plan and design services. For example, the Council operates a Youth Parliament to engage with young people, has a local Youth MP and children s champions. In adult care, service users and carers can engage in setting priorities and service redesign through a range of forums including the carers forum, the learning disability partnership and the mental health partnership. Local GP practices have Patient Participation Groups which routinely meet to consider issues of concern in relation to health. To supplement this regular engagement activity, we have met with a range of stakeholders to develop this plan and to co-design a new model of care and support for our Borough. This engagement has included people from our communities, third sector organisations and providers of services from across the Borough. A design fortnight was held in the summer of 2015, which included a series of 30 themed events. These events were open forums for people to discuss issues, ideas, innovation and to explore the opportunities that devolution to Greater Manchester will provide. In total, 225 people including individuals, voluntary organisations and community groups provided feedback on a range of themes. This engagement process was then supplemented by further involvement Page 17

21 work carried out by all partners on key transformational themes. One of the largest events in recent years was hosted by the CCG focusing on integrated care and services. The interactive event took place in October 2015 and attracted 140 local community participants. Subsequent to the design fortnight, further engagement sessions were held in September and October. The key points from these events and a summary of how we have built these into our new model of care are shown in the table in the Appendix to this document (Appendix 2.) Provider engagement As a membership organisation engaging and seeking views from primary care, including clinicians is a key theme that runs throughout all areas of work. All decisions affecting primary care medical are subject to agreement by the CCG s Primary Care Commissioning Committee, membership of which includes GPs, and the CCG s Clinical Commissioning Committee, which is led by a clinician, makes determinations on all CCG responsibilities (excluding Primary Care). Development of new models of care is led by GPs with support from the CCG as appropriate. Engagement with Primary Care in relation to the Locality Plan has been through a variety of mechanisms. The Locality Plan and the new models of care associated with it have been discussed with GPs at the CCG s Clinical Commissioning Committee meetings, at Locality Engagement Group meetings (LEG) at which all GP practices are represented, and in particular at a specially extended LEG meeting focused on just the Locality Plan. There have also been four patient engagement events held across the Borough. In addition there have been numerous evening meetings with GPs to discuss new models of care linked to the Locality Plan, Practice Nurse Forums and Practice Manager forums, and we hold quarterly members development meetings where discussion with all constituent practices takes place. Representatives from Pennine Acute Hospital Trust (PAHT) also attended multiple engagement sessions within the design fortnight in the summer of 2015, and this has been followed up through regular discussion through contract negotiations, in particular deflections affecting secondary care activity, and at the meetings of the North East Sector PAHT Transformation Group Representatives from Pennine Care Foundation Trust (PCFT) also attended multiple engagement sessions within the design fortnight. In addition, Children s plans have been being discussed via the mobilisation processes for Lot 1 and 2 contracts and through contract negotiations for those services remaining with the Trust. Representatives from PCFT Mental Health Trust attended multiple engagement sessions within the design fortnight, followed up in discussions through contract negotiations. The Locality Plan has also been considered by the Health and Wellbeing Board (at which NHS England has representation) on a number of occasions. Page 18

22 Feedback on how we have addressed the issues raised during this engagement work was given to stakeholders at an event held in January 2016, with representatives from health and social care, (adult and children s social care), providers (primary care, community and acute care and mental health), patient participation groups, the police, the voluntary, community and faith sectors and members of local communities. This event confirmed that our plan addresses local needs and expectations. People attending this event were invited to register an interest in becoming part of the implementing plans, which many did. We have worked with a range of stakeholders to develop a vision of where we want to be by 2021, and to develop a new model of care that will take us there (see Section above and Appendix 2 in the Appendix to this document for more details). By 2021 we want more people to be in control of their own health and wellbeing, managing their long term conditions well and being supported to achieve good health and wellbeing across their life. Implementing this vision will result in more people having increased years of healthy life, as well as increased years of life, as evidenced by the measures included within the performance management framework referred to below in section Our priorities In order to achieve our vision we will prioritise the following: 1. Extending lifestyle and behaviour change programmes aiming to have an impact at the earliest possible time. 2. Strengthening community engagements and ownership of health and wellbeing, building more opportunities for community and peer support, developing new solutions and support mechanisms alongside public services. 3. Growing early years and early intervention support, targeting children and adults at risk before problems take root. 4. Extending local mental health and wellbeing services, with individuals and community groups becoming a stronger part of the support available. 5. Integrate the commissioning of health, care and wellbeing so that services are put in place to meet all the needs of the person. This plan covers people of all ages. We want children in our Borough to have a good start, then as young adults and late as older adults to be able to live well and age well. Improving End of Life care is also an important part of our plan. The new model of health, care and support includes different support to that currently available for people of all ages. It seeks to fundamentally change the service offer to the public, to enable people to take more control over their own health and wellbeing, and changes the way we invest public Page 19

23 money to achieve good health and wellbeing. In time, the new model will achieve significant savings as people are able to make different choices and more long term conditions are prevented or better managed. To achieve the transformation we will pool resources and jointly commission services across health and social care, concentrating on the needs of the whole person in the design of the services, using co-production as our default way of working. Service design will be based on what matters most to the people who need that service, and individual care or treatment plans will be based on the outcomes individuals want and what matters most to them. People will be supported to take responsibility for decision making about their own care and treatment, and professionals will be challenged to enable this to happen. Our new model of care and support will focus investment in new ways of supporting people, placing greater emphasis on self-care, peer support, prevention, screening and informed and shared decision making. We believe this will reduce demand for planned and emergency health and care services, as more people choose more solutions closer to home, or choose to manage their health care conditions in a different way. The key outcomes we are seeking to achieve are shown in the table below. These are structured around the life course and aligned to the Greater Manchester Strategy with the addition of some system outcomes that underpin our new model of care and support. We recognise that some of these outcomes will not be seen in the life of this Plan and our programmes of activity are therefore based on improving outcomes in three-stages over a 15-year period to 2031 and beyond as follows: Short term outcomes for the next 1-5 years to improve outcomes for the current population and reduce demand on the system Medium term outcomes for the next 1-15 years aimed at future proofing the system by improving outcomes for the next generation through early intervention and prevention Longer term outcomes We have developed a tiered range of performance measures to help us to monitor our achievement towards these outcomes as shown in the diagram below. Tier 2 measures cover a wider range of activity, quality and efficiency measures that will help us to track our progress towards achievement of the targets at Tier 1. In the future, we expect that fewer people will need highly specialised care, enabling us to invest in ensuring the quality of highly specialised care for the future. Page 20

