NHS Stockport Clinical Commissioning Group Governing Body Part 1 A G E N D A

Transcription

1 Chair: Enquiries to: Ms J Crombleholme Laura Latham Laura.latham1@nhs.net NHS Stockport Clinical Commissioning Group Governing Body Part 1 A G E N D A The next meeting of the NHS Stockport Clinical Commissioning Group Governing Body will be held at Regent House, Stockport at 10.00am on 31 January 2018 Agenda item Report Action Indicative Timings Lead 1 Apologies Verbal To receive and note J Crombleholme 2 Declarations of Interest Verbal To receive and note 3 Approval of the draft Minutes of the meeting held on 29 November 2017 Attached To receive and approve J Crombleholme 4 Actions Arising Attached To comment and note J Crombleholme 5 Notification of Items for Any Other Business Verbal To note and consider J Crombleholme 6 Patient Story - Seven Day Access Video J Crombleholme 7 Corporate Performance Reports Written Reports To receive, assure and note a) Finance Report b) Integrated Performance Report 8 Stockport Together Highlight Report Written Reports M Chidgey G Mullins To consider T Ryley 9 Approval of Stockport Together Plans Written Report To approve the business cases following public consultation T Ryley 10 Mental Health Investment Plan Written Report 11 Locality Chairs Update Written Report 12 Report of the Chair Verbal Report To approve and adopt M Chidgey To receive and note Locality Chairs To receive and note J Crombleholme 001

2 13 Report of the Chief Operating Officer to include the following: Written Report To discuss and approve G Mullins Working Well Project Re-location of CCG Offices to Stopford House Stockport Town Centre Ambassador 14 Report of the Chief Clinical Officer to include the following: Written Report. To note R Gill Healthier Together 15 Safeguarding Annual Report Written Report To approve A Rolfe 16 Reports from Committees Finance and Performance Committee Primary Care Commissioning Committee Remuneration Committee Written reports To note the content of the reports and approve the recommendations of the Remuneration Committee V Owen Smith J Crombleholme J Greenough 17 Any Other Business Verbal J Crombleholme Date, Time and Venue of Next meeting The next NHS Stockport Clinical Commissioning Group Governing Body meeting will be held on 28 February 2018 at 10am at Regent House, Stockport. Potential agenda items should be notified to stoccg.gb@nhs.net by 3 February

3 NHS STOCKPORT CLINICAL COMMISSIONING GROUP MINUTES OF THE GOVERNING BODY MEETING HELD AT REGENT HOUSE, STOCKPORT ON WEDNESDAY 29 NOVEMBER 2017 PART 1 PRESENT Mrs J Crombleholme Mrs G Mullins Mr M Chidgey Mrs A Rolfe Dr P Carne Dr J Higgins Dr D Kendall Ms C Morgan Mr J Greenough Dr V Owen Smith Dr R Gill Dr Lydia Hardern Dr A Johnson Dr C Briggs Lay Member (Chair) Chief Operating Officer Chief Finance Officer Executive Nurse Locality Chair: Cheadle and Bramhall Locality Chair: Heatons and Tame Valley Secondary Care Consultant Lay Member for Primary Care Lay Member for Finance and Audit Clinical Director Public Health Chief Clinical Officer Locality Chair: Stepping Hill and Victoria Locality Chair: Clinical Director Quality and Provider Management IN ATTENDANCE Mr T Ryley Dr D Jones Mrs L Latham Mrs S Carroll Cllr T McGee Director of Strategy and Performance Director of Service Reform Associate Director Corporate Governance Healthwatch Stockport Stockport Metropolitan Borough Council 53/17 APOLOGIES There were no apologies received on this occasion. 54/17 DECLARATIONS OF INTEREST Dr J Higgins and Dr P Carne both confirmed that they had been offered and would accept Neighbourhood Lead Roles working for Viaduct Care. The roles would commence on 1 January The position regarding Conflict of Interest Management would be considered ahead of the roles commencing. 55/17 APPROVAL OF THE DRAFT MINUTES OF THE GOVERNING BODY MEETING HELD ON 27 SEPTEMBER 2017 The minutes of the meeting held on 27 September 2017 were approved as a correct record. 56/17 ACTIONS ARISING Actions Arising Digital element of Stockport Together Programme update to be reported to Governing Body in Autumn Patient Story Action can be removed from the log

4 Pharmacy Review This action was amended to note that discussion on local strategy development and commissioning for community pharmacy services would take place at the relevant meeting within the Greater Manchester context and not the Primary Care Commissioning Committee given it was not a CCG commissioning responsibility. 57/17 ANY OTHER BUSINESS C Morgan requested an item of Any Other Business on Communication. 58/17 PATIENT STORY The Governing Body heard from a patient who had been diagnosed with Type 2 Diabetes which there was a family history of. He explained that at the point of diagnosis he had been prescribed medication for the remained of his life and was advised that increased exercise and changes to his diet would positively impact. He attended the XPERT course run in Stockport and was sign posted to Stockport Walking for Health which he described as life changing. He noted that the 6 week long course included peer support, support to change lifestyle, lose weight and attendance at meetings. After attending his first walk his daily steps began to increase considerably, he had the confidence to join the PARIS Scheme run by Life Leisure. In 2 years he explained that he d lost weight and inches, carried on with his walking and gym attendance and changed his life considerably and been able to stop his medication and care for his ill partner. The Governing Body commented on the following elements of the story: Importance of ensuring those patients with a family history of diabetes adopt healthy lifestyles prior to diagnosis The impact for some patients of peer and group support and the power of learning together. Importance of expert patient programmes and benefits for individuals and the wider system in terms of preventative health. Opportunities to provide expert programmes and support for those without English as their first language and for BME groups Resolved: That Governing Body: 1. Note the Patient Story and express thanks to the patient for sharing his experience. 59/17 CORPORATE PERFORMANCE REPORTS M Chidgey provided an overview of the CCG s financial position as at October He confirmed that the CCG was forecasting delivery of the 2017/18 financial plan with a net risk position of 1.6m. He noted that financial planning was underway for 2018/19 and drew the Governing Body s attention to the Procurement Policy included within the report. He commented on areas of over performance in specific specialties or Providers. The Governing Body considered the following elements of the report: Opportunities which had arisen as a result of non-recurrent underspends around vacant posts in 2017/18 would not be available in 2018/19 as vacancies had been filled. Limited risk to the CCG on the Community Services contract in terms of over-performance given the nature of the block contract. Known staffing shortages across nursing roles both in Stockport and nationally and potential impact on quality of nursing provision. The overall strategy for moving resources from acute to the community through the Stockport Together transformation programme and the alignment of workforce capacity to deliver new models of care. Assurance was provided to Governing Body on behalf of the Finance and Performance Committee that the committee was sighted on the mitigation plan for the 1.6m and the associated risks

5 M Chidgey provided an update of the CIP planning and prioritisation process which was currently underway for 2018/19 which would be reported to the Governing Body Members in January In response to questioning, M Chidgey confirmed that the procurement for the Spinal Assessment and Treatment Centre had been an open procurement so any organisation (NHS or private provider) had been eligible to bid. Resolved: That Governing Body: (i) Note the year-to-date position is in line with plan. (ii) Note that an outturn breakeven position is forecast to be delivered. (iii)note that net risks totalling 1.60m are not reflected within the forecast and that a plan to mitigate the net risk has been developed and implemented. (iv)note that the position includes provision in full of the 0.5% non-recurrent uncommitted reserve as required by NHS England business rules. (v) Note that the Mental Health financial performance target is forecast to be achieved. (vi)note that a recurrent deficit of 1.71m is currently forecast to be carried forward into 18/19 and the risks associated with this. (vii) Note that CCG procurement policy decisions continue to be published on the CCG website. 60/17 STOCKPORT TOGETHER HIGHLIGHT REPORT T Ryley provided on overview of activity underway as part of the Stockport Together Programme with a focus on the public consultation and strategic risks relating to workforce, IM&T, implementation and delivery of benefits. Governing Body was informed of actions being taken to mitigate the risks locally and also across Greater Manchester. He noted that significant progress had been made by Providers in bringing the Alliance Agreement arrangements into operation that evidence of the delivery of benefits it was hoped would begin to show in the coming months. Governing Body was reminded of the timescales for the public consultation underway and T Ryley confirmed the approach which had been taken to gather feedback from stakeholders and the wider public. He noted that the responses would be independently analysed and a report provided back to Commissioners in early December. It would be published and a response to the recommendations provided by Commissioners to take through governance processes in January Equality Impact Assessments were noted to be under continual review and would remain so. The following elements were considered in detail by the Governing Body: The importance of continued review and refresh of the Equality Impact Assessments and contributions of key stakeholder groups representing those with protected characteristics. *J Higgins joined the meeting The importance of ensuring that workforce plans were in place to ensure the entire market remained stable and work underway with Greater Manchester to consider the whole care market in particular care home / home care elements. The continued commitment to IM&T driven transformation in Stockport and the requirement to ensure appropriate funds were identified for capital investment. Work commissioned by Directors of Nursing in Greater Manchester to raise the profile of and attract individuals to join the nursing workforce. Local challenges for nursing staffing in particular at NHS Stockport Foundation Trust. Conclusion of the procurement for the Multi-Speciality Community Provider (MCP) Feedback from General Practice regarding the crisis response pilot. Resolved: That Governing Body: Notes the update report. 3 61/17 LOCALITY CHAIR S UPDATE 005

6 L Hardern provided an overview of the revised approach to Locality Chair meetings and the greater opportunity provided for horizon scanning. She noted that key discussions included GP Connect and the survey undertaken with GPs relating to hospital breaches in order to assess opportunities where the impact could be reduced through collaborative work with NHS Stockport Foundation Trust. With regards to GP Connect it was noted that the opportunity to continue to build quick access routes and relationships between GPs and hospital consultants was of significant benefit to patients but continued focus on ensuring effective implementation and embedding of the system in the key specialities selected was essential. C Briggs confirmed that a resolution regarding sick notes had recently been agreed and the revised process had been implemented. Governing Body acknowledged the importance of behaviour change in ensuring all process changes and transformation projects were fully embedded and managed and monitored on a continued basis beyond the initial implementation period. Management and leadership capacity and capability was noted to be key to this and had already been flagged as a system risk. Resolved: That Governing Body: Notes the update report. 62/17 REPORT OF THE CHAIR J Crombleholme confirmed that there had been no Part 2 meeting prior to the Part 1 meeting. On behalf of the Governing Body and the CCG, J Cromblehome expressed sincere thanks to Dr C Briggs for the dedication, leadership and passion she had displayed as a Clinical Director of the organisation and noted she had made a significant impact on the delivery of health and care in Stockport. She confirmed she would leave the CCG at the end of December 2017 to take up a national clinical adviser role with NHS England. It was confirmed to the Governing Body that Dr J Higgins and Dr P Carne had accepted Neighbourhood Lead roles with Viaduct Care. Congratulations were expressed to them on behalf of the Governing Body and J Crombleholme confirmed that the implications and conflict of interest issues were being considered. The Governing Body was informed that J Crombleholme and C Morgan would swap portfolio areas, with C Morgan assuming responsibility for Patient and Public Involvement and J Crombleholme Primary Care. The changes would be formally enacted following approval by the Council of Members at the Annual General Meeting in July Thanks were expressed by the Governing Body to General Practice in Stockport for the high flu vaccination rates for 2 and 3 year olds, over 65s and others including pregnant women. 63/17 REPORT OF THE CHIEF OPERATING OFFICER G Mullins provided an overview of the key elements highlighted in the report. She noted that the Q2 Assurance meeting had been focused on transformation and there had been recognition of the continued development and quality of Stockport s plans and emerging implementation work. Other elements considered by the Governing Body included: 1. Winter Planning arrangements and continued system challenges. 2. Care Quality Commission (CQC) inspection ratings for Stockport Practices all at either good or outstanding and the thanks to be expressed to all working in General Practice for this achievement. 3. Complaints themes and trends. 4. Conclusion of the procurement for the Multi-Specialty Community Provider (MCP) A discussion took place regarding the Provider Alliance Arrangements which were operating in Stockport and the role of GPs as leaders within the arrangements

7 Resolved: That Governing Body: Notes the report of the Chief Operating Officer. 64/17 REPORT OF THE CHIEF CLINICAL OFFICER R Gill introduced the report and the following updates on the key elements were provided: Healthier Together and progress against key milestones as part of the implementation plan. EUR Ratifications Strategic Partnership Board Update In response to questioning it was confirmed that patient pathways were being re-designed to move to a single multi-disciplinary team approach. S Carroll commented positively on the approach to public engagement being undertaken within the South East Sector through the Public Voice Group. M Chidgey confirmed that stranded costs and overall financing of the transformation was under consideration as part of the Theme 3 work being led by Greater Manchester Health and Social Care Partnership (GMHSCP). V Owen Smith confirmed the process for EUR approvals across Greater Manchester and provided assurance regarding Stockport s active engagement in the arrangements. R Gill provided an overview of the Greater Manchester proposed model for Urgent Primary Care noting that General Practice would be at the centre of the pathway which differed from the NHS England approach. He noted the key number proposed for the public to call would be that of their GP. A discussion took place regarding timescales and the importance of ensuring pathways for other services including Pathfinder and Crisis response were aligned and navigation was as easy as possible. Governing Body noted the recent merger of Central and South Manchester Hospital Trusts noting that there had been no resource contribution sought from Stockport CCG. Resolved: That Governing Body: 1. Notes the report of the Chief Clinical Officer. 2. Confirms that the EUR Policies for Surgical correction of trigger finger, carpal tunnel syndrome and other aesthetic surgery had been ratified. 3. Requests that R Gill feedback to T Vell at GMHSCP on the Stockport view of the proposals for Urgent Primary Care including the importance of clear communications. 65/17 COMMISSIONING PLANS M Chidgey provided an overview of the CCG Commissioning Plans in a number of key areas. Commissioning a Specialist Stroke and Neurological Integrated Community Rehabilitation Service in Stockport Governing Body considered the proposal as outlined and sought confirmation about the definition of as soon as possible and requested that consideration be given to setting a standard within the specification on the basis of within xx number of days of discharge. C Morgan sought assurance regarding the engagement of patients are carers in the commissioning work and it was noted that the proposal had been endorsed by the Greater Manchester Stroke and Neurology Network. Resolved: That Governing Body: (i) Approve the need for this service within Stockport. (ii) Confirm that it is a priority service for inclusion within the CCG plan for 2018/19. (iii) Note that final approval on investment will be part of the overall CCG plan for 2018/19. Commissioning a Best Practice Pathway for Cardiac Imaging Governing Body considered the proposal to enact the contract notice issued to NHS Stockport Foundation Trust in 2014 noting the potential improvements in the pathway which could be delivered. In response to questions raised by S Carroll on behalf of Healthwatch regarding patient access to alternative sites, 5 007

8 including Manchester Royal Infirmary (MRI) it was noted that the CCG would continue to actively monitor access and travel arrangements. D Jones confirmed that the Public Voice Group had considered the issue and had been supportive of the change. Resolved: That Governing Body: Endorses enacting the contract notice given to NHS Stockport Foundation Trust in Procurement for a Spinal Assessment and Treatment Service Governing Body considered the procurement process as outlined in the report. Resolved: That Governing Body: 1) Notes that the CCG has followed a clear procurement process to determine the preferred provider of this service. 2) Delegates the decision on the recommendation of the report to the CCG Chief Finance Officer. 66/17 REPORTS FROM COMMITTEES (a) Quality Committee A Rolfe provided an overview of the work of the CCG s Quality Committee in particular noting specific actions on the risk log and mitigations, the diabetes deep dive work undertaken by the Committee and consideration of the revised Statement of Commitment for all partners of the Stockport Safeguarding Children Board. Resolved: That the report be noted. (b) Finance and Performance Committee P Carne provided an overview of the work of the CCG s Quality Committee with a focus on the CCG s Cost Improvement Programme (CIP) and Financial Position. Resolved: That the report be noted. 67/17 ANY OTHER BUSINESS C Morgan highlighted the importance of ensuring that Governing Body papers and written documentation produced by the CCG did not include acronyms without a consistent way of including the full term to ensure information was as accessible as possible. Governing Body noted the request, endorsed it and agreed to consider as part of internal processes for report writing and finalisation. (The meeting ended at 12.19pm) Public Questions (1) In response to questioning, T Ryley provided an explanation about the system s access to confirmed Transformation Fund monies noting that it could be carried forward into the 2018/19 financial year if spending plans had not been fully implemented in the existing year. (2) In response to questioning, G Mullins confirmed that the ambition for an MCP in Stockport remained the same and Providers were continuing to develop working arrangements as part of the Alliance Agreement in place. (3) In response to questioning, M Chidgey confirmed that the procurement for the Spinal Assessment and Treatment Centre would be an open procurement so any organisation (NHS or private provider) would be eligible to bid

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10 NHS Stockport Clinical Commissioning Group 29 November 2017 Actions arising from Governing Body Part 1 Meetings NUMBER ACTION MINUTE DUE DATE OWNER AND UPDATE Patient Story 58/17 December L Latham 1. Note the Patient Story and express thanks to the patient for sharing his experience Chief Clinical Officers Report 1. R Gill feedback to T Vell at GMHSCP on the Stockport view of the proposals for Urgent Primary Care including the importance of clear communications. 64/17 January 2018 R Gill Finance Report CIP planning and prioritisation process which was currently underway for 2018/19 would be reported to the Governing Body Members in January /17 January 2018 M Chidgey 010

11 Finance Report for the period ending 31 st December 2017 Month 9 NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group 7th Floor Regent House Heaton Lane Stockport SK4 1BS Tel: Fax: Text Relay: Website: 011

12 Executive Summary What decisions do you require of the Finance and Performance Committee? (i) Note the year-to-date position is in line with plan. (ii) Note that an outturn breakeven position is forecast to be delivered. (iii) Note that net risks totalling 0.64m are not reflected within the forecast. (iv) Note that the position includes provision in full of the 0.5% non-recurrent uncommitted reserve as required by NHS England business rules. (v) Note that the Mental Health financial performance target is forecast to be achieved. (vi) Note that a recurrent deficit of 3.10m is currently forecast to be carried forward into 18/19 and the risks associated with this. (vii) Approve the agreement of a 10 year lease for relocation of NHS Stockport CCG to 4th Floor Stopford House at an estimated total cost of 1.60m and note that this value is still subject to ongoing negotiations. Please detail the key points of this report The YTD and forecast outturn positions are in line with the planned in year surplus of 1.32m, however there remains net risk of 0.64m which is not included within the forecast position. As a result of activity levels being above planned levels, non-delivery of recurrent CIP and an increase in the number of CHC placements a 3.10m forecast recurrent deficit will be carried forward into 2018/19. What are the likely impacts and/or implications? Non-delivery of NHS England business rules and performance targets will result in increased scrutiny and will impact on the CCG s assurance rating. How does this link to the Annual Business Plan? As per 2017/18 Financial Plan. What are the potential conflicts of interest? N/A Where has this report been previously discussed? All issues have been on the agenda of the Finance and Performance Committee, this specific report is being presented for the first time. Clinical Executive Sponsor: Ranjit Gill Presented by: Mark Chidgey Meeting Date: 31 st January 2018 Agenda item: 7 Reason for being in Part 2 (if applicable) N/A 2 012

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14 Report of the Chief Finance Officer 1.0 Introduction This report provides an overview of the CCG s performance against Statutory Financial Duties and Financial Performance Targets highlighting both the year to date and forecast positions for 2017/18. This report provides an update on:- The financial position as at 31st December 2017 The forecast outturn position for 2017/ Statutory Financial Duties and Performance Targets As a CCG we are required to deliver statutory duties and financial performance targets that we have approved as a Governing Body. Table 1 below RAG rates our financial performance on both a Year to Date (YTD) and Forecast Outturn basis. Table 1: Statutory Duty and Performance Targets Area Revenue (Dashboard Table 1) Running Costs (Dashboard Table 1) Capital (Note: The CCG has not received a capital allocation in 2017/18) Statutory Duty Not to exceed revenue resource allocation Not to exceed running cost allocation Not to exceed capital resource allocation Performance YTD N/A Performance Forecast N/A 4 014

15 Area Performance Target Performance YTD Performance Forecast Revenue Underspend revenue resource allocation by 1.32m. Cash (Appendix 1 Table 9) Business Conduct (Appendix 1 Table 8) Operate within the maximum drawdown limit Comply with Better Payment Practices Code 0.5% Uncommitted Non- Recurrent Reserve Create a uncommitted 0.5% non-recurrent reserve CIP (Appendix 1 Table 6) Fully deliver planned CIP saving Mental Health Financial Performance Target Growth in Mental Health spend is at least equal to programme allocation growth Net Risk (Appendix 1 Table 7) All risk to be fully mitigated (NIL Net Risk) Integrated Assurance Framework (IAF) Finance Rating (Q3 anticipated) From 2017/18, NHS England moved to performance managing CCGs financial performance on an in-year basis. Because NHS Stockport CCG s 2016/17 plan was below the national target level our financial performance in 2017/18 must compensate for this and we will be measured against delivering a 1.32m in-year surplus. Previously members were notified that when reporting the CCG s statutory financial performance, prior year cumulative surpluses where to be included. NHS England has now issued guidance which sets out 5 015

16 that the reporting of CCG s statutory financial performance will align with the reporting of the CCG s in-year financial performance and exclude prior year cumulative surpluses. As required by the 2017/18 NHS Planning Guidance, the CCG has created a 0.5% (1.0% 2016/17) uncommitted reserve. In the event that the national NHS financial position deteriorates during the year the CCG will be required to release its 0.5% reserve, as a result surpluses would increase by 2.00m. The finance Quarter 3 Integrated Assurance Framework (IAF) rating has provisionally been assessed as green which is an improvement on the amber rating for Quarter 2. Whilst this improvement is welcomed it is the view of both the CCG and GMHSCP that risks remain. 3.0 Financial Position as at 31 st November 2017 Month 9 The financial position as at month 9 is summarised in Table 2 below with further detail provided in Appendix 1 to this report. Table 2: Summary of Financial Position at Month 9 Plan Actual (Favourable) (Surplus) / Deficit (Surplus) / Deficit / Adverse Variance 000s 000s 000s Month 9 YTD (988) (989) (1) Year End Forecast (1,318) (1,318) 0 The CCG has reported a YTD surplus of 0.99m and a forecast outturn surplus of 1.32m in line with plan. The forecast outturn includes CIP delivery of 17.37m (99.5%), against a plan of 17.45m of which 2.23m has been achieved by deploying the full CCG contingency against CIP delivery. However, members should note the net risk of 0.64m, which is not included within the forecast position. The net risk will materialise if either acute activity levels do not reduce from current levels or if compensating mitigations are not successfully implemented. 4.0 Programme Expenditure Acute Acute contract spend is 2.45m higher than year to date plan and forecast to overspend by 3.12m mainly due a shift in outpatient first and follow-up activity to outpatient procedures, a significant element of which is related to the impact of HRG4+. There is also non-elective over performance, due in part, to a change in clinical coding guidance whereby sepsis is used as the primary diagnostic code

17 Community Health The forecast overspend of 0.29m in Community Health is due to an increase in community neuro-rehabilitation placements. Continuing Care The forecast overspend of 0.63m is primarily due to an increase in the number of placements which aligns with changes to CHC process to reduce pressure on the acute system, in particular to reduce the number of Delayed Transfers of Care (DTOC). In addition, 4 high cost children s packages have been agreed which have a total cost of 0.38m per annum. Mental Health The Mental Health YTD over spend of 0.28m and forecast outturn over spend of 0.34m reflects funding costs associated with older people mental health services. The CCG is committed to implement all planned Mental Health schemes and investments in line with our local investment strategy. Prescribing The latest information from the NHSBSA provides actual prescribing expenditure for the months April to October. As this information is published 2 months in arrears, an estimate for November and December has been made giving rise to a 0.07m under spend for the period. The prescribing forecast of 49.23m reflects an underspend of 0.23m but includes significant unplanned charges for concessional pricing for drugs which are in short supply ( 2.75m) and Category M (generic drugs) price reduction benefits which, as part of a national financial risk reserve, are to be retained by NHS England ( 0.48m). Without these externally set charges the Prescribing budget would be contributing an additional 3.23m to CIP. NHS England has indicated that the price reduction benefits will be available to CCGs from August Primary Care The forecast overspend of 0.04m is mainly due to 2016/17 QOF achievement being higher than anticipated with the forecast overspend of 0.34m reflecting a higher QOF achievement estimate in 2017/18. An overspend of 0.26m due to sickness and parental leave cover is also forecast. These cost pressures have, in part, been offset by lower than planned increases in patient list sizes, reduction in the value of the Primary Care IM&T GMSS service level agreement and underspends within local enhanced services totalling 0.40m. 5.0 Running Costs (Corporate) The YTD underspend of 0.35m and forecast outturn underspend of 0.47m mainly reflect pay underspend due to staff vacancies. 6.0 Cost Improvement Programme (CIP) Year to date 15.71m (90.0%) of the 17.45m CIP plan has been delivered, of which 2.23m has been achieved by deploying the CCG 7 017

18 contingency in full against CIP delivery. It is forecast that 17.36m (99.5%), a shortfall of 0.12m will be delivered by year end. Within the 15.71m of CIP delivered to date is acute demand CIP of 6.82m which has been reported as delivered in full non-recurrently as a result of agreeing 17/18 contracts at 16/17 outturn and agreeing block contracts for A&E attendances, non-elective admissions and outpatient attendances with Stockport FT. 7.0 Recurrent (Underlying) Position Due to the planned level of Stockport Together benefits not being realised (i.e. activity levels being above planned levels), non-delivery of recurrent CIP and an increase in the number of CHC placements a 3.10m (Appendix 1 Table 1) forecast recurrent deficit will be carried forward into 2018/19. If this recurrent deficit is not fully addressed through the CCGs plan for 2018/19 then the CCG will not be compliant with NHSE business rules. This would have a significant impact initially on the CCGs assessment rating but more fundamentally on the CCGs ability to implement the commissioning strategy, in particular where service change is dependent upon investment. 8.0 Reserves Table 3 of Appendix 1 sets out the reserves held at month 9. Investments 6.59m includes in-year allocations, national must do s and those agreed collaboratively at a local GM level i.e. GM Risk share. Contingency has been deployed in full against the CCG CIP plan. Savings & Efficiency the ( 3.80m) reserve reflects the remaining value of CIP savings not yet embedded within expenditure budgets. 9.0 Financial Risks and Mitigations not in Forecast The CCG has a net risk of 0.64m (Appendix 1 Table 7) which has not been incorporated into the forecast position as at month 9. The main risks to the delivery of the financial plan are acute contract risks and increasing number of CHC placements. A plan to mitigate the net risk has been implemented by CCG Leadership Team and subsequently endorsed by the Finance and Performance Committee who receive regular updates on its delivery Office Move The Chief Operating report detailed lease arrangements for the 4 th Floor Stopford House. The financial consequences of approving a 10 year lease are c 1.6m (subject to ongoing negotiations)

19 12.0 Recommendations These are set out on the front sheet of this report. Mark Chidgey Chief Finance Officer January 2018 Documentation Statutory and Local Policy Requirement Cover sheet completed Y Change in Financial Spend: Finance Section below completed Y Page numbers N Service Changes: Public Consultation Completed and Reported in Document n/a Paragraph numbers in place Y Service Changes: Approved Equality Impact Assessment Included as Appendix n/a 2 Page Executive summary in place (Docs 6 pages or more in length) n/a Patient Level Data Impacted: Privacy Impact Assessment included as Appendix n/a All text single space Arial 12. Headings Arial Bold 12 or above, no underlining Y Change in Service Supplier: Procurement & Tendering Rationale approved and Included n/a Any form of change: Risk Assessment Completed and included n/a Any impact on staff: Consultation and EIA undertaken and demonstrable in document n/a 9 019

20 RAG Rating Key: TABLE 1 G Potential risk of overspend: less than or equal to 0 TABLE 2 A Potential risk of overspend: between 0 and 250k Month 9 Financial Dashboard Appendix 1 Month 9 Financial Position - as at 31 December 2017 Revenue Resource Limit (RRL) Confirmed (336,611) (336,611) 0 0.0% (451,880) (451,880) 0 0.0% (444,236) (444,236) 0 Net Expenditure R Potential risk of overspend: Over 250k YTD (Mth 9) Forecast 17/18 Recurrent Recurrent Recurrent Variance Budget Commitment (Favourable) / RAG Budget Actual Var Var Budget Actual Var Var Adverse RATING 000s 000s 000s % 000s 000s 000s % 000s 000s 000s Total RRL (336,611) (336,611) 0 0.0% (451,880) (451,880) 0 0.0% (444,236) (444,236) 0 Acute 182, ,670 2, % 242, ,010 3, % 239, ,483 3,611 Mental Health 25,164 25, % 34,021 34, % 33,522 33, Community Health 28,789 29, % 38,386 38, % 38,386 38, Continuing Care 11,488 11, % 15,320 15, % 15,320 16, Primary Care 37,580 37,490 (90) (0.2%) 50,547 50, % 49,711 49, Other 6,217 5,780 (437) (7.0%) 10,614 9,306 (1,308) (12.3%) 4,121 4, Sub Total Healthcare Contracts 291, ,396 2, % 391, ,898 3, % 380, ,222 5,290 Prescribing 37,094 37,020 (74) (0.2%) 49,459 49,231 (228) (0.5%) 49,459 49,231 (228) Running Costs (Corporate) 4,553 4,205 (348) (7.6%) 6,086 5,615 (471) (7.7%) 6,086 6,086 0 Reserves (Ref: Reserves Summary) 2,515 0 (2,515) 0.0% 3, (2,418) (74.7%) 2,725 5,801 3,076 Total Net Expenditure and Reserves 335, ,621 (1) (0.0%) 450, , % 58,270 61,118 2,848 TOTAL (SURPLUS) / DEFICIT (989) (990) (1) 0.1% (1,318) (1,318) 0 0.0% (5,034) 3,104 8,138 Acute Contract Performance Major Acute Commissioning contracts & AQP/IS Annual Budget Budget Year to Date Actual YTD Variance - Overspend / (Underspend) Forecast Outturn Forecast Forecast Variance - Overspend / (Underspend) '000 '000 '000 '000 '000 '000 Stockport Foundation Trust 151, , , , Manchester University NHS Foundation Trust 23,840 11,910 12, , University Hospitals of South Manchester FT 13,765 13,765 14, , Central Manchester University Hospitals FT 10,071 10,071 10,009 (62) 10,009 (62) Salford Royal FT 6,976 5,232 5, , The Christie NHS Foundation Trust 3,546 2,660 2, , East Cheshire NHS Trust 2,118 1,589 1, , Tameside & Glossop Integrated Care FT 1, (86) 1,161 (114) AQPs/IS 13,786 10,340 11, , Other 16,112 12,148 12, , Total Acute 242, , ,670 2, ,010 3,117 TABLE 3 TABLE 4 TABLE 5 Month 9 - as at 31 December 2017 Forecast Reserves Summary Reserves Commitments Forecast Bals Held Mth 9 Year End Amounts Held in CCG Reserves 000s 000s 000s Investments 6,588 4,330 (2,258) Contingency In-Year Allocations (282) Savings & Efficiency (3,796) (3,674) 122 Total Reserves 3, (2,418) TABLE 6 Statutory Surplus Forecast 000s Allocation (451,880) Less: Expenditure 450,562 In-Year Surplus (1,318) Add: Brought forward Surplus Allocation 0 Forecast Statutory (Surplus) / Deficit (1,318) Top Five Increases in Prescribing Spend by Drug Type Nov 15 - Oct 16 ( 000s) Nov 16 - Oct 17 ( 000s) Change ( 000s) Change in Change in No. Spend (%) Items (%) Cardiovascular System 6,567 7, % -0.4% Appliances 1,513 1, % 14.3% Stoma Appliances 1,649 1, % 3.7% Immunological Products & Vaccines % 4.1% Nutrition And Blood 2,912 2, % 3.3% TABLE 7 TABLE 8 Financial Risks Risk TABLE 9 Risk Value ( m) Comment Acute 1.78 In-year over performance Continuing Healthcare 0.50 Increase in the number of CHC placements Other I&E 0.10 Total Risks 2.38 Mitigations Mitigation Value ( m) Comment Further prescribing improvement 0.70 Contract management 0.75 Acute Contract Challenges Non recurrent CIP / Technical 0.29 Total Mitigations 1.74 Net Risks 0.64 Cashflow Summary - Month s Cash Limit for the Year 449,978 Cash drawn down YTD 332,777 Remaining cash 117,201 Actual cash drawn down (%) 74.0% Expected cash drawn down (%) 75.0% Public Sector Payment Policy (PSPP) - Measure of Compliance The Public Sector Payment Policy target requires CCG's to December YTD aim to pay 95% of all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. Number 000s Non-NHS Payables Total Non-NHS Trade Invoices Paid in the Year 9,975 79,317 Total Non-NHS Trade Invoices Paid Within Target 9,645 78,590 Percentage of Non-NHS Trade Invoices Paid Within Target NHS Payables Total NHS Trade Invoices Paid in the Year 2, ,127 Total NHS Trade Invoices Paid Within Target 2, ,980 Percentage of NHS Trade Invoices Paid Within Target Total NHS and Non NHS Payables Total NHS Trade Invoices Paid in the Year 12, ,444 Total NHS Trade Invoices Paid Within Target 11, ,570 Percentage of NHS Trade Invoices Paid Within Target We will continue to monitor our performance against the 95% 'Public Sector Payment Policy' (PSPP) target of invoices paid within 30 days of invoice. Performance is measured based on both numbers of invoices and value

21 Performance Update Report January 2018 NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group 7th Floor Regent House Heaton Lane Stockport SK4 1BS Tel: Fax: Text Relay: Website: 021

22 Executive Summary What decisions do you require of the Governing Body? Governing Body is asked to: (i) Note the format and timing of performance reporting in transitioning to a quarterly integrated performance report. (ii) Note the performance issues highlighted to the Governing Body, in particular the continued levels of urgent care performance.. Please detail the key points of this report Urgent Care performance remains the key performance area for improvement. What are the likely impacts and/or implications? These are identified in the report How does this link to the Annual Business Plan? The CCG s Annual Business Plan is based upon achievement of national standards. What are the potential conflicts of interest? There are no potential conflicts of interest Where has this report been previously discussed? n/a Clinical Executive Sponsor: Dr Ranjit Gill Presented by: Mark Chidgey Meeting Date: 31 st January 2018 Agenda item: 7 (a) Reason for being in Part 2 (if applicable) Compliance Checklist: Documentation Cover sheet completed Y / N Statutory and Local Policy Requirement Change in Financial Spend: Finance Section below completed To follow Page numbers Y / N Service Changes: Public Consultation Completed and Reported in Document n/a Paragraph numbers in place Y / N Service Changes: Approved Equality Impact Assessment Included as Appendix n/a 022

23 2 Page Executive summary in place (Docs 6 pages or more in length) n/a Patient Level Data Impacted: Privacy Impact Assessment included as Appendix Y / N All text single space Arial 12. Headings Arial Bold 12 or above, no underlining Y / N Change in Service Supplier: Procurement & Tendering Rationale approved and Included Any form of change: Risk Assessment Completed and included Y / Na n/a Any impact on staff: Consultation and EIA undertaken and demonstrable in document Y / N 023

24 Introduction The CCG Governing Body agreed to move to quarterly reporting of performance. The most recent performance report was provided in September 2017 and realigning to reporting at the end of each quarter means that the next report would be due in February Given the potential gap of 5 months, this report is provided as a short interim update report to ensure that the Governing Body remains sighted on key performance issues. As an interim update report the format and depth will differ from that which the Governing Body will receive in future. The timing and content of future reports in transition to the new integrated reporting format will be:- Governing Body Reporting Period Format Meeting January 2018 November 2017/18 Interim March 2018 Q3 2017/18 Interim May 2018 Q4 2017/18 Interim August 2018 Q1 2018/19 New Integrated Format Issues highlighted to Governing Body Urgent Care whilst the system has delivered a significant reduction in Delayed Transfers of Care (DTOC) the report shows waiting times for the Emergency Department (ED) that remain significantly below the national constitution standard. The performance is detailed to the end of November 2017, it is confirmed that in December performance was 71.5% and there were several 12 hour breaches. The urgent care system is yet to recover performance either to pre-winter levels or the national standard. In response, the CCG continues to work in partnership with providers to ensure that pathways are clear and services are resilient and safe. National funding secured in December is being used for schemes in Primary Care, Mental Health and Acute services as approved by the Stockport Urgent Care Delivery Board. Examples include additional medical staffing overnight within ED, additional Mental Health beds within Stockport and enhanced case management within primary care. Alongside these additional interventions the Stockport Together new models of care continue to be implemented. The Acute Interface is significantly implemented with additional ambulatory care capacity in place on the Stepping Hill site and GPs reviewing patients within the Emergency Department. The neighbourhood model of care, including 7 day GP access, acute home visiting and multi-disciplinary review of patients, is initiated but less well established with a planned full mobilisation date of March Elective Care Waiting times for elective treatment (measured by Referral to Treatment (RTT) within 18 weeks) and diagnostic tests (6 week waits) are both consistently close to the national standards but cumulatively fall short of the required levels. Performance for patients waiting at Stockport NHS FT are consistently above 024