24 TIER 1: Hi-level outcome measures (5-years) from GM Plan TIER 2: Proxy-measures for getting a good start, living well and ageing well Monitored by Integrated Commissioning Board and reported to Health & Wellbeing Board The key outcomes we are seeking (Tier 1) are shown in the table below. Tier 2 measures are set out in the Appendix to this document (Appendix 3). Together, this performance management framework will demonstrate how our activities are impacting on health and system outcomes, as well as the quality and efficiency of services for local people and communities. Page 21

25 Tier 1 Performance Measures Outcome Measure Getting a good start More Rochdale children will reach a good level of development cognitively, socially and emotionally Increase the percentage of children achieving a good level of development at the end of reception year by 20.9% to 69.2% (an additional 350 children) by 2021 (GM measure) Fewer Rochdale babies will have a low birth weight resulting in better outcomes for the baby and less cost to the health system Reduce the number of low birth weight of term babies by 34.6% to 2.1% (27 fewer babies) by 2021 (GM measure) Living well More Rochdale families will be economically active and family incomes will increase Reduce the percentage of children (under-16s) living in poverty by 14.3% to 21.1% (1,590 fewer children) by 2021 (GM measure) Fewer people will die early Reduce the under 75 mortality rate (all causes) per 100,000 of population to (1,664 people) by 2021 (local measure) Fewer people will die early from Cardiovascular disease Reduce under 75 mortality from cardiovascular disease considered preventable: 52 fewer deaths by 2021 (GM measure) Fewer people will die early from Cancer Reduce under 75 mortality from Cancer considered preventable: 112 fewer deaths by 2021 (GM measure) Fewer people will die early from Respiratory disease Reduce under 75 mortality from Respiratory disease considered preventable: 50 fewer deaths by 2021 (GM measure) Page 22

26 Outcome Measure Ageing well More people will be supported to stay well and live at home for as long as possible Reduce injuries due to falls in people aged 65-years and older: 243 fewer admissions to hospital due to falls by 2021 (GM measure) System outcomes Appropriate use of hospital, social and primary care Reduce attendances at Accident and Emergency by 20% by 2021 (local measure) Reduce emergency admissions to hospital by 20% by 2021 (local measure) Reduce emergency re-admissions to hospital by 20% by 2021 (local measure) Reduce hospital planned activity by 20% by 2021 People access high-quality services and feel safe at all times whilst using services Reduce avoidable hospital deaths by TBC by 2021 (local measure) Reduce hospital acquired infections by TBC by 2021 (local measure) Provision of the most cost effective and efficient health and social care services Reduce delayed transfers of care by 50% by 2021 (local measure) People feel confident in managing their own health, wellbeing and care and know how and where to access services when they need them Reduce avoidable emergency hospital admissions for ambulatory care sensitive conditions by 20% by 2021 (local measure) Increase the number of people who die in their place of choice by 20% by 2021 (local measure) Page 23

27 To achieve our vision, we need to have one high quality, sustainable health and social care system which is part of a wider system of public service delivery including, for example housing, employment, and police services. The new model needs to close the financial gap whilst at the same time improving health outcomes for people in both the short and the longer-term and improving their experiences of the care and support they receive. We know that 60% of early deaths can be prevented by thinking beyond traditional healthcare activities (as shown below), and we know that healthcare is absorbing activity as a consequence of under provision in other bits of the system Genetic predisposition Social circumstances Environmental exposure Health care Behavioural patterns Local services will make the best use of collective resources, making every contact count and maximising opportunities for early intervention and the prevention of ill health. 40% 30% Working together, we will promote good self-care and mental health, whilst protecting vulnerable people, and reducing health risks and the resulting need for services. The aims underpinning our model are therefore threefold as follows: To improve quality services To reduce cost To add years to life and add life to years 10% 5% 15% Determinants of health and their contribution to premature deaths Source: McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff(Millwood) 2002;21(2):78-93 cited We Can Do Better Improving the Health of the American People Steven A. Schroeder, M.D. Our approach is inter-generational, future-proofing the system to reduce future demand for services, by focusing on improving the outcomes for the next generation as well as the current generation. Everyone in our Borough will have a good start, will live and age well, and will be supported well at the end of their life. Page 24

28 A good prevention system We will continue to develop a public health approach for all of our population across the different stages of their lives with a focus on prevention. We want public health potential to be maximised across our entire local system, including in our communities, the places where people live and work, our voluntary and community sector and across all of our services (including preventative services, primary care, community services, acute and specialist services). Our overarching framework for achieving this is shown in the diagram below. Page 25

29 A new model of care We have developed a model of care that aims to shift the boundaries of traditional healthcare and is based on three broad principles as shown in the diagram below. Early help and support Joined up care in the right place Building individual and community resilience We will build individual and community resilience to prevent future ill health leading to a more sustainable system in the long term We will provide more and better help at an early stage for people who need low levels of support to prevent problems escalating We will review the current arrangements for people who need more intensive support (both in the short or long term) and re-commission services so that care is joined up and more of this support is available at home or in community settings Further details are provided in the Appendix to this document (Appendix 8). Page 26