25 our average performance with the majority of long waits for those patients accessing care at Manchester University Hospitals NHS Trust (formerly UHSM and CMFT). Risk on achievement of these standards has increased over the winter period as a consequence of the nationally led cancellation of some elective procedures. Where possible our providers have looked to minimise cancellations and day case procedures in particular have been relatively unaffected. The report shows that there have been a number of 52 week waits with the main themes being:- At SFT linked to administrative errors, additional training is being provided to staff. At Manchester University Hospitals NHS Trust a combination of long waits as the previously reported waiting list issues are addressed. In addition there is a very specialist plastic surgery service which is one of a very small number of services offering a specialist breast construction procedure. Demand for this procedure is very high and hence referrals are exceeding available capacity. Quality Indicators As highlighted in previous reports the number of reported mixed sex accommodation breaches has increased during 2017/18. It is believed that this is predominantly greater awareness of the standards resulting in improved reporting at both Pennine Care and SFT. Cancer Consistently good performance continues across the cancer standards. Mental Health Performance in Mental Health is consistently improved, the issues that can be seen in September were due to staffing issues within our services that have since been resolved. 025

26 NHS Stockport CCG Performance dashboard November 2017 Code A&E Waits Patients should be admitted, transferred or discharged within 4hours of their E.B.5 arrival at an A&E department 2016/ /2018 Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov 95% 73.37% 74.16% 79.76% 80.75% 87.10% 87.57% 87.29% 85.79% 85.61% 85.04% 83.50% 82.92% 84.41% E.B.S.5 No waits from decision to admit to admission (trolley waits) over 12 hours Ambulance ARP Category A calls resulting in an emergency response arriving within 8minutes Red (New ARP Measure) E.B.15.i Category A calls resulting in an emergency response arriving within 8minutes Red 1 E.B.15.ii Category A calls resulting in an emergency response arriving within 8minutes Red 2 E.B.16 Category A calls resulting in an ambulance arriving at the scene within 19 minutes Referral To Treatment Waiting E.B.3 Patients on incomplete non-emergency pathways waiting no more than 18 weeks from referral 75% 75% 95% 92% 91.97% 92.50% 92.76% 92.99% 92.47% 92.89% 92.52% 92.41% 91.97% 91.61% 91.83% 92.18% 92.23% E.B.S.4 Zero tolerance of over 52 week waiters Diagnostic test waiting times Patients waiting for a diagnostic test should have been waiting no more than 6 E.B.4 99% 98.65% 98.84% 99.19% 99.56% 99.15% 99.20% 98.84% 98.58% 97.97% 98.41% 99.07% 99.25% 98.81% weeks from referral Cancelled Operations E.B.S.6 Urgent operations cancelled a second time E.B.S.2 Number of patients not treated within 28 days of last minute elective cancellation. (Quarterly Measure) Cancer Waits E.B.6 Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP E.B.7 Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) E.B.8 Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 0 2 #N/A #N/A 4 #N/A #N/A 6 #N/A #N/A 2 #N/A #N/A 8 93% 96.98% 97.50% 97.22% 97.88% 97.17% 97.95% 97.05% 97.95% 98.83% 97.57% 97.20% 97.65% 97.68% 93% 97.10% 94.83% 95.03% 94.80% 93.62% 96.84% 94.85% 98.57% 97.44% 94.92% 98.37% 97.89% 96.56% 96% % 96.67% 96.32% % 99.15% % 98.45% 99.17% 98.54% 98.26% 99.25% % 99.13% E.B.9 Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% 96.77% % 96.77% 96.43% 95.83% % % % % 93.55% % % 98.68% E.B.10 E.B.11 E.B.12 E.B.13 E.B.14 NHS Constitution Indicator National Standard Standards to be replaced by 4 new standards currently being piloted. Maximum 31-day wait for subsequent treatment where that treatment is an anticancer drug regimen 98% % % % % % % % % % % % % % Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 94% % % % % % % 97.30% % % % % % 99.69% Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 88.89% 88.71% 92.75% 89.04% 91.67% 77.05% 82.00% 90.91% 89.71% 87.50% 91.89% 84.29% 87.03% Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers 90% % % 83.33% 83.33% % 82.35% % % % % % % 96.05% Maximum 62-day wait for first definitive treatment following a consultant's decision to upgrade the priority of the patient No National Standard 83.33% 85.71% 86.96% 92.59% 84.21% 85.00% 95.83% 69.23% 82.61% 90.91% 88.46% 80.00% 85.26% 2017/18 YTD to November

27 NHS Stockport CCG Performance dashboard November 2017 Code NHS Constitution Indicator National Standard Mental Health Care Programme Approach - % of people followed up within 7 days of dischrage from psychiatric inpatinet care Percentage of people experiencing first episode of psychosis accessing treatment within two weeks. Percentage of people referred to the IAPT programme treated within 6 weeks of referral Percentage of people referred to the IAPT programme treated within 18 weeks of referral IAPT Recovery rate - the percentage of people who are moving to recovery during the reporting period. 0.9 Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan Jan 95% 98.00% % % % 92.30% % % 93.80% % 98.26% 50% 90.00% 0.00% 88.90% 83.30% 80.00% % 60.00% 60.00% 60.00% 66.53% 75% 86.60% 83.70% 87.40% 87.10% 85.43% 88.40% 87.60% % 93.11% 89.09% 95% 98.00% 98.30% % 99.60% 99.60% % 90.00% % 99.67% 98.40% 50% 52.60% 52.80% 53.40% 51.50% 56.22% 52.89% 46.80% 52.40% 50.17% 52.02% IAPT access 1.25% 1.73% 1.21% 1.73% 1.78% 1.52% 1.61% 1.15% 1.57% 2.38% 1.62% Healthcare Acquired Infections E.A.S.4 HCAI measure (MRSA) E.A.S.5 HCAI measure (Clostridium difficile infections) Mixed Sex Accommodation Breaches E.B.S.1 Mixed Sex Accommodation Breaches /18 YTD to November

28 Stockport Together Programme Director s Report NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group Tel: Fax: Floor Text Relay:7th Regent House Heaton Lane Website:

29 Executive Summary What decisions do you require of the Governing Body? No decisions are required of the Governing Body This report is for consideration and note Please detail the key points of this report The report notes that is 3 years this month since the programme was launched at a Care Congress in January 2015 prior to any national programmes or initiatives. The report notes progress in the last quarter on administrative developments and describes briefly the progress on mobilisation of service developments. The Governing body s attention is drawn to five principal risks: Workforce System leadership changes Digital funding Benefits realisation Competing expectations What are the likely impacts and/or implications? The Stockport Together programme is a significant contributor to a number of key strategic goals. Success will contribute to: - Narrowing health inequalities and improving health outcomes - Improving performance of the urgent care system - Reducing the scale of the financial challenge in the economy - Delivering the five year forward view for primary care - Delivery of integrated health &social care services in line with the Greater Manchester strategic direction. How does this link to the Annual Business Plan? The Annual Business Plan includes delivery of improvements in the areas described and sets out the associated shifts in activity. What are the potential conflicts of interest? None Where has this report been previously discussed? Stockport Together Programme Board 2 029

30 Clinical Executive Sponsor: Gaynor Mullins Presented by: Tim Ryley Meeting Date: 31 st January 2018 Agenda item:

31 Stockport Together: Programme Director s Report 1. Introduction 1.1 This report updates the CCG Governing Body on the work undertaken in the last few months under the Stockport Together programme and draws the Governing Body s attention to the key risks The Stockport Together programme is a multi-partner collaboration looking to deliver a new integrated model of care for adults based at neighbourhood level. At the same time it is bringing together both providers and commissioners in greater integration and changing the basis of the future contractual model away from activity and service towards population health and delivery of outcomes The programme was initiated as an output of the Better Care Fund (BCF) in 2014 culminating in a care congress in January In the three years since we have worked together as a partnership to develop new approaches to all of the issues described above; first as a national Multi Specialty Community Provider (MCP) Vanguard (March 2015)and then one of the first sites in Greater Manchester to be awarded transformation funding (July 2016). 1.4 The principal partners are NHS Stockport CCG, Stockport NHS Foundation Trust, Pennine Care NHS Foundation Trust, Viaduct (GP Federation) and Stockport Metropolitan Borough Council. 2. Progress in last period 2. 1 In the last quarter we have been undertaking a consultation and considered the findings on the key policy principles underpinning the outline business cases endorsed by the Governing Body in July Following this a proposal is being put before the CCG Governing Body today (See Item 9) and to the Council cabinet on the 6 th February If approval to proceed is given by both bodies, the commissioners will be able to move to contract for the service reforms as set out in the business cases. 2.2 In the meantime we have continued to test new models of care and develop the commissioner and provider partnership arrangements. The key areas of progress in the last quarter are described below. 2.3 Communications & Public Involvement The Consultation concluded on Thursday 30 th November 2017, there were a total of 518 responses.17 of which were from organisations including protected groups. The total number of people represented by these groups from the Stockport area was just over 38,000. The Independent analysis of responses was published on Friday 22 nd December via the web site and social media, and a draft Response (with recommendations) was written and presented to Adult Social Care and Health Scrutiny Committee on Tuesday 16 th January Equality Impact Assessments (EIAs) were also revised, quality assured and published at the end of December Further consideration under item

32 2.4 Stockport Together Evaluation The Evaluation Summary document and interview topic guide have been signed off. The evaluation summary has been shared with Joint Commissioning Board and the Evaluation Leaders Group. Stockport is the first GM locality to commence the Local Care Organisation (LCO) evaluation, and the first wave of Stakeholder interviews have been scheduled and have now begun. 2.5 Benefits Management Plan Good progress to establish a Task and Finish Group to oversee the phase 2 of the benefits realisation work; Tier 1 (programme benefits) and Tier 2 (service mobilisation) metrics are being finalised and an Early Warning System dashboard presented to Stockport Neighbourhood Care Management Team. This work is being overseen by the Programme Director with support from all partners. 2.6 Integrated Commissioning There has been continued development of Adult Social Care, Quality and Mental Health Strategies under an integrated approach, via the Stockport Joint Commissioning Board. A review of SMBC Growth and Reform Programme for Adult Social Care and Public health has been undertaken through this joint arrangement. The CCG and Council are agreeing a process to develop the next stage of commissioner integration. The CCG are also due to re-locate their offices to Stopford House, and this co-location is part of that strategic approach to more integrated working. A joint team is leading the Viaduct Care contract negotiation with a view to sign-off post business case approval. In addition, there is a joint planning process in place. 2.7 Creation of Integrated Provider Form Recruitment to post of Managing Director concluded, and Caroline Drysdale has taken up the post on the 4 th January. Other posts within the SNC Management Structure have been announced including Dr Karl Bonnici has been appointed as Associate Medical Director for Urgent Response, and Paula Friggieri will take up the role of Associate Director for Integrated Neighbourhood Services. A successful Greater Manchester LCO peer review process was held on the 8 th January. 2.8 Outcomes Framework The Joint Commissioning Board (JCB) has considered how the Outcomes Framework and segmentation can be used without there being a single contract. It was agreed that: 1. A population segmentation approach to strategic commissioning and effective implementation of the Integrated Service Solution 2. Testing of outcomes in advance of forming part of a contract by monitoring agreed measures against trajectories from April 2018 but not linking financial payment. 3. Developing a communications strategy around What Matters To Me to provide a narrative for describing Stockport s approach to commissioning and delivering outcomes. 2.9 Integrated Service Solution The following services are now fully mobilised and work underway to optimise 5 032

33 Active Recovery Crisis Response Ambulatory Ill Service Ambulatory Care Unit Enhanced Domiciliary Care The following services have commenced mobilisation and will be in place by April 2018 Transfer to Assess Enhanced Case Management 7 day GP access Falls Service Psychological Medicines Service Enhanced Medicines Service The following are due to commence mobilisation shortly: GP Acute Home Visiting and Clinical Triage Direct access Physiotherapy Find and Treat Given the integrated nature of the services it is anticipated that benefits delivery will commence once the full range of services are mobilised and will increase as services are further optimised. 3. Risks The programme has both a detailed risk register for each area of work and an overall Assurance Framework containing 20 strategic risk areas. The report wants to draw the Governing Body s attention to five in particular: 3.1 Workforce: There are three factors to note in particular. The programme is not immune to the existing challenge of recruitment affecting the NHS and Social Care currently. By working together in a partnership way providers have made good progress on this to date and this is being supported by Greater Manchester initiatives. The current workforce plans are focussed on the implementation of the business cases in particular the neighbourhood teams. However, there is not yet a sufficiently strategic borough wide approach to workforce. The Joint Commissioning Board has initiated further discussions with other partners on taking this next level of work forward. The local authority and Stockport Foundation Trust are currently consulting their staff on moving to the new way of working. The providers are working with Trade Unions and staff concerned to try and resolve the concerns that they have expressed about these proposals, and very much hope this can be achieved. 3.2 System Leadership: There have been a number of changes in the leadership of the system with new Chief Executives at SMBC, Stockport Foundation Trust, and Pennine Care Foundation Trust. A permanent replacement Caroline Drysdale has replaced Keith Spencer as the interim 6 033

34 Director of Stockport Neighbourhood Care. The new Chief Executives group are spending time together in March to reflect together on their collective leadership approach; and there early thoughts to bring together many of those who attended the first Care Congress in 2015 in early summer to celebrate progress and the approach for the implementation phase of Stockport Together. 3.3: Digital Funding: We have made excellent progress on developing integrated records and common digital infrastructure. Greater Manchester in approving our investment agreement set an expectation of 3.1m of national digital funding. We have planned and utilised much of this but full access to the national funding is yet to be confirmed. Work is underway with Greater Manchester to gain certainty on the level of funding that we will access. Whilst there is a shared expectation that national digital funding will resolve this, at this stage that cannot be viewed as certain. Our approach to this risk has been to prioritise within the overall funding that is available and therefore implementation of the key systems associated with this has progressed. However, there is clearly a consequent impact on other areas of the programme, primarily within the enabler workstream. A full review and re-prioritisation is underway to ensure that we continue to progress the new models of care. 3.4: Benefits Delivery: Whilst we have made some progress on reducing rates of growth, triaging out people from A&E to more appropriate settings and reducing length of stay for those patients admitted for 2 or more days, we have not made all the progress anticipated. This is in large part due to later than envisaged implementation of key schemes due to business case and consultation processes. To mitigate this we are in a position to rapidly mobilise enhanced and new community based services over the next three months subject to approval to proceed. Ensuring that the new models of care are fully funded from a combination of recurrent and non-recurrent income streams will be a key component of the plans of the Stockport Together partners in 2018/ : Competing Demands: The national challenges faced by the NHS this winter, and requirements of the national and GM planning guidance are and will continue to compete for change and leadership resources. As far as possible the partners are looking to bring the programme into core business processes and align national and GM requirements to mitigate this, but as the transformation funding ceases the capacity available to lead change will reduce

35 Approval of Stockport Together Plans Recommendations in light of Public Consultation and Equality Impact Assessments NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group 7th Floor Tel: Fax: Text Relay: Regent House Heaton Lane Website: 035

36 Executive Summary What do you require of the Governing Body? Consider and scrutinise carefully the feedback from the public consultation, the updated equality impact assessments (EIAs), the views of the Adult Social Care & Health Scrutiny Committee and the proposed response. Approve the recommendation at to: Approve the approach described in the previously endorsed outline business cases and proceed to implementation subject to recommendations as set out in Section 5 of this report. Adopt a series of recommendations regarding our approach to implementation in light of the feedback and as set out in section 5.1.2, namely to: Adopt the 7 recommendations arising from the public s feedback. Approve the proposals to review progress as described at section 6.1.2: The Health & Care Integrated Commissioning Board (HCICB) will consider in public a report on progress in addressing the recommendations as set out in section 5 of this paper and the EIA action plans. This report will be presented in September 2018 and reviewed again in July Please detail the key points of this report - The Governing Body endorsed a number of outline business cases in July 2017 subject to public consultation - A reminder of the statutory duties of the governing body in making such decisions - The process to date - A reminder of the case for change includes: o Performance and quality o Health inequalities o The NHS five year forward view o The Greater Manchester Devolution Plans o The economic and financial challenges - The findings of the independent analyst following the consultation and the response including that of Adult Social Care & Health Scrutiny Committee. The key findings were o Strong support for the new ways of working and neighbourhood model o Concern over potential for being in a position to close beds in the future. o A lot of valuable insight and concern on implementation issues that should lead to improvements in our plans including in public involvement and presentation of information; involvement of wider partners; the implementation of the neighbourhood model; access for people in protected characteristic groups; workforce and 036

37 information sharing. The response covers these areas and makes recommendations. There are four documents: - The Recommendation paper - The Independent Analysts report on the Consultation - The Equality Impact Assessments - Transcript of Adult Social Care & Health Scrutiny Committee of January 16 th What are the likely impacts and/or implications? The paper recommends the approval to proceed on the implementation of the business cases with a number of recommendations as to how this implementation might be strengthened. If this is approved contracts will be varied or signed and responsibility for delivery will transfer to the alliance of local providers under oversight of the joint commissioners. If the Governing body are not able to adopt the recommendation to proceed then we will need to reconvene the partnership to consider the way forward to address the Governing body concerns or develop new ways of addressing the principle drivers. Benefit delivery will by necessity slow further. How does this link to the Annual Business Plan? The Stockport Together plans have formed the heart of strategy and plans for over three years. What are the potential conflicts of interest? In making this decision the CCG is giving authorisation to proceed on implementation of business cases which will potentially benefit GPs. However, the specific remuneration issues are addressed through contract negotiations that would follow approval and not the broad principles and approach set out here. Where has this report been previously discussed? Adult Social Care & Health Scrutiny Committee 16 th January 2018 The Joint Commissioning Board CCG Leadership Team Clinical Executive Sponsor: Dr Ranjit Gill Presented by: Tim Ryley 037

38 Meeting Date: 31 st January 2018 Agenda item: 038

39 Contents Stockport Together Response to Consultation Report Stockport Together Consultation Analysis Report Equality Impact Assessment: Stockport Together Equality Impact Assessment: Ambulatory Care Equality Impact Assessment: Intermediate Tier Equality Impact Assessment: Outpatients Equality Impact Assessment: Neighbourhoods Appendix 1: Transcript from Adult Social Care and Health Scrutiny Committee 039

40 1. Introduction 1.1 Decisions requested The Cabinet of Stockport MBC and the Governing Body of NHS Stockport CCG are asked to: Consider and scrutinise carefully the feedback from the public consultation, the updated equality impact assessments (EIAs), the views of the Adult Social Care & Health Scrutiny Committee and the proposed response. Approve the recommendation at 4.5.2: Approve the approach described in the previously endorsed outline business cases and proceed to implementation subject to recommendations as set out in Section 5 of this report. Adopt a series of recommendations regarding our approach to implementation in light of the feedback and as set out in section 5.1.2: Adopt the 7 recommendations arising from the public s feedback. Approve the proposals to review progress as described at section 6.1.2: The Health & Care Integrated Commissioning Board (HCICB) will consider in public a report on progress in addressing the recommendations as set out in section 5 of this paper and the EIA action plans. This report will be presented in September 2018 and reviewed again in July Scope of report and regulatory requirements This paper summarises and reminds members of the process to date and the context and basis for the endorsement of outline business cases made in July 2017 (Sections 1-3). It then describes and responds to the feedback report on the consultation and includes the updated equality impact assessments (EIAs) and associated action plans with three specific recommendations (Sections 4 & 5): A recommendation on the policy questions directed to the public (Section 4); A recommendation on issues to be addressed in implementation, identified through the consultation feedback (Section 5) It then concludes with a proposal on how the recommendations will be reviewed and a timeline by which such a review should be undertaken (Section 6) Section 14Z2 of the NHS Act (as amended) requires the health commissioner to involve the public where there are changes to the manner in which services are provided or the range of services available. The effect of the proposed strategy is 040 5

41 changes to both. Undertaking a public consultation on the proposed strategy demonstrates compliance with the Act For a consultation to be lawful the output of the consultation process must be conscientiously considered by the decision makers; that is the report must be read and considered. Similarly, it is important the EIAs are also considered conscientiously to comply with the Public Sector Equality Duty (Section 149 Equality Act 2010) Members, as decision makers, should actively consider whether they have enough information to make the decision CCG Governing Body members are reminded that in making commissioning decisions they must consider the NHS Tests required before making changes. These were considered when endorsing the outline business cases in July 2017, but it is important that the Governing Body remain cognisant of these when making final decisions. Test 5 (Alternative capacity) is specifically part of the consultation. 1. Strong public and patient engagement; 2. Consistency with current and prospective need for patient choice; 3. A clear clinical evidence base; 4. Support for proposals from clinical commissioners; 5. New capacity is in place if bed capacity is likely to reduce. 1.3 Process to date In July 2017 all the partners of the Stockport Together Programme endorsed a series of outline business cases. That endorsement was subject to a public consultation on the underpinning strategy and policy to be led by the joint commissioners. The Cabinet and Governing Body at the time of endorsement noted a number of caveats to be addressed in implementation (section 1.3.5) The attached document Stockport Together Independent Consultation Analysis provides an independent analysis on the feedback gathered during the consultation carried out between the 10 th October and 30 th November The Cabinet and Governing Body are required to take into account this feedback and any new evidence presented before making a final decision. At the same time we have taken the opportunity to update the EIAs (Appendix 1); these must also be taken into account in making the decision The Stockport Together partners are NHS Stockport CCG, Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust, Pennine Care NHS 041 6

42 Foundation Trust, and Viaduct Care CIC (the GP Federation). The CCG and Council as the commissioners undertook the Consultation and are required to make the final decisions The Outline Business Cases endorsed by all the partners across June and July 2017 were: Acute Interface: This described investment in three areas within the Accident & Emergency Department (A&E) at Stockport NHS Foundation Trust and the associated benefits: refinements to triage, an ambulatory ill work-stream and an ambulatory care service. This can be found here: Intermediate Tier: This document set out the case for bringing together 20 or more disparate services. The new intermediate tier service will provide effective crisis response to support community staff to avoid unnecessary hospital admission and much improved support on discharge including transfer to assess arrangements. This can be found here: Outpatients: The Outpatients Business Case described plans for reducing unnecessary outpatient appointments and better utilisation of modern technology to ensure advice and decision-making is more cost effective and provided where appropriate without a hospital visit; and how GPs and consultants can work together much more as a team. This can be found here Neighbourhood: At the heart of our proposals is the vision of a neighbourhood-centric model of health and social care led by GP practices working collaboratively. This case describes neighbourhood investment in new primary care and community-based services including general practice, the third sector, social care and mental health. This can be found here: Economic Case: This outline business case pulled together the economic benefits of the above proposals and described the further challenges of a potential 150m financial challenge by It also described in detail how the investments would be funded as well as the risk / gain share arrangements between the partners to support collective ownership of these challenges. This can be found here: On endorsement of the outline business cases in 2017, the commissioners noted a number of areas they wanted to see given additional focus during implementation and mobilisation of the schemes subject to the consultation outcome. Briefly the caveats were noted as: 042 7

43 Risk: The risk / gain share agreements would be written into contracts with the Stockport Together providers Plans: Fully detailed implementation and benefits realisation plans would be produced for each area Enablers: The system would continue to ensure appropriate support and resources were made available to implement the changes Workforce: A fully developed workforce strategy and plan would be developed Public Engagement: A formal consultation would be undertaken and learning would be applied; and that continual involvement would take place throughout implementation Evaluation: There would on-going measurement of activity Mental Health: There would be greater demonstration of the integration of mental health services throughout any implementation, especially in Neighbourhoods, Acute Interface and Intermediate Tier; and that the full mental health investment strategy would be presented to the CCG Governing Body This report and approvals of any of the recommendations contained within it are understood to be building on and strengthening these caveats rather than setting them aside Following publication of the Independent Analysts report this along with the EIA went to Adult Social Care and Health Scrutiny Committee on the 16 th January The full transcript of the discussion is attached at Appendix The committee made a number of observations and asked a number of questions; a summary of these is captured below: 1. Appreciation of the robustness and responsiveness of the public consultation 2. Assurance that the approach would not mean staff are operating at levels beyond their competence (See 5.7.2) 3. Clarification on how we would continue to ensure the quietest and least heard voices are influencing future developments (See and 5.2.1) 4. Concerns about the safeguarding of personal data if working with the voluntary sector (5.10.3) 5. Assurance that we will not reduce hospital resources to an extent that we cannot address future surges in demand We will pick these up under the relevant responses in Section 4 and Section

44 2. The Case for Change 2.1 Introduction Before responding to the feedback from the consultation it is perhaps helpful to remind decision makers of the rationale behind the significant strategy and policy changes underpinning the outline business cases In the overarching economic business case, the Stockport Together partnership states its aim as being to ensure the best possible outcomes for local people at a time of growing demand and restricted funding. This statement brings together both our ambition for better outcomes and the reality of significant financial constraints. The proposals being consulted on set out the plans to address a number of challenges: 2.2 Performance & Quality Within Stockport we currently admit many more people to hospital than similar areas across Greater Manchester and England, and we face a number of challenges in meeting national waiting time standards within the Emergency Department Current community health and care services are delivered by a number of individual services each with their own line management structures, numerous referral and assessment processes, multiple electronic and paper records, different operating hours and competing expectations. This leads to frustration for both individuals and professionals working in this environment and delays in and fragmentation of service delivery. 2.3 Health Inequalities Stockport has one of the widest Health Inequalities gaps within the borough of anywhere in England, people live approximately 11 years longer in the least deprived areas of Stockport compared to the most deprived areas (12.8 years for males and 9.7 years for females). It is a statutory duty of the public sector to seek to narrow this. Whilst many of the factors that drive this gap are wider determinants of health such as education, housing, employment and clean air there are factors that are more directly influenced by health and social care policy The strategy underpinning the outline business cases seeks to ensure a greater link between the NHS and the local authority and hence increase the opportunity to address the wider determinants of health. Further, by building and integrating services at a neighbourhood level, the investments can be better aligned 044 9

45 to need, and the scale of services and the way they are delivered can better reflect the needs of the specific and distinctive populations in each area. 2.4 Five Year Forward View The NHS five year forward view sets out the challenges facing the NHS, including more people living longer with more complex conditions; increasing costs whilst funding remains flat; and rising expectation of the quality of care. In response, it places much greater emphasis on integration of systems and ways of working. Currently 70% of all health and social care spend in Stockport is used by people with one or more long-term condition. These individuals account for 50% of GP appointments, and 7 out of 10 hospital beds In particular the forward view focuses on: Prevention and empowerment Greater patient and service user control and choice Removal of barriers between care organisations A new deal for GP practice Requirement to rebalance demand, efficiency and funding of the NHS General practice. 2.5 GM Devolution Greater Manchester Devolution is important in shaping the thinking within our plans. The GM (Greater Manchester) Integrated Health and Social Care Strategy describes five specific themes where change is envisaged and each GM locality is required to demonstrate delivery in these areas. These plans align in particular with Theme 1: Population Health and Theme 2 Transformation and Community Based Services. The award of 19m from the GM Health & Social Care Partnership was predicated on delivery of change in these areas In addition, there is significant work underway as part of changes in Greater Manchester which is of specific relevance to enabling areas, including: Estates, Workforce and IM&T. Stockport s enabling approaches are aligned to the subregional direction and are actively engaging in this work. 2.6 Economic and financial Health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current form, the health and social care system is financially unsustainable. If no changes are made, we have forecast that by 2020/21 there will be a combined deficit of 157m across Stockport s health and social care services

46 2.6.2 Even if we did have further significant investment in health and social care we would then face the challenge that there are not sufficient levels of qualified staff. Already the NHS faces significant challenges recruiting doctors and nurses. If existing services expanded in their current form they would soon become clinically unsafe Therefore, fundamental changes have to be made to ensure that the people of Stockport continue to receive the highest quality care in the most appropriate environment possible in the current circumstances These changes will not reduce the amount of money we spend on health and social care in Stockport. Rather they will mean we can better manage the increased demands within the resources we have available The plans are about investing money into different parts of our health and social care system (for example, GP practices and neighbourhood care services) to ensure we can meet the increased care needs that we face. 2.7 A hospital-centric service model The proposal set out in the business cases is to invest 16.3m by Most will be in services outside of hospital or at the front of hospital in the A&E and associated departments. This investment will firstly mean that the current predicted growth in hospital services will not materialise. This will contribute 18m to support the investment described above. It is also expected to mean that 25m of services currently provided in a hospital settings will no longer be needed. This is in line with our existing over-use of hospital compared to similar areas which also creates an increase in demand for short term residential and nursing care to support early discharges, making the economy a comparatively high user of these services The total benefit of 43m per year is a contribution towards the estimated 157m per year gap we face between current expenditure and predicted growth in demand by 2021 in a do nothing scenario. Therefore, the business cases do not address the totality of the financial challenge the local health and social care economy faces. Each organisation will also need to continue to deliver their own cost improvement plans each year, equating to 88m in total by Consultation and areas for influence 3.1 Throughout October and November 2017, the two commissioning partners of Stockport Together carried out a public consultation on the underlying strategy and policy set out in full in the Stockport Together business cases

47 3.2 The outline business cases were published in June 2017, after having been through the appropriate channels at each of the partner organisations including Adult Social Care & Health Scrutiny Committee. These cases were developed by local professionals (doctors, nurses, social workers and managers) with input from local people and using the best available national and international evidence. 3.3 A listening exercise was undertaken during June and July 2017 in which meetings were held across the borough and individuals were contacted in GP surgeries to shape the issues and questions that should be put to the public and interested stakeholders in the consultation. 3.4 The consultation document, Have Your Say, provided abridged information on the Stockport Together plans, focusing on three key policy areas of influence (listed below). The full document can be found at: It sign-posted interested parties to the business case documents for further information and detail (on the Stockport Together website). Changing the way we plan and organise services: this will focus on key principles including the integration of health and social care; the integration of physical and mental health services; and the underlying shift of resources from acute hospital provision in order to further address parity of esteem for mental health and strengthen integrated community based services including primary and social care. Neighbourhoods: the way in which physical health, social care and mental health services are organised at a neighbourhood level. This will focus on the geographical appropriateness of the neighbourhoods as described and their role as the principle organisational construct of the future model of care. Hospital beds: the test to apply, if the strategies result in the need to decommission acute hospital beds. This will focus on how the partnership will apply the tests set out by NHS England prior to any bed closures if they should arise. 3.5 The proposals in the consultation were based on pilot work across the borough, the expertise of our staff, professional experience in other parts of the country, and national and international evidence. 3.6 Members of the public and interested stakeholder organisations were provided the opportunity to state how far they agreed or disagreed with the general direction of travel as set out by Stockport Together

48 3.7 Prior to consultation, a mandate was agreed which set out the Stockport Together partners aim: to ask people and organisations in Stockport with an interest in health and care services for their views concerning the proposed changes to the ways health and care services are organised in Stockport. 3.8 The aim was for the Governing Body of the Clinical Commissioning Group and the Cabinet of Stockport Metropolitan Borough Council to understand the views of the public on the changes proposed and gather any additional evidence that the public or interested stakeholders might wish to present on the efficacy or otherwise of the plans, before making their decisions on whether to proceed with the proposals. 4. Response to Policy 4.1 Recommendation On the basis of the response to the consultation the broad recommendation is that the approach set out under Stockport Together, as described in the five outline business cases, should proceed as described. However, there are a number of changes in the detail of how these are implemented that will be described in the next section (Section 5) of this report In coming to this recommendation a number of factors have been taken into account and these are set out below. 4.2 Neighbourhoods and the way we plan and organise services Responses indicated support for the first two proposals: to integrate services and do so on a neighbourhood basis. This is the heart of the proposals and the new way of delivering services and therefore a significant endorsement. Most consultees from the online, postal, and face-to-face survey support the proposal to change the planning and organising of services. 72% of respondents either tend to agree or strongly agree. Similarly, the majority (87%) of consultees responding to the street survey tended to agree or strongly agree in support of the proposal (p8-9, Stockport Together Consultation Analysts Report). Looking at the intention to move to a neighbourhood model, 71% of consultees from the online, postal, and face-to-face survey tended to agree or strongly agree with the proposals. The same figure (71%) of street survey consultees also tended to agree or strongly agree (p22, Stockport Together Consultation Analysts Report)

49 by combining health and social care the new system will be more efficient, respond to peoples needs, improve communication and be cost saving it makes sense to have services for the communities based around the communities themselves. We can share our resources if we work as "neighbourhoods" A number of items of evidence were presented. Two provided some further support to the approach. Evidence from the BMJ on the current risks in the English Health & Care system supports the approach to increase investment in the community. It concludes that: We suggest that spending should be targeted on improving care delivered in care homes and at home; and maintaining or increasing nurse numbers. (p17, Stockport Together Consultation Analysts Report) Age UK submitted evidence of the pathfinder-led Age Concern Cornwall (p25, Stockport Together Consultation Analysts Report). This showed integrated working (including the voluntary sector) improved health, wellbeing and quality of life whilst reducing costs across the system. It should be noted that the very first pilots for our integrated enhanced case management approach known as Stockport One were based on this thinking and we were advised heavily by Cornwall. The involvement of the third sector through The Prevention Alliance (TPA) is indicative of this learning NHS Watch have contributed significantly in the various involvement mechanisms undertaken throughout the development of our plans and culminating in the consultation. They raised a number of matters: the underlying financial driver to the proposals; the alignment with national initiatives such as the STP (Sustainability & Transformation Plans) programme, the potential privatisation of the NHS, concerns about decommissioning of beds, and concerns about some aspects of the evidence base. The decommissioning of beds and the financial question were raised by others and will be addressed at section 4.3 and section respectively. It is important to note that NHS Watch see the development of neighbourhoods and additional investment in community as positive factors. Specifically they presented counterevidence in two areas: NHS Watch suggest the evidence that hospital admissions (and therefore need for beds) are reduced by changing the way community services work (in particular 1 These and all other quotes shown in italics are taken directly from the independent analysis report

50 integration) is weak. They quote the King s Fund ( as counter evidence to be considered. We would agree with this evidence, but our proposals do not suggest that the mere act of integration of services will produce such a result but rather that significant additional investment in the community is also required. The evidence for this is stronger particularly as we start from a position of extremity when it comes to the hospitalisation of people. We are also insisting as set out in our proposed tests that there is local evidence of impact before any change in bed use is undertaken NHS Watch also challenged the NHS campaign view that 10 days in hospital can lead to the equivalent of 10 years ageing in the muscles. We reviewed the evidence and accepted that a stay in any bed rather than a stay in hospital beds specifically was where the evidence pointed and will no longer use this statement, despite it being commonly used across the NHS. However, again because of wider evidence and a higher starting point we do believe reductions in length of stay will contribute to our plans. However, we do recognise that this will not be easy and have described in our consultation clear plans to test the system before reducing bed capacity and these tests formed part of the consultation NHS Watch expressed the view that the proposals being implemented here are similar to those being undertaken across the country under the banner of STPs. There are undoubtedly similarities in for example the development of stronger out-ofhospital systems preventing and proactively managing ill-health. Equally, one factor in our plans is the need to live within our means, a common challenge. However, our plans differ from STPs in a number of ways. They do not claim to address the full financial challenge; the plan has not been imposed externally but been developed by local clinicians and other professionals and was started before the STP programme came into being, launched at a Care Congress in January 2015; STPs cover a much larger area and thus include hospital reconfiguration in their planning. The Stockport Together proposals do not In their opinion, the greater integration of services will lead to increasing privatisation, in particular the creation of Accountable Care type Organisations (ACO). It is important that members bear in mind the distinction between the new models of care with close integration and the formation of a single entity to deliver the services. The outline business cases and the underpinning strategy that was consulted on neither pre-determined nor proposed the creation of a single entity. This would require further consultation in due course. Therefore in approving the greater integration of service delivery and the development of neighbourhoods, members are not approving the creation of an accountable care organisation No further specific evidence was presented that was contrary to the policy approach that the business cases encapsulated in these areas. However, there was

51 concern expressed about the quite large geographical size of the neighbourhoods and the fear that a single hub in each area would be detrimental. neighbourhoods may be too big - Tame Valley includes Reddish and Brinnington - will there really only be one neighbourhood centre between them? This is predominantly an implementation issue but given it is directly concerned about neighbourhoods it is addressed here. It is important to distinguish between administrative hubs (where district nurse and social care teams come together), and service delivery points (where people receive services). Our plans are not to have a single service delivery point in each neighbourhood. So, for example our plans for Heaton and Tame Valley GP 7 day services recognise that people Reddish and Brinnington will need services as travel between the two areas would be difficult and counter to addressing health inequalities. It is the local leadership in each area who understand how that area will shape the way in which services are best delivered. A specific recommendation in Section 5 will look to reinforce this Other evidence was submitted but was less directly related to the underlying policy and will be addressed in the thematic section related to the approach to implementation (Section 5). 4.3 Basis for decommissioning of beds There was less agreement on the test for decommissioning beds. 40% of online, postal and face-to-face respondents agreed they were appropriate; 33% disagreed. In the street surveys 55% did not agree whilst 41% supported them (p30-31, Stockport Together Consultation Analysts Report). decommissioning beds is an irresponsible suggestion. Beds will always be needed, regardless of whether care is in the community the tests if carried our honestly and rigorously would deliver the answer that is needed to make the savings that are envisaged It is important to note additional money to invest in models of care that help people stay well enough not to need hospital care is available only as a short term measure. For these new ways of working to be successful in the medium and long