30 What will be different? For local people More people will have healthy lifestyles which prevent them from becoming ill There will be more help for people when they first need it, so that problems don t become severe and need intervention Early help will be available in four community hubs which will offer joined up support by multi-agency teams and staff More help will be available closer to home through voluntary and community support and health and social care support in the community for people with longterm conditions Fewer people will need to access urgent care and emergency hospital or residential admissions and those who do won t stay as long, instead being supported in community settings and at home For staff Staff will work flexibly across organisational boundaries in multidisciplinary teams supported by single patient records and joined up IT systems comprising Council members and officers and CCG Board members and officers Services will be jointly commissioned by the Council and the CCG There will be joint leadership led by a new Director of Integrated Commissioning a joint post across the Council and CCG and joint commissioning arrangements led by a joint Commissioning Team Risks will be shared by the Council and the CCG For budgets The Council and the CCG will pool their budgets to use for jointly commissioned services There will be joint investment, joint decisions on savings and efficiencies, and the sharing of financial risks We will map our pathways across our programmes of work to ensure optimal delivery of joined up care in the right place and at the right time. The diagram below provides an overview of the model of care and the principles that underpin it. Specialists will see more people in community rather than hospital settings Staff will share premises to provide joined up care to local people For leadership and decision-making Decisions will be made by an Integrated Commissioning Board Page 27

31 Sustainability A financially sustainable health and social care system that works in a joined up way, focusing on building independent and resilient people and communities, prevention, self-care and self-help, early help, choice and care closer to home for those who need it Principles A move from being reactive to proactive help, support and intervention Services commissioned will be co-designed with people who use them to reduce duplication Integrated, joined up care, with fewer handoffs Personalised care that offers choice and is closer to home Planned, coordinated care Assets Shared data and intelligence A skilled and flexible workforce Single patient records Assistive technologies Pooled budgets, shared use of buildings and workforce Making best use of community assets Primary Care Transformation Transformation initiatives Programme 1: Prevention and self-care Programme 2: Getting help in the community Programme 3: Getting more help Programme 4: Getting specialist help Programme 5: Mental health Programme 6: System transformation Page 28

32 What changes will we make? We will reinvest existing resources (both staff and budgets) to deliver change and will also seek investment from the Greater Manchester Transformation Fund. The key changes we plan to make over the life of this plan are set out below. Programme 1: Prevention and self-care We will develop an assets based approach to all our work and services, building on all our strengths, potential and resources to better connect our services with each other and with communities Through this, local people will feel more able to connect with others to develop strong social networks and local people will live, work and play in settings that support health and wellbeing from birth to old age Local people will have easy access to preventive services offered, and we will reach out to those who don t and ensure that people are aware and act on early signs of problems Local people will be supported to take as much control of their own lives as possible and we will support others to do the same We will tackle the causes of poor health including poverty, debt, housing, unemployment, environment and crime and reduce negative impacts on health and wellbeing We will upscale mental wellbeing and resilience work We will enhance and enable successful volunteering, self- help, selfcare and community action, alongside early help as required We will provide behaviour change programmes to tackle lifestyle priorities including aspiration and motivation to change, tobacco, obesity, blood pressure, uptake of preventive services and alcohol Programme 2: Getting help in the community We will ensure that people with multiple or complex conditions receive coordinated and proactive help, extending the current case management approach to more people We will extend the range of help available for people with ongoing long term conditions, taking a personalised approach to care and support planning, and through the use of a wide range of support services We will extend the range of care and support for carers recognising the critical role they play in keeping people well, at home and also the health care needs carers themselves face We will bring expertise out of intensive services to support people at home where necessary We will develop and implement an all age early help offer, supporting people to manage and be in control of their own care and support, and where possible able to return to manage with support from prevention and self-care services We will extend the care and support services available to people at, or near, the end of life. This will aim to support people to die in their place of choice but crucially to make advance decisions about their care and Page 29

33 treatment with the full knowledge and understanding of the implications We will streamline access to housing advice and support We will establish a new frailty programme to proactively support frail older people Programme 3: Getting more help We will enhance community provision of service to reduce the need for local people to access Getting more help service We will increase the use of assistive technology to support those managing long term conditions and disabilities We will focus resources on people with Dementia, recognising the impact this has on people s ability to remain independent. We will commission a more responsive reablement and rehabilitation service We will roll out integrated elective care pathways We will repatriate existing patients with learning disabilities back to the Borough We will provide more flexible and responsive respite services for families with children with disabilities We will implement an effective edge of care provision to prevent children moving into care We will deliver a clear ADS pathway to manage demand and provide support to those affected by this condition Programme 4: Getting specialist help We will repatriate local people back to the Borough or GM conurbation from out of area placements and reduce the number of children with complex needs placed out of Borough We will commission local provision of Specialist / Forensic Learning Disability treatments We will deliver GM Learning Disability Fast Track objectives We will build local foster care and adoption capacity to meet local demand We will ensure synergy with the GM Trauma Network, GM Neuro Rehabilitation services and GM Healthier Together Programme for those who need specialist help and to improve outcomes for people with cancer Programme 5: Mental health Mental health threads through each of our other programmes and support for people with mental health conditions will be provided within all offers, depending on the severity of the condition and stage at which the condition is identified or diagnosed. Actions we will take to support people with mental health conditions include: Embedding the Five Ways to Wellbeing as a framework for prevention and sustainable recovery Providing a timely and accurate assessment closer to home, to ensure local people receive the right level of support Reducing the number of people reaching mental health crisis through rapid access to the right level of Page 30