52 term, budgets for hospital care need to be reduced and the money spent on community care There is a natural concern shared by all in the partnership about any reduction in the bed base, and this undoubtedly and understandably informed the views expressed by the public and stakeholder organisations. It would therefore appear that for some the response was to bed reductions per-se rather than the right and proper test on whether the need had or had not reduced. Our plan is to only close beds if these tests are met and thus our community investments are effective The one piece of additional evidence submitted was the CQC report on Stepping Hill rating the Urgent & Emergency Care as Inadequate. The concern was that an already overstretched hospital would suffer further if beds were removed (p32, Stockport Together Consultation Analysts Report). I would hope that there would always be sufficient hospital beds to cope with winter emergencies, etc On a related matter, a number of people expressed concern that if beds were removed we would not be able to address surges in demand. Adult Social Care and Health Scrutiny Committee also sort assurance about this and the pace at which any beds would be removed. There are not a fixed number of beds in the system currently and we always have more beds open in winter. This ability to flex capacity will remain a requirement even if from a potentially lower baseline if we meet the tests demonstrating a lower overall requirement. Capacity will be retained to allow this flexibility and for a time to readjust our plans should we need to Given the reality of the current pressures and the natural concern of the public, it is proposed that members ensure rigorous application of the national test as set out in the consultation document with scrutiny of the statistical validity of any evidence prior to decommissioning of capacity; and that the ability to operationally manage emergencies is described There was also concern expressed about what would happen if we were unable to decommission beds, and thus shift resources to the community as the strategy intends. The economic business case describes the response to such a scenario in the risk / gain share arrangements. This will leave individual organisations with significant challenges, but is a shared risk. 4.4 More general concerns raised

53 4.4.1 However, there were a number of more general concerns raised that members should consider when making the necessary decisions: Firstly, there was a concern expressed by some that the changes were too complex and others expressed a view that they did not have enough detail to go on in making the decision. don't really understand all the proposals. very little information has been provided to answer this question In truth this is a complex and significant set of changes. During the process we presented the high level policy decisions in the consultation document and also referred people to publically available detail on the five outline business cases. We had already done a series of briefings as part of an eight week listening exercise; this then informed the key questions we needed to address in the formal consultation. In both the listening exercise and the consultation, information was available on the business cases in three forms: A high level summary, a more detailed executive summary and a fully detailed business case. We also responded to any group or individual that requested specific clarification either through a faceto-face visit or in writing. However, given the complexity and to ensure that we continue to take the public with us it will be important that we do not see the end of the consultation as an end to public involvement on the issues and we reflect on how we present complex data as simply as possible There were also concerns expressed that we might not get a representative response from the population and that the more articulate members of the community would draw resources away from the more deprived areas, and thus increase inequalities across the borough. the more articulate and forceful middle-class will demand better services, and draw resources away from disadvantaged parts of the borough widening health inequalities This issue was also raised by the Adult Social Care and Healthy Scrutiny Committee. We sought to address the first issue of under representation by not only engaging directly with stakeholder groups with a known interest in the consultation, but also to address the likely bias of this former approach through street surveys. The sample size of the latter was more representative of the population in terms of

54 age and gender. It also included people from every part of Stockport as street surveys took place in each neighbourhood. However, footfall issues meant that there is still a higher representation from affluent areas in the borough. That said there is no significant difference in levels of support or otherwise between areas. We also sought feedback from specific protected characteristic groups. However, during implementation, further work to involve the public in developing the specific change proposals required to implement these high-level policy decisions at local level, for example on the location of service delivery points in neighbourhoods will be worth further attention In regards the second issue of resource allocation. There are some indications that under the current system the more articulate receive a greater share of resources. One of the reasons for developing the neighbourhood model is to ensure that resource allocation is focussed most on those who need it, and local professionals with local communities design a service delivery approach that best fits their area There was a general concern raised in a number of ways, even by those supportive of the general approach, on the chances of success given the underlying seriousness of the financial challenge. There was also a sense that we were masking the scale of the challenge given the situation we currently face. the document is not sufficiently honest the driver for change is to make savings on health and social care in a time of increasing (legitimate) demands you are not saying anything about the under resourcing of social care. This is a serious omission which makes it hard to assess your proposals It is true that the underlying financial challenges driven by demography and inflation are higher than any growth the NHS locally will receive, or that the Council will be able to fund by raising its income and that these proposals will not resolve these fully. This is reflective of the national picture. The Economic Case explained up-front that the estimated shortfall of doing nothing is 157m. The proposals set out in the business cases will deliver 43m towards this. However, that still leaves the individual partners and the changes that are taking place at a Greater Manchester level, needing to deliver 114m. This approach therefore makes a significant contribution to addressing the financial challenges but does not in itself fully resolve the challenge. Through this programme we are attempting to improve the way we use our resources by intervening earlier when the need is lower and by reducing the

55 fragmentation of the system. We do not underestimate the challenge of both achieving the benefits of these proposals nor of addressing the remaining gap There were particular concerns expressed about the challenges facing Social Care and that these could undermine the overall plans. you are not saying anything about the under resourcing of social care. This is a serious omission which makes it hard to assess your proposals leader keeps telling people that adult social care will bankrupt the council The intention behind our proposals in this respect is three-fold. By working more closely with the health service we are looking to mitigate the growing demand for social care through earlier identification of disease and other factors leading to a loss of independence. Further by integrating services we can look to utilise the whole health and social care budget where it is best deployed in the whole system. Thirdly, we will look through closer integration to reduce administrative costs by reducing duplication of processes and management. 4.5 Summary and Proposal The current versions of Equality Impact Assessments (EIAs) indicate that the changes proposed in the outline business cases will not detrimentally affect protected characteristic groups at a policy or strategy level from a public perspective and generally would be seen as beneficial. There are some impacts on staff groups in terms of changes of hours which have been and will continue to be addressed through staff consultation However, there are a number of issues highlighted particularly on accessibility which will need to be addressed during implementation and are addressed in section 5.2 and Approach to implementation 5.1 Introduction and Recommendation In addition to the views and evidence provided regarding the specific policy questions there was a significant amount of important information gathered that

56 should inform how we proceed with the implementation of the models of care described in the business cases. In this section we will draw out the key emerging themes and make a series of recommendations on action that should follow The recommendation that members of the Council Cabinet and the CCG Governing Body are asked to adopt the 7 recommendations arising from the public s feedback These themes are not prioritised in any particular order as each has merit in its own right. 5.2 Involving the public During the consultation, one of the most common themes to emerge was involvement. Consultees, whether they are individuals or organisations, are keen to be more involved in contributing to key decisions that are being made about the future of our local health and care services. Whilst the engagement process is recognised as important, its stop/start nature frustrates many people. These recommendations attempt to address some of these concerns by initiating a way of working that allows both individuals and organisations to work alongside our commissioners and providers to play a more substantive and meaningful role in influencing the shape of our future health and care services. Involve first, Change second The need to engage again in order to understand better operational changes emanating from implementation of strategic proposals. More frequent/routine engagement with staff and patients/public. Using local people, volunteers as consultation enablers, engaging directly with those unable to respond online or in writing Shared leadership involve wider stakeholders in decisionmaking, staff, patients, third sector Consult more widely with those least able to respond It is recommended that (1):

57 - We review how, as commissioners and providers, we further engage and involve local people those who use health and social care services as well as those who do not. We accept that, in the past, consultation outreach has sometimes appeared start/stop. Going forward, we will act on comments made by consultees which suggest we should involve local people in a more consistent, regular, and sustained way. - From January 2018, Commissioners will consider a method of engagement that involves collaborative working amongst stakeholders. It will build on comments received during this consultation about how we avoid complexity in our communications, promoting innovation and opportunity within our health and care system. -Through more effective engagement techniques, we will specifically build-in checks and balances to ensure there is an equal and fair representation for people who often do not have their voices heard. - We will review how we present financial information, and the need to provide greater clarity around how funding is directed (on what services), and how this compares to previous years. We would hope that greater familiarity of issues, through more regular and consistent involvement, creates better understanding of those issues amongst patients and our wider stakeholder groups. - We continue to work closely with the new Citizens Representation Panel to ensure closer working with our operational leads and move closer to a culture of shared leadership in decision making. - We proactively build on the networks and contacts already achieved and established through this consultation. This will enable us to build greater involvement of local people in decision making about their health and social care services particularly those less able to access services, for example visually impaired, deaf and disabled people. - Work with GPs and the new Neighbourhood model structures to establish local networks that create meaningful and early involvement of local people in decision making. We will establish channels of communication and engagement that will regularly update patients and the public on progress some of these channels will include Patient Participation Groups, collaborative working between patients and clinicians and greater use of digital media to support information flow to both patients and the public. 5.3 Equality and Diversity

58 Under the Equality Act 2010, certain population characteristics are given protection. They are: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation On the lead-up to, and during the consultation process, the CCG reviewed and updated the existing Equality Impact Analysis (EIA) for Stockport Together and the four key work stream areas, as a way of considering the effect on different groups given protection under the Equality Act. There are a number of key reasons for conducting an Equality Analysis, including: to consider whether the policy will help eliminate unlawful discrimination, harassment and victimisation to consider whether the policy will advance equality of opportunity between people who share a protected characteristic and those who do not to consider whether the policy will foster good relations between people who share a protected characteristic and those who do not to inform the development of the proposed policy. The establishment of these EIAs within our operational implementation plans, will require a positive and proactive approach to the involvement of protected groups. As a result, we recommend that (2): -We adopt the revised equality impact assessments (EIAs) as a common standard of operating, embedding the actions into the implementation plans for each of our work streams and operational plans for our wider health and social care system. -We regularly monitor the implementation of these standards, updating as appropriate to reflect local need and national best practice. -We proactively maintain the networks we have built over recent months to enhance our engagement and involvement with the wide range of protected groups that exist locally in Stockport. We will also commit to building on the foundations of our recent equality impact assessments (EIAs) for each of the business areas. This will include awareness and training sessions for operational leads and service providers, to ensure the full engagement and involvement of those who are identified as protected under the Equalities Act

59 5.4 Greater involvement of third sector A number of consultees, particularly among the key stakeholders groups, raised a desire for the third sector to have a greater involvement. There was a concern that when they were involved they were seen purely as providers of predetermined plans rather than having a seat at the decision making table. third sector / voluntary sector is not meaningfully engaged or considered within Stockport Together planning and believe this is missing a key resource that could assist there is a need to involve the charitable sector with Stockport Together on much more than consultations. there is an opportunity to partner with the sector and better coordinate its response to the needs of Stockport residents without necessarily spending more money The third sector has been involved with some additional investment earmarked in the business cases for specific schemes; and through The Prevention Alliance (TPA) they are integral to enhanced case management proposals for example However, the concern is recognised that the third sector have not had a formal position in the partnership. Therefore, it is recommended that (3): - The joint commissioners undertake to ensure that the third sector in Stockport have a more formal position in the partnership arrangements in the review of programme governance recently commissioned by the Chief Executives group and due to be in place for April Whilst accepting the business cases identify new sets of services, we will reconsider how we integrate the support of the Third Sector, ensuring more robust networks of support for the neighbourhood model. 5.5 Mental Health There was some disappointment expressed that mental health was not a more significant component of the plans. It was also commented on that it was not clear about the degree of integration between physical and mental health services

60 there needs to be better mental health services that residents can access quickly when needed before a crisis escalates mental health and physical health should go hand in hand and receive the same input In endorsing the outline business cases, the commissioners expressed similar concerns (See section 1.3.5). NHS Stockport CCG has since developed a wider mental health investment strategy which is coming to the CCG Governing Body for approval in January This will set out investments of 9.6m recurrently However, the commissioners recognise the opportunity for greater integration of services in the community needs to be pursued and as such it is recommended that (4): - The current contracting round ahead of April 2018 sets out a clear intention that community mental health services are integrated with neighbourhood teams; and - NHS Stockport CCG further strengthens the clinical leadership in mental health with a particular emphasis on integration of mental health with physical health and social care; especially given the priority of parity of esteem on the NHS agenda and to these proposals. 5.6 Wider Determinants of Health The greater integration of commissioning arrangements between the Council and the CCG are an important factor underpinning these proposals. In part this is to ensure that the wider determinants of health are considered alongside more traditional public health and medical interventions to prevent ill-health. The consultees mentioned housing in particular as something they felt was missing from the existing arrangements. Stockport Homes Carecall can prevent falls as well as dealing with the aftermath saves significant number of ambulance call outs Stockport Homes can give Public Health messages to customers as we see people regular (sic) and can prevent them reaching crisis point

61 5.6.2 It is therefore recommended that (5) in moving ahead with implementation of the plans: - Any considerations for greater integration of commissioning functions set out how the wider determinants of health including housing, leisure and education will be aligned; and - The joint commissioners undertake to ensure that Stockport Homes has a more formal position in the partnership arrangements in the review of programme governance recently commissioned by the Chief Executives group and due to be in place for April Workforce The public sector, with or without the proposed changes, faces a significant workforce challenge in the next few years. There are already significant shortages of doctors, nurses, and social care staff. This is already impacting on service delivery and was an important driver behind the need to change the model to one of early intervention rather than late intervention, which requires more specialist care. The consultees also expressed concern as have the commissioners in their caveats to endorsement of the business cases (See section 1.3.5). assurances [needed] that there was sufficient capacity in the community There were also concerns expressed that in reviewing the skill mix we would lower the standards of care and have less qualified staff undertaking tasks only fully qualified staff should undertake. The Adult Social Care and Health Scrutiny Committee sort assurance on this point. It is important to remind members that these plans have been developed and led by professional staff and commissioners, and will keep safety under constant review. A detailed functional analysis has been undertaken in drawing up the plans to ensure that tasks are appropriate to the qualification of the staff undertaking them and to ensure that staff spend more of their time undertaking tasks only they are qualified to undertake. there is an element of risk to patient safety from any move to a lower tier care, with less specialist provision. This risk needs to be understood and mitigated

62 5.7.3 Changes to working practice will be as significant as actual numbers and therefore an important consideration within implementation will be culture and organisational development Given the importance of this issue to successful implementation of the proposals, and the requirement to demonstrate that new services are safely established in the community before decommissioning beds, the commissioners are recommended (6) to require of providers as part of contract agreements: - A robust and comprehensive workforce plan and strategy to include the planned for establishment, the impact on other important sectors, and organisational development; and - Monthly reporting against a workforce tracker, tracking actual versus required establishment. 5.8 Seven-day services Members of the public broadly welcomed the greater range of seven-day service provision. However, there was a degree of scepticism. they really need to get a grip of GPs and make them work more late and early evening shifts like the rest of the NHS can 7-day working mean it please Illness doesn t stop on Friday nights & restart on Monday morning social workers should be available 7 days a week. Needs don t go away at weekends! there are already 7-day services in place both in hospital and the community I do not see how your Business plan will save money in the long term It is true that there is already seven-day delivery in some services. The proposals are to invest and thus strengthen community based-services including general practice. In particular the proposals are for those services that are required to intervene quickly to prevent deterioration becoming an unnecessary crisis. 5.9 Running Costs

63 5.9.1 It is imperative that as much of any available resource is directed to frontline staff and service delivery. A number of responses proposed that reductions in management capacity should be the primary source of efficiencies. too many managers, not enough nurses and care staff... ensure effective transparent use of public funds. Too much is wasted on ever increasing numbers of managers and not enough on frontline clinicians... if you can find them The greater integration of commissioning and provision set out in our plans is based on an assumption that there will be some efficiency gains in management. So for example, a single neighbourhood team rather than two or three will require less management. The Provider Alliance is expected to reduce overheads once changes are implemented. The Council in its current proposals have set out 350k reductions in social care management costs. NHS Stockport CCG is currently running at c 18per head of population instead of the allowed this is equivalent to a saving of 1.35m Even if we were to double these reductions, the impact on the overall efficiency requirement of 157m would be negligible. However, we remain committed to keeping management costs under constant review and directing as much resource as possible to the frontline Integration of Data Among the consultees responding positively there was recognition of the need for effective single records, and not restricting this to just Stockport. having a person's information in one place will reduce duplication, stop errors in communicating between different teams and save time... develop a common records system across Greater Manchester. It is not good enough when any hospital says, you are out of area, we do not have your records " The move to single electronic record systems is underway in Stockport and through Care Centric, work is underway to ensure information can be shared among providers across Greater Manchester. However, it is important that the public

64 at large and individual patients give consent for the use of their personal information, with appropriate rigorous safeguards by other professionals in place. For the involvement of the third sector to be truly effective, this will need to be beyond the boundaries of public bodies. Stockport remains committed to both appropriate sharing through single record systems and individual consent The Adult Social Care and Health Scrutiny Committee raised the concern that data would be too easily available to say volunteers. The current Information Governance safeguards are being robustly applied and we are working closely with the Information Commissioner and the BMA legal advisers. Further all the systems we are putting in have role based access and audit to ensure that only those staff with a right to access can do so, and that consent is always sought. It is recommended (7) that: - Further work is undertaken to promote the benefits of sharing information and the efforts being taken to locally protect data from misuse to support consent from the wider public and specific individuals 6. Next Steps 6.1 Monitoring Recommendation The Council Cabinet, CCG Governing Body and their associated committees will have routine monitoring approaches in place to oversee the implementation of any changes of this nature It is proposed that in addition to these, The Health & Care Integrated Commissioning Board (HCICB) will consider in public a report on progress in addressing the recommendations as set out in section 5 of this paper and the EIA action plans. This report will be presented in September 2018 and reviewed again in July Further Involvement and Consultation All the stakeholder groups who participated in the Consultation have been sent a copy of the report and, following approval of the response, will be offered the opportunity to discuss them further with senior commissioners

65 6.2.2 The approval does not negate the need to consult further on significant service changes that might be made in the future as a result of policy decisions being taken today, for example the location of service delivery points in neighbourhoods. 6.3 Notification and Contracts On behalf of the Council Cabinet and CCG Governing Body, Joint Commissioners will publish the decision and recommendations and will formally notify all relevant service providers of the intention to contract accordingly Commissioners will then move to ensure that the proposals as set out in the outline business cases are contracted for with the alliance partners both collectively and individually as required. 7. Summary and Proposal 7.1 There has been a significant, considered and important response from the public. It is right that in taking decisions on the key policy questions and proceeding to implementation of the business cases decision makers reviews these carefully. 7.2 The main thrust of the proposals (the creation of, and investment in, a more integrated and community based system delivered in neighbourhoods) was strongly supported by the public. 7.3 However, there were greater concerns and scepticism expressed about one-ofthe mechanisms to fund this investment (decommissioning of hospital beds) and the tests to ensure that we had fundamentally altered the need for these beds. 7.4 The public and key stakeholders also made a number of comments and suggestions about things that could strengthen implementation of plans. Whilst not in themselves being reasons not to precede it is important that they are considered and plans are adjusted and strengthened accordingly It is therefore recommended that the approach described in the previously endorsed outline business cases is approved and we proceed to implementation subject to a series of recommendations as set out in Section 5 of this report

66 8. Table of recommendations Recommendation 1: Involving the public We review how, as commissioners and providers, we further engage and involve local people those who use health and social care services as well as those who do not. We accept that, in the past, consultation outreach has sometimes appeared start / stop. Going forward, we will act on comments made by consultees which suggest we should involve local people in a more regular, meaningful and sustained way. From January 2018, Commissioners will consider a method of engagement that involves collaborative working amongst stakeholders. It will build on comments received during this consultation about how we avoid complexity in our communications, promoting innovation and opportunity within our health and care system. Through more effective engagement techniques, we will specifically build-in checks and balances to ensure there is an equal and fair representation for people who often do not have their voices heard. We will review how we present financial information, and the need to provide greater clarity around how funding is directed (on what services), and how this compares to previous years. We would hope that greater familiarity of issues, through more regular and consistent involvement, creates better understanding of those issues amongst patients and our wider stakeholder groups. We continue to work closely with the new Citizens Representation Panel to ensure closer working with our operational leads and move closer to a culture of shared leadership in decision making. We proactively build on the networks and contacts already achieved and established through this consultation. This will enable us to build greater involvement of local people in decision making about their health and social care services particularly those less able to access services, for example visually impaired, deaf and disabled people. Work with GPs and the new Neighbourhood model structures to establish local networks that create meaningful and early involvement of local people in decision making. We will establish channels of communication and engagement that will regularly update patients and the public on progress some of these channels will include Patient Participation Groups, collaborative working between patients and clinicians and greater use of digital

67 media to support information flow to both patients and the public. Recommendation 2: equality and diversity We adopt the revised equality impact assessments (EIAs) as a common standard of operating, embedding the actions into the implementation plans for each of our work streams and operational plans for our wider health and social care system. We regularly monitor the implementation of these standards, updating as appropriate to reflect local need and national best practice. We proactively re-establish the networks we have built over recent months to radically enhance our engagement and involvement with the wide range of protected groups that exist locally in Stockport. We will also commit to building on the foundations of our recent equality impact assessments (EIAs) for each of the business areas. This will include awareness and training sessions for operational leads and service providers, to ensure the full engagement and involvement of those who are identified as protected under the Equalities Act Recommendation 3: greater involvement of the third sector The joint commissioners undertake to ensure that the third sector in Stockport have a more formal position in the partnership arrangements in the review of programme governance recently commissioned by the Chief Executives group and due to be in place for April Whilst accepting the business cases identify new sets of services, we will re-consider how we integrate the support of the Third Sector, ensuring more robust networks of support for the neighbourhood model. Recommendation 4: mental health The current contracting round ahead of April 2018 sets out a clear intention that community mental health services are integrated with neighbourhood teams. NHS Stockport CCG further strengthens the clinical leadership in mental health with a particular emphasis on integration of mental health with physical health and social care; especially given the priority of parity of esteem on the NHS agenda and to these proposals. Recommendation 5: wider determinants of health Any considerations for greater integration of commissioning functions set out how the wider determinants of health including housing, leisure and education will be aligned. The joint commissioners undertake to ensure that Stockport Homes has a more formal position in the partnership arrangements in the review of programme governance recently

68 commissioned by the Chief Executives group and due to be in place for April Recommendation 6: workforce A robust and comprehensive workforce plan and strategy to include the planned for establishment, the impact on other important sectors, and organisational development. Monthly reporting against a workforce tracker, tracking actual versus required establishment. Recommendation 7: Integration of data Further work is undertaken to promote the benefits of sharing information and the efforts being taken to locally protect data from misuse to support consent from the wider public and specific individuals

69 Report 22 December 2017 Stockport Together Independent Consultation Analysis ASV

70 Contents 1 EXECUTIVE SUMMARY Introduction Summary Findings Service Proposals Overall Observation Common Themes INTRODUCTION Introduction The Consultation Process Responses to the Consultation Demographics, Online, Postal and Face-to-Face Survey Interpreting the Responses SERVICES Introduction - Services Do you agree with our proposals? Why? (Q1b) Other Evidence to Consider (Q1c) NEIGHBOURHOODS Introduction - Neighbourhoods Do you agree with our proposals? Why? (Q2b) Other Evidence to Consider (Q2c) HOSPITAL BEDS Introduction Hospital Beds Do you agree with our proposals? Why? (Q3b) Other Evidence to Consider (Q3c) OTHER INFORMATION OR PROPOSALS Introduction Thematic Analysis DISCUSSION GROUP MEETINGS Introduction Thematic Analysis SUMMARY Introduction Summary Findings Service Proposals Overall Observation Common Themes ASV

71 9 APPENDIX ONE: ONLINE, POSTAL & FACE-TO-FACE DEMOGRAPHICS Disability Race Sexuality Religion Gender Reassignment (Is your gender different to that assigned at birth?) ASV

72 1 EXECUTIVE SUMMARY Findings in Brief 1.1 Introduction Stockport Together is a partnership of the five health and social care organisations that serve the people of Stockport: NHS Stockport Clinical Commissioning Group (CCG); Pennine Care NHS Foundation Trust (mental health services); Stockport Metropolitan Borough Council; Stockport NHS Foundation Trust (Stepping Hill hospital and community health services); and Viaduct Care (a federation representing all Stockport GPs.) Health and social care in Stockport faces many major challenges, some unique, others in common with the rest of Greater Manchester. Stockport Together has secured 19 million through an agreement with the Greater Manchester Health and Social Care Partnership (GMHSCP) to address these challenges by: Reducing inequalities; Supporting people to live healthier lives; Improving access to GPs and other integrated community health and social care services; Increasing access to community mental health services; Improving care for vulnerable people; and Reducing the pressures on hospital services especially those at Stockport NHS Foundation Trust (Stepping Hill Hospital). Stockport Together conducted a public consultation (10 th October to 30 th November 2017) on their broad strategic principles to achieve these aims, prior to formally adopting them. The specific areas on which the consultation sought public views were: Changing the way health and social care services are planned and organised in Stockport; The plans to organise health, social care, and mental health services in teams that work in eight neighbourhoods; and Ensuring hospital services are in place for those that need them while reducing pressure on those services. In summary: The overwhelming majority of respondents support the partnership s aims of changing the ways in which health and social care is planned; Again, the majority supported the plans to reorganise services based around a neighbourhood delivery model; and ASV

73 There was significantly less support for any reduction in hospital beds, with as many if not more opposing the idea. The specific details of each service proposal along with some general observations distilled from the consultation findings are discussed in the remainder of this brief summary. 1.2 Summary Findings Service Proposals Considering the specifics of the service proposals there was broad support for the outline strategic proposals, however, this was less clear around the issue of closing hospital beds Planning and Organising Services There was support for the broad proposals to reorganise the way health and social care in Stockport, with: 72% of respondents to the online, postal, and face-to-face survey tend to agree or strongly agree with the proposal; 87% of respondents to the street survey expressed a common opinion in support. However, the following also needs to be taken into consideration: Working together Recognising the benefits of the approach suggested in the Stockport Together proposals being consulted on the opportunity to maximise these through earlier work with the third sector (voluntary and community) was highlighted for consideration. Accessibility Many respondents expressed concerns over the way in which Stockport residents would be able to access the proposed services if they faced specific difficulties. Consider Local and Individual Need The Stockport Together partners need be mindful of the variations in need between neighbourhoods in Stockport and of individuals within those neighbourhoods in designing new service provision. Emphasis on Mental Health Consultees were very clear in directing the Stockport Together consultation to give equal weight in consideration of mental health needs and physical health, and therefore placing an enhanced emphasis than that currently enjoyed. Ensure Social Care is Supported Within the considerations of the consultation there is a direction that social care funding and more importantly adequate social care provision is available, as well as closer cooperation and coordination between these two elements of the proposals. Scepticism ASV

74 It is also clear that the consultors (NHS Stockport CCG and Stockport MBC) will have to overcome a level of scepticism from the public over the realism of some aspects of the proposal to be able to achieve the savings it seeks to make A Neighbourhood Delivery Model Again, there was very strong support for the proposals to organise health and mental health services into eight neighbourhood teams: 71% of respondents to the online, postal, and face-to-face survey tend to agree or strongly agree with the proposal; and 71% of respondents to the street survey expressed a common opinion in support. However, the following factors identified by consultees also need to be taken into consideration: The consultation process and the danger of domination by the articulate and engaged Specific concern was raised by consultees of the potential for the process to be disproportionately influenced by the articulate middle-class respondents to the consultation. While all contributions are welcome, the issue for consideration by the consultors is recognising the ability of this group to articulate their concerns while recognising the needs of those less able to express themselves. Local provision, knowledge, and accessibility Consultees recognised the benefits of the proposal to organise service around a neighbourhood model. The key benefits were felt to be: Provision of services in a familiar location, in an area people know well and are comfortable in; The focus of service around local GPs who generally have an established relationship and a record of need and past care; and A central and local location that reduces the burden of travel to service. Where are the resources to support the proposal? Many consultees expressed an overall concern that the proposals, as detailed in the consultation document, did not provide enough evidence that the proposals were based on sound financial plans. Which in turn led to concerns over the overall sustainability of the proposals. A much-needed focus on mental health, but is it enough? There was a recognition from consultees that the proposals added a very important focus on caring for those with mental health needs in their own community, which was very well received. However, some consultees felt this service offer did not go far enough in meeting the needs of the residents of Stockport. Are the proposed neighbourhoods too big? ASV

75 Many respondents to the consultation felt that the scale of the neighbourhood model was not well enough explained in the proposals. This in turn led to concerns that the description of a neighbourhood was too big, and would not be recognised by residents as such, which raised further concerns over the distances to travel and population covered by a neighbourhood centre, an issue which may need to be addressed by the consultors. More questions to be answered before this proposal looks complete While most consultees recognised the outline advantages of neighbourhood working, many also felt that there was a lack of detail in the proposals in the consultation document which led to more questions. The feeling was that Stockport Together will be required to provide more detail before many consultees felt confident in responding to the consultation, including the role the third sector would or could play in the proposals Reducing Hospital Beds The proposals to reduce the number of hospital beds was significantly less welcome by consultees, with 40% of respondents to the online, postal, and face-to-face survey tend to agree or strongly agree with the proposal and a third (33%) disagreeing/strongly disagreeing; and 41% of respondents to the street survey expressed a common opinion in support, however the majority (55%) expressed opinions disagreeing/strongly disagreeing with the proposals. In considering these results the following needs to be taken into consideration: Capacity, demand, and the perceived need for hospital based rehabilitation Many respondents to the consultation felt that the tests were flawed simply because, in their view, the number of hospital beds required for the borough was fixed based on the population level. Consultees also took the view that Stockport needs more hospital beds not less, and with many stating the opinion that a sensible approach would appear to be some sort of mothballing rather than a real reduction. The premise behind these views being the need to respond to any future upsurge in demand. This was compounded by a minority view that hospital stays should involve an important element of rehabilitation prior to discharge, which would further increase the requirement for hospital beds. This should be a self-evident truth A more pragmatic view from consultees was that the proposed tests would be proof in themselves of the need for less beds. If they were incorrect, the number of hospital beds would be likely to remain static. ASV

76 Moving people home quicker results in better care - if adequate provision for home care exists Many respondents to the consultation shared the view that the best care for patients was in their own home, recognising the detrimental impact prolonged hospital stays have on health, particularly for the elderly. However, this was tempered with realism, in that home care only works in appropriate circumstances, people without a support network will be left isolated and the lack of sufficient after care will result in a return to a hospital bed. All of which are counter to the overall objectives of reducing hospital stays. Providing adequate transitional support to the hospital beds Coupled with concerns over the need for care at home, consultees highlighted the need for the provision of adequate provision of transitional support for those not yet ready to return home, but no longer in need of hospital care. This was interchangeably described as step down, transitional or assessment beds, where patients can regain their independence. Without this element being explicitly dealt with within the proposals many were unconvinced. Confidence required that the capacity exists in the community to cope Consultees were only convinced of the reduction in hospital beds if there was evidence to support provision of adequate capacity in community care to support the proposed changes. Many consultees expressed concern that this was not explicit within the proposals contained in the consultation document. Starts somewhere else than in hospital The view of many consultees was that the argument for reduced beds starts outside the hospital and other clinical settings and called for a focus on other social determinants of health, and the ability to influence positive lifestyle changes. Savings elsewhere? Some consultees provided the view that the proposals to cut hospital beds were looking for cost savings in the wrong area, and the reduction in management overhead in the new organisation could achieve much of the saving. A smaller group of consultees took the view that reductions in hospital bed numbers would not be enough, even when considered with efficiency savings elsewhere in the system. 1.3 Overall Observation Common Themes Aside from the specific comments on the individual proposals for service change there are several common themes emerging from the consultation responses that are important for the consultors to consider. These were: Governance and accountability There was an overall concern that the consultation, although currently only addressing broad strategic themes did not provide confidence that robust arrangements were in ASV

77 place for governance, measurement, and accountability. Without this detail consultees would find it difficult to decide on specific service proposals. Role of the third sector Throughout the consultation responses the contribution of voluntary and community (third) sector partners is valued and valuable. However, they appear to be observers rather than participants in the process which overlooks the value and experience they bring to the benefit of Stockport. The consultation process speak and listen There were some specific criticisms of the consultation process, despite the relatively high response rate, which included: The lack of detailed information to decide on; The question/response format being limited restricting the ability of consultees to respond meaningfully; The way in which consultation was conducted, with too much reliance on online and social media and less with face-to-face contact. This was also reflected in the discussion group responses traditional Q&A sessions and not proactive opinion seeking. This could suggest the need for a wider approach to engagement through co-production approaches rather than a reliance on setpiece consultation. Within this, it is worth considering the complexity of the language and format used in the consultation document, perhaps reflecting on the average UK reading age of 9, and how this impacts comprehension and participation. Equity of consideration mental and physical health The need to give equal consideration to mental health, which given the perceived status as the poor relation, many felt required preferential treatment. Scepticism Many, but by no means all consultees expressed an ongoing cynicism with the process, feeling that it had all been done before or that the evidence for the changes did not exist. Stockport Together will need to respond constructively to this and provide evidence of positive change to convince this group. We get it, show us transparency and honesty The feeling was the ability of the public to understand the proposals was often underestimated and Stockport Together should provide a consultation that is clear in the benefits and drawbacks of the proposals alongside the rationale and accountability. Access for all The issue of affluent, literate and engage communities was raised as a concern. The specific issues were: ASV

78 The potential for disproportionate influence from middle class consultees; and Concerns over those with the self-awareness to seek health support (the worried well) predominantly in affluent areas taking a higher share of services than areas less health literate. Cross boundary working Demands on health and social care services are not unique to Stockport and consultees were aware of other initiatives in Greater Manchester and other bordering areas. The concern for consultees was the extent to which this was taken account of in Stockport Together s proposals and the impact on inflowing/outflowing services provided across boundaries. Staff Consultees felt that one of the main challenges to be addressed by Stockport Together in developing and delivering their proposals was the issue of staff, including: Consideration of recruiting more GPs, nurses, care assistants and other clinical roles alongside social care staff to address service demands in the face of national shortages; The willingness and support from GPs to deliver the neighbourhood model; The capability and capacity of community staff to deal with the increased demand. Care homes and transitional support Stockport Together s proposals appear to consultees to rely upon increased care home capacity and the availability of transitional/step down beds to move people from hospital quicker. The level of detail in the proposals does not make it clear if this has been considered and is in place. Changes in lifestyle and behaviour Outside of the proposals there was a strong feeling from consultees that to effect the changes described there is a need for more preventative interventions. The view being that by the time people are being dealt with by the proposed services, it s too late. Early intervention is required in the community, including schools, which is a wider remit than the proposals, but felt to be the motivator for real change and savings. ASV

79 2 INTRODUCTION Context and background 2.1 Introduction Stockport Together is a partnership of the five health and social care organisations that serve the people of Stockport: NHS Stockport Clinical Commissioning Group (CCG); Pennine Care NHS Foundation Trust (mental health services); Stockport Metropolitan Borough Council; Stockport NHS Foundation Trust (Stepping Hill hospital and community health services); and Viaduct Care (a federation representing all Stockport GPs.) Health and social care in Stockport faces many major challenges, some unique, others in common with the rest of Greater Manchester. Stockport Together has an opportunity to begin to address these issues having secured 19 million through an agreement with the Greater Manchester Health and Social Care Partnership (GMHSCP). The aims of this agreement include: Reducing inequalities; Supporting people to live healthier lives; Improving access to GPs and other integrated community health and social care services; Increasing access to community mental health services; Improving care for vulnerable people; and Reducing the pressures on hospital services especially those at Stockport NHS Foundation Trust (Stepping Hill Hospital). Against this background the overall objective of the public consultation was to provide the people of Stockport, and other stakeholders in the community, the opportunity to offer comment and questions on these broad strategic principles prior to formally adopting the proposals. The specific areas in which the consultation sought public views were: Changing the way health and social care services are planned and organised in Stockport; The plans to organise health, social care, and mental health services in teams that work in eight neighbourhoods; and Ensuring hospital services are in place for those that need them while reducing pressure on those services. ASV

80 2.2 The Consultation Process The Stockport Together public consultation on their broad strategic principles ran between 10 th October to 30 th November The consultation followed the principles of a continuous dynamic dialogue 1 and compensating methods were introduced when potential gaps in coverage were identified. The specific methods employed as part of the consultation and included in this analysis were: A consultation survey available electronically or in hard copy with submissions received either online, by post or face-to-face; A series of consultation discussion groups; and An on-street survey, using a slight variant of the standard consultation questionnaire to reflect the methodology, with a representative sample of the population in neighbourhood centres. Respondents were also invited to provide additional evidence for consideration by the Stockport Together partnership in their deliberations over formal adoption of the proposals. The consultation was promoted through the following channels: Launch communications through local press and online; Social media (Facebook, Twitter, etc.) activity throughout the consultation period; A consultation document Have your say: Stakeholder consultation on the proposed changes to the way health and social care services are organised in Stockport (containing key information and a self-complete questionnaire returnable by Freepost), supported by flyers, distributed to: Libraries; Charities/voluntary organisations; GP practices; Pharmacies; Stockport NHS Foundation Trust staff and patients; Key community figures; Accessible format versions of the consultation document and supporting information sensory disabilities, other languages. Hard copies of the consultation document were used in groups and meetings to support the discussions and capture views in a face-to-face setting. 1 Taken from the Consultation Institute s definition of consultation. ASV

81 2.3 Responses to the Consultation In total 527 responses (514 survey responses plus 13 discussion groups) received during the consultation period, were provided for analysis, and included in this report. Method Responses Street Survey 303 Face-to-Face 22 Postal 10 Online 179 Total 514 In addition, notes of fourteen discussions group meetings were provided for analysis as follows: 1. Alvanley Health Champions Patient Participation Group (PPG) 2. Breathe Easy Group 3. Bredbury PPG 4. Cheadle PPG 5. Disability Stockport 6. Marple PPG 7. Mental Health Carers Group 8. Poets Corner Action Group 9. NHS Watch 10. Walthew House Deaf group Walthew House Deaf group Walthew House Visually Impaired group Walthew House Visually Impaired group Healthwatch Stockport Additional evidence submitted for consideration as part of the consultation survey was: Question 1c, related to the way we plan and organise services : Two personal responses; An alternative view from NHS Watch; Carers UK State of Caring Report 2017 Stockport Together Consultation, Response from Liberal Democrat Group; Health and Care Forum response; Mental Health Carers Group response; Effects of health and social care spending constraints on mortality in England: a time trend analysis, BMJ Open, 16/11/17, Watkins J, et al. Question 2c, related to providing care through a neighbourhood model : Newquay Pathfinder Evaluation. Question 3c, related to hospital beds : Mental Health Carers Scenarios; CQC Stepping Hill Hospital Quality Report. ASV