34 support and a managed approach to care We will shift the balance of the current system from acute inpatient services to local community provision, and reducing out of area placements Programme 6: System transformation Four-bespoke community service hubs will be provided to offer gateway and management for the entire remodelled health and social care system. The focus of the offer will be on delivering early access and shifting the balance towards a preventive system, whilst offering coordinated support, and facilitating rapid access at the point of need. This is not just about the front end of care but the nerve centre will track patients through the system and offer opportunities for preventive and proactive intervention with local people of all ages Hubs will signpost to support and coordinate local peoples journeys through the system with particular attention on referrals to Prevention and self-care and Getting help in the community where appropriate The hubs will offer care and support at the right time in the right place to minimise duplication and to prevent escalation. Cost savings will be reinvested into a sustainable system The hubs will identify high risk presentations and escalate at the appropriate time to the support necessary The hubs will initiate an all age early help assessment and refer into Getting help in the community locality based teams The hubs will provide a co-ordinated multi agency response at all points in the system Rochdale Change Co-operative is a catalyst for radical and sustainable system change. We will bring in expertise and knowledge which allows us to challenge current norms for public service delivery, identifying new and innovative ways to deliver, and implement and embed this through developing local talent The initial focus will be on 4-interrelated systemic change programmes delivered on a Borough wide level, to create a new cooperative relationship between local people, business and agencies. These change programmes form the foundation upon which successful implementation of our new model for health and social care delivery is built We will initiate a dialogue in the Borough which results in a change of behaviour in our local people, businesses and agencies resulting in more effective use of resources. This will include promotion of healthy lifestyles, self-care and self-help and the most appropriate routes for people to take when they need help, to discourage people from accessing GP appointments or attending at Accident and Emergency (A&E) for minor ailments that do not need this level of intervention. We will also work with the clinical and the non-clinical workforce to ensure that their behaviours reinforce the behaviours we are seeking to develop. We will develop a strong communications message to highlight the cost of inappropriate responses. For example, we know that the reductions we are seeking in attendances at A&E by 2021 could pay for 25 newly qualified nurses, or 34 newly qualified police officers, or 32 newly qualified teachers or 22 newly qualified social workers, and we will promote these types of messages as Page 31

35 part of our behaviour change programme. We will deliver and embed a model of collaborative commissioning in which services are co-designed by local people, providers and commissioners We will develop effective communication and marketing strategies with local people which build on their assets and overcome current barriers We will work with the Nerve Centre to utilise data and intelligence to deliver proactive and ongoing quality improvement in all services. As demand for acute and specialist services reduces, we expect to see improvements in the quality of those services for the people who need them. The case study shown below describes how a young person will use the new system to address needs. Safeguarding children and young people and vulnerable adults Living a life free from harm and abuse is a fundamental right for every person, and we have both a statutory and a moral responsibility to promote the welfare of children and young people and protect adults from abuse and risk of harm. Safeguarding is therefore a thread that runs through the work-streams of this plan. We will commission services that protect individual human rights, promote dignity, independence and well- being, hear and respond to the needs of children, young people, adults and carers and demonstrate assurance that any child, young person or adult thought to be at risk is safeguarded and protected from harm and abuse. Page 32

36 Case study: Lucy is a 16 year old who has just finished her GCSE s and has a place at Sixth Form College to study for A-levels, and then go onto to university. She does not access services other than those universally available (prevention and self-care). Lucy had been feeling very tired, thirsty and was losing weight so her mum took her to see her GP (prevention and self-care). He identified that Lucy had very high blood sugar levels and diagnosed type 1 diabetes, and arranged for her to be admitted immediately to the local hospital (getting more help). Lucy spent one night in hospital where her blood sugars were stabilised and she was seen by the diabetes specialist nurse, taught how to inject insulin, given a lot of information and referred to the paediatric diabetes specialist nurses (PDSN) in the children s community nursing team (getting help in the community). Over the course of the next few weeks Lucy and her family were seen at least weekly by the PDSN and monthly by the consultant (getting help). As the family adjusted to the diagnosis and Lucy became more confident in managing her condition the frequency of visits reduced. Lucy decided that she wanted to manage her insulin administration via an insulin pump, which was provided, and again she received more intensive support from the PDSN. After a couple of weeks, Lucy was confident that she could manage, and she kept in touch with her PDSN via text or telephone call as and when needed. She carried on with her life and gained her A- levels accessing online advice or her PDSN as and when needed (prevention and self-care and some getting help in the community when needed). One morning Lucy felt very ill and her blood sugar levels were very high. She was taken to A&E and admitted to hospital (getting more help). The cause was quickly identified and as Lucy was generally managing her condition well she was discharged without needing to stay in hospital overnight. The PDSN checked in with her to make sure that Lucy was well and managing. Since then Lucy has commenced university and she is carrying on with her life (prevention and self-care). She contacts the PDSN (getting help in the community) by phone if something s not right, so one day when her bloods were very high they had a telephone conversation every 30 mins until her levels came down which avoided a further hospital admission. Lucy s care continues to be overseen by the consultant, but on a day to day basis she manages her condition at a prevention and self-care level, occasionally getting help in the community from her diabetes nurse when she needs it. Page 33

37 communities that reaches across all relevant organisations, leading to shared ownership and accountability by the Board s constituent members. The Board s purpose is: The CCG and the Council have been working in partnership since the CCG s inception in April The organisations are co-located in the Council s new flagship building in Rochdale, and a number of services have been jointly commissioned over the past 3-years, some notable examples being the well regarded Sunrise Team, which has been successfully tackling child sexual exploitation in the Borough, and the Intermediate Tier Service (see case study below). The Health and Wellbeing Board was established under the Health and Social Care Act 2012 to lead the improvement of the health and wellbeing of the Borough population, with a specific focus on tackling health inequalities. The Board meets once every two months. Since its inception, the Board has been striving to join up commissioning strategies across the NHS, social care, public health and other partners that contribute to health and wellbeing. The Board s vision was contained in the Health and Wellbeing Strategy , and this is now replaced with this joint Health and Wellbeing Strategy and Locality Plan. The Health and Wellbeing Board has provided shared leadership of a strategic approach to the health and wellbeing of the Borough and its To ensure that all available resources to support health improvement and people s quality of life are used efficiently and to their full potential To lead an assessment of the health and wellbeing needs of the local population, producing a highlevel Joint Strategic Needs Assessment to inform priority setting To develop a joint health and wellbeing strategy providing an overarching framework and priorities identified for action within which commissioning plans for the NHS, social care, public health and other health and wellbeing related services are developed To shift the focus of services from crisis management to a preventative approach at key points in the whole life course To challenge all partners to fully deliver their contribution to the Borough s priorities for health and wellbeing To lead joint working and ensure coherent and co-ordinated commissioning strategies, including those of the NHS Commissioning Board To provide public accountability for services which are directly related to the health and wellbeing of the local population Page 34

38 To ensure all partners fully understand what outcomes the Board are working to and use robust performance management structures to measure progress and success To maintain an oversight of the allocated public health budgets and how these are spent To pull together the commissioning activities of the NHS locally and the Council where this aligns with delivery of the joint health and wellbeing strategy and, through integrated commissioning, require assurances from joint commissioning structures of value for money and equity of access and outcomes The Board comprises representatives from the Council (both elected members and senior officers), the CCG (Governing Body members and senior officers), the Borough Commander (Greater Manchester Police), and representatives from HealthWatch, the Council for Voluntary Service (CVS) and from NHS England. In 2015, a Shadow Integrated Commissioning Board (ICB) was established as a sub-committee of the Health and Wellbeing Board to take responsibility for the management and monitoring of the Better Care Fund. This Board meets once every month and will be fully established (i.e. it will cease to operate in shadow form) on 1 st April 2016 with the remit to manage and monitor delivery of this plan. Membership of the ICB comprises Council elected members, members of the CCG s Governing Body and senior officers from the Council and the CCG. Early in 2016, we will also establish an Integrated Provider Board, to include representatives from health and social care providers (acute, community and primary care and the independent care sector) as well as voluntary and community sector providers. Delivery or our ambitions will be supported through these governance structures (see Section 2.14) and we expect to see real measurable changes year on year from The CCG and the Council has used this governance infrastructure to develop this plan. There has been an Integrated Commissioning Steering Group in place comprising senior representatives from the Council and the CCG as well as housing providers to develop the plan and the new model of care. A wide range of stakeholders have been engaged in identifying priorities to develop this plan (see Section 1.2.6). Regular progress updates have been made to the ICB and to the Health and Wellbeing Board. The ICB has recently given approval for the joint appointment of a new Director of Integrated Commissioning who will be the lead accountable officer for the delivery of the plan. The new Director will lead an executive team focused on the delivery of this and supported by the programme management arrangements detailed in Section 2.14 below. We will also bring commissioning teams across the Council and the CCG together in 2016 to commission Page 35

39 across the whole pathway and the whole system. Integrated Commissioning will be supported by a pooled budget. Our ultimate intention is to pool all council adult social care, children s and public health budgets with CCG commissioning budgets and we intend to progress this in 2 phases for operational and assurance reasons. The first phase, commencing in April 2016, will include adult health and social care and be focused on enabling the delivery of years 1 and 2 of this Plan. Once the initial phase is embedded, the remaining parts of the budget will be pooled, with one single commissioning function led by the Director of Integrated Commissioning, accountable to the Council s Chief Executive and the Chief Operating Officer of the CCG. We anticipate this will be April We are continuing to consider new models for provider partnerships and the form that our existing and newly formed partnerships might take in the future. Our newly commissioned urgent / intermediate tier services are already delivered through a provider partnership, led by Pennine Acute Hospitals Trust. This new intermediate tier service is already a fully integrated health and social care service that is delivering demonstrable and significant results, with a single vision, operating model and outcomes. This could develop into a different organisational entity should there be an added value opportunity to doing so. In addition, following a competitive tender process, our community / neighbourhood healthcare services will also be delivered through a provider partnership, also led by Pennine Acute Hospitals Trust. It is our intention that, during 2016, this will be integrated with Adult Social Care Assessment and Care Management Services. However, as with almost all other councils, social care is delivered by many external third and independent sector providers, along with staff employed directly by individuals through the use of personal budgets. All of these providers are important when considering how partnerships might develop and be led in the future. The arrangements outlined above have been enabled through our local integrated commissioning process and procured competitively. The process and specifications reflect the ambitions and developments envisaged in this plan. The outcome of this process presents an opportunity to pursue the model of a single integrated provider for the Borough. We are however also convinced of the need to ensure that mental health and key social care providers especially local residential, nursing and domiciliary providers - are fully integrated. Their skills, experience and potential are yet to be fully realised within the system. We are therefore reflecting on the organisational form, the opportunities and emerging evidence, before committing to a particular model. Page 36

40 Whatever the model, it should enable better quality of care, improved measured outcomes for the person, and significant cost efficiencies resulting both from the model itself and the impact on reduced demand. A new provider partnership has already been formed which brings together all the NHS (primary, secondary and community), social care and third sector providers who are part of the provider partnership delivering our new Intermediate Tier and Community Neighbourhood Services. This partnership is responsible for delivering the outcomes required for the new service models and holding all partners to account in doing so. The partnership could, if benefits can be shown, develop into a new organisational form in the future. At the current time, the partnership has one vision, one set of objectives and one primary provider, and this is the vehicle through which whole system transformation is being delivered. Page 37