82 2.3.1 Demographics Street Survey The demographic make-up of the street survey sample is shown below (age, gender and residence were the only characteristics captured). Age Frequency Percent % % % % % % Prefer Not to Say 1 0.3% Total % Gender Female % Male % Not Answered 4 1.3% Prefer not to say 1 0.3% Total % Respondent Postcode (First characters only provided) Cheadle 1 0.3% SK % SK % SK % SK % SK % SK % SK % SK % SK % SK % SK % SK % SK % SK % Not answered 1 0.3% Total % ASV

83 2.4 Demographics, Online, Postal and Face-to-Face Survey The overall demographic characteristics of consultees providing online, face-to-face, or postal responses to the consultation are shown below. Age ASV 2017 Frequency 12 Percent % % % % % % % Prefer not to say 5 2.3% Not Answered % Total % Gender Female % Male % Transgender 3 1.4% Prefer not to say % Not Answered % Total % Ethnicity Asian/British - Bangladeshi 1 0.5% Asian/British - Chinese 1 0.5% Black/British African 1 0.5% Not Answered % White: British % White: European 3 1.4% White: Gypsy/Traveller 2 0.9% White: Irish 6 2.8% Other ethnicity/race 9 4.2% Total % Religion Buddhism 4 1.9% Christianity % Islam 1 0.5% Judaism 2 0.9% No religion % Other 15 7% 083

84 Frequency Percent Not Answered % Total % Disabled Yes No Not Answered Prefer not to say Total Sexual Orientation Bisexual Gay Heterosexual/straight Lesbian Not Answered Other 2 0.9% Prefer not to say % Total % Is your gender different to that assigned at birth? Yes % No % Prefer not to say % Not Answered % Total % ASV

85 2.5 Interpreting the Responses ASV 2 was commissioned to provide an independent analysis of the consultation. The specific methods applied to analyse the findings were: Quantitative Analysis: the findings from the survey-based consultation approaches (online, postal, and face-to-face consultation surveys and street survey) were each analysed separately to recognise the differences 3 in the respondents and sampling approach. The closed responses were analysed using industry standard proprietary statistical analysis software 4 with manual thematic coding used for the free text responses to group them into themes reflective of the sentiment expressed. Qualitative Analysis: the findings from the focus group discussion-based consultation approaches are based on an approach where the data from the session notes is analysed and responses grouped into themes that most closely represent the views expressed 5. This allows us to report the findings based on an accurate reflection of the sentiments expressed, qualitative data does not allow for commentary on the specific number of times comments are made within these coded themes. The communications to promote the consultation and the methods used were designed to promote maximum participation, allowing all to contribute. It is important to note, however: Respondents to the online, postal, and face-to-face surveys are self-selecting, representing the views of those who are aware of and engaged in the topic area. This is more likely to include the views of service users, carers, staff, and others with a direct interest in the services, but cannot be said to represent opinion from the entire population. This is very important opinion, but cannot be treated as being statistically reliable. The street survey of residents of Stockport is representative at the population level, considering the views of all irrespective of current service use. This is the only statistically reliable response 6, but does not necessarily reflect the views of services users. This report presents the result of that independent analysis and is intended to inform decision makers of the views of consultees and to provide them with a summary of additional evidence which they wish them to take into conscientious consideration. 2 ASV is a trading style of ASV Research Ltd 3 Online, postal, and face-to-face are treated as one category with similar aims and response mechanisms. 4 SPSS 5 Our approach is based in the employment of Classic Grounded Theory. 6 Using 2016 Mid- Year Population Estimates for Stockport the results of the street survey are reliable to a confidence level of 95% with a confidence interval of +/ ASV

86 3 SERVICES Changing the way we plan and organise services 3.1 Introduction - Services The consultation document provided the following context to inform individual responses. We know how to work with you to prevent disease. We have the medicines and treatments to improve the health of people with long-term illnesses. We have the skills to provide care when you are vulnerable. It makes sense for us to change the way we work so we can better use these to improve the health of local people, rather than wait until they are so ill they need hospital treatment or completely lose their independence. Sometimes a stay in hospital is not needed or is only needed for a very short time. We want to reduce the number of people who have to be admitted to hospital by diagnosing them earlier and treating them quicker. For those who do require hospital care we want to support them to return home as soon as possible. We want more services that help diagnose and treat people in their communities. We think that bringing GPs and other health and social care professionals closer together with more resources, will help prevent many people becoming so ill they need to go to hospital and will help others maintain their independence longer. Older people tell us that going into hospital can be a stressful experience, even when they know they need to. In Stockport there s a higher chance that patients will be admitted to hospital and kept in longer after treatment than in other similar places in England. In June the partner organisations published four outline business plans that show how they would work together. Through this work, we re planning to do several things: Identify the people with long-term illnesses who are most likely to end up in hospital for urgent treatment Develop new integrated community health and social care teams built around GPs to help those patients stay well Expand and integrate services that provide mental health support in the community developing a more holistic approach to meeting peoples needs Identify those patients who would benefit from rapid short- term support when they arrive at hospital and divert them to a specialist treatment centre that has immediate access to their records and can treat them quickly Give patients the support and care they need to return home from hospital quickly, where possible without an overnight stay ASV

87 Give patients access to outpatient services traditionally provided at hospital in different ways utilising modern technology and either in their home, or at neighbourhood health centres. The effect of these proposals is to move resources from treating people in hospital when they become seriously ill, to identifying and addressing their social care, physical and mental health needs at home and in the community before they become serious enough to require hospital treatment or completely lose their independence. As a consequence of our proposals when people do need hospital care we will be able to offer higher quality care more quickly. Respondents were asked three questions, one closed and two open about these proposals, these were: To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? (Closed response using a ranking of 1-5 where 1 is Strongly Agree and 5 is Strongly Disagree a sixth option Don t Know was also provided). Why do you say this? (Free text response). Do you have any additional evidence that decision-makers should consider before they make this decision? (Free text response). 3.2 Do you agree with our proposals? Participants in the consultation, whichever method was used, were all asked the following question. To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? Discussed in turn below are the responses from the: Online, postal, and face-to-face survey; and Street survey. These data are treated separately to recognise the previously discussed differences in sampling and motivation to participate. Further details of the responses for the online, postal, and face-to-face survey are shown in Appendix One. Demographics beyond those reported are not available for the street survey. ASV

88 3.2.1 Online, Postal, and Face-to-Face When overall sample is considered most consultees from the online, postal, and faceface survey support this proposal. 72% of respondents either tend to agree or strongly agree that Stockport Together should change their approaches to planning and organising health and social care services as shown below. Overall agreement/disagreement Frequency Percent Strongly agree % Tend to agree % Neither agree nor disagree 9 4.2% Tend to disagree % Strongly disagree % Don't know % Not Answered % Total % When the consultation responses are considered by consultee age there is little difference in agreement, with the main differences being the group who are fully in agreement and the group who are significantly lower at 50%. However, these latter variations can most likely be explained by low sample size. The breakdown is shown on the next page % % % % % % % When considered by gender women are significantly more in favour of the proposals than men 7. Female 80% Male 68% 7 The figures shown are a percentage of the sub category i.e. 88% of all women responding. ASV

89 3.2.3 Street Survey The majority (87%) of consultees responding to the street survey supported the proposal, either tending to agree or strongly agreeing that Stockport Together should change their approaches to planning and organising health and social care services. Overall agreement/disagreement Frequency Percent Strongly agree % Tend to agree % Neither agree nor disagree % Tend to disagree 7 2.3% Strongly disagree 4 1.3% Don't know 8 2.6% Not Answered 1 0.3% Total % When considered by age of respondent there is no significant variation in opinion % % % % % % When considered by gender of respondent there is little difference in opinion between men and women on this proposition. 88% of women agree/strongly agree 86 % of men agree/strongly agree 3.3 Why? (Q1b) When asked why did you provide that answer participants in the consultation gave a range of responses, these have been analysed and grouped into broad themes representing the overall sentiment. Recognising the similarity of the responses and for brevity in reporting we have analysed them together irrespective of the method of contribution to the consultation. The main themes developed from the consultation are discussed below, all relating to the question: To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? ASV

90 3.3.1 Concerns over Funding Proposals Respondents expressed concerns over the overall funding modelling in the consultation proposals, both for NHS and local authority funding, centred around: Concerns over the challenges to services through strategic decisions outside local control, from central government policy. There was also practical recognition that with reduced funding there is a need to manage available resources most efficiently; Perceptions that the overall objective of the consultation was designed to cut costs rather than deliver better services; and An expressed desire to better understand the way the funding would work under the proposed changes. How it differs to that provided in the current circumstances; and An overall concern that detailed costings are not provided at a level that would help inform decisions. without proper funding, resources and staffing, any reorganisation will result in a second-rate system... There were also concerns expressed that any savings made through these proposals would be cancelled out by requirements to make budget cuts across health and in particular social care. any financial savings will be swallowed up by massive budget cuts health and wellbeing of citizens of Stockport will be worsened as a result Additional Key Partners A theme from consultees was the need to consider other partners in the Stockport Together model. Issues highlighted include links between homelessness and poor mental health. Stockport Homes were specifically mentioned as a potential partner to address many health issues. Stockport Homes Carecall can prevent falls as well as dealing with the aftermath saves significant number of ambulance call outs. Stockport Homes can give Public Health messages to customers as we see people regular (sic) and can prevent them reaching crisis point. ASV

91 Concern was also expressed that the role of voluntary and community organisations was not adequately explored in the proposals, which in itself was felt to be a considerable oversight. third sector / voluntary sector is not meaningfully engaged or considered within Stockport Together planning and believe this is missing a key resource that could assist Bureaucracy and Management Concerns were expressed around a perception that the proposals could result in increasing managerial staff, rather than frontline service delivery too many managers, not enough nurses and care staff... However, there was a countervailing argument that where resources are available they need to be managed as efficiently and at as low a cost as possible. you need to manage the funds closely to make sure it s used properly There were also concerns expressed over the existing senior leadership record of achievement, and the extent to which proposals were based on understanding of the challenges faced by frontline health and social care staff on a day-to-day basis. have the council leaders been to spend a day shadowing all health and social care services I very much doubt it Consultation Complexity An overall comment from many respondents was the complexity of the consultation subject, the specific service areas, and the wording of the questions themselves, with many feeling this was a barrier to full participation. don't really understand all the proposals. don't fully understand the question ASV

92 3.3.5 Support for the Proposals Overall, consultees welcomed the consultation s proposals for rearranging the way services are delivered with the caveat that they are, perhaps, too generalised. The local focus of the proposals, and specifically developing an integrated service built around GPs was welcomed. However, this was also a point of concern for some in that while welcome placed additional pressure on what was felt to be an already overstretched service. local people want good quality services delivered by competent staff in a welcoming and safe environment There was recognition from many respondents of the need to make these changes based both on resources and efficiencies and the improved wellbeing of communities through reduced clinical interventions. There needs to be a change because there are insufficient resources to carry on as is ; because Hospital care and resources are better focused where clinically appropriate and needed health and wellbeing have been shown in numerous studies to benefit from less clinical approaches in the community The proposed rearrangement of services was also seen as providing more efficient communications and the opportunity reductions in duplication of effort between NHS and social care staff. by combining health and social care the new system will be more efficient, respond to peoples needs, improve communication and be cost saving having a person's information in one place will reduce duplication, stop errors in communicating between different teams and save time... ASV

93 3.3.6 Inequalities Consultees recognised the potential for improvement in health and social care outcomes through the proposals under consultation, however, concern was expressed that the focus on physical wellbeing was prioritised over that of residents mental health. For too long there has been inequalities between physical health care and mental health care. It is our hope that the changes will present more parity of esteem not only within services, but also within the larger community. Many consultees thought this an important issue for the consultation to consider Specific Needs of Equalities Groups There was a call for the consultation to consider the specific needs of the Lesbian, Gay, Bisexual and Transgender (LGBT) communities in Stockport, specifically the need for services that revolve around a supportive and understanding GP. making prevention more accessible to LGBT people by ensuring that services most likely to be needed such as drug and alcohol and mental health services, are designed and delivered to meet the specific health needs of this community of identity Service Concerns Specific concerns were expressed by consultees around the proposals under consultation. First, the issue of social care funding was raised and specifically how the current levels of support for adults will be maintained under the Stockport Together proposals. leader keeps telling people that adult social care will bankrupt the council Coupled with this was a concern expressed over perceptions that the proposals would lead to delivery of community based health and social care services with a lower qualified workforce. there is an element of risk to patient safety from any move to a lower tier care, with less specialist provision. This risk needs to be understood and mitigated... ASV

94 3.3.9 An Ageing Population Consultees identified a need for realism in the proposals being consulted on in relation to the ageing population of Stockport. The concern expressed was around the extent to which the proposals had taken the population profile into account, and the need to accurately reflect this in future service provision. Stockport NHS has 19.4% above the national average of over 65s the needs of a changing demographic linked to the changes in society since the foundation of the NHS make it vitally important that we ensure our services are tailored to local need Alongside this call for realism, is the call for the provision of social care packages, on time and in time for the older population to preserve independence and reduce reliance on hospital support. my gran is 91 years old and she had to stay in hospital for 6 months as they had no care package available as Marple was fully subscribed Openness, Honesty, and Transparency Another overarching theme from consultees was that of scepticism around the intent of the consultation. I remain somewhat sceptical wonder whether sufficient resources will be made available to preventative services to enable them to be sufficiently available to those who need them? Coupled with this was a concern expressed in varying forms by many consultees, that the consultation was not sufficiently honest in its intent and description of the proposed changes to the delivery of local services in Stockport. the document is not sufficiently honest the driver for change is to make savings on health and social care in a time of increasing (legitimate) demands you are not saying anything about the under resourcing of social care. This is a serious omission which makes it hard to assess your proposals ASV

95 This was felt to be mitigated by more transparent planning, monitoring, and reporting of the changes as they progress, along with a more detailed description of costs and service outcomes. An over reliance upon social media as the main means of engaging with the public and patients, when many are not able to access this; The need for expert support for GPs when dealing with mental health issues; Concerns with the Have your say questionnaire: Confusing and conflicting requests for information; The lack of robust evidence behind the statements; 24 ASV 2017 any plans the new Stockport Together Trust make to achieve the advertised goals should be fully investigated, properly planned and accurately costed 3.4 Other Evidence to Consider (Q1c) When people were asked the question: Do you have any additional evidence that decision-makers should consider before they make this decision? They were able to respond in two ways by: i. Uploading documents either reports, responses, or comments to the consultation website; or ii. Providing additional comments as free text. Evidence submitted in these ways, related to...changing the way we plan and organise services is discussed in turn below Uploaded Evidence In total, eight pieces of documentary evidence were submitted to the consultation for consideration. These were: Two personal responses; An alternative view from NHS Watch; Carers UK State of Caring Report 2017; Stockport Together Consultation, Response from Liberal Democrat Group; Health and Care Forum response; Mental Health Carers Group response; Effects of health and social care spending constraints on mortality in England: a time trend analysis, BMJ Open, 16/11/17, Watkins J, et al Personal Responses Two personal responses were received, the names and specifics of these are not detailed for reasons of data protection and patient confidentiality, however, in summary their concerns covered: 095

96 Concerns over the wording of questions; and Concerns over the depth of equality monitoring questions An Alternative View from Stockport NHS Watch Stockport NHS Watch provided an uploaded submission. The submission covered a range of issues in depth, and included a broad and robust challenge to the evidence base used for the consultation and perceived adherence to a national model which could lead to cuts in hospital services. However, the general principles were welcomed, particularly Neighbourhood Hubs, and the need to transfer hospital bed savings to be transferred to community care. An overall concern expressed was the perception that the accountable care organisation created would be vulnerable to privatisation Carers UK, State of Caring Report 2017 A submission was received as a copy of the State of Caring 2017 report produced by Carers UK. This report highlights the contribution made by carers, the lack of recognition they feel for that 132bn unpaid care, and the impact on their health and wellbeing. The call in the report for a contribution that is understood and valued appears an important message to Stockport Together Stockport Together Consultation, Response from Liberal Democrat Group The submission received from the Stockport Liberal Democrat is in support of the overall objectives of Stockport Together. However, there were some specific issues requiring clarification. Including: the role and composition of the Implementation Board; Overall governance and accountability; workforce implications; and the impact evaluation of Stockport Together Health and Care Forum response The submission from the Health and Care Forum focused on the key questions they felt need to be addressed by the Healthier Stockport an issues document. These included: The number of GP practices in Stockport in special measures, the number of full-time equivalent GPs in Stockport; unfilled GP vacancies in Stockport and the extent to which paperwork burdens have been reduced for GPs; Bringing to the attention of Stockport Together the wider plans for hospitals in Manchester under the Healthier Together initiative; The targets set around Mental Health in the Stockport Locality Plan 2016; Concerns that the consultation was not being put to the public in a convincing manner listing 14 detailed issues to support this statement; and Concluding, that the aims is good but the means of achieving effective and complete implementation does not convince ASV

97 Mental Health Carers Group response The submission received from the Mental Health Carers Group provided a number of statistical tables and other information demonstrating impact. Including an extra 330 vulnerable adults discharged from secondary to primary care in Stockport. The overall concern was the apparent lack of focus on serious mental illness in favour of a concentration on wellbeing, ending with questions over the responsibility for duty of care and accountability Effects of health and social care spending constraints on mortality in England: a time trend analysis, BMJ Open, 16/11/17, Watkins J, et al. A submission was received to the consultation as an upload of a recent article published in the British Medical Journal (BMJ), the abstract for the article states: Results Spending constraints between 2010 and 2014 were associated with an estimated (95% CI to ) higher than expected number of deaths compared with pre-2010 trends. Deaths in those aged 60 and in care homes accounted for the majority. Public Expenditure on Social Care (PES) was more strongly linked with care home and home mortality than Public Expenditure on Health (PEH), with each 10 per capita decline in real PES associated with an increase of 5.10 ( ) (p<0.001) care home deaths per These associations persisted in lag analyses and after adjustment for macroeconomic factors. Furthermore, we found that changes in real PES per capita may be linked to mortality mostly via changes in nurse numbers. Projections to 2020 based on trend was cumulatively linked to an estimated (95% CI and ) additional deaths. Conclusions Spending constraints, especially PES, are associated with a substantial mortality gap. We suggest that spending should be targeted on improving care delivered in care homes and at home; and maintaining or increasing nurse numbers. ASV

98 3.4.2 Thematic Analysis As well as providing the opportunity to upload supporting documents to the consultation website, consultees were also asked if they had any additional comments they would like to add in relation to the way services will be arranged in the future. These have been grouped into broad themes as shown below Working together Recognising the benefits of the approach suggested in the Stockport Together proposals being consulted on, the opportunity to maximise these through earlier work with the third sector (voluntary and community) was highlighted for consideration. there is a need to involve the charitable sector with Stockport Together on much more than consultations. there is an opportunity to partner with the sector and better coordinate its response to the needs of Stockport residents without necessarily spending more money Accessibility Many respondents expressed concerns over the way in which Stockport residents would be able to access the proposed services if they faced specific difficulties. This included consideration of, among others: Elderly and infirm people; People with sensory and learning difficulties; Homeless people; and Those who did not speak English as their first language. There is a clear call for the consultors to consider the access needs of specific groups how do I cope If I had a low IQ or older age or English was a second language Consider Local and Individual Need Consultees called for the consultors (NHS Stockport CCG and Stockport MBC) to be mindful of the variations in need between neighbourhoods in Stockport and of individuals within those neighbourhoods in designing new service provision. the decision makers should always have the needs of people/patients uppermost in their minds rather than the easiest way to deliver the budget cuts required ASV

99 the more local things are the better - the needs of people in Bramhall are very different to those in Brinnington Emphasis on Mental Health Consultees were very clear in directing the Stockport Together consultation to give equal weight in consideration of mental health needs with physical health, and, therefore, placing an enhanced emphasis than that currently enjoyed. it needs to have more of a holistic approach (relation) was in Stepping Hill Hospital and they just drugged her up (then) a specialist care centre and it helped her enormously mental health and physical health should go hand in hand and receive the same input Ensure Social Care is Supported Within the considerations of the consultation consultees are clear that for the successful implementation of the proposals, social care funding, and more importantly adequate social care provision is available. There was a corresponding call closer cooperation and coordination between the heal and social care elements of the proposals. at present there is no cooperation between the medical staff and the social care staff on the ground Scepticism It is also clear that the consultors will have to overcome a level of scepticism from the public over the realism of some aspects of the proposal to be able to achieve the savings it seeks to make. the Public consultation before the last JSNA identified access to GP as the most significant problem with health and social care. savings are considerable but there is no evidence being given to the general public to substantiate these ASV

100 4 NEIGHBOURHOODS Delivering health and mental health services in neighbourhood teams 4.1 Introduction - Neighbourhoods The consultation document provided the following context to inform individual responses. Stockport Together currently divides Stockport into eight neighbourhoods, each serving the differing needs of the people within that area. The outline business cases set out proposals to organise health and mental health services in teams that work as one in these neighbourhoods. The neighbourhood model we propose will see services working together with general practice at the centre: Enhanced Case Management GPs, working with local neighbourhood teams, will identify those individuals most at risk of losing their independence or requiring emergency hospital care. They will then work with those individuals and their carers to develop care plans and provide more intensive, proactive, and tailored support across 7-days a week. In doing so they will be able to spot deterioration quickly and intervene more rapidly, reducing the need for people to require care outside their home. Direct access physiotherapy the aim is to reduce the number of patients with Musculoskeletal (MSK) conditions having to have consultations with GPs before they access physiotherapy services. This will help to provide more timely access to support, improving patient experience, and freeing up GP capacity. Mental wellbeing significant numbers of GP appointments are spent working with people who have various social needs or low mental wellbeing. Where no specific medical help is required, GPs will be able to refer the patient to a care navigator who will develop a personalised care and wellbeing plan. They will also help people to access a range of services such as self-help, mental health alliance and other voluntary sector groups. Find and prevent additional support will be put in place to help GPs identify people from their practice who have yet to develop complex care needs, but whose lifestyle would suggest they re at risk of doing so. Individuals will then be invited for enhanced health checks within the neighbourhoods. There will then be a range of local options available to individuals to help them improve their health and reduce the risk of long-term ill health. Self-care support and coaching will be offered to people with a long-term condition or those with risk factors which increase the likelihood of developing a long-term condition. An assessment of people s ability to manage their conditions will be made. This will identify the right level of support for that person, and allow support to be tailored ASV

101 Respondents were asked three questions, one closed and two open about these proposals, these were: To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? (Closed response using a ranking of 1-5 where 1 is Strongly Agree and 5 is Strongly Disagree a sixth option Don t Know was also provided). Why do you say this? (Free text response). Do you have any additional evidence that decision-makers should consider before they make this decision? (Free text response). 4.2 Do you agree with our proposals? Participants in the consultation, whichever method was used, were all asked the following question. To what extent do you agree that health and mental health services should be organised on the neighbourhood model as described? Discussed in turn below are the responses from the: Online, postal, and face-to-face survey; and Street survey. This data is treated separately to recognise the previously discussed differences in sampling and motivation to participate. Further details of the responses for the online, postal, and face-to-face survey are shown in Appendix One. Demographics beyond those reported are not available for the street survey Online, Postal, and Face-to-Face When considered overall there is overwhelming support for this proposal from respondents to the online, postal, and face-face survey, with 71% of respondents either agreeing or strongly agreeing that health and mental health services should be organised on the neighbourhood model as described. Overall agreement/disagreement Frequency Percent Strongly agree % Tend to agree % Neither agree nor disagree 15 7% Tend to disagree % Strongly disagree % Don t know 4 1.9% Not Answered 15 7% Total % ASV

102 When considered by age of respondent there is overwhelming support for the proposition from those aged 16 to 34, with a drop off to support between 70 and 75% from those aged 35+. While the latter is still supportive it perhaps indicates that there is a need to consider the concerns of older residents in more depth when developing option details and moving into implementation % % % % % % % Consideration by gender show little difference in levels of support from consultees. Female 77% Male 73% Street Survey Overall consultees engaged through the street survey were supportive of the proposition with 71% agreeing/strongly agreeing. Overall agreement/disagreement Frequency Percent Strongly agree % Tend to agree % Neither agree nor disagree % Tend to disagree % Strongly disagree % Don t know % Not Answered 3 1% Total % When considered by age of consultee the spread of support shows 18-24, and generally more supportive with around 80% support. The other age groups were still supportive at the slightly lower rate of 65% % % % % % % Considered by gender there are no differences between men and women in terms of their support for the proposition. Female 71% Male 71% ASV

103 4.3 Why? (Q2b) When asked, why did you provide that answer, participants in the consultation gave a range of responses. These have been analysed and grouped into broad themes representing the overall sentiment of consultees in relation to: To what extent do you agree that health and mental health services should be organised on the neighbourhood model as described? Recognising the similarity of the responses and for brevity in reporting, we have analysed all together irrespective of the method of contribution to the consultation The consultation process and the danger of domination by the articulate and engaged Specific concern was raised by consultees of the potential for the process to be disproportionately influenced by the articulate middle-class respondents to the consultation. While all contributions are welcome, the issue for consideration by the consultors is recognising the ability of this group to articulate their concerns, while recognising the needs of those less able to express themselves. the more articulate and forceful middle-class will demand better services, and draw resources away from disadvantaged parts of the borough widening health inequalities To some extent this could be said to be an extension of the widely discussed concerns over the complexity of the consultation process, and the barrier to participation this places on those less able to respond Local provision, knowledge, and accessibility Consultees recognised the benefits of the proposal to organise services around a neighbourhood model. The key benefits were felt to be: Provision of services in a familiar location, in an area people know well and are comfortable in; The focus of service around local GPs who generally have an established relationship and a record of need and past care; and A central and local location that reduces the burden of travel to service. Your GP's surgery is local, so it is a good idea to have other care based locally it makes sense to have services for the communities based around the communities themselves. We can share our resources if we work as "neighbourhoods". ASV

104 4.3.3 Where are the resources to support the proposal? Many consultees expressed an overall concern that the proposals, as detailed in the consultation document, did not provide enough evidence that the proposals were based on sound financial plans. Which in turn led to concerns over the overall sustainability of the proposals. there is not enough financially for care in the community looks to build on a system already under huge strain!? Sounds good in planning but can resources work practically A much-needed focus on mental health, but is it enough? There was a recognition from consultees that the proposals added a very important focus on caring for those with mental health needs in their own community, which was very well received. more health services to the neighbourhoods who need them most... there needs to be better Mental health services that residents can access quickly when needed before a crisis escalates However, some consultees felt this service offer did not go far enough in meeting the needs of the residents of Stockport. disappointed that only low level mental health needs are explicitly addressed. severe and enduring mental illness is not specifically mentioned Are the proposed neighbourhoods too big? Many respondents to the consultation felt that the scale of the neighbourhood model was not well enough explained in the proposals. This in turn led to concerns that the description of a neighbourhood was too big, and would not be recognised by residents as such, which raised further concerns over the distances to travel and population covered by a neighbourhood centre, an issue which may need to be addressed by the consultors. neighbourhoods may be too big - Tame Valley includes Reddish and Brinnington - will there really only be one neighbourhood centre between them? ASV

105 4.3.6 More questions to be answered before this proposal looks complete While most consultees recognised the outline advantages of neighbourhood working, many also felt that there was a lack of detail in the proposals in the consultation document which led to more questions. The feeling was that Stockport Together will be required to provide more detail before many consultees felt confident in responding to the consultation, including the role the third sector would or could play in the proposals. very little information has been provided to answer this question it is hard to give a simple answer to such a complex issue. Service delivery has moved from central to local delivery over periods of time and both have their strengths and weaknesses continues to not understand or effectively engage with possibilities from the VCS (voluntary and community sectors) 4.4 Other Evidence to Consider (Q2c) When people were asked the question: ASV 2017 Do you have any additional evidence that decision-makers should consider before they make this decision? They were able to respond in two ways by: iii. iv. Uploading documents either reports, responses, or comments; or Providing additional comments as free text. Evidence submitted in these ways, related to delivering health and mental health services in neighbourhood teams is discussed in turn below Uploaded Evidence There was one document submitted for consideration which provided evidence from a neighbourhood-based pilot, led by Age Concern, in Newquay, Cornwall, felt to have relevance for Stockport Together People, Place, Purpose Newquay Pathfinder Evaluation The pathfinder led by Age Concern Cornwall and Isles of Scilly, was designed to deliver three key outcomes: 1. Improved health, wellbeing, and quality of life; 2. Integrated working works; 3. Cost reduction across the whole system. The service provided targeted wraparound support, motivating at-risk older people to achieve their aspirations through a guided conversation. An Age UK worker supports

106 individuals to identify their goals, and to coordinate a management plan that is delivered by statutory and community services and support. The support, using volunteers, aims to build people s social networks, making them better connected to their community and more resilient. The Age UK worker is part of a multi-disciplinary team which includes GP, district nurse, matron, and social workers The benefits 23% improvement in peoples self-reported wellbeing. 87% of practitioners say integration is working very well and their work is meaningful. 30% reduction in non-elective admission cost. 40% drop in acute admissions for long term conditions. 5% cost reduction and reduction in demand for adult social care Thematic Analysis Respondents provided their thoughts and comments to offer the consultor (Stockport Together) with additional evidence they should consider in making any decisions for the future. These responses have been grouped into broad themes, representative of expressed opinions, as shown below Earlier intervention, focusing on preventions Some consultees suggested the proposals should include earlier interventions in a preventative model, including in primary and secondary school education, both in physical and mental health of Stockport s young people. there is growing need in schools for better mental health support through liaisons between practicing doctors and nurses and counsellors and other support workers such as Play Therapists, Speech Therapists, Art therapists etc Which leads onto a view among many consultees, and agreement with the consultation, that the Stockport Together programme should focus on wider preventative action across the local population at any age. The feeling being, that this would reduce hospital and other clinical interventions, saving cost in the wider system. prevention is always better (and more cost effective) than cure ASV

107 4.4.4 Consult more widely with those least able to respond Consultees commented on their perceptions of the limitations of the consultation mechanisms employed in this initial strategic discussion, and offered some practical solutions for the future, based on: Developing some form of outreach consultation approach, engaging with those who are least likely to be able to respond online or in writing; Adopting an information sharing approach, telling all households in the borough what changes are being proposed; Rely less on external resources (e.g. management consultants) and explore using local people and organisations as consultation enablers. go to the public: how many older and frail people use computers and can fill in online forms? stop paying expensive management consultants send each household a detailed and truthful account of any sensible changes proposed discussed thoroughly with NHS staff who carry out this work Equal access Consultees expressed concern over the cost pressure placed on NHS services by the worried well and a corresponding concern that people from less affluent areas were equally less likely to access services. The issue for the consultor from this appears to be the need to ensure that services are accessed equally, without penalising those who seek care, or threatening the lawful duty of the NHS to provide care free at point of use. I heard that spend on people in Bramhall is the highest in Stockport as they seek out services. We should aim to ensure there is an agreed set of things that are treated across Stockport Supporting the population, recognising the reality of an ageing population Respondents to the consultation provided the view that while the proposals are welcome, they also reflect the reality of the population of Stockport and much of the rest of England. The population of Stockport is ageing, and services must adapt to these circumstances - it is the right and proper thing to do. it should be viewed as an investment in healthcare services for the future for an increasing and ageing population and must not be ASV

108 either a cost cutting exercise or 'moving the deckchairs around on the titanic Scepticism Again, a common theme in the additional evidence and commentary, relate to a level of scepticism in responses with some consultees expressing the view that the consultation is a waste of time....this is irrelevant as the commissioners have already made this decision and begun an implementation phase you are wasting people s time. No one wants it... ASV

109 5 HOSPITAL BEDS Providing services for those that need them and reducing pressure 5.1 Introduction Hospital Beds The consultation document provided the following context to inform individual responses. We are proud of our local hospital and the staff who do an excellent job at looking after patients in their time of need. We want people to know that those staff and services are here to stay for people who need them. We also want to reduce the pressure on those services so when needed, they can offer even higher quality care. Currently more people in Stockport are admitted to hospital than in other similar areas in England, and when admitted people often stay longer than necessary. Our proposals include supporting people to change lifestyles and so preventing or delaying the onset of ill health; proactively identifying people at risk and intervening earlier; and when people experience being ill, providing additional support in the community. We will also invest in more resources to support people when they go home from hospital. This means they are less likely to be kept waiting for discharge. If decision-makers choose to adopt the approaches and our proposed interventions are successful, we forecast there will be a reduction in the number of people needing treatment at Stepping Hill and other hospitals. A reduction in people needing treatment may mean hospital beds are no longer needed. NHS England stipulates that if unused hospital beds are to be decommissioned, commissioners must demonstrate that one of the following conditions is met: Demonstrate that sufficient alternative provision, such as increased GP or community services, is being put in place alongside or ahead of bed closures, and that the new workforce will be there to deliver it; and/or Show that specific new treatments or therapies, such as new anti- coagulation drugs used to treat strokes, will reduce specific categories of admissions; or Where a hospital has been using beds less efficiently than the national average, that it has a credible plan to improve performance without affecting patient care (for example in line with the Getting It Right First Time programme). Respondents were asked three questions, one closed and two open about these proposals, these were: To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? (Closed response using a ranking of 1-5 where 1 is Strongly Agree and 5 is Strongly Disagree a sixth option Don t Know was also provided). 38 ASV

110 Why do you say this? (Free text response). Do you have any additional evidence that decision-makers should consider before they make this decision? (Free text response). 5.2 Do you agree with our proposals? Participants in the consultation, whichever method was used, were all asked the following question. To what extent do you agree that this test would be appropriate, if in the future Stockport Together must consider decommissioning in-patient beds at Stepping Hill hospital? Discussed in turn below are the responses from the: Online, postal, and face-to-face survey; and Street survey. These data are treated separately to recognise the previously discussed differences in sampling and motivation to participate. Further details of the responses for the online, postal, and face-to-face survey are shown in Appendix One. Demographics beyond those reported are not available for the street survey Online, Postal and Face-to-Face Surveys When considered as an overall sample, there is some support for this proposal from respondents to the online, postal, and face-face survey, with of 40% respondents either agreeing or strongly this test would be appropriate, if, in the future Stockport Together must consider decommissioning in-patient beds at Stepping Hill hospital. This is less clear cut than other proposals in the consultation with 33% of respondents disagreeing or strongly disagreeing. Overall agreement/disagreement Frequency Percent Strongly agree % Tend to agree % Neither agree nor disagree % Tend to disagree % Strongly disagree % Don't know % Not Answered % Total % When considered by age there is little significant variation in opinion in overall agreement, except for the group, which can be discounted due to small sample size ASV

111 % % % % % % % Considered by gender there is less support from women than men. Female 39% Male 47% Street Survey Consultees responding to the street survey were against the proposition with 55% disagreeing/strongly disagreeing and only 41% agreeing/strongly agreeing. Overall agreement/disagreement Frequency Percent Strongly agree % Tend to agree % Neither agree nor disagree % Tend to disagree % Strongly disagree % Don't know % Not Answered 2 0.7% Total % When the responses of consultees to the street survey are considered by age the strongest opposition comes from the age group (55%), with 65+ being significantly less opposed (36%). Support Oppose % 55% % 35% % 43% % 48% % 52% % 36% When considered by gender there is a common level of opposition, however more men tend to support the proposition than women. Support Oppose Female 38% 44% Male 46% 43% ASV

112 5.3 Why? (Q3b) When asked why did you provide that answer participants in the consultation gave a range of responses, these have been analysed and grouped into broad themes representing the overall sentiment of consultees in relation to: To what extent do you agree that this test would be appropriate, if in the future Stockport Together must consider decommissioning in-patient beds at Stepping Hill hospital? Recognising the similarity of the responses and for brevity in reporting, we have analysed all together irrespective of the method of contribution to the consultation Capacity, demand, and the perceived need for hospital based rehabilitation Many respondents to the consultation felt that the tests were flawed simply because in their view, the number of hospital beds required for the borough was fixed, based on the population level. cannot see it working - can only fit so many people on a ward decommissioning beds is an irresponsible suggestion. Beds will always be needed, regardless of whether care is in the community Consultees also took the view that Stockport needs more hospital beds not less, and with many stating the opinion that a sensible approach would appear to be some sort of mothballing rather than a real reduction. The premise behind these views being the need to respond to any future upsurge in demand. as long as it remains possible to re-commission these beds should that become necessary I would hope that there would always be sufficient hospital beds to cope with winter emergencies, etc This was compounded by a minority view that hospital stays should involve an important element of rehabilitation prior to discharge, which would further increase the requirement for hospital beds. because I think it's important to rehabilitate rather than just discharge them ASV

113 5.3.2 This should be a self-evident truth A more pragmatic view from consultees, was that the proposed tests would be proof in themselves of the need for less beds. If they were incorrect, the number of hospital beds would be likely to remain static. beds will close themselves if these changes work the tests if carried our honestly and rigorously would deliver the answer that is needed to make the savings that are envisaged Moving people home quicker results in better care if adequate provision for home care exists Many respondents to the consultation shared the view that the best care for patients was in their own home, recognising the detrimental impact prolonged hospital stays have on health, particularly for the elderly. less time in hospital and help in the patient s own surroundings sounds good However, this was tempered with realism, in that home care only works in appropriate circumstances. People without a support network will be left isolated and the lack of sufficient after care will result in a return to a hospital bed. All of which are counter to the overall objectives of reducing hospital stays. not all people have someone at home to help care. They would feel isolated only if the after care is followed up and the patient doesn't end up back in hospital Providing adequate transitional support to the hospital beds Coupled with concerns over the need for care at home, consultees highlighted the need for the provision of adequate provision of transitional support for those not yet ready to return home, but no longer in need of hospital care. This was interchangeably described as step down, transitional or assessment beds, where patients can regain their independence. Without this element being more explicitly dealt with within the proposals, many were unconvinced. decommissioning acute beds needs to be coupled with supply of step up/ step down beds and discharge to assessment facilities... ASV

114 5.3.5 Confidence required that the capacity exists in the community to cope Consultees were only convinced of the reduction in hospital beds if there was evidence to support provision of adequate capacity in community care to support the proposed changes. Many consultees expressed concern that this was not explicit within the proposals contained in the consultation document. assurances that there was sufficient capacity in the community Starts somewhere else than in hospital The view of many consultees was that the argument for reduced beds starts outside the hospital and other clinical settings. This called for a focus on other social determinants of health, and the ability to influence positive lifestyle changes. prevention and support for people to change life styles reduced bed numbers are bad reduce patients who go to hospital by prevention more work needs to be done in changing people's behaviours so that they don't end up in hospital - reducing the demand on beds Savings elsewhere? Some consultees provided the view that the proposals to cut hospital beds were looking for cost savings in the wrong area and the reduction in management overhead in the new organisation could achieve much of the saving. how can reducing the amount of beds be a good thing? Reduce meddling managers instead A smaller group of consultees took the view that reductions in hospital bed numbers would not be enough, even when considered with efficiency savings elsewhere in the system....don't believe that more efficient use of GPs, district nurses and other services will lead to reducing hospital patient numbers. At best it will offset some of the current underfunding of the NHS ASV

115 5.4 Other Evidence to Consider (Q3c) When people were asked the question: ASV 2017 Do you have any additional evidence that decision-makers should consider before they make this decision? They were able to respond in two ways by: v. Uploading documents either reports, responses, or comments; or vi. Providing additional comments as free text. Evidence submitted in these ways, related to...providing services for those that need them and reducing pressure is discussed in turn below Uploaded Evidence In total two pieces of documentary evidence were submitted to the consultation for consideration. These were: Mental Health Carers Scenarios; CQC Stepping Hill Hospital Quality Report Mental Health Carers Scenarios A submission was received that detailed five scenarios from the perspective of mental health carers: Getting help in (continual) crisis; Getting help to have an acceptable standard of life; Getting help to prevent suicide; Information sharing with GPs; and Getting medical help before a crisis occurs. The submission concluded with two questions for consideration in the consultation: 1. How can Stockport Together help in these scenarios? 2. What will happen to our loved ones when we are no longer able to support them? CQC Stepping Hill Hospital Quality Report A submission was provided for consideration in the consultation of the Care Quality Commission s Quality Report for Stockport NHS Foundation Trust Stepping Hill Hospital. The report is dated 3/10/17 and relates to an inspection visit 21, 22 and 28 March The overall rating for the hospital saw Urgent and Emergency Care rated as Inadequate and Medical Care (including older people s care) as Requires Improvement. This evidence was submitted to support the following statements: My evidence is only apocryphal, but nevertheless telling. A friend of ours who has been disabled with severe arthritis for many years and has had several operations for hip and knee replacements throughout her adult life has just returned home from

116 a knee replacement. She reports that the quality of care has greatly deteriorated since her last operation some years ago, with hard-pressed nursing staff taking much too long to respond to patient calls for bed pans and medication. This is backed up by the recent CQC report marking Stepping Hill as "requiring improvement". At age 69, I am very worried about having to go into hospital in the current climate Thematic Analysis Respondents provided their thoughts and comments to provide the consultor with additional evidence they should consider in making any decisions for the future. These responses have been grouped into broad themes, representative of expressed opinions, as shown below Measuring the impact of Stockport Together As a response to the overall concern over the reduction in hospital beds, perhaps the most unpopular element of the proposals under discussion, many consultees suggested a need to be clear on the impact of the proposals, if implemented. The main concern was around the effectiveness of community care in keeping patients from returning to hospital. An effective measure to gauge Stockport Together s success was levels of readmissions. a measure - readmissions by neighbourhood - should be monitored regularly. Will give a good guide to success or failure Closer working with the care home community Many consultees recognised the potential interdependence between reduced numbers of hospital beds and wider social care, specifically the ability of the care home sector, already under significant financial pressure, to cope with the potential additional demand. Again, focus was on the level and quality of intermediary/ step down care likely to be available in the borough. review how nursing homes and other suitable residential facilities can take people who don't need to be in hospital but are not ready to manage at home yet needs further investment in residential/short stay beds ASV

117 5.4.3 A need for increased primary care provision Most respondents identified the need for the consultor to recognise, within their proposals, the need to develop an increased capacity in primary care, beyond the existing levels to ensure the reduction in beds will be achievable. they really need to get a grip of GPs and make them work more late and early evening shifts like the rest of the NHS they'll need a lot more GPs and district nurses for this to work ASV

118 6 OTHER INFORMATION OR PROPOSALS Information or proposals decision makers should consider 6.1 Introduction As a final element of the consultation document, consultees were asked: Is there any other information or proposals you think decision makers should consider? Participants in the consultation gave a range of responses, which have been analysed and grouped into broad themes representing the overall sentiment of consultees. 6.2 Thematic Analysis The main themes to emerge from consultee responses were as follows Speak to people first, change second The principles of consultation were endorsed by respondents, who suggested that post this discussion on the broad strategic principles, Stockport Together should consider engaging with staff and service users to understand the operational perspective. speak to staff already working for the services speak to the patients already receiving care in the community / home More services Consultees also identified the potential for consideration of new or enhanced services to adapt/react to the challenges set by the broad strategic proposals discussed in the consultation. These included: The need for gap analysis in service provision considering the suggestions from this consultation and conducting subsequent impact analysis for detailed service proposals; The need to develop an increased primary care offer, which is acknowledged as potentially difficult considering shortages of GPs; Consideration of changes in social care to foster less reliance on hospital beds and retain people s independence in their own homes. needs analysis across health and social care to identify the gaps... we need more GPs ASV

119 better access to more GP/Advanced Nurse Practitioner assessments in social care...resume an old style "home help " service for shopping, befriending etc, where personal care is not needed but for things that are important to older people Consultation with decision makers Many consultees expressed the perception that to be successful Stockport Together should have wider discussions with key decision makers before developing solutions. greater Consultation with NHS England utilise local MP's by inviting them to see first-hand Stockport NHS facilities especially when stretched so they can also report back to central government Step down/step up care A further emphasis was placed on the provision of short stay beds for those leaving hospital and unable to return home immediately. Consultees viewed this provision within a social care setting as a key element of the success of the proposals to reduce hospital beds and stays. consider halfway houses, i.e. the old-fashioned convalescent homes would relieve the bed blocking in Stepping Hill Hospital further investment in packages of care and short stay beds. Already too much pressure on current care providers how will manage the winter pressures The consultation structure and presentation as a barrier to participation In providing further comment and evidence for consideration by the consultors a recurring theme is around the complexity of the consultation document and the difficulties faced in completion. The main concerns focused around: The call for the provision of more information to support the decision consultees were being asked to decide upon; The complexity of the questions themselves; and The overall format, requiring responses on complex issues within an overly simple format. I find it hard to complete the questionnaire as the information provided is inadequate ASV

120 as a large voluntary sector organisation working around local people in later life we are being asked to express our views through this sort of questionnaire. We have started it and left it and struggled to complete it many times as is so hard to offer meaningful comment on such complexity in this format Transparency and honesty Consultees urged Stockport Together to ensure that the proposals for change were conducted within an environment that: Puts patient needs first; and Provides best use of public funds, including the avoidance of more bureaucracy. please don't lose sight of the fact that people who are genuinely ill need compassion and help, not decisions made purely for monetary reasons ensure effective transparent use of public funds. Too much is wasted on ever increasing numbers of managers and not enough on frontline clinicians... if you can find them Within this, there is a call from consultees to recognise the reality of the situation and to continue to be honest with the public, explaining what the NHS can provide and what it cannot. stop raising public expectations that they can have everything provided by NHS Consideration of other approaches and sectors to support Stockport Together Consultees, particularly local voluntary and community sector organisations, offered support to Stockport together, not only of the proposal aims, but also of the opportunity to add their resources and experience to aid deliver solutions. (we) understand the pressures on Stockport Together in the current economy the need to do things differently. also, that it offers a fantastic opportunity to change things and would welcome the chance to work more with it ASV

121 6.2.8 Mental health issues don t always exist in isolation Many consultees raise the issue of more than one condition, in relation to mental health, existing at the same time. This was felt to be an issue of concern for older people, but not exclusively so and Stockport Together was asked to consider the combined needs of mental and physical issues as one issue rather that separately. (older people) often present with multiple issues over a number of areas - physical mental social etc Real seven day a week working There was a degree of scepticism around the discussions of seven day working made in the proposals, with many consultees expressing the view that much of current health and social care provision does not reflect the working patterns prevalent in Stockport. Equally, there is a view that a correspondingly large number of services do already work seven days a week, which caused some to question the claimed cost savings in the proposals. can 7-day working mean it please Illness doesn t stop on Friday nights & restart on Monday morning social workers should be available 7 days a week. Needs don t go away at weekends! there are already 7-day services in place both in hospital and the community I do not see how your Business plan will save money in the long term Specific services While consultees welcomed the general principles of the proposals, some felt that the lack of detail was a point of concern, with many raising concerns around the continued or enhanced service provision, including but not limited to: Adaptation of service delivery to the needs of Stockport residents with learning or sensory disabilities; Specialist provision such as sexual and women s health clinics; and Access to services such as weight loss, smoking cessation. there is no mention of sexual health services, which are a very important aspect of staying healthy saves money elsewhere in the health and social care economy ASV

122 I would be particularly concerned, as a parent of a son with a learning disability(ld), that suitable provision was included in these proposals to cater for people with a LD Data Sharing Many consultees also expressed a desire for Stockport Together to develop a common data sharing platform within the Stockport health and social care system and ultimately across Greater Manchester. This was felt to be an important step in ensuring consistent and good quality care within the proposed changes. develop a common records system across Greater Manchester. It is not good enough when any hospital says, you are out of area, we do not have your records " ASV

123 7 DISCUSSION GROUP MEETINGS Discussion groups 7.1 Introduction The Stockport Together consultation team conducted several discussion groups with specific interest groups, between the 16 th and 27 th of November Thirteen groups were provided to us for analysis, these were: 1. Alvanley Health Champions Patient Participation Group (PPG) 2. Breathe Easy Group 3. Bredbury PPG 4. Cheadle PPG 5. Disability Stockport 6. Marple PPG 7. Mental Health Carers Group 8. Poets Corner Action Group 9. NHS Watch 10. Walthew House Deaf group Walthew House Deaf group Walthew House Visually Impaired group Walthew House Visually Impaired group 2 Two of these discussion groups were conducted as a series of face-to-face interviews and were included and are analysed in the main consultation feedback (groups 12 and 13). The results from these groups are excluded from the analysis in this section. The reports from the remainder of these groups have been analysed and grouped into themes representing the sentiment expressed across all groups 7.2 Thematic Analysis While each of the discussion groups followed the initial approach of handing out copies of the consultation document, encouraging the participants to complete online or in hard copy, the remainder of the session followed an unstructured Q&A approach. The resulting thematic responses are relatively wide ranging focused on both issues and potential solutions for consideration by the consultors. The emerging discussion themes, in no order of importance, were as follows The implications of cross-boundary working A consistent theme across the groups was the extent to which Stockport Together has considered and develop mitigation for bordering areas responding to the same challenges and changing their health and social care services. Specifically: How are they doing things differently, are we learning from them? How is Stockport working with them? What agreements exist around continued provision and receipt of services into/from those areas? How is duplication of effort between the areas managed? An example of Cheshire East not accepting Stockport assessments, and redoing them was cited. ASV

124 7.2.2 Specific models of support The groups developed several positive suggestions around the role local voluntary and community sector organisations can play to support the aims of Stockport Together, including: The integration of Disability Stockport s local delivery model into the neighbourhood model to foster learning from what works; The provision of Citizens Advice services in neighbourhood centres to address wider issues contributing to mental and physical conditions; Closer working with specialist organisation, such as Age UK, to deliver the proposals; Provision of space in existing community buildings to support neighbourhood working Access to service The consensus from the groups was that the key to success of the Stockport Together proposals was addressing the issue of access to services, through: Clear communication of the changes in services to ensure all Stockport residents are aware of how to access services; Deliver a seven-days a week, twenty-four hours a day, first class service to all residents of Stockport; Providing access to care through a single telephone number irrespective of the nature of the service required - health or social care; Developing a consistent response from health and social care providers that delivers care personalised to the individual Retaining and recognising staff The groups recognised that GPs are at the heart of much of the success of the proposals, as will be other clinicians, alongside a flexible and responsive social care workforce. There were several suggested challenges for Stockport Together to address in moving to delivery of the proposals in this respect, namely: There are acknowledged staff shortages for both GPs and nursing staff, how with Stockpot Together respond to this national issue to ensure local services; Have the existing staff been consulted on the proposals, without their support it is difficult to see how the proposals can be implemented successfully; Have issues such as costs to staff of working such as car parking at NHS and local authority sites been considered; Have private care agencies been consulted on the implications for their staff. However, it should be recognised that this is may include sensitive or individually identifiable data, and due care should be taken in any sharing of this by the consultor. ASV

125 7.2.5 The pressure faced by care homes The groups demonstrated a consensus of concern over the implications of the Stockport Together proposals around the potential pressure placed on an already overstretched care home sector. This could be addressed through measures such as: Nurses and GPs working in care homes, although this needs to be paid for; Providing more care in the community to maintain people s independence in their own home; Ensuring people with sensory disabilities, such as being deaf, are supported in care homes, with provision of translators and specific activities Supporting people, maintaining service, and addressing mental health issues A key concern to be addressed by Stockport Together, identified by the discussion groups was the ability of the proposed changes to continue to maintain current standards and move to improve them. Concerns centred around: The ability of GP practices, at the heart of the neighbourhood model, to maintain current levels of service, which is likely to require more GPs at a time of national staff shortages; Dealing with more people with comorbidity, which will require more time to effectively deal with their concerns; Supporting people with specific needs to be able to effectively access the neighbourhood services including learning disabilities and sensory disabilities (deaf, blind, and deaf-blind); Dealing with increased numbers of people with dementia in the community. Set against these issues was the concern that the pressures on neighbourhood services in dealing with the usual will result in less time and attention for people with mental health issues, despite a stated aim to improve this. This was further compounded by concerns over the apparent scarcity of GPs with mental health as a professional specialism Transition from hospital care to home Consultees engaged through discussion groups were clear that the proposals were based on an overall reduction in length of hospital stay and bed numbers, however there were concerns that people would need additional support to recover. the only solution is to get people through the hospital quickly, but this doesn t mean they re fully recovered The overall feeling was that the issue of providing transitional support care beds in a social care setting was not adequately described in the proposals and will need to be addressed more clearly. ASV

126 7.2.8 Services free at the point of care? The tension between the provision of health and social care as one service was recognised by many consultees in the groups, specifically: The legal requirement to deliver NHS services free at the point of care; and For social care to be means tested. Solutions being investigated or that should be considered addressing this issue to ultimately deliver costs savings discussed in the groups included: Exploring joint commissioning and pooled budgets between health and social care; Explaining clearly to patients and service users the tension between free and means tested care; and Informing people of the costs of their failed appointments Other partners The groups largely felt that the proposals, as they stood, ignored many partners, who can support or hinder successful implementation, including, but not limited to: The voluntary and community sector (VCS) in Stockport who have links that NHS and local authority partners will find difficult to duplicate and have the potential to introduce innovation and low-cost delivery; GPs, who many recognised as private business and without their buy-in and support the proposals will be difficult to implement; Housing sector partners, mostly social but not ignoring private landlords with their access to a large percentage of the resident population; Private sector care agencies, who will delivery many of the required social care services; The care home sector, who will be required to support the need for additional transitional beds and out of hospital care People get it ; take them with you The groups identified that the people of Stockport are generally more astute than they re given credit for, with many citing the fact that much so-called misuse is getting the right service at the right time from an unresponsive system. The call was for a clear communication of the benefits and drawbacks of the proposals to allow people to make informed choice on more detailed proposals, included: The extent to which the plans are future proofed to withstand future political changes and other systemic shocks; and The continuity plans in place to deal with emergency situations and how any issues will be addressed. ASV

127 Is this just another bureaucratic approach - we want services, not managers? As with other consultation mechanisms, the discussion groups echoed the sentiment of scepticism. Issues discussed included: Service for Stockport residents is paramount, the proposals must be clear that they are not just wasting money on more managers and measurement systems. The lack of clear evidence that so-called smarter working, will save money; A concern that the efforts to respond to the consultation were a waste of time due to the perception that implementation of the proposals were already under way. ASV

128 8 SUMMARY Emerging findings for consideration in decision-makers deliberation 8.1 Introduction Consideration of the public consultation conducted by Stockport Together on the partnership s broad strategic principles between 10 th October to 30 th November 2017 allows us to provide a summary on the following: Specific observations on the strategic service proposals; and Overall observations on the common themes across all discussion areas and consultation methods. Each of these is discussed in turn below. 8.2 Summary Findings Service Proposals Considering the specifics of the service proposals there was broad support for the outline strategic proposals, however, this was less clear around the issue of closing hospital beds Planning and Organising Services There was support for the broad proposals to reorganise the way health and social care in Stockport, with: 72% of respondents to the online, postal, and face-to-face survey tend to agree or strongly agree with the proposal; 87% of respondents to the street survey expressed a common opinion in support. However, the following also needs to be taken into consideration: Working together Recognising the benefits of the approach suggested in the Stockport Together proposals being consulted on the opportunity to maximise these through earlier work with the third sector (voluntary and community) was highlighted for consideration. Accessibility Many respondents expressed concerns over the way in which Stockport residents would be able to access the proposed services if they faced specific difficulties. Consider Local and Individual Need The Stockport Together partners need be mindful of the variations in need between neighbourhoods in Stockport and of individuals within those neighbourhoods in designing new service provision. ASV

129 Emphasis on Mental Health Consultees were very clear in directing the Stockport Together consultation to give equal weight in consideration of mental health needs and physical health, and therefore placing an enhanced emphasis than that currently enjoyed. Ensure Social Care is Supported Within the considerations of the consultation there is a direction that social care funding and more importantly adequate social care provision is available, as well as closer cooperation and coordination between these two elements of the proposals. Scepticism It is also clear that the consultors (NHS Stockport CCG and Stockport MBC) will have to overcome a level of scepticism from the public over the realism of some aspects of the proposal to be able to achieve the savings it seeks to make A Neighbourhood Delivery Model Again, there was very strong support for the proposals to organise health and mental health services into eight neighbourhood teams: 71% of respondents to the online, postal, and face-to-face survey tend to agree or strongly agree with the proposal; and 71% of respondents to the street survey expressed a common opinion in support. However, the following factors identified by consultees also need to be taken into consideration: The consultation process and the danger of domination by the articulate and engaged Specific concern was raised by consultees of the potential for the process to be disproportionately influenced by the articulate middle-class respondents to the consultation. While all contributions are welcome, the issue for consideration by the consultors is recognising the ability of this group to articulate their concerns while recognising the needs of those less able to express themselves. Local provision, knowledge, and accessibility Consultees recognised the benefits of the proposal to organise service around a neighbourhood model. The key benefits were felt to be: Provision of services in a familiar location, in an area people know well and are comfortable in; The focus of service around local GPs who generally have an established relationship and a record of need and past care; and A central and local location that reduces the burden of travel to service. Where are the resources to support the proposal? Many consultees expressed an overall concern that the proposals, as detailed in the consultation document, did not provide enough evidence that the proposals were ASV

130 based on sound financial plans. Which in turn led to concerns over the overall sustainability of the proposals. A much-needed focus on mental health, but is it enough? There was a recognition from consultees that the proposals added a very important focus on caring for those with mental health needs in their own community, which was very well received. However, some consultees felt this service offer did not go far enough in meeting the needs of the residents of Stockport. Are the proposed neighbourhoods too big? Many respondents to the consultation felt that the scale of the neighbourhood model was not well enough explained in the proposals. This in turn led to concerns that the description of a neighbourhood was too big, and would not be recognised by residents as such, which raised further concerns over the distances to travel and population covered by a neighbourhood centre, an issue which may need to be addressed by the consultors. More questions to be answered before this proposal looks complete While most consultees recognised the outline advantages of neighbourhood working, many also felt that there was a lack of detail in the proposals in the consultation document which led to more questions. The feeling was that Stockport Together will be required to provide more detail before many consultees felt confident in responding to the consultation, including the role the third sector would or could play in the proposals Reducing Hospital Beds The proposals to reduce the number of hospital beds was significantly less welcome by consultees, with 40% of respondents to the online, postal, and face-to-face survey tend to agree or strongly agree with the proposal and a third (33%) disagreeing/strongly disagreeing; and 41% of respondents to the street survey expressed a common opinion in support, however the majority (55%) expressed opinions disagreeing/strongly disagreeing with the proposals. In considering these results the following needs to be taken into consideration: Capacity, demand, and the perceived need for hospital based rehabilitation Many respondents to the consultation felt that the tests were flawed simply because, in their view, the number of hospital beds required for the borough was fixed based on the population level. Consultees also took the view that Stockport needs more hospital beds not less, and with many stating the opinion that a sensible approach would appear to be some sort ASV

131 of mothballing rather than a real reduction. The premise behind these views being the need to respond to any future upsurge in demand. This was compounded by a minority view that hospital stays should involve an important element of rehabilitation prior to discharge, which would further increase the requirement for hospital beds. This should be a self-evident truth A more pragmatic view from consultees was that the proposed tests would be proof in themselves of the need for less beds. If they were incorrect, the number of hospital beds would be likely to remain static. Moving people home quicker results in better care - if adequate provision for home care exists Many respondents to the consultation shared the view that the best care for patients was in their own home, recognising the detrimental impact prolonged hospital stays have on health, particularly for the elderly. However, this was tempered with realism, in that home care only works in appropriate circumstances, people without a support network will be left isolated and the lack of sufficient after care will result in a return to a hospital bed. All of which are counter to the overall objectives of reducing hospital stays. Providing adequate transitional support to the hospital beds Coupled with concerns over the need for care at home, consultees highlighted the need for the provision of adequate provision of transitional support for those not yet ready to return home, but no longer in need of hospital care. This was interchangeably described as step down, transitional or assessment beds, where patients can regain their independence. Without this element being explicitly dealt with within the proposals many were unconvinced. Confidence required that the capacity exists in the community to cope Consultees were only convinced of the reduction in hospital beds if there was evidence to support provision of adequate capacity in community care to support the proposed changes. Many consultees expressed concern that this was not explicit within the proposals contained in the consultation document. Starts somewhere else than in hospital The view of many consultees was that the argument for reduced beds starts outside the hospital and other clinical settings and called for a focus on other social determinants of health, and the ability to influence positive lifestyle changes. Savings elsewhere? Some consultees provided the view that the proposals to cut hospital beds were looking for cost savings in the wrong area, and the reduction in management overhead in the new organisation could achieve much of the saving. A smaller group ASV

132 of consultees took the view that reductions in hospital bed numbers would not be enough, even when considered with efficiency savings elsewhere in the system. 8.3 Overall Observation Common Themes Aside from the specific comments on the individual proposals for service change there are several common themes emerging from the consultation responses that are important for the consultors to consider. These were: Governance and accountability There was an overall concern that the consultation, although currently only addressing broad strategic themes did not provide confidence that robust arrangements were in place for governance, measurement, and accountability. Without this detail consultees would find it difficult to decide on specific service proposals. Role of the third sector Throughout the consultation responses the contribution of voluntary and community (third) sector partners is valued and valuable. However, they appear to be observers rather than participants in the process which overlooks the value and experience they bring to the benefit of Stockport. The consultation process speak and listen There were some specific criticisms of the consultation process, despite the relatively high response rate, which included: The lack of detailed information to decide on; The question/response format being limited restricting the ability of consultees to respond meaningfully; The way in which consultation was conducted, with too much reliance on online and social media and less with face-to-face contact. This was also reflected in the discussion group responses traditional Q&A sessions and not proactive opinion seeking. This could suggest the need for a wider approach to engagement through co-production approaches rather than a reliance on setpiece consultation. Within this, it is worth considering the complexity of the language and format used in the consultation document, perhaps reflecting on the average UK reading age of 9, and how this impacts comprehension and participation. Equity of consideration mental and physical health The need to give equal consideration to mental health, which given the perceived status as the poor relation, many felt required preferential treatment. Scepticism Many, but by no means all consultees expressed an ongoing cynicism with the process, feeling that it had all been done before or that the evidence for the changes did not exist. Stockport Together will need to respond constructively to this and provide evidence of positive change to convince this group. 61 ASV

133 We get it, show us transparency and honesty The feeling was the ability of the public to understand the proposals was often underestimated and Stockport Together should provide a consultation that is clear in the benefits and drawbacks of the proposals alongside the rationale and accountability. Access for all The issue of affluent, literate and engage communities was raised as a concern. The specific issues were: The potential for disproportionate influence from middle class consultees; and Concerns over those with the self-awareness to seek health support (the worried well) predominantly in affluent areas taking a higher share of services than areas less health literate. Cross boundary working Demands on health and social care services are not unique to Stockport and consultees were aware of other initiatives in Greater Manchester and other bordering areas. The concern for consultees was the extent to which this was taken account of in Stockport Together s proposals and the impact on inflowing/outflowing services provided across boundaries. Staff Consultees felt that one of the main challenges to be addressed by Stockport Together in developing and delivering their proposals was the issue of staff, including: Consideration of recruiting more GPs, nurses, care assistants and other clinical roles alongside social care staff to address service demands in the face of national shortages; The willingness and support from GPs to deliver the neighbourhood model; The capability and capacity of community staff to deal with the increased demand. Care homes and transitional support Stockport Together s proposals appear to consultees to rely upon increased care home capacity and the availability of transitional/step down beds to move people from hospital quicker. The level of detail in the proposals does not make it clear if this has been considered and is in place. Changes in lifestyle and behaviour Outside of the proposals there was a strong feeling from consultees that to effect the changes described there is a need for more preventative interventions. The view being that by the time people are being dealt with by the proposed services, it s too late. Early intervention is required in the community, including schools, which is a wider remit than the proposals, but felt to be the motivator for real change and savings. ASV

134 9 APPENDIX ONE: ONLINE, POSTAL & FACE-TO-FACE DEMOGRAPHICS Disability, Race, Sexuality, Religion, and Gender Reassignment (note: these were not recorded for street) 9.1 Disability Services Don't know Not Answered Strongly agree Tend to agree Neither agree nor disagree Strongly disagree Tend to disagree No. % No. % No. % No. % No. % No. % No. % To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? No 9 6.7% 2 1.5% % % 4 3.0% 8 5.9% 6 4.4% Yes 2 4.2% % % % 3 6.3% 3 6.3% 3 6.3% Not Answered 0 0.0% % 1 6.3% % 1 6.3% 1 6.3% 0 0.0% Prefer not to say 0 0.0% 0 0.0% % % 1 7.1% 1 7.1% 1 7.1% Neighbourhoods To what extent do you agree that health and mental health services should be organised on the neighbourhood model as described? No 3 2.2% 2 1.5% % % % 6 4.4% 7 5.2% Yes 1 2.1% % % % 1 2.1% % 4 8.3% Not Answered 0 0.0% % % % 0 0.0% % 0 0.0% Prefer not to say 0 0.0% 0 0.0% % % % % 0 0.0% Hospital Beds To what extent do you agree that this test would be appropriate, if in the future Stockport Together has to consider decommissioning in-patient beds at Stepping Hill hospital? No % 2 1.5% % % % % % Yes % % % % 3 6.3% % % Not Answered 0 0.0% % 0 0.0% % 1 6.3% 0 0.0% % Prefer not to say 1 7.1% 0 0.0% % % 0 0.0% % % ASV

135 9.2 Race Services Not Answered Don't know Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree No. % No. % No. % No. % No. % No. % No. % To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? Asian/British - Bangladeshi 0 0.0% 0 0.0% 0 0.0% 1 100% 0 0.0% 0 0% 0 0.0% Asian/British - Chinese 0 0.0% 0 0.0% 0 0.0% 1 100% 0 0.0% 0 0% 0 0.0% Black/British - African 0 0.0% 0 0.0% 1 100% 0 0.0% 0 0.0% 0 0% 0 0.0% Not Answered % 1 4.3% % % 1 4.3% 0 0% 2 8.7% Other ethnicity / race 0 0.0% 0 0.0% % 0 0.0% % % % White: British 7 4.2% % % % 7 4.2% 9 5.4% 8 4.8% White: European 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% % White: Gypsy/Traveller 0 0.0% 0 0.0% % % 0 0.0% 0 0.0% 0 0.0% White: Irish 0 0.0% 0 0.0% % % 0 0.0% 0 0.0% 0 0.0% Neighbourhoods To what extent do you agree that health and mental health services should be organised on the neighbourhood model as described? Asian/British - Bangladeshi 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% Asian/British - Chinese 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% % 0 0.0% Black/British - African 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% 0 0.0% Not Answered % 0 0.0% % % 1 4.3% 1 4.3% % Other ethnicity/race) 0 0.0% 0 0.0% % % 0 0.0% % % White: British 7 4.2% 4 2.4% % % % 8 4.8% 9 5.4% White: European 0 0.0% 0 0.0% 0 0.0% % % 0 0.0% % White: Gypsy/Traveller 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% 0 0.0% White: Irish 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % ASV

136 Hospital Beds Not Answered Don't know Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree No. % No. % No. % No. % No. % No. % No. % To what extent do you agree that this test would be appropriate, if in the future Stockport Together has to consider decommissioning in-patient beds at Stepping Hill hospital? Asian/British - Bangladeshi 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% Asian/British - Chinese 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% Black/British - African 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% % 0 0.0% Not Answered % 1 4.3% 1 4.3% % 1 4.3% 0 0.0% % Other ethnicity/race 0 0.0% 0 0.0% % % 0 0.0% % % White: British 9 5.4% % % % % % % White: European 0 0.0% 0 0.0% 0 0.0% % % 0 0.0% % White: Gypsy/Traveller 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% White: Irish % 0 0.0% % % % 0 0.0% 0 0.0% ASV

137 9.3 Sexuality Services Not Answered Don't know Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Count % Count % Count % Count % Count % Count % Count % To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? Bisexual 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% % % Gay 0 0.0% % % % % 0 0.0% 0 0.0% Heterosexual/straight 2 1.4% 9 6.3% % % 4 2.8% 6 4.2% 7 4.9% Lesbian 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% 0 0.0% Not Answered % 0 0.0% 1 3.8% % 1 3.8% 1 3.8% 1 3.8% Other 0 0.0% 0 0.0% % 0 0.0% % 0 0.0% 0 0.0% Prefer not to say 2 6.1% 1 3.0% % % 2 6.1% 2 6.1% % Neighbourhoods To what extent do you agree that health and mental health services should be organised on the neighbourhood model as described? Bisexual 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% % Gay 0 0.0% 0 0.0% % % 0 0.0% 0 0.0% % Heterosexual/straight 2 1.4% 4 2.8% % % % 8 5.6% 4 2.8% Lesbian 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% 0 0.0% Not Answered % 0 0.0% % % 0 0.0% 0 0.0% % Other 0 0.0% 0 0.0% % % 0 0.0% 0 0.0% 0 0.0% Prefer not to say 2 6.1% 0 0.0% % % 3 9.1% 3 9.1% % Hospital Beds To what extent do you agree that this test would be appropriate, if in the future Stockport Together has to consider decommissioning in-patient beds at Stepping Hill hospital? Bisexual 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % ASV

138 Not Answered Don't know Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Count % Count % Count % Count % Count % Count % Count % Gay 0 0.0% 0 0.0% 0 0.0% % % % % Heterosexual/straight 4 2.8% % % % % % % Lesbian 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% Not Answered % 0 0.0% 1 3.8% % 1 3.8% 2 7.7% % Other 0 0.0% 0 0.0% % % 0 0.0% 0 0.0% 0 0.0% Prefer not to say 2 6.1% 1 3.0% % % % 3 9.1% % ASV

139 9.4 Religion Services ASV 2017 Not Answered Don't know Strongly agree Tend to agree 68 Neither agree nor disagree Tend to disagree Strongly disagree Count % Count % Count % Count % Count % Count % Count % To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? Buddhism 0 0.0% 0 0.0% % % 0 0.0% % 0 0.0% Christianity 5 4.6% 5 4.6% % % 2 1.9% 4 3.7% 4 3.7% Islam 0 0.0% 0 0.0% 0 0.0% 0 0.0% % 0 0.0% 0 0.0% Judaism 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% 0 0.0% No religion 2 3.6% 3 5.4% % % 4 7.1% 2 3.6% 5 8.9% Not Answered % 2 7.4% % % 1 3.7% 1 3.7% 2 7.4% Other 0 0.0% 1 6.7% % % 1 6.7% % % Neighbourhoods To what extent do you agree that health and mental health services should be organised on the neighbourhood model as described? Buddhism 0 0.0% 0 0.0% % % 0 0.0% 0 0.0% 0 0.0% Christianity 5 4.6% 1 0.9% % % 6 5.6% 4 3.7% 6 5.6% Islam 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% 0 0.0% Judaism 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% 0 0.0% No religion 2 3.6% 1 1.8% % % % 5 8.9% 2 3.6% Not Answered % 1 3.7% % % 0 0.0% 0 0.0% % Other 0 0.0% 1 6.7% % % 1 6.7% % % Hospital Beds To what extent do you agree that this test would be appropriate, if in the future Stockport Together has to consider decommissioning in-patient beds at Stepping Hill hospital? Buddhism 0 0.0% 0 0.0% 0 0.0% % % % 0 0.0% Christianity 6 5.6% 9 8.3% % % 9 8.3% % % 139

140 Not Answered Don't know Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Count % Count % Count % Count % Count % Count % Count % Islam 0 0.0% 0 0.0% % 0 0.0% 0 0.0% 0 0.0% 0 0.0% Judaism 0 0.0% 0 0.0% % % 0 0.0% 0 0.0% 0 0.0% No religion 4 7.1% % % % % % % Not Answered % 2 7.4% 1 3.7% % 1 3.7% 2 7.4% % Other 0 0.0% 1 6.7% 1 6.7% % % 0 0.0% % ASV

141 (Is your gender different to that assigned at birth?) 9.5 Gender Reassignment Services Not Answered Don't know Strongly agree Tend to agree Neither agree nor disagree Tend to disagree Strongly disagree Count % Count % Count % Count % Count % Count % Count % To what extent do you agree or disagree that Stockport Together should change their approaches to planning and organising health and social care services as outlined? Yes 0 0.0% % % % 0 0.0% % % No 2 1.3% 9 6.0% % % 5 3.3% 6 4.0% 8 5.3% Prefer not to say 2 7.4% 1 3.7% % % % 1 3.7% % Not Answered % 0 0.0% 1 4.0% % 1 4.0% 1 4.0% 1 4.0% Neighbourhoods To what extent do you agree that health and mental health services should be organised on the neighbourhood model as described? Yes 0 0.0% % % % % 0 0.0% % No 1 0.7% 3 2.0% % % % 9 6.0% 7 4.6% Prefer not to say 2 7.4% 0 0.0% % % % 2 7.4% % Not Answered % 0 0.0% % % 0 0.0% 0 0.0% % Hospital Beds To what extent do you agree that this test would be appropriate, if in the future Stockport Together has to consider decommissioning in-patient beds at Stepping Hill hospital? Yes % 0 0.0% % % % 0 0.0% % No 3 2.0% 1 0.7% % % % 9 6.0% 7 4.6% Prefer not to say 0 0.0% 2 7.4% % % % 2 7.4% % Not Answered 0 0.0% % % % 0 0.0% 0 0.0% % ASV

142 Keep in touch T: E: 142

143 Stockport Together STRATEGIC PLAN Equality Impact Assessment Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 143 and Viaduct Health (a federation representing all Stockport GPs) 1

144 Contents 1. Introduction P About the Public Sector Equality Duty P Scope of this Impact Assessment P Stockport Together. P The economic case. P The new models of care: P. 7 Neighbourhoods... P. 7 Intermediate Tier... P. 8 Outpatients P. 9 Ambulatory Care.. P Governance of the programme P Assessing the Impact of Stockport Together on the Community. P Stockport community data P Implications for the community and service users.. P Consultation with Service Users, Carers and the Public. P Assessing the Impact of Stockport Together on the Workforce... P Workforce data.. P Implications for the Workforce. P Consultation with Staff.. P Recommendations / Equality Action Plan P Appendices... P The Stockport Context of the EIA... P Workforce Profiles. P. 60 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 144 and Viaduct Health (a federation representing all Stockport GPs) 2