41 Case study: New Integrated Intermediate tier services - MAKING IT REAL In , as part of our early integrated commissioning work, the Council and the CCG decided to review the effectiveness of intermediate care services, with reference to national benchmarks and particularly to challenge the effectiveness of local services in avoiding hospital admissions and supporting early discharge. We wanted to know how well the range of Intermediate tier services worked together and provided a joined up offer for the public, and how efficient they were in terms of lengths of stay and outcomes. We also wanted to understand how well used they were and how referral pathways worked. The services had been established for several years, with residential intermediate care resource centres provided by the Council, and an urgent community care team provided by Pennine Care Foundation Trust. A joint team was established to undertake this work, which involved acute and primary care clinicians from the outset, with strong clinical and social care leadership throughout the work. The team undertook a detailed analysis of the circumstances of individuals admitted in an emergency as part of this work and this fed into the service redesign. It also involved feedback from people using the services and their relatives. A new model of care emerged from this work, which coincided with the introduction of the Better Care Fund (BCF). It was agreed, across the system, that we would take the opportunity to commission a new and significantly extended intermediate tier of services. As commissioners we envisaged a provider collaborative coming together to ensure that the primary, community, social and acute systems all pulled together in the same direction, within a single outcomes focused partnership, to make this new service offer effective. Together we identified an investment of 5.5 m in these services, some of this preexisting in associated services and some invested through the BCF, the latter made possible by planned diversions from acute hospital care. The whole of the budget for the service was then included in our BCF. An integrated commissioning exercise and competitive tender then followed with encouragement from commissioners for a provider partnership, of one form or another, to emerge from the process. This was challenging for all existing and future providers, but was also seen as an opportunity. The contract was awarded to a new provider partnership led by Pennine Acute Hospital Trust (PAHT), with significant contributions from GP care, BARDOC, and Council provided services into the new service model. As a result Pennine Acute Hospital Trust have invested in a new Intermediate Unit at Rochdale Infirmary, which is due to open in the coming weeks (the service has been provided from another unit at Rochdale Infirmary in the interim), and additional residential intermediate tier beds are provided at Tudor Court in Heywood. This building is now managed by PAHT and 70 Council intermediate care staff working in the residential units have transferred, very successfully, to PAHT as the lead provider. Social care staff are fully integrated and instrumental in the new offer. As well, we have a much extended home based intermediate tier offer, with care in the units only being used in conjunction with care at home; as part of the same pathway. This is supported by a real time case record that allows GPs (and others) to track the progress of people within the system. The service became operational on 1 September It has already delivered impressive outcomes, which are monitored on a monthly basis through an enhanced performance management approach between commissioners and providers. The contract rewards achievement of the key outcomes. The service is effective and accessible, and is over achieving on the emergency admissions deflection expectations. Lengths of stay in the residential part of the service have been significantly reduced with the enhanced medical support for patients and the extended care at home offer enabling more efficient transfers through the pathway. This has been an exercise in integrated commissioning and integrated provision, bringing the system together and requiring everyone to change to achieve better outcomes. So far it is exceeding expectations to the point that we are already seeking opportunities to extend it, including bringing the responsibility for transfers of care and the Council s enablement service under the single line management of the intermediate tier service. This is one of our local examples of whole system change which we include as an example of how we are working together now, and intend to develop further through extending our integrated commissioning and pooled budget approach across the whole of the adult health and care system in 2016 and beyond. Page 38

42 Alcohol reduction Case Study The Council recognised some years ago the impact that alcohol, drugs, domestic abuse and mental health have on local people and services, and we have therefore prioritised work in these areas over the past few years to address this. The Health and Wellbeing Board has worked with the Borough s Safer Communities Partnership to agree a Borough Community Safety Strategy and plan, a Drug and Alcohol Plan and a Domestic Abuse Strategy. We have set out below, an example of a specific programme undertaken by this partnership to address the rising rates of alcohol related attendances at local hospitals. A public health partnership approach to reducing the rates of alcohol admissions Where we were: We had high and rising hospital attendance and admissions related to alcohol We saw a group of people who repeatedly attended A&E for alcohol People s complex needs were not being met in a hospital setting including their social needs, debt, mental health and housing There were high numbers of alcohol related hospital attendances by young people There were rising costs We already had a borough wide alcohol strategy in place which highlighted the rising admissions as a priority What we did: Assessed need, reviewed the evidence and developed a trust wide alcohol strategy within Pennine Acute Hospital Trust Collaboratively commissioned and developed a trust wide Alcohol Liaison Service delivered to a single specification Developed staff training and internal alcohol pathways and policies Introduced screening and brief intervention at all A&E and Urgent Care Centre sites Developed an approach targeting those who re-attended most often Developed an Assertive Outreach approach to actively support frequently attending patients out into the right services to meet their wider health and social needs Obtained Lottery funding to appoint a specialist nurse to develop and implement a young people s alcohol pathway in the trust Re-enforced local partnership work between the Health and Community Safety Partnerships to deliver a system wide response to reduce alcohol harm through joint work Integrated our services for drug and alcohol treatment and recovery The impact: We reduced alcohol related hospital admissions for adults from a rate of 751 per 100,000 in to 713 per 100,000 in A case study audit of assertive outreach showed the wider health and social needs of patients were being met There was a reduction in frequent re- attendance at hospital More appropriate use of hospital staff time Staff welcomed the alcohol liaison service and reported the impact of it on their time Alcohol related admission costs fell Page 39