145 1. Introduction The partner organisations across Stockport (Stockport NHS Foundation Trust, NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust, Stockport Metropolitan Borough Council and Stockport s GP federation, Viaduct Care) are working alongside GPs and voluntary organisations to develop a single strategic plan to improve health and social care services across the borough Stockport Together. Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current fragmented form, the health and social care system is financially unsustainable. If no changes are made, by 2010/21 there will be a combined deficit of 156m across Stockport s health and social care services. The Stockport Together programme aims to create a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bed-based care. In doing this, we want to ensure that our plans are fair and support all community groups. 1.1 The Public Sector Equality Duty The Public Sector Equality Duty, as set out in the Equality Act 2010, requires public authorities, in the exercise of their functions, to have due regard to the need to: eliminate unlawful discrimination, harassment and victimisation advance equality of opportunity between different community groups foster good relations between people who share a protected characteristic and those who do not. The Act explains that having due regard for advancing equality involves: removing or minimising disadvantages suffered by people due to their protected characteristics taking steps to meet the needs of people from protected groups where these are different from the needs of other people encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Having due regard to the need to foster good relations between persons who share a relevant protected characteristic and persons who do not share it involves having due regard, in particular, to the need to: tackle prejudice, and promote understanding. Compliance with the duties may involve treating some persons more favourably than others; but that is not to be taken as permitting conduct that would otherwise be prohibited by or under the Equality Act Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 145 and Viaduct Health (a federation representing all Stockport GPs) 3

146 The characteristics given protection under the Equality Act 2010 are: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation Equality Analysis is a way of considering the effect on different groups given protection under the Equality Act. There are a number of key reasons for conducting an Equality Analysis, including: to consider whether the policy will help eliminate unlawful discrimination, harassment and victimisation to consider whether the policy will advance equality of opportunity between people who share a protected characteristic and those who do not to consider whether the policy will foster good relations between people who share a protected characteristic and those who do not to inform the development of the proposed policy. 1.2 Scope of this Impact Assessment This document analyses the potential impacts of the strategic plan for Stockport Together. As such, it is intentionally high level in its review of the programme, focussing on the direction of travel, investment plans and governance of the changes underway. The Stockport Together programme is made up of four key work streams - the detailed models of care. For each of these work streams, a business case has been developed, outlining: the case for change; the new model of care; investment plans; and intended outcomes. A full Equality Impact Assessment has been undertaken for each of these work streams to note and mitigate any differential impacts on protected groups, which vary by work stream. All of the business cases can be found on the Stockport Together website at: The Equality Impact Assessments and a report on engagement undertaken with protected groups in our community can be found on the Stockport Together website at: Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 146 and Viaduct Health (a federation representing all Stockport GPs) 4

147 1.3 Stockport Together The partner organisations across Stockport (Stockport NHS Foundation Trust, NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust, Stockport Metropolitan Borough Council and Stockport s GP federation, Viaduct Care) have worked alongside GPs and voluntary organisations to develop a single strategic plan to improve health and social care services across the borough. It is recognised that over the coming years, health and social care will be subject to increasing demand from an ageing population, combined with a financial position that will not increase in line with this demand. The Stockport Together programme seeks to address these challenges The Economic Case The health and social care system in Stockport is unsustainable in its current form. If working practices do not change, the financial position is set to deteriorate so that if no action is taken by 2020/21 there will be a c 156.8m deficit in the Stockport Locality as set out in the table below. Financial Forecast - Do Nothing Gap ( 000s) Partner Organisation: 2016/ / / / /21 Stockport MBC 10,500 18,193 27,316 34,031 40,464 Stockport CCG 5,121 13,377 29,162 37,083 37,080 Stockport FT 34,398 42,400 54,400 63,622 75,764 Pennine Care 0 1,661 2,266 2,871 3,476 Total Deficit 50,019 75, , , ,784 In response, the partners working across Health and Social Care in Stockport have developed a system-wide sustainability plan to address this significant financial challenge. The plan combines internal cost improvement plans in each partner organisation with investment in Stockport Together s new models of care, which will generate a sustainable system and deliver savings to the system. The plan also includes implementation of the Greater Manchester Health & Social Care Partnership s programmes of change, which will also contribute to financial savings over the 5 years of this plan. The Stockport Together business cases will require recurrent investment of 16.4m and will deliver a recurrent benefit of 43m, giving a net system benefit of 26.7m. The sustainability plan will not meet the full anticipated deficit of 156m by the end of the 5 year plan, but will reduce this to around 20.5m as well as creating a new model of care that is sustainable in the face of ongoing population growth, ageing and costs. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 147 and Viaduct Health (a federation representing all Stockport GPs) 5

148 Planned Savings Programmes to Address the Forecast Deficit ( 000s) Partners Savings Plans: 2016/ / / / /21 Stockport MBC ( 10,500) ( 18,193) ( 20,590) ( 23,669) ( 23,946) Stockport CCG ( 7,871) ( 17,444) ( 24,778) ( 33,282) ( 33,882) Stockport FT ( 28,836) ( 15,000) ( 30,000) ( 30,000) ( 30,000) Pennine Care Investments: 2016/ / / / /21 Stockport Together ,121 19,739 18,986 Resulting Savings: 2016/ / / / /21 Stockport Together 0 0 ( 23,974) ( 34,080) ( 45,470) GM Themes 0 ( 3,000) ( 7,000) ( 12,000) ( 22,000) Overall Impact ( 47,207) ( 53,637) ( 86,221) ( 113,292) ( 136,312) The success of the Stockport Together plans is contingent on the system s ability to ensure that the 15% of people most at risk of hospitalisation are supported to manage their care better, with evidence based community alternatives to avoid unnecessary hospital stays. For this reason, there will be significant investment in: GP practices GP Practices working together across neighbourhoods Integrated community services for both physical and mental health, social care and third sector provision Community-based Crisis Response, Intermediate Care and Reablement. The table below sets out the detail of planned investments in Stockport Together, by work stream, as well as the intended benefits of each area. Stockport Together Investments and Benefits by Work Stream ( 000s) Investment Benefit Net Work Stream 2018/ / / / / /21 Benefit Ambulatory Care 2,500 2,334 2,168 ( 4,871) ( 6,089) ( 6,089) ( 3,921) Intermediate Tier 2,457 1,532 1,103 ( 3,275) ( 4,003) ( 4,730) ( 3,628) Neighbourhoods 12,106 11,445 10,987 ( 11,170) ( 14,907) ( 20,465) ( 9,478) Outpatients 2,280 2,128 2,117 ( 6,833) ( 9,150) ( 11,765) ( 9,647) TOTAL 19,344 17,439 16,375 ( 26,150) ( 34,149) ( 43,049) ( 26,674) Taken together, the business cases deliver the evidence-based community alternatives and enhanced capacity which, properly implemented, will avoid unnecessary and costly hospital interventions, making the system financially sustainable for the future. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 148 and Viaduct Health (a federation representing all Stockport GPs) 6

149 1.3.2 The New Models of Care The five organisations have developed a strategy for the borough with professionals and leaders across Stockport. The main work streams of the programme are: Neighbourhoods Intermediate Tier Services Outpatients Ambulatory Care The following section provides an overview of each work stream and their potential impacts on protected groups. This is intended as a high level introduction. The full business cases and can be found on the Stockport Together website at: The detailed Equality Impact Assessments for each work stream can be found at: These EIAs look at the demographics of staff and service users, feedback from protected groups, potential impacts of the work stream, and improvements that mitigate against any negative impact and generate positive impacts for protected groups. a) Neighbourhoods The Neighbourhood model will see Primary Care, Mental Health, Community Healthcare, Adult Social Care and voluntary sector services working together with people and communities to achieve improved health and social care outcomes. There will be an increased focus on prevention - identifying the causes of poor health, such as an unhealthy lifestyle and helping people to address this and proactively managing people with complex care needs to stay independent and manage their condition without requiring hospital intervention. The Neighbourhood business case proposes the development eight neighbourhood teams. These teams will include a number of different health and social care professionals. The overall aim is to ensure that care be delivered closer to home, with particular focus being given to those in the community that need the most support. Increased prevention work should benefit all protected groups. However, we know that access to our preventative services is lower among some communities than others. Particular efforts should be undertaken to ensure that work on screening uptake is tailored to those protected groups exhibiting lower access to the services, with culturally appropriate campaigns targeting those groups most at risk for different conditions and services. Integrated neighbourhood teams will have a major beneficial impact on older people, people with disabilities / long-term conditions, and their carers, reducing the need to attend multiple services and repeat stories and tests with each service. Providing more care at home or in the community will also support those with mobility issues, caring or work commitments. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 149 and Viaduct Health (a federation representing all Stockport GPs) 7

150 However, specific actions will be needed to ensure high standards for people from all protected groups, including ensuring that venues for community clinics are accessible to all. To improve access, services should be culturally appropriate and staff should receive training in specific equality issues related to their field. The full analysis of potential impacts by protected group and an action plan for mitigating impacts and reducing inequalities can be found at: b) Intermediate Tier The Intermediate Tier refers to those health and care services that provide additional support to prevent an unnecessary hospital admissions or an early admission to long-term residential care and that promote faster recovery from illness to maximise independent living. In Stockport there are over 20 such services which have developed in isolation over the past ten years. While each service has significant strengths, collectively the Intermediate Tier is fragmented and difficult to navigate, resulting in difficulties accessing the right service and duplication for service users. The current range of services focusses mainly on supporting people after their condition has escalated, requiring a hospital admission. As a result, there is little capacity to respond to people in crisis and prevent unnecessary hospital admissions. This business case describes how care and treatment could be delivered in a person s normal place of residence or as close to home as possible. It describes a 24 hour health and social care system that better meets people s needs, and offers flexible, personcentred care that will help people when they need to move between hospital and primary care settings. At the same time, improvements will be made to community bed-based care, with the aim of reducing the average length of stay from 4 weeks to 2 in line with the national approach. This work should see a positive impact on the entire community by reducing waste and offering all communities the same service levels. However, we recognise that the impact will be felt most by older people, those with long-term conditions or disabilities and their carers. For the most part, this impact should be positive ensuring that people are treated as close to home as possible when hospital visits are not necessary, ensuring that everyone receives a high standard of care and appropriate referrals / prescriptions, reducing unnecessary waiting for referrals from one intermediate care service to another, and reducing duplication of assessment and tests undertaken by different teams currently going into a patient s home. To ensure that no negative impacts are felt by any groups, a full impact assessment of the plans has been undertaken, setting out a detailed action plan to ensure that care provided in people s homes is culturally sensitive, community clinic venues are accessible, and that bed based care is fully accessible to all protected groups. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 150 and Viaduct Health (a federation representing all Stockport GPs) 8

151 The full analysis of potential impacts by protected group and an action plan for mitigating impacts and reducing inequalities can be found at: c) Outpatients Outpatient attendances have grown by 17% locally a 15% growth in GP referrals and 20% growth in referrals from other professionals, including hospital consultants. In our current model, people are referred to hospital and receive specialist advice and support, often followed by recurrent follow-ups. Around 40-50% of outpatient appointments in Stockport result in advice and / or pharmaceutical treatment only, without the need for the patient to physically visit the hospital. Alternative approaches to the traditional model could deliver more effective solutions outside of the hospital, using technology to enable communications, advice and treatment between patients, GPs and specialists. The outpatients work stream of Stockport Together aims to reduce the number of unnecessary outpatient attendances over the next 3 years by providing alternatives to the traditional way in which they are currently delivered. It aims to improve patient care by providing support, information and advice through improved technology and access to community resources. This will help people to be more confident in managing their own care. As a result, the work stream will reduce waste and offer and cost. However, we recognise that this will have a differential impact on some protected groups older people; people with disabilities; women who are more likely to receive referrals from their GP. For the most part, this impact should be positive ensuring that people are treated as close to home as possible when hospital visits are not necessary. The full assessment of this work stream looks at ensuring that community venues for outpatient appointments are fully accessible, care provided at home is culturally appropriate and the use of technology includes support for those with disabilities or limited English as well as traditional appointments options for those who struggle with new technology. The full analysis of potential impacts by protected group and an action plan for mitigating impacts and reducing inequalities can be found at: d) Ambulatory Care While the rate of A&E attendances at Stepping Hill Hospital is on a par with the national average, people in Stockport are much more likely to be admitted to hospital rather than treated and discharged particularly those with Ambulatory Care Sensitive (ACS) conditions, which should be treatable in the community and not require hospital admissions. This outline business case proposes changing the way the Emergency Department is set up in three ways: Implementing primary and secondary care Collaborative Triage; Providing of a co-located primary care Ambulatory Illness Team; and extending the operating hours of the Ambulatory Care Unit. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 151 and Viaduct Health (a federation representing all Stockport GPs) 9

152 This proposed way of working will strengthen the triage process by improving the availability of senior decision makers within the team. This will include having primary care expertise within the department (for example, having a GP in A&E), access to patients electronic record (with appropriate safeguards), and improving the decision making protocols and processes. Behind A&E triage there will be a new service operating 8am to midnight 7 days a week to deal with peak periods of demand. It will meet the needs of people who do not require full A&E services, but may need some lower level support (for example reassurance about a rash). It is estimated this primary care led service will see more than 300 people a week, leaving A&E staff free to work with people with more serious needs more promptly. The existing Ambulatory Care Unit will extend opening hours so that it will go from seeing 160 to 350 people a week and be open 8am to midnight 7 days per week. The unit will diagnose, treat, stabilise and discharge people where their condition does not require overnight hospital care but short-term medical input. Planned additional capacity, along with access to GP records for the clinical team, revised pathways and dedicated specialist staff and equipment will reduce admissions through ED by 40 per week. More importantly it will ensure people who need a brief medical intervention are treated quickly and returned home safely rather than being admitted unnecessarily. Access to emergency services is vital to all community groups, but the over-use of current services and high rates of emergency admissions are making this unsustainable. This area of work aims to improve the quality of current services, which should have a positive impact on all community groups. In particular, older people, those in care homes and nursing homes, people with long-term conditions and children are the highest users of current unscheduled care services. This programme will improve the service for these groups, offering improved clinical pathways for conditions, reducing the length of stay in hospital and giving emergency services access to the patient s records so that they receive the right care in the right place. The full analysis of potential impacts by protected group and an action plan for mitigating impacts and reducing inequalities can be found at: Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 152 and Viaduct Health (a federation representing all Stockport GPs) 10

153 1.3.3 Governance of the Programme The Stockport Together programme brings together the main public sector organisations in Stockport. The Chief Executives Group is ultimately accountable for delivery of the Programme, owning and promoting the shared vision, and holding Senior Responsible Officers to account for delivery. Stockport Together Programme Board seeks assurance on the implementation of the new care models and services, has responsibility for any changes to the programme, oversight of key strategic risks, and manages public consultation and engagement. A Provider Alliance Board is responsible for the operational implementation of the new care models as outlined in the Business Cases, for addressing issues and supporting staff engagement. From Spring 2018 governance will be managed in two distinct ways: joint commissioners (Stockport Council and NHS Stockport CCG) will take responsibility for ensuring that plans are embedded in provider contracts and for monitoring the delivery of plans, savings and benefits Stockport Neighbourhood Care will bring together service providers (Stockport FT, Pennine Care, Adult Social Care, and the GP Federation) to collaboratively deliver changes and provide a fully integrated service to local people. Commissioner oversight of programme implementation and benefits delivery will track progress on equality action plans and how benefits impact protected groups. New contracting arrangements will clearly set out the responsibilities of the new integrated provider to ensure equality of access and reduce inequalities in outcomes faced by protected groups. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 153 and Viaduct Health (a federation representing all Stockport GPs) 11

154 2. Assessing Impact of Stockport Together on the Community 2.1 Stockport Community data The total population of Stockport is currently 286,775 (Mid-year Population Estimates, 2014), a figure which has been relatively stable over the last 10 years. The information below details the population data available in relation to equality and diversity in Stockport. This data has been used alongside feedback from local community groups to consider how the priorities and actions outlined in our plan are likely to impact on different groups. Stockport has an older age profile than the national average, with comparatively high numbers of residents aged and low numbers of year olds. The median age at the 2011 census was 41 (up from 39 ten years ago) and recent mid-year population estimates identify that 19.4% of the population is aged 65 or over, which is higher than the national average. Percentage of Population Age 0 to 4 Age 5 to 7 Age 8 to 9 Population by age group Age 10 to 14 Age 15 Age 16 to 17 ENGLAND NORTH WEST Greater Manchester Stockport Age 18 to 19 Age 20 to 24 Age 25 to 29 Age 30 to 44 Age 45 to 59 Age 60 to 64 Age 65 to 74 Age 75 to 84 Age 85 to 89 Age 90 and over 18.4% of Stockport residents are living with a long-term illness or disability. 8 of Stockport s 21 wards have levels of LLTIs above the national average, including all of Stockport s Priority 1 areas (those with the highest levels of deprivation). 8.6% of the population say their long-term condition or disability has a significant limiting impact on their daily activities. 11.3% of the population would describe themselves as unpaid carers. 2.5% provide 50 or more hours of unpaid care a week. Stockport s birth rate has increased steadily since over 3,400 babies were born to Stockport residents in Birth rates are higher among Stockport s ethnic minority groups and in areas of deprivation. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 154 and Viaduct Health (a federation representing all Stockport GPs) 12

155 Stockport s Black & Minority Ethnic (BME) population has risen from just 4.3% in 2001 to around 8% at the 2011 census. If white ethnic minorities are included, such as Irish, Polish and traveller populations, this percentage rises to 11%. Areas to the west of the borough have the highest proportion of ethnic diversity particularly among younger populations. Percentage of the population 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% White British Other White Ethnicity in Stockport Black Asian Mixed Race Other Ethnicity Series1 89% 3.10% 0.70% 4.90% 1.80% 0.60% The majority of Stockport residents are Christian (63.2% - down from 75% at the last census), which is 4% greater than the national average. 25.1% of Stockport residents have no stated religion (up from 14.2% at the last census), which is in line with the national average. Stockport s second largest religion is Islam, which makes up 3.3% of the population - this is well below the national average of 5%, but the local figure has almost doubled since the last census. Stockport s population is split almost equally by gender (51.1% female, 48.9% male), which mirrors the national trend. Life expectancy in Stockport is higher for women at 83 years and 79.7 years for men. There is currently no demographic data on local trans-gender residents, though recent consultation undertaken as part of Stockport s LGBT needs assessment offers a greater insight into this community group. There is a lack of reliable data available regarding the profile of the LGBT community in Stockport. The government estimates that between 5% and 7% of the UK population is LGB, which would equate to 14-20,000 people in the borough. A full break down of local health statistics by protected characteristics can be found in Appendix 1 Stockport Context. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 155 and Viaduct Health (a federation representing all Stockport GPs) 13

156 2.2 Implications for the Community and Service Users Anticipated implications at a high level are identified in section At the strategic programme level, we anticipate that Stockport Together will have a beneficial impact on service users and the community, by: Creating a sustainable system that meets local needs into the future Tailoring services to the needs of local people, as identified in Stockport s Joint Strategic Needs Assessment Shifting the balance of care from reactive services that support people once they are ill to a preventative and proactive approach that supports people to live well and remain independent Treating service users as individuals with a range of health and social care needs, rather than focusing on separate conditions Coordinating care to wrap around the individual Undertaking care as close to home as possible. In particular, this should have a positive impact on: Older people, who are more likely to need health and social care services People with a disability or long-term condition Carers, who will benefit in particular from the coordination of care for people with multiple conditions, the integration of services to wrap around the patient and the transfer of care as close as possible to home reducing the burden of travel and coordinating appointments, currently shouldered by carers Ethnic minority groups, religious minority groups, LGBT members of the community and men who we know are less likely to use our services and will benefit from more targeted prevention. Potential negative impacts identified include: People using current services may be discharged from the service, seen in a different setting, or by a different professional / team A number of protected groups are, for various reasons, less likely to access primary and preventative services, which the programme aims to increase Increased use of new technology to manage self-care may be less accessible to some protected groups Potential for confusion among integrated teams as to which interpretation service to use (currently primary care, community services, and social care services running) may result in reduced access to interpretation New integrated venues will need to be accessible and publicised in a variety of formats Increased care in a patient s home will need to be culturally appropriate Potential for confusion in navigating services as the system transitions between the old and new arrangements. Patient facing communications and engagement will help overcome this. In all cases, this redesign is based on health and care need, prioritising the most vulnerable and changing services to provide the most appropriate care to meet needs. Further analysis of detailed designs and equality action plans can be found in the Equality Impact Assessments for each work stream: Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 156 and Viaduct Health (a federation representing all Stockport GPs) 14

157 3. Consultation with Service Users, Carers and the Public Since 2013 engagement and co-production has been undertaken across Stockport on the integration of health and social care services. In , 700 people were spoken to at a number of events in Marple and Werneth where the initial integrated locality pilot was launched. In January 2015, 100 leaders and staff from health and social care; NHS Stockport Clinical Commissioning Group, Stockport NHS Foundation Trust, Pennine Care NHS Foundation Trust and Stockport Metropolitan Borough Council took part in a two day Congress to help shape the future of Stockport s Health and Social Care services. Following the congress, engagement meetings were re-initiated across the whole of Stockport. Over 500 people fed into the case for change and vision for the future of health and social care. A Citizen s Representation Panel (CRP) was established in October 2015 to feed in local views throughout the design and implementation phase. In June 2017, Stockport Together ran a Listening Phase to reach wider groups, giving information on the plans and feeding in views to develop the business cases. Finally, a formal consultation was undertaken between October and November 2017 to make final recommendations on the decision whether to adopt the business cases and agree investment plans in January A wide variety of engagement and communication methods were used to reach more people and different groups within Stockport s community and give a better understanding of local views on the public services and priorities for change. Information was disseminated in a range of formats: Online surveys Paper surveys Public events Speakers at local community groups Health Information Stalls using accessible infographics Patient and Citizen Representation Panels Roadshows Workshops Fliers and consultation documents handed out in clinics and displayed in Libraries, Pharmacies and GP Practices Customer services monitoring, including views expressed in letters, complaints, petitions and patient feedback. One of the key tools for feeding back to local people is the CCG s engagement website: which allows for the use of translation into other languages, BSL video clips, and easy read images in surveys. The site also allows people to take part in engagement anonymously and provides remote access for those who cannot or do not wish to attend traditional town hall meetings. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 157 and Viaduct Health (a federation representing all Stockport GPs) 15

158 For those without access to the internet, more traditional engagement events are undertaken as well as speakers attending existing community group meetings, a presence at local events with information stalls and staff attend local GP Practices and clinics as well as major shopping centres to give out information and take views from people who would not traditionally engage in public sector events. Events were undertaken in accessible local venues across each area of Stockport, and participants can request interpretation, specific dietary options for catering or other special requirements to allow them to attend and participate. Write-ups of events were sent out to local groups after they have met with the partners. Sign-up sheets are also taken at all public events so people who wish to receive a write-up of the event can have this sent to them in their preferred format. Articles summarising formal consultations are included in the local Council publication that is delivered to all households in Stockport. In addition, feedback reports are sent to the Healthwatch for inclusion in their regular newsletter and targeted feedback articles are also included in a wide range of local newsletters. Documents include a message explaining how information could be obtained in an alternative language or format. As well as making efforts to ensure that engagement is accessible to all, public engagement and consultation included targeted meetings with local groups representing protected characteristics to ensure that all voices were heard and all concerns / impacts understood. The partners have a database of over 1,500 local groups, which is used to involve local people in engagement. The table below sets out the key groups used as points of contact for reaching protected groups. It should be noted that this is not a comprehensive list and protected groups are also involved in other engagement work as individuals fall under a number of categories. Protected Characteristic Age Disability Local Groups Age UK Bramhall U3A Gatley U3A Stockport College Stockport Savvy Young Minds Disability Stockport Walthew House Stockport MIND Rethink Stockport Mencap Pure Innovations Alzheimers Society COPD patient group Stockport Cerebral Palsy The Together Trust Rescare Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 158 and Viaduct Health (a federation representing all Stockport GPs) 16

159 Protected Characteristic Gender reassignment Pregnancy & Maternity Race Religion & Belief Sex Sexual Orientation Local Groups Hope 4 Disability Stockport Carers Forum Signpost for Carers Stockport Carers of Adults with Autism Carers of Adults with Learning Disabilities Press for Change LGBT Foundation MORF Manchester Concord Maternity Services Liaison Committee African & Caribbean Community Association (ACCA) Ethnic Diversity Service Nexus Nia Kuumba Asian Heritage Centre Wai Yin Chinese Society Siyanda Trust Stockport Inter-Faith Network Stockport MELA Forum St Ambrose Church Salvation Army Cheadle Muslim Association Stockport Buddhist Temple Cheadle Women s Institute Offerton ladies Circle Women s Royal Voluntary Service, Stockport Stockport Women s Centre Stockport Women s Aid PARIS gym Stockport Taxi drivers Sky & BT (local employers with predominantly male employees) People Like Us Stockport LGBT Foundation Stockport Savvy Under the Rainbow The overarching themes from the public events were that: People generally understood the need to make changes, given the changing population and numbers of people with long-term conditions Many of the services currently provided in hospital could be undertaken closer to home in GP Practices, clinics, or even in the patients home Current services are fragmented and people don t want to keep repeating their story at each appointment. Frontline staff don t always seem to be aware of other services and what s available We need to look at improving care for Long-Term Conditions and there should be more support for Carers Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 159 and Viaduct Health (a federation representing all Stockport GPs) 17

160 People want more information about where to go or what to do when they are ill they want alternatives to A&E. Local people want more care delivered closer to home A number of residents have raised issues with the cost of car parking at Stepping Hill Hospital, particularly for those on low incomes and people with multiple long-term conditions who need to attend more than one clinic. Older patients, people with disabilities and those with English as a second language have raised issues around communications from the hospital with appointment letters sent by post in a standard format that does not consider requirements for Braille, large print, Makaton or translation into other languages. Access to services particularly GP appointments and the availability of hospital Consultants should be improved at weekends GP surgeries should provide more appointments Local people want there to be more focus on Mental Health Services often treat a single condition, rather than looking at the needs of the individual Online access viewed as right thing to do but some fear less IT empowered people will be disadvantaged Clearer information about how to access services should be provided. Communications need to be in an accessible format, whether that is appointment letters, access to booking or information leaflets Any new venues need to be accessible Staff should be trained to understand and be sensitive to different needs It is important that, where possible, patients receive continuity of care, particularly for more vulnerable patients, offering a named lead There was a lot of support for preventative measures and the better management of long-term conditions through GP Practices and community services Prevention and taking personal responsibility for health came out as the top suggestions from members of the public on how we improve some of the issues facing public services There should be a more joined up approach to care By protected group, the following priorities and issues were raised: Age People want more information about where to go or what to do when they are ill they want alternatives to A&E. Local people want more care delivered closer to home A number of residents have raised issues with the cost of car parking at Stepping Hill Hospital, particularly for those on low incomes and people with multiple long-term conditions who need to attend more than one clinic. Older patients, people with disabilities and those with English as a second language have raised issues around communications from the hospital with appointment letters sent by post in a standard format that does not consider requirements for Braille, large print, Makaton or translation into other languages. People without web based access or skills will need help accessing online care or records. GP surgeries should provide more appointments Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 160 and Viaduct Health (a federation representing all Stockport GPs) 18

161 Online access viewed as right thing to do but some fear less IT empowered people will be disadvantaged It is important that, where possible, patients receive continuity of care, particularly for more vulnerable patients, offering a named lead Disability Services are fragmented and people don t want to keep repeating their story at each appointment. Frontline staff don t always seem to be aware of other services and what s available Services often treat a single condition, rather than looking at the needs of the individual We need to look at improving care for Long-Term Conditions and there should be more support for Carers People with sensory disabilities report issues accessing services, particularly when letters are all sent in a single format for some this inaccessibility had resulted in thoughts of suicide British Sign Language users expressed issues accessing emergency appointments Clinicians tend to treat the condition and not see wider, holistic needs of the patient Mental health will need to be strengthened in the neighbourhood plans. Older patients, people with disabilities and those with English as a second language have raised issues around communications from the hospital with appointment letters sent by post in a standard format that does not consider requirements for Braille, large print, Makaton or translation into other languages. Online access viewed as right thing to do but some fear less IT empowered people will be disadvantaged People without web based access or skills will need help accessing online care or records. Communications need to be in an accessible format, whether that is appointment letters, access to booking or information leaflets Any new venues need to be accessible Gender Identity Trans people experience some of the most significant health inequalities and frequently experience abuse, harassment and violence Staff should be trained to understand and be sensitive to different needs Local residents noted pockets of good practice, but a general lack of knowledge about how to meet the needs of trans patients among health professionals, particularly in secondary care Marriage & Civil Partnerships Staff should be trained to understand and be sensitive to different needs, including visiting rights for same sex partners Pregnancy & Maternity Changes will likely have a positive impact on parents with young children, who struggle to arrange childcare for hospital appointments Changes will likely have a positive impact for pregnant women who may find it harder to travel into hospital for their appointment Race Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 161 and Viaduct Health (a federation representing all Stockport GPs) 19

162 Older patients, people with disabilities and those with English as a second language have raised issues around communications from the hospital with appointment letters sent by post in a standard format that does not consider requirements for Braille, large print, Makaton or translation into other languages. People want more information about where to go or what to do when they are ill they want alternatives to A&E. Clearer information about how to access services should be provided. Communications need to be in an accessible format End of life care, in particular, needs to be sensitive to cultural differences Religion or Belief Staff should be trained to understand and be sensitive to different needs End of life care, in particular, needs to be sensitive to religious beliefs Sex Male patients are less likely to attend medical appointments, in part due to restricted opening times which clash with work Flexible opening times could improve access for men More information should be made available online particularly for men who are less likely to go to their GP Sexual Orientation Some people face more barriers than others when faced with the need to change lifestyles or behaviour. Access to services particularly GP appointments and the availability of hospital Consultants should be improved at weekends Staff should be trained to understand and be sensitive to different needs, including visiting rights for same sex partners Older LGBT people are more likely to live alone and less likely to have informal support from families and social networks, but often do not get their needs met by adult social care services Drug and alcohol services in Stockport should consider the specific needs and experiences of LGBT residents Local residents have reported positive feedback of GP and mental health services, which are friendly nd very non-judgemental Community and voluntary sector services were highly praised for meeting LGBT needs Sexual health services in Stockport were seen as not meeting LGBT needs and very restrictive in opening times Feedback from engagement was used to design the Stockport Together programme and to inform Equality Impact Assessments. A full report of engagement on Stockport Together and a breakdown of engagement by protected groups can be found on the Stockport Together website. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 162 and Viaduct Health (a federation representing all Stockport GPs) 20

163 4. Assessing the Impact of Stockport Together on the Workforce The traditional divide between primary care, community services, mental health, social care, and hospitals is increasingly a barrier to the personalised and coordinated health services patients need. An integrated Local Care Organisation (LCO) model brings these teams in a proactive, community-based model that shifts a significant proportion of care out of the hospital and closer to home. However, the model presents more than just a structural change an LCO requires a major cultural shift to a new way of working, centred round prevention and empowerment of service users and delivering significant efficiencies to sustain high quality services into the future. 4.1 Workforce Baseline data Health and social care in Stockport is overseen by a single Health & Wellbeing Board, given Stockport s geographic footprint which combines a coterminous Clinical Commissioning Group and Local Authority. Services are provided by one local acute hospital, which also runs our Community services; a main mental health provider, 1 ambulance service provider, 47 GP Practices, working towards developing a single primary care Federation model and one out-of-hours GP service. Services work closely with a range of third sector providers and 64 local care homes. However, this baseline and strategy focuses on the 7,303 staff (5,875 full-time equivalents) directly employed in the above health and social care services. Our Combined Workforce Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 163 and Viaduct Health (a federation representing all Stockport GPs) 21

164 The vast majority of staff across health and social care in Stockport are employed by Stockport NHS Foundation Trust % of full-time equivalents. This combines the 64.62% of employees working in the hospital with the 7.89% of staff in Community Services. Adult Social Care and Public Health make up the next biggest chunk of the workforce 10.77%, followed by primary care (8.37%) and mental health (8.35%). The following section describes the trends highlighted across the workforce profiles Full time/part time split Current structures reveal variation in working patterns across the different parts of the system. Primary Care has particularly high levels of part-time working. Staff working in social care are much more likely to work full-time Gender Traditionally, public services have attracted more women than men. In Stockport, the modal employee is a white woman in her 50s who is Christian, heterosexual and has no disabilities This varies across sectors and roles, though the overarching trend is the same in each service. Community services have the least male employees - just 9% of full-time equivalents. The gender differential is least stark in social care, but even here men make up just a quarter of the workforce Ethnicity Primary Care has the most ethnic diversity, the least being in community services, where % of employees are white. Within the sectors, ethnic diversity varies according to roles. In acute services, there is more ethnic diversity among medical and estates teams. In primary care, it is GPs who provide the most ethnic diversity to the overall workforce makeup Age The most prominent feature of the workforce is its age profile. The majority of employees across the system are in their fifties. Social care has the oldest age profile of all sectors, the youngest being in hospital services. A high proportion of the workforce is already in their fifties and therefore more likely to retire in the coming years: Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 164 and Viaduct Health (a federation representing all Stockport GPs) 22

165 54% of community staff 50% of social care staff 47% of primary care staff 41% of mental health staff 38% of acute staff The rates are particularly high among nursing staff particularly in primary and community care, support workers, admin and managers. This poses a potential problem for the development of an LCO, based on a preventative style of working. The vast majority of these skills lie in primary and community services, where the age profile is higher and staff with the key skills for a preventative, out-of-hospital model are closer to retirement age. Consequently, work will need to be undertaken to support the development of preventative community-based skills among acute staff and to allow for intra-team learning among current staff to ensure that vital skills are not lost when staff retire. This is also a key message for Health Education North West in planning the training of future health and social care staff to ensure that new recruits coming into the system reflect the new balance of skills required in our new model Sexual Orientation Declaration of sexual orientation amongst the workforce is low and as such work to develop a consistent understanding of this across the Health and Social Care economy is required. Present data shows a significant proportion of the workforce as prefer not to state and of those that have, the largest proportion have identified themselves as Heterosexual / Straight. Further data analysis will be undertaken to understand this protected group in Stockport Religion or Belief The largest religion identified across the workforce is Christinity, for example within Community, Acute and Mental Health between 46 52% of the workforce identify themselves as Christian. This is much lower within Social Care (10%) and isn t currently known within Primary Care. As with Sexual Orientation there are large numbers of the workforce who are identified as not declared. Further data analysis will be required for these protected characteristics to produce a consistent understanding across Stockport s Health and Social Care economy Marriage/Civil Partnership, Gender Reassignment, Pregnancy / Maternity Staff records do not currently contain data on marital status, gender reassignment, pregnancy and maternity. Further data analysis will be required for these protected characteristics as part of the Equality Impact Assessment on changes to staffing. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 165 and Viaduct Health (a federation representing all Stockport GPs) 23

166 4.2 Implications for the Workforce Stockport Together requires a major cultural shift for all employees working within Health and Social Care. A more detailed understanding of the implications for the Workforce is set out within the work stream level EIAs and will be advanced as part of the staff engagement processes that would be standard in developing new service models, and consulting with staff in advance of implementation as required. It is anticipated that changes could affect staff in the following ways: Where they are located; o As more care is delivered in a patient s home or in a neighbourhood setting, roles may shift from a hospital to a community setting, or from a provider headquarters to integrated neighbourhood hubs Team composition; o Line management in multi-disciplinary teams can no longer be restricted by professional background. Training and workforce culture; o The workforce will be empowered to work more in partnership with carers and volunteers locally, and will help to develop community capacity and skills. o Development will be required to support staff to take on new devolved leadership responsibilities and to help autonomous professions to share accountability. o Staff will need to learn about the different roles across the system and how to best use capacity. This will require us to address professional hierarchies. o Newly integrated teams will need to be developed through values alignment and team building. o Whenever possible, training will be undertaken jointly across professions and organisations to support greater awareness and understanding of roles. o The workforce themselves must be mobilised and empowered to improve efficiency and effectiveness, adopting a shared approach to change management and quality improvement. o A range of knowledge and skills are needed to enable person-centred care and support planning, and a number of approaches and training courses have been developed: Where and by whom they are employed; o There will be an inevitable shift of capacity from the hospital into community and primary care services. o Staff will increasingly need to work across organisational, professional and service boundaries. Working Hours; o Extending hours and changing shift patterns to enable 7 day working and extended hours for some services. Job roles and responsibilities o The integration of health and social care will incur role-blurring and result in the development of new generic roles to take the pressure off teams we don t have enough of and cannot easily recruit to. o This will reduce the number of very specialist roles in each sector to support multi-disciplinary team working that is more flexible and responsive to local service user needs. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 166 and Viaduct Health (a federation representing all Stockport GPs) 24

167 o New roles are required to create a sustainable new model that enables person-centred care, such as: generic health and social care roles; health coaches; care navigators; personal assistants; physicians assistants; primary care paramedics; advanced practitioners for geriatric care; and communitybased specialists. 5. Consultation with staff Ongoing engagement is taking place with staff and a workforce engagement lead has been identified. Formal staff consultation may be required for some services, and is already underway for the services forming part of the Neighbourhoods model and extending social care and district nursing to deliver 7-day and extended hours services. That process is nearing conclusion and is a good example of how Stockport Neighbourhood Care will manage other similar staff engagement for other future service changes. Given the extent of change and the range of potential implications for the workforce it is recommended that any planned future consultation includes representation or focus groups including individuals from protected groups and is backed up by an Equality Impact Assessment of staff changes. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 167 and Viaduct Health (a federation representing all Stockport GPs) 25

168 6. Recommendations / Equality Action Plan This Equality Impact Assessment has highlighted a number of potential impacts of the Stockport Together Strategy on protected groups within our staff and community. The following plan sets out the high level actions required to mitigate any potential negative impacts on protected groups and to take advantage of opportunities to reduce inequalities in outcomes. It also identifies links to actions within the detailed Equality Impact Assessments of work streams, which will be embedded in work stream implementation plans. Actions will be embedded into the Stockport Together implementation plan and monitored as part of delivery by the Stockport Together Programme Management Office. Theme Ref Action Lead/s Deadline Links to work stream actions Governance & compliance ST01 Equality Actions to be included in Stockport Together Implementation Plan Lesley Brown / Andrew Messina, Programme 31/01/2018 AC01; IT01; N01; OP01 (actions to be embedded into work stream operational plans) Managers ST02 Ensure ownership and progress of actions Caroline Drysdale, 31/01/2018 SNC MD and Lesley Brown, Programme Manager ST03 Monthly updates on implementation (including progress on equality actions) monitored by Stockport Together PMO Lesley Brown / Andrew Messina, Programme Managers 28/02/2018 AC02; IT02; N02; OP02 (progress reports to PMO) Engagement and active patient / citizen input ST04 Develop a robust and meaningful engagement approach which includes protected groups, and maximises the opportunity of Citizens Representative Panel James Brown, Head of Communications 31/03/2018 AC03; IT03; N03; OP03 (work stream comms / engagement plan) Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all 168 Stockport GPs) 26

169 Contracting ST05 Engagement and complaints to be monitored by protected groups to ensure there are no adverse impacts on any groups ST06 Communications plan for roll-out of the service changes, including: Map of stakeholders (including protected groups) Communications formats to meet needs to stakeholders Leaflets and other publicity to use inclusive images and language to demonstrate accessibility to all community groups ST07 Provider contract development to set out the legal requirements of the new integrated organisation to follow duties under the Equality Act and Accessible Information Standard, including: Equality monitoring & reporting Interpretation and translation services Accessible facilities ST08 Contracts with care home / bed-based care providers to set out the legal requirements to follow duties under the Equality Act and Accessible Information Standard, including: Equality monitoring & reporting Interpretation and translation services Accessible facilities ST09 SNC to set out how they intend to meet the Accessible Information Standard in the new service model: James Brown, Head of Communications James Brown, Head of Communications Tim Ryley, Programme Director Gillian Miller, IC Director Commissioning leads Gillian Miller, IC Director Commissioning leads Caroline Drysdale, SNC MD 31/03/2018 AC04; IT04; N04; OP04 (patient engagement and complaints monitored by protected group) 31/03/2018 IT10; N08; OP08 31/03/2018 N06; OP06 (provider contracts) 31/03/2018 IT06 31/03/2018 AC05; N05; OP05 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all 169 Stockport GPs) 27

170 Service Access Agreement on Interpretation service (currently 3 services at SMBC, Primary Care and SFT) Collating data on formats required by patients Equality monitoring process System for sending patients communications in the correct format (e.g. Braille, large print) Service Level Agreements in place for translation of information into other formats (Braille, BSL videos, audio format, other languages) Alternative contact methods to phone for deaf patients (e.g. Text-Relay service; text messaging; ; face-to-face) ST10 Service access to be monitored by protected group and changes as a result of Stockport Together tracked. ST11 Patients and carers views to be sought in the planning of the new venues, including neighbourhood hubs and community bed based care. ST12 Venue of new facilities / clinics assessed to ensure full access, including: Disabled parking Disabled toilets Changing facilities Hearing loops ST13 Transport options for accessing new venues should be widely publicised to family and Caroline Drysdale, SNC MD & work stream operational leads Estates Estates Estates Head of Comms 31/03/2018 IT08 AC09; OP13 (service user data reporting) 31/03/2018 IT09; N07; OP07 31/03/2018 IT11 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all 170 Stockport GPs) 28

171 Staffing carers. ST14 IM&T plan developed to include: Training on how to use any self-care technology Alternative options for patients who are unable to use self-care technology Training on how to use skype technology for virtual appointments Alternative options for patients who are unable to access virtual appointments ST15 Equality Impact Assessment of how the new service models will affect staff ST16 Staff consultation on new service model and any changes to roles / places of work ST17 Develop a staff training plan, including: Equality & Diversity Training Use of interpretation and translation services Equality monitoring to comply with AIS Paul James, IM&T lead Sue Williams, HR lead Sue Williams, HR lead Sue Williams, HR lead 31/03/2018 IT12; N09; OP09 31/03/2018 AC06; IT13; N10; OP10 31/03/2018 AC07; IT13; N11; OP11 31/03/2018 AC08; IT15; N12; OP12 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all 171 Stockport GPs) 29

172 Tel: Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

173 7. APPENDICES 7.1 Appendix 1 The Stockport Context of the EIA Health statistics in Stockport by protected characteristics Age Stockport has a slightly older age profile than the national average, with a greater number of residents aged than the national average and particularly low numbers of residents aged between years 1. The ageing population is a major demographic trend in the borough. Currently there are 50,823 people in the borough aged 65+ and 6,682 people aged 85+, which is well above the national average. 1 Stockport s Joint Strategic Needs Assessment, April 2011 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

174 Percentage of GP registered population over age 65 Percentage of population over age 65 (average is 16.9%) 25% to 35% 17% to 25% 10% to 16.9% 4.5% to 9.9% (11) (75) (93) (11) This map has been reproduced with the kind permission of Ordnance Survey on behalf of The Controller of Her Majesty's Stationery Office. Crown Copyright. Unauthorised reproduction infringes Crown Copyright and may lead to prosecution or civil proceedings. All Rights Reserved. HA Stockport PCT Areas of affluence, including Bramhall, Cheadle and Marple tend to have the highest population of people aged 65+. Concentrations of those aged 85+ can be found across the borough clustering around nursing and residential homes. Percentage of GP registered population over age 85 Percentage of population over age 85 (average is 2.2%) 4.5% to 8% (10) 2.2% to 4.5% (59) 1% to 2.2% (103) 0.1% to 1% (18) This map has been reproduced with the kind permission of Ordnance Survey on behalf of The Controller of Her Majesty's Stationery Office. Crown Copyright. Unauthorised reproduction infringes Crown Copyright and may lead to prosecution or civil proceedings. All Rights Reserved. HA Stockport PCT Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all 174 Stockport GPs) 32

175 Local projections based on the population size in 2009 suggest that Stockport will continue to age, with an additional 12,018 people aged over 65 by Year Population Aged 0-14 Aged Aged ,975 48, ,548 50, ,975 48, ,795 57, ,216 49, ,057 59, ,926 50, ,715 60, ,003 51, ,017 62,841 The biggest increase is expected within the year age group as the post-war baby boomers move into retirement. There are likely to be 3,712 more 85+ year olds by And by 2019 as much as 20.3% of the population could be aged an increase of 9,200 people. The overall aging population, however, is masking an increasing birth rate. Over 3,400 babies were born to mothers resident in Stockport in This follows a national upturn in birth rates, in part due to mothers who delayed first pregnancy in the 1990s starting their families. In addition, Stockport has seen a rise in its relatively small Black and Minority Ethnic population since the last census, among which birth rates and family size are traditionally higher. Analysis of births in 2006/07 shows that more than 10% babies born in Stockport were of Black or Minority Ethnic (BME) ancestry, which is significantly higher than the BME proportion of the local population (just 4.3% at the last census). Births of Asian and Asian British ancestries (chiefly Pakistani) were the most common. Age & Health Emerging national evidence suggests that although people are living longer, the number of years for which they are living in poor health at the end of life is also increasing. The UK s aging population is recognised as having an impact on healthcare, with 35% of people aged 75+ taking 4 or more prescribed medicines. The community healthcare services in Stockport made an estimated 60,800 district nursing contacts with people aged 65+ and an estimated 21,000 contacts with people aged 85+ in 2006/07. Like other parts of the UK, Stockport is facing a major change in health needs as a result of the aging population. In the next five years there will be an additional 2,700 people aged 65 and over. If nothing else changes this will result in: 1,400 additional hospital admissions each year 700 additional A&E attendances 180 extra nursing and residential care beds (equivalent of 6 new homes) 3,400 additional district nurse contacts 900 people requiring help with domestic tasks. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

176 At the last census in 2011, the over 65 population in Stockport reported generally good health, with 77.5% categorizing their health as good or fairly good. Of the 22.5% who reported not good health, there was a clear link to geography. A third of people aged 65+ in Brinnington & Central ward reported that their health is not good. This is half as much again as the Stockport level. Manor and Reddish North wards also have particularly high levels. The Priority 1 areas had significantly high levels, rising to double the Stockport percentage in the Town Centre where 41.1% of people report that their health is not good. The proportion in this age group who are not in good health is about double the proportion in the age group. Currently 6,600 older people aged 65+ and 950 older people aged 85+ live in areas of poverty; as the population ages we can expect this level to rise as the local population ages. Brinnington and Central ward has the highest percentage of older people living in the 20% most deprived areas this accounts for 1,652 older people and is nearly 90% of all older people in the ward. Davenport and Cale Green ward has over a quarter of older people living in the 20% most deprived areas (524 older people) and Offerton ward has a fifth (510 older people). Bredbury Green and Romiley ward also has a high number of older people living in the 20% most deprived areas (510 older people). Cheadle & Gatley and Marple South have the highest number of older residents requiring social care. In 2009, over 10,000 pensioners in Stockport were claiming some type of disability benefit. The rate for Stockport has gone up since 2007 from 52 claimants per 1000 residents to 60 per 1000 in 2009.The ward with the highest rate of Disability Living Allowance claimants is Brinnington & Central where there are claimants per 1000 population. This compares to a rate of 59.5 for Stockport and 65.5 for England. Davenport & Cale Green ward and Reddish North ward also have particularly high rates. Over 60% of people aged over 65 in Brinnington & Central reported having a long term limiting illness in the 2001 census, compared to 49% across Stockport and England. There are also high levels in Davenport & Cale Green ward and Reddish North ward. The percentage of people in this age group reporting a limiting long term illness is almost three times the proportion in the age group. Dementia usually affects older people and becomes more common with age. About 6% of those over the age of 65 will develop some degree of dementia, increasing to about 20% of those over the age of 85. Dementia can also develop in younger people, but is less common, affecting about 1 in 1,000 of those under 65. Although most of the people who develop dementia are over the age of 60, it s important to remember that dementia is not a normal part of growing old, and that most people never develop dementia. Stockport s GP practices have identified a total of 1,538 people on their disease registers for dementia - a level which can be expected to increase over the next five years. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

177 Predicted trends in Stockport dementia cases over time Age & Gender Trends in people with dementia Stockport residents aged 65+ Males Females All Residents Year , ,134 2, ,456 1,489 3, , ,159 2, ,485 1,553 3, , ,235 2, ,550 1,708 3, , ,336 2, ,681 1,907 4, , ,512 2, ,874 2,202 4,643 Source: POPPI Brinnington and Central ward has the highest rate of dementia in the over 16 population, followed by Reddish North ward. Both of these wards have double the Stockport rate of 6.3 per 1,000 people. National estimates (POPPI) suggest that there is significant under-diagnosis of this condition in primary care, and that in fact there are an estimated 3,550 people aged 65+ with dementia in the area; only 40% of whom are known to primary care services. According to the NHS Information Centre, in March 2008 there were 1,175 people aged 65+ registered as blind or partially sighted. There is a clear link between age and loss of sight: 79% of all people registered with Stockport Council as blind were aged 65 or over; and 83% of those registered as partially sighted were over 65. Registered with Age: All people the Council as: Blind Partially Sighted Total However information from the RNIB suggests that 20% of the population aged 75+ will be registered as blind or partially slighted - around 4,900 people in Stockport. Work needs to be undertaken to reconcile these two different sources of information. According to the NHS Information Centre, in March 2010 there were 710 people in Stockport registered as deaf or hard of hearing. Of these people, 565 were aged 65 or over (79.6%),and 500 were aged 75 or over (70.4%). Registered with Age: All the Council as: Deaf Hard of Hearing Total Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

178 Again, the link between loss of hearing and the aging process is very clear in this data. While only 33% of residents registered as deaf are 65+, local pensioners make up 90.4% of residents registered with the council as being hard of hearing. In Stockport it is currently estimated that 7,550 people aged 65+ will not be able to manage mobility activities on their own (e.g. walking out-of-doors, using the stairs or getting in or out of bed), 15,670 people age 65+ will be unable to manage self-care activities on their own (e.g. bathing, feeding or cutting their toenails) and 17,100 will be unable to manage domestic tasks on their own (e.g. shopping, vacuuming or dealing with personal affairs). Rates of falls in the elderly are high in Stockport, particularly in Brinnington & Central Ward at over 8 times the national average. Falls are a major cause of disability and the leading cause of mortality due to injury in older people aged over 75 in the United Kingdom. Carers In 2011, 11.3% of residents said that they provided unpaid care to someone. This figure is marginally higher than the national average of 10%. 2.5% of Stockport residents also report that they provided over 50 hours of unpaid care, similar to the national average of 2.4%. With the number of people requiring complex care packages increasing and the general population ageing, the number of unpaid carers in the borough is likely to increase. Carers are a valuable resource for the health and wellbeing economy of Stockport, but being a carer can have adverse effects on mental wellbeing and financial stability. Carers Health Local engagement indicates that many carers in Stockport are too busy caring for others to think about their own health, leading to missed appointments particularly for preventative measures such as screening. The resulting impact is one of high stress levels and mental health problems. Disability The 2011 census indicates that 18.4% of Stockport residents are living with a limiting long-term illness (long-term illness, health problem or disability which limits daily activities or work). 8 of Stockport s 21 wards have levels of limiting long term illness above the England and Wales average and all of Stockport s Priority 1 areas reported higher levels of LLTIs than the national average. The likelihood of having a disability is not evenly spread across the population. Unsurprisingly, rates of disability increase with age, and for those aged 65+ almost half of all people reported having a long-term condition. Women are more likely than Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

179 men to have a disability, and people from some ethnic and religious groups especially some Asian Muslims appear more likely to report an LLTI or disability. In both cases, the differences tend to become more accentuated at older ages, so for example nearly 2 in 3 Pakistani and Indian women over 65 had a LLTI or disability in According to the NHS Information Centre, 1,505 people in Stockport were registered as blind or partially sighted in March In March 2010 there were 710 people in Stockport registered as deaf or hard of hearing. Stockport provides social services to 4,100 adults as a result of physical disability, frailty or temporary illness and there are 4,309 wheelchair users in the borough. 900 people living in Stockport are currently registered with the Council s Learning Disability Service; 430 children living in Stockport aged 0-17 years are registered on the children s disability databases as having moderate learning disability while 70 are registered as having severe learning disability. Another measure of the number of disabled people in Stockport is the number of vehicle badges in circulation. The Council issues vehicle badges for people who are physically or visually disabled (Blue Car Badges). In 2010, 15,100 people in Stockport held a valid Blue Badge. This equates to around 5% of the local population. However, among residents of retirement age, the figure goes up to almost 25%. (Department for Transport Statistics) Overall in Stockport the uptake of disability related benefits is lower than the national average with 9,900 claiming Incapacity Disablement Allowance (IB/SDA) and 14,400 claiming Disability Living Allowance (DLA). The uptake of IB/SDA is high across all age groups in Brinnington & Central and Davenport & Cale Green wards, although amongst older people uptake also high in Bredbury & Woodley as well as Edgeley & Cheadle Heath, indicating a potential social care demand. Challenges are emerging from rising numbers of people at all ages with complex care needs, highlighted particularly by commissioners but also by the public. Areas of particular concern are CAMHs (Child and Adolescent Mental Health), ADHD (Attention Deficit Hyperactivity Disorder) and autism in children and young people and autism and learning, physical and sensory disabilities for adults. Disability & Health It is important to differentiate between disability and ill-health. Having a disability, impairment or long-term health condition does not automatically mean that a person is in a permanent state of poor health. Nationally, the association between adults with LLTI/disability and poor socioeconomic position is linked to the poor employment prospects of disabled people. Families with disabled children also live in greater levels of poverty in part due to the cost of providing care and the limits that caring for a disabled child can place on parents economic prospects. There is also evidence that you are more likely to have a child with a disability if you are from a lower socioeconomic background (Spencer, N Health Consequences of Poverty for Children. London: End Child Poverty). Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

180 National research by disability charities and health organisations point to the strong link between many of the inequalities faced by people with a disability from educational attainment and unemployment rates to bullying and hate crime to repercussions in mental health and wellbeing. Similarly, research into coping with long-term conditions points to an increased likelihood of suffering from stress, anxiety and depression. In England, more people with an LLTI or a disability have a General Health Questionnaire (GHQ) score of 4 or more - indicating mental health problems - compared to people with no LLTI or disability. Percentage of people in England with a GHQ-12 score of 4 or more People with an LLTI or disability 26% People with no LLTI or disability 7% Whole Population 13% (11% of all men / 15% of all women) Source: Health Survey for England 2008 Research by the Institute for Health Research at Lancaster University in 2007 suggests that children and young people with learning disabilities are 6 times more likely to have mental health problems than other young people. There is also a clear association between disability and obesity. Medication side effects, reduced mobility and socio-economic circumstances could all increase likelihood of obesity. In the 2008 Health Survey for England, 72% of people with an LLTI did not have a healthy weight compared with 61% of those without an LLTI. The Disability Rights Commission s Interim Report in Equal Treatment: Closing the Gap - found that one person in three with a learning disability is obese, compared to just one in five of the general population. Gender Identity Trans is an umbrella term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth. Trans people may describe themselves using one or more of a wide variety of terms, including (but not limited to) Transgender, Transsexual, Gender-fluid, Non-binary, Gender-variant, Crossdresser, Genderless, Agender, Nongender, Third gender, Two-spirit, Bigender, Transman, Transwoman, Trans masculine, Trans feminine and Neutrois. Locally we do not have data on how many people in Stockport identify as Trans. However, approximately 1 in 11,500 people in the world are or have gone through gender transition. Since the legislation has provided protection in services and employment the numbers coming forward for gender transition has started to rise. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

181 Gires reported a 24% increase on the previous year in National estimates now suggest that 1% of the population is gender variant. Gender Identity & Health Gender variance describes the personal discomfort experienced by individuals whose psychological identification as men or as women (the gender identity) is inconsistent with their phenotype and with the gender role typically associated with that phenotype. Both gender role and phenotype may, therefore, be sources of distress. The condition may be experienced to varying degrees, and be expressed in a variety of ways. These may be intermittent or permanent. Sometimes, gender variance that is initially expressed intermittently later becomes permanent. When gender variance is profound and persistent, it is usually referred to as transsexualism. Since it is a subjective experience, it can only be diagnosed in accordance with what is said by the individuals who experience it. There are no tests that provide an absolute diagnosis. Transsexualism is neither a lifestyle choice nor a mental disorder, but a condition that is now widely recognised to be largely innate and that responds well to medical care. Trans people experience some of the most significant health inequalities and frequently experience abuse, harassment and violence. The Count me In Too Survey undertaken in Brighton and Hove in 2008, which had a small sample (N=800) and was geographically specific, nonetheless shows possible differences in the experience of transgender people compared to the population as a whole: 30% of transgender respondents (N=13) said that their physical health was poor or very poor compared to 8% of non-transgender respondents; 44% of transgender respondents (N=19) reported good or very good health status, compared to 77% non-transgender. However, there is currently no clear evidence from the small amount of data available about the levels of long-standing health problems or disability in this population. According to the Department of Health, more than 30% of trans people living in the UK report having experiences discrimination from professionals when accessing a range of health care services. Many people may experience discomfort in their gender from a young age and attempt to repress their feelings and live according to society s rules. Regardless of social position or class after 'coming out', due to limited understanding of their lives, Trans people are at high risk of being shunned by family, friends, colleagues and social networks and these experiences place Trans people at risk of: Alcohol abuse Depression 2 Gender Variance in the UK (GIRES June 2009) Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

182 Suicide (1:3 have attempted suicide [UK / USA]) Self-harm Violence (transphobic behaviour primarily toward MTF) Substance abuse 35% of the Trans population reporting having made at least one suicide attempt prior to accessing the treatment they are seeking and young people experiencing gender dysphoria are at an increased risk of self-harm and overdose. Although social attitudes have become more accepting towards trans people, discrimination and prejudice persist, with a resulting impact on the health and wellbeing of this section of the population. These experiences place many trans people at risk of alcohol abuse, depression, suicide, self-harm, violence, substance abuse and HIV. Mental health problems can sometimes be seen as a potential symptom of wider difficulties that minorities face within society. The UK s largest survey of trans people (N = 872) found that 34% (more than one in three) of adult trans people have attempted suicide. Stockport s recent LGBT Needs Assessment notes: There exists a lack of local and national research into trans communities, with a lack of comprehensive and system wide trans status monitoring meaning that the specific needs of this community, on a national and local level, are often not well evidenced. A 2017 assessment of the needs and experiences of trans people in the UK identified several key areas where trans people experience significant inequalities and substantial barriers, including reduced access to mainstream health and social care services; inequality within specialist gender identity services; poorer mental health; poorer social wellbeing, increased drug and alcohol use; and poorer overall health. In 2016 Manchester City Council embarked on a series of consultations and engagement activities with local trans people and their organisations in order to improve its own data and to explore the prevailing issues and opportunities experienced by Manchester s trans population. Through this consultation, a number of thematic areas emerged which have a significant impact on the lives of trans people. These are: Young People and Education, Health, Housing, and Domestic Violence. A significant proportion of trans people had experienced transphobic bullying or discrimination, with participants also acknowledging high rates of homelessness, low levels of good health, and high prevalence of domestic abuse. It is likely that the themes and findings unearthed in national and local research will correspond to the experiences of Stockport s trans population. 3 3 Stockport LGBT Needs Assessment _Stockport_LGB T_Needs_Assessmen.pdf Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

183 Stockport LGBT Needs Assessment can be found at: Needs-Assessment.pdf Pregnancy & Maternity Stockport s Total Fertility Rate (TFR), calculated as the average number of children per woman, has remained between 1.5 and 2 over the past three decades, rising slightly in recent years. This has been mainly in line with the national average. Over 3,400 babies were born to mothers resident in Stockport in This follows a national upturn in birth rates, in part due to mothers who delayed first pregnancy in the 1990s starting their families. Live births per 1000 population in Stockport Source: Office of National Statistics Birth rates are highest in the more deprived areas of the borough and among ethnic minority groups. In Brinnington one of the priority areas for tackling deprivation birth rates are 50% higher than the Stockport average. In addition, Stockport has seen a rise in its relatively small Black and Minority Ethnic population since the last census, among which birth rates and family size are traditionally higher. Ethnicity Trends in Stockport Births Hospital Births 2006/07 Total Population at 2011 Census White British White Other Mixed Asian / Asian British Black / Black British Other Ethnic Group 89.5% 2.6% 1.3% 4.2% 0.8% 1.6% 89% 3.1% 1.8% 4.9% 0.7% 0.6% Source: Contract Minimum Dataset & ONS Census of Population 2001 Analysis of births in 2006/07 shows that more than 10% babies born in Stockport were of Black or Minority Ethnic (BME) ancestry, which is significantly higher than the BME proportion of the local population (just 4.3% at the last census).births of Asian and Asian British ancestries (chiefly Pakistani) were the most common. Access to Stockport s IVF services over recent years has shown in particular a high rate of service uptake by residents of Pakistani heritage - 5.6% of all patients, despite making up just 1.04% of the local population. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

184 Education services are also reporting increasing numbers of children from BME ancestry reaching school age, along with increasing numbers of children with English as an additional language. Patterns of birth rates show a clear deprivation profile, as deprivation increases so do the numbers of births. General fertility rates in the most deprived areas are 30% higher than the Stockport average and 65% higher than in the least deprived areas. Infant mortality is a rare phenomenon, affecting a fraction of a per cent of children born each year. Age at Death Number of Deaths Percentage 0 day % 1 day % 2-6 days % 7-13 days % days % days % 2-12 months % All Infants Low birth weight is an enduring aspect of childhood morbidity, a major factor in infant mortality, and has serious consequences for health in later life. In Stockport, the number of children with a low birth weight (defined by the World Health Organisation as less than 2500 grams) is lower than the national average and has remained fairly static over the last decade. The only real exception is in Brinnington & Central ward. Over the period of this ward saw a significantly higher proportion of low birth weights than the national average. Over the past decade, this rate has steadily declined to around the national average, but remains above the Stockport level. Death in the next four years of life (age 1 to 5 years) is even more rare with on average only 2 children in this age group in Stockport dying a year. 70% of the deaths over the last 5 years have been as a result of congenital conditions and prematurity, again causes strongly associated with maternal circumstance, smoking in pregnancy and breastfeeding. 3 deaths were due to accidental causes, causes which should be preventable. Overall childhood mortality rates in Stockport (children aged 1-15 years) are very rare, but extremely distressing for families involved. Over the past five years, the main cause of death among children aged 1-15 was accidents, assault and selfharm, which accounted to more than a third of all deaths. Cause Deaths Number Percentage Infectious & Parasitic Diseases 1 3.6% Cancer 2 7.1% Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

185 Endocrine, Nutritional & Metabolic Diseases 1 3.6% Diseases of the Nervous System 0 0.0% Diseases of the Circulatory System % Diseases of the Digestive System 1 3.6% Diseases of the Respiratory System % Congenital Anomalies % Perinatal condition 1 3.6% Accidents, assault and self-harm % Unascertained % Total 28 - The most common reasons for admissions to hospital in the first year of life in Stockport are respiratory and digestion conditions (especially gastroenteritis). There are strong associations between smoking in pregnancy and the home and the risk of chest infections in children. Similarly breast feeding is known to be protective; reducing gastrointestinal disorders in babies and young children. Infant mortality, accident rates, emergency admissions, A&E attendances, teenage pregnancy and poorer educational achievement in school are all associated with deprivation. Immunisation is one of the most important weapons for protecting individuals and the community from serious diseases and, after clean water, is the most effective public health intervention in the world for saving lives and promoting good health. In the United Kingdom, a full programme of vaccination is provided for children up to the age of 2 years, with certain boosters before they join mainstream education, to be taken before they reach 5 years. The primary course protects against diphtheria, tetanus, pertussis (whooping cough), polio, haemophilus influenza type b, pneumococcal infection and meningitis C and is given in a series of injections in the first year of life. After a child reaches 1 year of age they are also offered the MMR vaccine which protects against measles, mumps and rubella (German measles). Pregnancy and Maternal Health Smoking during pregnancy is a key determinant of low birth weight, which in turn is the single most important risk factor in perinatal and infant mortality. Maternal smoking also impacts negatively on the likely future health outcomes of a child. Smoking in pregnancy all Stockport mothers 2006/ / / /10 Number of maternities 3,279 3,316 3,374 3,419 Proportion of mothers smoking 12.4% 15.7% 16.4% 17.8% Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

186 Over recent years, the number of mothers smoking has risen to almost a fifth. The main focus for NHS Stockport is on reducing levels of smoking during pregnancy particularly in deprived areas where the smoking rates and fertility rates are higher. Breastfeeding is accepted as the best form of nutrition for infants, providing all the nutrients a baby needs to ensure the best start in life. Exclusive breastfeeding is recommended for the first six months of an infant's life. Breastfeeding initiation is a good proxy indicator for infant health as infants who are not breastfed are five times more likely to be admitted to hospital with infections in their first year of life. Figures show that in 2006/ % of mothers in Stockport initiated breastfeeding and that 40.5% of new mothers sustained breastfeeding to at least 4 weeks - these figures represented a marked improvement in the long-term trend. With increased investment in health promotion, this trend has continued to rise, so that in 2009/10, 73.8% of all mothers who delivered babies in Stockport were initiating breastfeeding. Race When compared to the national average, Stockport is not particularly ethnically diverse, however, over recent years the ethnic diversity of the borough has increased significantly. In 2001 only 4.3% of the population were from non-white ancestry compared to 8.7% nationally. By the 2011 census 9.6% of Stockport s population came from a non-white background, compared to14.5% nationally. Ethnic Group Stockport North West England White All white categories 90.4% 90.2% 85.5% British 89.0% 87.1% 79.8% Irish 1.4% 0.9% 1.0% Gypsy or Traveller 0.0% 0.1% 0.1% Other White 1.7% 2.1% 4.6% Mixed All mixed categories 1.8% 1.6% 2.2% White and Black Caribbean 0.6% 0.6% 0.8% White and Black African 0.3% 0.3% 0.3% White and Asian 0.5% 0.4% 0.6% Other Mixed 0.4% 0.3% 0.5% Asian All Asian categories 4.9% 6.3% 7.7% Indian 1.0% 1.5% 2.6% Pakistani 2.4% 2.7% 2.1% Bangladeshi 0.2% 0.7% 0.8% Chinese 0.6% 0.7% 0.7% Other Asian 0.7% 0.7% 1.5% Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

187 Black All Black categories 0.7% 1.3% 3.4% Caribbean 0.3% 0.3% 1.1% African 0.3% 0.8% 1.8% Other Black 0.1% 0.2% 0.5% Other All other categories 0.6% 0.60% 1.0% Arab % 0.4% Other Ethnic Group 0.3% 0.3% 0.6% Source: 2011 Census Stockport s ethnic minority populations have a younger age profile on average than the White British population. In 2007, 9.8% of primary school children and 6.9% of secondary school children were from Black and Minority Ethnic groups. In 2006/07, 8.8% of babies born were from Black and Minority Ethnic groups. These trends clearly indicate a continuous growth in Stockport s Black and Minority Ethnic population, which needs to be considered when planning services and undertaking consultation. The geographical spread of ethnic communities indicates a clear east-west divide, with the Eastern side of the borough exhibiting less ethnic diversity, while minority communities tend to live in the western side of the borough, closer to central Manchester. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

188 To the west, Marple & Bredbury, have the least ethnic diversity, with above average white populations. To the East, Cheadle, Gatley & the Heatons have the most diversity. Stockport s Black population is particularly under-represented in Marple and Hazel Grove. Significantly, the pockets of larger black communities are to be found in some of the borough s more deprived wards like Offerton or Brinnington & Central. Heald Green, Cheadle & Gatley and Heatons North wards have particularly well established Asian communities. Mixed race communities are well represented in the Heatons, Cheadle & Gatley, as are the Chinese community and other ethnic minorities. Race & Health Every individual s health is influenced by a number of factors, including their genes, their experiences in life, and the quality of care and treatment they receive when they need it. A person s ethnicity is a complex mix of their country of origin, ancestry, culture, language and religion. Different elements in this picture will be more or less important at different points in time and in different contexts. National evidence indicates that Pakistani and Bangladeshi groups are more likely to report poor health than average. These groups are more likely to experience poor mental health, more likely to report a disability or limiting long-term illness, and more likely to find it hard to access and communicate with their GPs than other groups. It is unclear how far these worse-than-average outcomes are related to Pakistani and Bangladeshi people s relatively poor socio-economic position. At the last census, there were marked variations in rates of long-term illness or disability which restricted daily activities between different ethnic groups in England and Wales. After taking account of the different age structures of the groups, Pakistani and Bangladeshi men and women had the highest rates of disability. Rates were around 1.5 times higher than their White British counterparts. Chinese men and women had the lowest rates. In some groups the difference between men and women in their rates of disability was much greater than in others. In the Indian, Pakistani, Black Caribbean and Black African groups, women had higher rates than men. In the White British and White Irish groups it was men who had higher rates than women. Statistically, BME groups have higher rates of diabetes, smoking, heart attacks, cancer, and mental health problems, but lower levels of screening and healthcare access. New migrant communities have different health needs from established minority communities, and increasing ethnic, linguistic and cultural diversity demands new responses from health services. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

189 Asylum seekers and refugees have particular health concerns due to the impact of relocation and possible past experience of trauma. Research is generally limited on their general levels of health due to the hidden nature of the population. Asylum seekers and refugees may be affected by: the impact of detention, particularly on children if they are detained Difficulties accessing GP treatment and consequent increased reliance on Accident and Emergency services Uncertainty and lack of clarity among service providers about asylum seekers eligibility for secondary healthcare services resulting in care being withheld in some cases Inadequate response to communicable diseases, particularly Tuberculosis. The health of asylum seekers with HIV/AIDs is negatively affected by the policy of dispersal at short notice and chargeable HIV treatment for refused asylum seekers. Also the human rights implications around the deportation of failed asylum seekers with HIV/AIDS Ethnicity is not systematically recorded by cancer registries in the UK. As a result, the evidence of potential cancer inequalities within and between BME communities is often produced through smaller scale studies, which are statistically less reliable. Cancer Incidence By Major Ethnic Group, England, Age White Asian Black Chinese Mixed Other Unknown Total ,889 3,270 2, ,403 43, , ,279 3,415 3, , , ,332 All 435,168 6,685 6, ,058 3, , ,595 Source: Hospital Episode Statistics (HES) Generally, people from black and minority ethnic groups are at a significantly lower risk of getting cancer than the white population. However, differences were found for some specific cancers: Asians are at a significantly lower risk of getting any of the four major cancers (breast, prostate, lung and colorectal), plus several other less common cancer sites (including cancers of the bladder, brain and CNS, kidney, oesophagus, ovary, pancreas and malignant melanoma of the skin) Black communities have a significantly lower risk of getting three of the four major cancers (breast, lung and colorectal), plus several other less common cancer sites (including cancers of the bladder, brain and CNS, oesophagus, ovary, pancreas and malignant melanoma of the skin) Both the Chinese and Mixed ethnic groups tended to have significantly lower incidence rates than Whites for each of the four major sites of cancer examined Mouth cancer rates are higher among Asian women and South Asians of both genders Asian women aged 65 and over have a higher risk of cervical cancer, but under the age of 65 the chances of getting cervical cancer are significantly lower among Asian women than white women Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

190 Liver cancer is between 1.5 and 3 times more likely in Asians than in Whites In comparison with white ethnic groups, black people have significantly higher rates of multiple myeloma and stomach cancer Black males of all ages have significantly more likely to have a diagnosis of prostate cancer than white men Both males and females from the Black ethnic group also have higher rates of cancers of the stomach, liver as well as myeloma Black females, aged 65 years and over, have a higher risk of cervical cancer compared with Whites And a 2008 study suggests that breast cancer occurs at a younger age, and as a more aggressive tumour type among black women (Rowen et al., Early onset of breast cancer in a group of British black women, British Journal of Cancer, 2008). Lifestyle behaviours of different ethnic groups have a big impact on cancer rates some positive and some negative: BME communities tend to eat more fruit and vegetables than the general population BME groups also tend to have a lower fat intake in their diets BME communities, apart from the Irish, were found to be much less likely to exceed recommended drinking levels or binge drink Minority ethnic groups tend to have lower levels of participation in exercise Black African and Black Caribbean communities are more likely to be obese than the general population Among men smoking rates appear to be higher among a range of different BME communities, including Bangladeshi, Caribbean, and Chinese For women, rates of smoking are generally lower in BME communities BME communities tend to have higher levels of chewing of tobacco and related products. Although nationally this is quite rare, a study of the Bangladeshi community for the British Dental Journal found 78% of those questioned chewed tobacco products. (Williams, Dental services for the Bangladeshi community, British Dental Journal, 1999). Awareness and access to screening programmes is another major factor. Nationally, Black and Minority Ethnic groups are less likely to take part in cancer screening programmes. 43% of Black and Minority Ethnic Women do not practice breast awareness at home, 45% of Black and Minority Ethnic Women over 50 years have never been to a breast screening, 75% of which say this is because they have never been invited. Attitudes to using preventative services and to specific diseases, as well as the (real or perceived) attitudes of service providers to BME individuals, may act as barriers to uptake of vital screening services. At the same time it is important to remember that BME communities are dynamic between generations, with second generation migrants often having information and support needs more similar to the indigenous population, rather than those of their parents. Only half of people who are of South Asian heritage are likely to take up bowel cancer screenings, which drops to a quarter for Muslims. This is in comparison to two-thirds of people who are not Muslim or not of South Asian heritage. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

191 There is considerable research nationally which demonstrates that South Asian people living in the UK are 50% more likely to die from coronary heart disease that there White counterparts. (Bhopal et al Ethnicity and socioeconomic inequalities in coronary heart disease, diabetes and risk factors in Europeans and South Asians, Journal of Public Health Medicine, 25, 2, pp , 2004). Men born in South Asian but living in the UK are 50% more likely to have a heart attack or angina and Black adults living in the UK but born in the Caribbean are 50% more likely to die from a stroke related incident that the UK average (Race for Health). Patterns of mental wellbeing by ethnicity are complex and there are ongoing debates as to how assessment of this issue is affected by cultural and or linguistic differences. In the Health Survey for England 2004, Pakistani men and women, and Bangladeshi men had higher risk of high GHQ-12 scores than the general population Gender Percentage of people with a GHQ-12 score 4 or more by ethnicity Black Caribbean Black African Indian Pakistani Bangladeshi Chinese Irish General Population GHQ 13% 11% 16% 15% 18% 9% 12% 11% of 4+ Male Risk ratio GHQ 18% 19% 14% 20% 15% 13% 15% 15% of 4+ Female Risk ratio Risk ratios compared the prevalence for a given ethnic minority group with the prevalence in the general population, after adjusting for age in each group. For example, a risk ratio of 2.0 means that a particular group is twice as likely as the general population to have that condition. Source: Health Survey for England 2004 Rates of admission and of compulsory detention in mental health institutions are higher among Black Africans, Black Caribbean, mixed White/Black Caribbean, White/Black African and also Black other groups which represents an enduring and worrying inequality (Care Quality Commission Count me in 2009) a factor which may be reflected in the higher rates of suicide among young Black Caribbean and Black African men aged years. Black and Minority Ethnic people in the UK are up to 44% more likely to be detained under the Mental Health Act compared to the average, and rates of admission into hospital are three or more times higher for black and white-black mixed groups compared with the average. The rate of depression is 60% higher in BME groups, and young Asian women are twice as likely as young white women to commit suicide. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