43 The HMR Strategic Estates Group compromises of all public sector partners in the Borough. An Estates Strategy for the Borough is currently in development which will outline the approach to support integration through the efficient and effective use of the estate. The strategy aims to identify opportunities which will drive out service and / or cost benefits and enhance the quality of the estate. We are seeking opportunities to share estate where possible and have already begun to identify the existing estate (location, use and condition) across the partnership. The management of publicly owned assets will be coordinated across the Borough and be supported by a clearly defined vision, integrated asset strategy and delivery plan. The focus of work will foster improved connectivity across all public and voluntary organisations with the specific aim of gaining a greater understanding of their strategic and operational needs. This will enable the achievement of greater integration of assets in relation to future service delivery models while mindful of the need for overall equality of access to services across the community. Asset data will be stored and accessible upon a shared and open ICT platform and all key asset information will be widely available to support informed asset and service decision making. Estate utilisation studies are being commissioned via the group in relation to primary care, community and acute providers buildings. Feasibility studies of potential future assets have already been completed to support identification of key buildings as defined in our Locality Plan such as community service hubs. This has included work with Greater Manchester Police for example, to review the potential future use of existing police stations which are being disposed of. The group is also working closely with our Borough economic and regeneration colleagues to agree key opportunities to maximise estates. Health care planning work has also been delivered in relation to Rochdale Infirmary to understand the estate requirements for the future transformation of the current site. Reform is at the heart of our approach. Services will be co-ordinated around family needs enabled by new technologies. We will: Reduce the dependency and demand for services by building independence and resilience amongst local people and communities Invest in early intervention and prevention Integrate and streamline services across the Borough Develop a flexible and experienced workforce that is able Page 40

44 to work across organisational boundaries to meet future challenges Embrace whole system thinking, examining current systems flow and the redesign / co-design and codelivery of services Adopt a life-course approach from pre-birth, through childhood, adolescence (getting a good start), working age (living well), up to old age (ageing well) and end of life. This will improve many outcomes for local people in the short-term but importantly will also put in place the building blocks for future generations to enjoy good health and wellbeing. Our Families Data Warehouse will connect across work streams and partnerships ensuring effective targeting of services and our plans for the development of a public service reform hub will take our intelligence gathering and single front door ambition for vulnerable people to an enhanced level. We are taking learning and good practice from a range of sources including our Public Service Reform pilot, our nationally acclaimed community champions, front line / key workers and advocates and will use this to develop workable solutions to change behaviours, and build confidence. We understand how the lack of skills, worklessness and poor housing impacts on health and wellbeing and will ensure that our activities are appropriately linked to other public service reform work streams being undertaken in Greater Manchester to address these issues. Different perspectives can lead to radically different solutions, and we know we can tap into the experiences and ingenuity of citizens and staff to solve big challenges through collaborative commissioning. We therefore want to create a dialogue with communities and individuals to not only understand their needs but also their assets and their aspirations, and to create an environment where providers are incentivised to collaborate with each other, sharing risks and rewards and where the voluntary and community sector feel safe and empowered to innovate and improve services. Central to our model of care and support is the principle of no decision about me without me for all stakeholders. To make this happen, we need to understand the experiences of the local population, the barriers they face and the outcomes they expect by having a continuous dialogue with local people and providers. We will continue to involve patients, carers and local people, and community leaders, representatives and groups, in the planning, design and commissioning of services. We will continue to develop existing networks, building on our already strong relationships with communities to establish new and innovative partnerships. We will continue to support local GP practices to develop their own Patient Participation Groups and from these groups form a Patients Participation Page 41

45 Forum to reflect the demographics of Practice populations. We will be accountable to local people for the delivery of this Plan, and will develop new ways of engaging with local people to do this. Fundamental to the success of the Plan are behaviour changes by commissioners, providers and people in our Borough. We will use our recent experiences in the co-design of services to develop our new model of care and support, together with recent work we have undertaken with the Innovation Unit to develop a model of collaborative commissioning as shown in the diagram below. support and the role of providers in delivering the required changes. Primary Care is central to our new model of health care and support. Currently, some people go to see their General Practitioner (GP) when their problem could or should be addressed elsewhere in a wider system. Many people cannot access a GP appointment in a timely way to meet their needs or their perceived needs. Local people want and expect same day access to GP s when they are feeling unwell. People who work want to be able to access their GP outside of normal working hours. To address these challenges, we are developing a Primary Care Strategy, to widen access and make use of other associated practitioners within the system. The key elements of our strategy will be: To support General Practice to drive new models of care and to support primary care providers to work collaboratively with wider public service and health providers to develop a Local Care Organisation which will deliver joined up out of hospital care Provider involvement in the transformational process is also a key factor in our plans. This includes health care providers, providers of adult and children s social care services, housing providers and the voluntary and community sector. We will establish a provider forum to discuss the implementation of this plan and our new model of care and Development of the Primary Care workforce including potential new clinical roles (for example physician associates) and increased integration of community pharmacists into general practice (to deliver minor ailments care and medication reviews for example) The development of the nursing workforce (e.g. secondary care nurses conversion to practice Page 42

46 nurses, increasing the number of Advanced Nurse Practitioners, and the implementation of social prescribers within primary care) Development of the GP workforce into clinical commissioning leaders and a new GP incentive scheme to attract and retain new GPs To embed the 7-day access to Primary Care Services into core provision of routine Primary Care Medical Services, thus ensuring equitable levels of access across General Practice Our new Primary Care service model will include the development of integrated health and social care hubs across our Borough (see Programme 6 referred to below) incorporating health promotion, early intervention services, first contact support from new generic workers, integrated neighbourhood community and social care teams social prescribers, 7-day access to GPs and social care, intensive community services / out of hospital care, domestic abuse support, community policing, skills and employment support, housing officers, leisure and physical activity services. The new primary care estate will see development of suitable sites / buildings for hubs and the enhancement of existing practice premises to support merged/colocated practices. Expansion of demonstrator information technology systems innovation across the whole of the Borough Provider development will see federated GP provider development with the potential to develop alliance / collaborative working with Community Providers and Social Care to deliver the hub model (see below). Integrated community primary, health and social care services We will develop a new level of integration. Primary care will be aligned and direct support provided into general practices covering the following: Health interventions: District Nurses, Occupational Therapists, Physiotherapists, Speech and Language and GPs Social care support Carers support Domestic abuse advice and support Skills and employment advice and support Housing advice and support Leisure and physical activities Community policing Stronger Families advice and support Healthy Minds advice and support Our strategy is already well advance and will be finalised by the end of June The new primary care information technology infrastructure will see: One clinical system to enable appropriate sharing of patient records Integration of health and social care systems Our new model of care and support will be achieved through six interrelated programmes of work, underpinned by our Primary Care Strategy, and we have developed this Page 43

47 into a single implementation plan which can be seen in the Appendix to this document (Appendix 6). Programme 1 Prevention and selfcare Most people resolve issues in their lives without recourse to services at all, drawing on the support of their families, friends and local communities throughout their lives. This programme of work builds on this premise, by developing the building blocks that people need to support themselves to thrive and cope, to stay healthy, to achieve and prosper. We will be extending the local offer to fill some gaps where more open access to support would assist more people to help themselves, and to coordinate services better to reduce duplication and costs. This will be underpinned by our work on prevention and self-care described in Part 1. We will continue to prioritise the causes of poor health. We will link our health and wellbeing programmes with our local programmes on poverty, debt, housing, unemployment, environment and crime and reduce negative impacts on health and wellbeing. This service will also help people to find early help and support them through it for a period of time, if necessary. It will be a personalised service, helping people who currently need some help but not necessarily from a GP, other primary care or social care. Not only will this better support people but it frees up opportunities for GPs and other health and care professionals to focus more time and resources on those that need their help. Four-new community service hubs being developed under Programme 6 will provide early help and support and many people will be supported by these hubs without having to access Primary and social care. The new service hubs are therefore a critical part of our model. We envisage more health care advice being available through pharmacies linked to the new service hubs, along with easy access to the full range of prevention and self-care services, and essentially mental health self-help, community support and counselling offers. Programme 2: Getting help in the community If a person has not been able to be helped by prevention services, they will be referred onto the getting help level of service. Currently the time offered to people who have significant and emerging needs can be quite limited. We are going to change this so that once a person has this level of need they will immediately receive more comprehensive and better coordinated care. Multi-disciplinary teams supporting children and adults will work together, linked to a comprehensive set of support services that can be personalised to the person making use of the principles of personalisation in adult social care and comprehensive early help assessments in children s services. There will also be work with children and families through family support arrangements. Most people will be supported and will be able to achieve the outcomes they want for themselves through this extended level of service. It will be supplemented, as and when required Page 44

48 by other more intensive specialist interventions, pulled out of secondary care rather than people being referred to secondary care. Specialist services will reach into the community teams to avoid a person s difficulties escalating to the point that they need an emergency hospital admission, an admission to a care home or a child needs to be looked after by the Council. Programme 3: Getting more help There will be times when the getting help offer needs to be enhanced by even more support and this will be provided through our third programme of work. This more intensive support will still be provided to people in the community, and it may only be required for a short period of time. We will be enhancing our existing integrated tier of intermediate services as part of this programme. There will also be intensive work programmes with children and families through commissioned services that offer a higher level of support such as the Child and Adolescent Mental Health Service (CAMHS). Another example is the more intensive services, including medical, nursing and social care that we will make available to people at the end of their life. Alongside this, the service will work with people to discuss and communicate options with them, as part of putting people in more control of the care and treatment options available and supporting them to make more considered decisions about what is right for them and their families. Getting help and getting more help are part of the same spectrum. We envisage both these levels of service will grow in our model, year on year as need is reduced in the specialist level of intervention. Programmes 1, 2 and 3 are inextricably linked to the delivery of our Primary Care Strategy (see section 2.5 above). Programme 4: Getting specialist help This programme represents our specialist services for people who need to be cared for in a 24 /7 setting, or children who need to be looked after. However, we see all of these reducing significantly over the life of our Plan. When people do enter this level of care, our focus will be on quality and effectiveness, with discharge back to getting help level services at the earliest point where possible. Programme 5: Mental health Fundamental to our model is better mental health and wellbeing support for people of all ages in our Borough. Mental wellbeing is intrinsic to people s motivation, confidence and ultimately success in managing their own needs and taking control over their own health and care, and as such, mental health will cut across Programmes 1-4 above. Our Mental Health Strategy has a strong focus on prevention, recovery and outcomes and therefore underpins our model. It has three key priorities: More effective prevention services Improved and more flexible access to services through our revised Mental Health front door offer, Page 45

49 which delivers all age services, providing assessment and care plan development for both mental wellbeing and the treatment of mental illness. The service will be delivered through a partnership approach, which provides access to holistic person-centred care, from statutory and third sector providers, covering 24/7 day access Improved Service delivery for people with severe mental illness support prevention and self-care and early help. These new centres will be a critical part of our model. Underpinning this programme is the Rochdale Change Triangle. This model connects three enablers to achieve the transformational change we are seeking, shown at the three points of the triangle in the diagram below. Key enabling activities are included within Programme 6. In line with our Mental Health Strategy, we have recently increased spend on Mental Health services and are focusing this additional investment on the following areas: Early Intervention in psychosis Enhanced early intervention and prevention for Children and Young People Improving access to Psychological Therapies (primary care mental health) service offer Liaison psychiatry and Street Triage Mental Health Crisis Care Concordat Mental Health care system improvements Programme 6: System transformation Our final programme is an enabler and will address the wider system transformation that will be needed to make sure our new model of care delivers the outcomes we are seeking and manages complex dependency across the wider system. This programme will be inextricably linked to a number of the Greater Manchester work streams referred to in the Appendix to this document (Appendix 5). Under this programme, we will develop four new service centres to Page 46

50 Page 47