192 Almost one in five people of South Asian origin living in the UK will develop diabetes, compared to one in twenty-five among the general population. This increased prevalence is coupled with earlier disease onset: UK South Asian people tend to develop diabetes eleven years earlier than their white counterparts (at age forty-six versus age fifty-seven) and at a Body Mass Index less than their white counterparts (Mukhopadhyay et al., A comparison of glycaemic and metabolic control over time among South Asian and European patients with Type 2 diabetes, Diabetic Medicine, 2006). According to research as part of the 1999 Health Survey for England, Bangladeshi men were the most likely group in England to smoke cigarettes (44%), followed by White Irish (39%) and Black Caribbean men (35%). Men from each of these ethnic groups were more likely to smoke than men in the general population (27%). Chinese men (17%) were the least likely to smoke. Similar proportions of Pakistani (26%) and Indian (23%) men smoked as in the general population. Like men, White Irish and Black Caribbean women had the highest smoking rates in 1999 (33% and 25% respectively), although only White Irish women had a rate higher than the general population (27%). However, unlike men, women in every other minority ethnic group were much less likely to smoke than women in the general population. Although very few Bangladeshi women smoked cigarettes, a relatively large proportion (26%) chewed tobacco. This method of using tobacco was also popular among Bangladeshi men (19%), but they tended to use it in conjunction with cigarettes. Religion or Belief The majority of Stockport residents are Christian (63.2% - down from 75% at the last census), which is 4% greater than the national average. 25.1% of Stockport residents have no stated religion, which is 11% higher than at the previous census. Religion Stockport % National Figure Buddhist 0.3% 0.5% Christian 63.2% 59.4% Hindu 0.6% 1.5% Jewish 0.5% 0.5% Muslim 3.3% 5.0% Sikh 0.1% 0.8% Other religion 0.3% 0.4% No religion 25.1% 24.7% Religion not stated 6.5% 7.2% Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

193 Compared to England, Stockport has fewer residents with a religion that is not Christian. However, over the past decade the numbers have increased significantly from 3.7% to 5.1% of Stockport residents. Religion & Health Religious belief may affect the acceptability of aspects of medical care (e.g. diagnostic procedures, certain types of treatment) and also of the potential impact of religious observances on health and/or treatment plans e.g. during periods of fasting. Nationally, statistics point to a link between religion or belief and health. In particular, minority religious groups in the UK exhibit worse general health. However, locally this correlation is less apparent, possibly due to the geographic spread of Stockport ethnic and religious minority groups, who are less likely to be concentrated in areas of deprivation than the national trends. The 2001 Census data for Britain revealed large differences in self-reported not good health between religious groups. Among men, not good health was highest among Muslims (13%) and those reporting Any other religion (12%) and lowest among Jewish men (7%). Among women, the highest percentage was again among Muslims (16%) with the percentage among Sikhs (14%) and Any other religion (14%) also being high, and lowest again among the Jewish group (7%) (compared to around 8% for Christian men and women). Locally, health reporting among the Christian population mirrors almost exactly the Stockport trends. Religion Good Health Fairly Good Not Good Life Limiting Health Health Illness Buddhist 60.26% 30.46% 8.79% 12.87% Christian 67.79% 22.52% 9.69% 18.98% Hindu 72.93% 20.09% 5.83% 13.27% Jewish 77.20% 15.84% 6.12% 13.38% Muslim 73.52% 19.18% 6.94% 13.10% Sikh 57.27% 21.59% 5.29% 13.22% Other religion 59.57% 27.93% 9.72% 25.46% No religion 74.67% 19.03% 6.32% 10.92% Religion not stated 72.36% 19.05% 8.58% 19.39% All Stockport 69.61% 21.82% 9.09% 17.80% The local Hindu, Jewish & Muslim populations reported above average levels of good health compared to the average Stockport population. While the Buddhist, Christian, Sikh & other religion communities reported lower than average levels of good health this was made up for by significantly higher than average levels of fairly good health. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

194 Not good health was particularly low among the Hindu and Sikh communities. And reports of life limiting illness were fairly consistent across religious groups, the lowest reports being among atheists and the highest among other religious groups. Sex Stockport s population is split almost equally by gender (51.1% female, 48.9% male), which mirrors the national trend. Area Population Male % Female % Stockport 283, , % 144, % Greater Manchester 2,601,000 1,325, % 1,357, % However, significant differences appear in the gender breakdown of older people with 19.3% of people over 65 being women also reflected nationally. Life expectancy in Stockport is higher for women at 83 years, compared to 79.7 years for men. New experimental evidence for healthy life expectancy suggests that women, although living longer, experience disability at an earlier age than men. Locally, female healthy life expectancy is 64.9 years compared to 65.5 years for men. This is an important finding if proven; a thorough investigation of healthy life expectancy locally is on-going. Gender & Health Nationally, there is evidence across a range of health services that patterns of access, uptake and treatment diverge between women and men. The patterns are, however, complex, so that both men and women appear to be disadvantaged in some areas of healthcare. Men tend to access GP services less often than women this may only in part be based on need but on the appropriateness of services and how accessible they are to men. They also appear to ignore symptoms of ill health and delay seeking healthcare more often than women. Men may be more likely than women to self-medicate in harmful ways, e.g. through use of alcohol and drugs when experiencing mental distress. However, there is evidence that maternity services frequently fail to provide satisfactory services to women, and particularly to women from ethnic minority backgrounds (Allmark 2010). Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

195 Cancer became the most common cause of death for females in 2006 and remained the second most common cause of death for males. For males, death rates from cancer peaked in 1984 at 2,899 per million and subsequently fell to 2,201 per million in Death rates from cancers for females reached a peak in 1989, at 1,905 per million, and then fell gradually to 1,569 per million in Between 1971 and 2008, the age-standardised incidence of cancer has increased by around 24 % in males and 49 % in females. There is evidence from varied sources that men are less likely than women to take up preventive measures, such as screening. For instance, the evaluation of phase 2 of the National bowel cancer screening programme in England found lower rates of uptake in men than women (48% versus 56%). Number of Cancer Area Registrations Number of Deaths Male Female Male Female Stockport North West 14,700 15,000 9,640 8,990 England 105, ,000 67,300 61,900 UK 134, ,000 85,100 78,500 There are clear gender differences when specific mental health disorders are examined. Anxiety, depression and eating disorders are more commonly reported in women, substance misuse and anti-social personality disorders are more commonly reported in men. For men, there are particular concerns around the under-diagnosis, and therefore lack of treatment for mental health conditions which are not captured in evidence in the previous points. These are believed to account, at least in part, for the much higher risk to men of becoming homeless or being imprisoned, for example. Nationally, women are more likely than men to receive treatment for minor mental health conditions. However, more than twice as many male as female psychiatric inpatients are detained and treated compulsorily (Allmark 2010). Men (66%) are significantly more likely than women (55%) to be overweight or obese. However, despite this men are hugely under-represented in weight management programmes. For example, only 26% of people attending scheduled weight loss management programmes in GP practices, 26% of participants of in Counterweight, a national primary care intervention programme, and 12% of attendees of a pilot partnership programme involving Slimming World were men. National data suggests that women are more likely to eat healthily than men, but many women do not get enough exercise. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

196 Sexual Orientation There is a lack of reliable data available regarding the profile of lesbian, gay & bisexual community in Stockport and indeed in the UK. However, the government estimates that between 5% and 7% of the UK population is lesbian or gay, which is also accepted by Stonewall. This would equate to around 14-20,000 people in the borough. In the Integrated Household Survey included a question about sexual orientation for the first time. 95% of adults identified themselves as Heterosexual/Straight 1% of adults identified themselves as Gay or Lesbian 0.5% of adults identified themselves as Bisexual 0.5% identified themselves as Other just under 3% of adults stated they Don t know or Refused the question fewer than 1% of respondents provided No response to the question Sexual Identity Men Women All Adults Heterosexual / Straight 94.6% 94.9% 94.8% Gay / Lesbian 1.3% 0.6% 1.0% Bisexual 0.3% 0.7% 0.5% Other 0.5% 0.5% 0.5% Don t know / Refusal 2.8% 2.9% 2.8% No response 0.6% 0.4% 0.5% Source: Integrated Household Survey April 2009 March 2010, ONS Broken down by region, the percentage of respondents identifying themselves are gay / lesbian or bisexual adults goes up to around 1.5% in the North West. 0.2% of people in the 2011 census were in a civil partnership a figure which is consistent across Stockport, the North West and nationally. In 2017 Stockport published its first ever LGBT Health Needs Assessment. Local research demonstrates that those in younger age groups are more likely to identify as LGBT, probably due to the increase in social acceptability of coming out within this age group. This may account for the higher percentage of LGB people in work and lower percentage retired than for the heterosexual population of Stockport. This is likely to change over time, as these individuals age, leading to an overall increase in the percentage of the population. Stockport s highest concentration of LGBT people appears to be in the North West of the town. This is likely to continue to be the case due to expected changes in housing. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

197 The Integrated Household Survey 2014 found the likelihood of an adult declaring an LGB identity decreased with age. In 2014, 2.6% of adults aged 16 to 24 identified as LGB, decreasing to 0.6% of adults aged 65 and over. A YouGov poll in 2015 found that 49% of young people did not identify as exclusively heterosexual 4, which may indicate higher prevalence of LGB identities within the under-18 age group, or a higher prevalence of willingness to be open about having an LGB identity within this age group. 4 YouGov Poll, August Available: Archive %20Sexuality.pdf Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

198 In 2014, twice as many men responding to the IHS identified themselves as gay (1.5%) when compared with women who identified themselves as gay or lesbian (0.7%). By contrast, women were more than twice as likely to identify themselves as bisexual (0.7%) compared to men (0.3%). These statistics are closely matched with the 2013 IHS. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

199 Sexual Orientation & Health Data for England and Wales from the Citizenship Survey in 2007 indicates that perceived health levels for LGB respondents were largely similar to heterosexual respondents, and similarly that there is no significant difference between levels of LLTI/disability. Prescription for change, a large-scale opportunistically recruited survey which explored the general health of over 6,000 lesbian women from England, Scotland and Wales reported similar findings: 80% of lesbians who completed the survey reported good or excellent health whilst 2% reported not good health. In the 2009/10 household survey, gay men and lesbian women (80.4%) were marginally more likely than heterosexuals (78.8%) to report being in good health, but bisexuals (73.6%) were much less likely to report being in good health. Adults aged over 18 who identified as LGB were more likely to be smokers, or to have smoked in the past, than those who identified as heterosexual: 22.7% of heterosexual respondents reported currently smoking cigarettes and 34.9% were ex-smokers. In comparison, 33.3% of people who identified as LGB currently smoked and 32.4% were ex-smokers 42.4% of adults who identified as heterosexual have never smoked, compared with 34.3% of people who identified as LGB Adults aged 18 and over who identified as bisexual were less likely to smoke than those who identified as gay or lesbian: 39.8% of bisexual respondents had never smoked compared with 31.5% of gay and lesbian respondents. Although the majority of LGB people do not experience poor mental health, research suggests that some LGB people are at higher risk of mental disorder, suicidal behaviour and substance misuse. According to Stonewall, 42% of gay men have clinically recognised mental health problems compared with just 12% of predominantly heterosexual men, but 55% of gay men are scared to come out to their GPs due to fear of homophobia or confidentiality issues. Gay men are at higher risk of sexually transmitted infections (STIs), including chlamydia, syphilis, hepatitis and herpes. Rates of gonorrhoea among gay men in England have climbed steadily over the last 10 years. GMFA estimates that in 2005 almost 4,000 gay men were treated for gonorrhoea in sexual health clinics in England, with incidence being considerably higher in London than in other areas (Gay Men Fighting AIDS Health behaviour can differ between lesbian women and heterosexual women: they attend less frequently for routine screening tests such as mammography and cervical smears, and may therefore be less likely to benefit from early detection of cancers (Cochran, SD, Mays, VM, Bowen, D et al. (2001) Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women, American Journal of Public Health). Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

200 National data makes it clear that there is a real gap in awareness about cancer screening needs both among lesbian women and healthcare professionals: as few as 64% of lesbians, compared to 80% of all women, have had a cervical screening in the past 3 years 15% of lesbian and bisexual women over the age of 25 have never had a cervical screening, compared to 7% of women in general over half of lesbians have had no sexual health screening in the last 3 years approximately 75% of lesbians have had sexual intercourse with the opposite sex, but penetrative sex is not the only contributing factor to cervical cancer 10% of lesbians have shown smear abnormalities In a national survey, 12% (128 out of 1,066) of eligible lesbians had never had a smear test. Those surveyed were also less likely to practise breast awareness on a regular basis and were less likely to re-attend for breast screening (Fish, J and Anthony, D (2005) UK national lesbians and health care survey, Women and Health). Being lesbian is not a risk factor for breast cancer, but there are a number of lifestyle issues that may increase their risk (Fish, J and Wilkinson, S (2003) Understanding lesbians healthcare behaviour: the case of breast self-examination, Social Science and Medicine), such as being: more likely to delay childbirth (until their 30s); less likely to have children; less likely to seek regular gynaecological care; more likely to be overweight; and more likely to drink alcohol than heterosexual women. Stockport LGBT Needs Assessment can be found at: Needs-Assessment.pdf Socio-Economic Status Although Stockport as a whole is a relatively affluent borough, there are particular areas within the borough that have high levels of deprivation. Heaton s & Tame Valley are the most deprived areas, especially the Brinnington & Central wards. Other significant areas of deprivation are Stepping Hill & Victoria. There are also smaller pockets of deprivation in Bramhall & Cheadle and Marple & Werneth that are masked by analysis even at ward level. 11% of the population live in one of 22 small areas that fall within the top 20% most deprived in England. Stockport has a slightly higher than average rate of people who are economically active (69% compared to 67% nationally). However, this can vary significantly across wards, for instance in Brinnington just 59% of people are economically active. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

201 The gap in life expectancy between Stockport most affluent and deprived areas is currently 13.6 years for men and 9.9 years for women, highlighting the key impact of deprivation on health outcomes. This remains a major priority in Stockport and a key issue in the Health & Wellbeing Strategy. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

202 7.2 Appendix 2 Workforce Profiles 100% Gender Balance 90% 80% 70% % of staff 60% 50% 40% 30% 20% 10% 0% Primary Care Community Acute Care Mental Health Social Care Female 84% 91.00% 78.05% 79.85% 74.35% Male 16% 9.00% 21.95% 20.15% 25.65% % Ethnicity % 80.00% % of staff 60.00% 40.00% 20.00% 0.00% Primary Care Community Acute Care Mental Health Social Care BME 23.13% 5.57% 17.58% 13.73% 10.73% White 76.87% 94.43% 82.42% 86.27% 89.27% Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

203 50 Age profile Primary Care Community Acute Care Mental Health Social Care % Working Patterns % 80.00% % of staff 60.00% 40.00% 20.00% 0.00% Primary Care Community Acute Care Mental Health Social Care Full-time 37.25% 57.95% 50.43% 56.95% 64.63% Part-time 62.75% 42.05% 49.57% 43.05% 35.37% Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

204 Stockport Together AMBULATORY CARE BUSINESS CASE Equality Impact Assessment Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 204 and Viaduct Health (a federation representing all Stockport GPs) 1

205 1. Introduction The partner organisations across Stockport (Stockport NHS Foundation Trust, NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust, Stockport Metropolitan Borough Council and Stockport s GP federation, Viaduct Care) are working alongside GPs and voluntary organisations to develop a single strategic plan to improve health and social care services across the borough Stockport Together. Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current fragmented form, the health and social care system is financially unsustainable. If no changes are made, by 2010/21 there will be a combined deficit of 156m across Stockport s health and social care services. The Stockport Together programme aims to create a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bed-based care. In doing this, we want to ensure that our plans are fair and support all community groups. 2. The Public Sector Equality Duty The Public Sector Equality Duty, as set out in the Equality Act 2010, requires public authorities, in the exercise of their functions, to have due regard to the need to: eliminate unlawful discrimination, harassment and victimisation advance equality of opportunity between different community groups foster good relations between people who share a protected characteristic and those who do not. The Act explains that having due regard for advancing equality involves: removing or minimising disadvantages suffered by people due to their protected characteristics taking steps to meet the needs of people from protected groups where these are different from the needs of other people encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Having due regard to the need to foster good relations between persons who share a relevant protected characteristic and persons who do not share it involves having due regard, in particular, to the need to: tackle prejudice, and promote understanding. Compliance with the duties may involve treating some persons more favourably than others; but that is not to be taken as permitting conduct that would otherwise be prohibited by or under the Equality Act Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 205 and Viaduct Health (a federation representing all Stockport GPs) 2

206 The characteristics given protection under the Equality Act 2010 are: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation Equality Analysis is a way of considering the effect on different groups given protection under the Equality Act. There are a number of key reasons for conducting an Equality Analysis, including: to consider whether the policy will help eliminate unlawful discrimination, harassment and victimisation to consider whether the policy will advance equality of opportunity between people who share a protected characteristic and those who do not to consider whether the policy will foster good relations between people who share a protected characteristic and those who do not to inform the development of the proposed policy. 3. Scope of this Impact Assessment A full equality impact assessment of the Stockport Together programme has been undertaken and can be found on our website at: The high level Strategy is backed up by four detailed work streams, which each address changes to different service areas: Neighbourhoods (Healthy Communities and Core Neighbourhood Services) Intermediate Tier Services Acute Interface Ambulatory Care Acute Interface Outpatients The purpose of this document is to look in detail at the practical and operational impacts of proposed changes to the way Ambulatory Care is provided. Actions arising from this impact assessment will be embedded into the Ambulatory Care implementation plan and monitored as part of delivery by the Stockport Together Programme Management Office. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 206 and Viaduct Health (a federation representing all Stockport GPs) 3

207 4. Equality Impact Assessment 1. Name of the Strategy / Policy / Service / Project 2. Champion / Responsible Lead 3. What are the main aims? AMBULATORY CARE EIA Stockport Together Ambulatory Care Business Case Margaret Malkin, as Director of Integrated Care for SNC, supported by: Dr Karl Bonnici, Associate Medical Director Dr Jen Harrup, Associate Director Sue Plummer, Associate Director of Nursing Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current fragmented form, the health and social care system is financially unsustainable. If no changes are made, by 2010/21 there will be a combined deficit of 156m across Stockport s health and social care services. We believe that a reconfiguration of existing services is required to reduce waste, to coordinate care for our most vulnerable service users and to meet the growing demand for health and social care within our combined budgets. Changes to the operation of the Emergency Department will be introduced to include: Implementing primary and secondary care Collaborative Triage; Providing of a co-located primary care Ambulatory Illness Team; and extending the operating hours of the Ambulatory Care Unit. The proposed model will strengthen triage arrangements improving the seniority of front-end decision makers, including primary care expertise access to clinical staff to patients electronic record with appropriate safeguards, and improving decision making protocols and pathways. Behind the ED triage there will be a new primary care service operating 8am to midnight 7 days per week to address peak periods of demand. It will meet the needs of the ambulatory ill who do not require full ED services. It is anticipated this service will see 315 people per week on average, leaving ED staff free to meet more serious needs more promptly. This business case proposes increasing the Ambulatory Care Unit s capacity and opening hours so that it will go from seeing 160 people per week to seeing 350 people per week and be open 8am to midnight 7 days per week reflecting known periods of demand. The unit will diagnose, treat, stabilise and discharge people where their condition does not require overnight hospital care but short-term medical input. Planned additional capacity along with access to GP records for the clinical team, revised pathways and dedicated Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 207 and Viaduct Health (a federation representing all Stockport GPs) 4

208 specialist staff and equipment will reduce admissions through ED by 40 per week. More importantly it will ensure people who need a brief medical intervention are treated quickly and returned home safely rather than being admitted unnecessarily. 4. List the main activities of the project: 5. What are the intended outcomes? 6. Who currently uses this service? Implement collaborative triage and streaming function in Stepping Hill Emergency Department Implement new primary care specialist stream in Stepping Hill Emergency Department Extend the hours of the Ambulatory Care Unit Stepping Hill emergency department and improve flow to manage patients home safe that day through effective utilisation of ACU pathways. Ultimately, Stockport Together aims to develop a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bedbased care. The Ambulatory Care work stream of Stockport Together should: Reduce the number of patients with an ambulatory care condition presenting at ED who are subsequently admitted to a hospital bed Reduce the proportion of people presenting at the front door of ED who are subsequently managed in the ED Address the management and flow of undifferentiated ambulatory care patients through the ED Contribute to the reduction in the number of admissions of patients with ambulatory care conditions admitted to hospital across the economy Contribute to the reduction in the proportion of people attending ED who are admitted for any reason Contribute to delivering the ED NHS constitution indicator of 95% of people seen within 4 hours Contribute to the move towards 7-day working Contribute to an improved working environment in the ED Ensure that the financial benefits of the changes will be greater than the costs incurred across a 3 year period. IMPACT ON SERVICE USERS Any person presenting to Stepping Hill Emergency Department (including direct referrals from Stockport GPs). The number of people attending the Emergency Department at Stepping Hill Hospital is average for the Greater Manchester area, however the number of those urgent attendances which result in an admission to hospital is high. Stockport s Joint Strategic Needs Analysis reports that there are around 94,000 ED Attendances made by Stockport residents each year. Attendances are highest for children and over 65s. Trends of ED attendance by deprivation show a similar pattern as admissions with rates far higher in the most deprived areas at all ages. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 208 and Viaduct Health (a federation representing all Stockport GPs) 5

209 Anecdotal evidence suggests that homeless people, asylum seekers, refugees and those new to the country are more likely to use the ED due to difficulties registering with a GP or a lack of awareness of local services. Men and residents in the more deprived areas of Stockport are also more likely to use the ED as the main access point to healthcare as they are less likely to attend their GP practice, screening and preventative services. Weekly number of attendances at the Emergency Department at Stepping Hill (April 2016) Stockport has a high non-elective admission rate per head of population, and a higher than typical proportion of those attending the ED are admitted (c30%). All Emergency Admissions MCP Sites & England Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 209 and Viaduct Health (a federation representing all Stockport GPs) 6

210 Emergency Admissions - Activity (per 1,000 population) Vanguard: Stockport Together - NCM: MCP (14Q4-15Q3) Stockport Together MCP Vanguards Non-NCM 140 Emergency Admissions - Activity (per 1,000 population) Tower Hamlets Integrated Provider Partnership Principia Partners in Health Better Local Care (Southern Hampshire) Lakeside Healthcare (Northamptonshire) Wellbeing Erewash Non-NCM Encompass (Whitstable, Faversham and Canterbury) Calderdale Health & Social Care Economy West Cheshire Way MCP Modality Birmingham & Sandwell All together better Sunderland West Wakefield Health & Wellbeing Ltd Fylde Coast Local Health Economy Dudley Multispecialty Community Provider Stockport Together One of the areas where Stockport benchmarks high is in admissions for people with Ambulatory Care Sensitive Conditions, where effective management in the community should prevent the need to attend the hospital. As such, people with a disability and their carers tend to be higher users of the ED.- Unplanned Hospitalisation for those with Ambulatory Care Sensitive (ACS) conditions Further information on protected characteristics within Stockport s population can be found in the full Equality Impact Assessment of the Stockport Together Strategy: Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 210 and Viaduct Health (a federation representing all Stockport GPs) 7

211 A breakdown of local service users and their needs can also be found in Stockport s Joint Strategic Needs Assessment: 7. Are there any clear gaps in access to this service? (e.g. low access by ethnic minority groups) 8. Are there currently any barriers to certain groups accessing this service? (e.g. no disabled parking / canteen doesn t offer Kosher food / no hearing loop) 9. How will this project change the service offered? (is it likely to cut any services?) The Emergency Department is open 24/7 to anyone who arrives at the hospital. Access tends to be higher among a number of protected groups for various reasons: Men are less likely to attend their GP practice and instead use A&E as a last resort Similarly, residents in more deprived areas of Stockport, who are less likely to attend screening, preventative and primary care, are higher users of the ED ED attendances are high among young children and older patients Refugees, asylum seekers and new residents who are unaware of community services tend to rely on hospital care Homeless people who struggle to register with a GP practice also tend to rely on the ED for medical care. The Emergency Department is open 24/7 to anyone who arrives at the hospital, However, community groups have noted particular issues accessing emergency care for those with English as a second language and for deaf patients, who struggle to find interpretation and often have to rely on distressed and untrained family members to translate. Local residents have noted issues with the lack of car parking available at the hospital site, as well as the cost of parking charges, which is particularly felt by those from deprived areas, the unemployed, pensioners and carers. The proposed changes to the ED service will result in: Enabling more people to be effectively managed home on the same day of ED attendance Preventing unnecessary hospital stays and by doing so preventing complications related to a hospital stay (infections, muscle weakness, reduced confidence / skills) Avoiding duplication More joined up working between health and social care and with third sector. This project will change processes to improve the quality of clinical referrals and reduce unnecessary surgery or treatment. As such, it should have a positive impact on all service users, particularly those protected groups who are more likely to attend the ED. 10. If you are going to cut There are no cuts to services as a result of this business case. All patients will be seen by an appropriately qualified clinician on presentation at ED. Anybody Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 211 and Viaduct Health (a federation representing all Stockport GPs) 8

212 any services, who currently uses those services? (Will any equality group be more likely to lose their existing services?) 11. If you are creating any new services, who most likely to benefit from them? (Will any equality group be more or less likely to benefit from the changes?) 12. How will you communicate the changes to your service? (What communications methods will you use to ensure this message reaches all community groups?) who attends ED and is assessed as requiring more intensive support whether short-term or requiring a bed will receive the necessary care. People attending ED will have access to the most appropriate health professional to manage their level clinical need in a timely fashion. The new service will be equitable for all groups. The main beneficiaries will be people with Ambulatory Sensitive Conditions which will include many people with various long-term conditions. Many of these people will be older and people with a disability. Patients should see no real change when they attend ED as this is mainly a procedural change. However, the design and implementation of the service has been undertaken in consultation with various groups, including staff engagement sessions, attending GP locality meetings, partnership working with ambulance service, patient reference groups, Citizens Reference Panel, patient stories to highlight change, information at GP practices, newsletters and information at website and social media. Public engagement and consultation included meetings with local groups representing protected characteristics to ensure that all voices were heard and all concerns / impacts understood. Information was disseminated in a range of formats: Online survey Paper surveys Public events Fliers and consultation documents handed out in clinics and displayed in Libraries, Pharmacies and GP Practices The consultation document included a message explaining how information could be obtained in an alternative format. Events were undertaken in accessible local venues across each area of Stockport, offering interpretation where required. 13. What have the public and patients said Engagement with the Citizens Reference Panel was received positively. Representatives felt it would ensure people s health would be managed in the most appropriate way according to clinical need. (See Section 5.1 in the main Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 212 and Viaduct Health (a federation representing all Stockport GPs) 9

213 about the proposed changes? (Is this project responding to local needs?) 14. Is this plan likely to have a different impact on any protected group? Age Carers Disability business case). A full write up of engagement can be found on the Stockport Together website at: Can you justify this differential impact? If not, what actions will you add into the plan to mitigate any negative impacts on equality groups? IMPACT Young children and older people are high users of the Emergency Department and, as such, are more likely to be impacted by the changes ED admissions are particularly high among people with ACS conditions. A such, their carers are likely to be impacted by the changes ED admissions are particularly high among people with ACS conditions, who are covered by the protected characteristic of disability. MITIGATION This represents a positive impact on a protected group which is objectively justifiable under the Equality Act, as the changes aim to ensure that everyone attending the ED is seen by the most appropriate clinician and receives the right course of treatment for their needs, reducing unnecessary hospital stays which can have negative impacts on health and independence. Again, this represents an objectively justifiable impact on a protected group, reducing the burden on carers of unnecessary hospital stays and improving the service in the ED. Again, this represents an objectively justifiable impact on a protected group, reducing the burden of unnecessary hospital stays and improving the service in the ED. Gender Reassignment Marriage / Civil Partnership Pregnancy & Maternity Deaf and hard of hearing patients have noted issues with a lack of BSL interpretation in the ED. ED admissions are particularly high among parents of young children. The new service should offer access to skype BSL interpretation (currently available in primary care) and staff training on how to access this to ensure that deaf patients have equal access to emergency care. Again, this represents an objectively justifiable positive impact on a protected group, improving the service in the ED and reducing Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 213 and Viaduct Health (a federation representing all Stockport GPs) 10

214 unnecessary hospital admissions. Race Religion & Belief Sex Sexual Orientation 15. How many staff work for the current service? 16. What is the potential impact on these employees? (including potential Anecdotal evidence suggests that refugees, asylum seekers and new residents are more likely to attend the ED due to a lack of awareness of local services. Residents have noted issues accessing interpretation in an emergency. Men are less likely to attend preventative services and GP practices, attending ED as a last resort when conditions escalate. As such, they are more likely to be impacted by the changes in the ED. This represents a positive impact on a protected group, improving services for all users. The service should include phone interpretation services and staff training on how to use this, to ensure equal access for people with English as a second language. Again, this represents an objectively justifiable impact on a protected group, reducing unnecessary hospital stays and improving the service in the ED. IMPACT ON STAFF There are currently 313 people full-time equivalents working in emergency care at Stepping Hill Hospital across the Emergency Department, Ambulatory Care Unit, Medical Assessment Unit, Transfer Unit and Discharge Lounge: 169 were nursing staff, 40 medical or dental, 78 worked in Additional Clinical Services; 36 worked in admin 258 were female and 55 were male 70 employees were in their 20s; 88 in their 30s; 74 in their 40s; 66 in their 50s; and 15 employees were in their 60s 6 had a disability; 231 had no disability; and 76 did not wish to declare their disability status 243 where White British; 12 from a minority white background; 22 Asian; 5 mixed race; 3 Black; 4 recorded their ethnicity as other backgrounds; and 24 did not state their ethnicity 162 employees recorded their religion as Christian; 28 Atheist; 6 Muslim; 1 Buddhist; 1 Hindu; 20 recorded their religion as other ; and 95 did not wish to record their religion or belief 212 employees were heterosexual; 5 employees were LGB; and 96 did don t wish to declare their sexual orientation This business case will mostly see a change in the procedures used in the Emergency Department. The balance of staff may shift to more people working in the Ambulatory Care Unit, which will open for longer hours, or the Medical Assessment Unit, so that patients are appropriately monitored rather than being admitted to a hospital bed. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 214 and Viaduct Health (a federation representing all Stockport GPs) 11

215 redundancies, role changes, reduced hours, changes in terms and conditions, locality moves) 17. Is the potential impact on staff likely to be felt more by any protected group? Age Carers Disability Gender Reassignment Marriage / Civil Partnership Pregnancy & Maternity Race Religion & Belief Sex Sexual Orientation 18. What communication has been undertaken with staff? 19. Do all affected workers have A new GP Streaming Service will bring in additional primary are employees to manage those ED attendances that do not require hospital care. If so, can you justify this difference? If not, what actions have you put in place to reduce the differential impact? IMPACT The balance of age among current employees is reasonably evenly spread, so changes are not likely to have a differential impact on the basis of age Staff with caring responsibilities may be limited in any changes they can make to shifts or working hours Staff with disabilities may require reasonable adjustments to their working hours or duties The majority of employees are White British, as such, most likely to be impacted by the change The majority of employees are female, and as such women are most likely to be impacted by change MITIGATION Any changes in roles or working patterns will be subject to staff consultation and will be managed under HR policies, offering equal opportunities for TUPE, reasonable adjustment and flexible working rights. No redundancies are expected as a result of this change. A range of staff have been involved in design sessions for Stockport Together representing a wide range of roles. Staff engagement sessions, team briefs, newsletters, 1 to 1s, drop-in Q&A sessions and daily reviews in the ED have been used to communicate changes with staff as well as HR support, team building and culture change sessions. Yes this is part of the work force development plan Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 215 and Viaduct Health (a federation representing all Stockport GPs) 12

216 genuinely equal opportunities for retraining or redeployment? 20. Who are the stakeholders for the service? IMPACT ON STAKEHOLDERS ED Staff, Urgent Care operational delivery leads Clinical Directors Business Managers at Stockport NHS FT Mastercall (providers of primary care specialist function) 21. What is the potential impact on these stakeholders? 22. What communication has been undertaken with stakeholders? 23. What support is being offered to frontline staff to communicate this message with service users / family / carers? 24. How will you monitor the impact of this project on equality groups? 25. Action Planning Changes to ways of working Changes to system process Release / source funding and spend responsibly Contract negotiations Regular meetings, presentations and s have been used to keep stakeholders up to date on progress. There is regular support from the operational delivery teams to support them in their discussions. Equality data is collected by providers including: deprivation (postcode), age, disability, ethnicity; gender; religion; sexual orientation. This will be mapped against the equality data for Stockport as a borough as part of the public sector equality duty. If this highlights potential underrepresentation of certain groups, further analysis will be undertaken to understand the reason and an action plan will be developed to improve equality. Patient and carers surveys might also highlight inequalities which will then be acted upon. An action plan has been set out at the end of this document to capture all actions identified through the course of this Equality Impact Assessment required to: Mitigate any potential negative impacts Take advantage of opportunities to reduce inequalities Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 216 and Viaduct Health (a federation representing all Stockport GPs) 13

217 Respond to patient and public engagement. Actions in this plan will be included in the implementation plan for delivery of the Outpatients changes. At a strategic level, progress on the EIA action plan will be monitored regularly by the Stockport Together Programme Management Office as part of the governance framework for delivery of the work stream. EIA SIGN OFF 26. Sign off EIAs should be approved by the work stream s Senior Responsible Officer and sent to an equality specialist for quality assurance before sign off. Final EIAs should be attached to the final Strategy / Policy / Business Case before being presented to the relevant decision making Board. a. SRO Name: Margaret Malkin b. Quality Assurance Quality Assured by: Angela Dawber Date: 20/12/2017 c. Board Approval EIA considered by / Date: Joint Commissioning Board 04/01/2018 Scrutiny Committee 16/01/2018 SMBC Cabinet 17/01/2018 CCG Governing Body 31/01/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 217 and Viaduct Health (a federation representing all Stockport GPs) 14

218 5. AMBULATORY CARE Equality Action Plan Ref. Action Lead Deadline AC01 Equality Actions to be included in Ambulatory Care Implementation Plan Margaret Malkin 31/01/2018 AC02 Ambulatory Care programme to send monthly updates on implementation (including Margaret Malkin 28/02/2018 progress on equality actions) to Stockport Together PMO AC03 Develop future engagement strategy for the work stream, identifying key Margaret Malkin 31/03/2018 stakeholders (including protected groups) and optimal communications methods (including translation and interpretation requirements) AC04 Patient engagement and complaints to be monitored by protected groups to ensure there are no adverse impacts on any groups Margaret Malkin & SNC management 31/03/2018 AC05 Stockport Foundation Trust to outline the process for meeting the Accessible Information Standard in the new service model: Agreement on Interpretation service (including phone access for foreign languages and skype access for BSL in the ED) Collating data on formats required by patients Equality monitoring process Alternative contact methods to phone for deaf patients (e.g. Text-Relay service; text messaging; ; face-to-face) team Margaret Malkin & SFT management team AC06 Equality Impact Assessment of how the new service model will affect staff Margaret Malkin & HR AC07 Staff consultation on new service model and any changes to roles / places of work Margaret Malkin & HR AC08 Develop a staff training plan, including: Margaret Malkin & Equality & Diversity Training HR Use of interpretation and translation services Equality monitoring to comply with AIS AC09 Establish baseline data for the number of service users by protected groups and then monitor on a regular basis as the changes are implemented. 31/03/ /03/ /03/ /03/2018 Margaret Malkin 31/01/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

219 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

220 Stockport Together INTERMEDIATE TIER BUSINESS CASE Equality Impact Assessment Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 220 and Viaduct Health (a federation representing all Stockport GPs) 1

221 1. Introduction The partner organisations across Stockport (Stockport NHS Foundation Trust, NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust, Stockport Metropolitan Borough Council and Stockport s GP federation, Viaduct Care) are working alongside GPs and voluntary organisations to develop a single strategic plan to improve health and social care services across the borough Stockport Together. Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current fragmented form, the health and social care system is financially unsustainable. If no changes are made, by 2010/21 there will be a combined deficit of 156m across Stockport s health and social care services. The Stockport Together programme aims to create a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bed-based care. In doing this, we want to ensure that our plans are fair and support all community groups. 2. The Public Sector Equality Duty The Public Sector Equality Duty, as set out in the Equality Act 2010, requires public authorities, in the exercise of their functions, to have due regard to the need to: eliminate unlawful discrimination, harassment and victimisation advance equality of opportunity between different community groups foster good relations between people who share a protected characteristic and those who do not. The Act explains that having due regard for advancing equality involves: removing or minimising disadvantages suffered by people due to their protected characteristics taking steps to meet the needs of people from protected groups where these are different from the needs of other people encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Having due regard to the need to foster good relations between persons who share a relevant protected characteristic and persons who do not share it involves having due regard, in particular, to the need to: tackle prejudice, and promote understanding. Compliance with the duties may involve treating some persons more favourably than others; but that is not to be taken as permitting conduct that would otherwise be prohibited by or under the Equality Act Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 221 and Viaduct Health (a federation representing all Stockport GPs) 2

222 The characteristics given protection under the Equality Act 2010 are: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation Equality Analysis is a way of considering the effect on different groups given protection under the Equality Act. There are a number of key reasons for conducting an Equality Analysis, including: to consider whether the policy will help eliminate unlawful discrimination, harassment and victimisation to consider whether the policy will advance equality of opportunity between people who share a protected characteristic and those who do not to consider whether the policy will foster good relations between people who share a protected characteristic and those who do not to inform the development of the proposed policy. 3. Scope of this Impact Assessment A full equality impact assessment of the Stockport Together programme has been undertaken and can be found on our website at: The high level Strategy is backed up by four detailed work streams, which each address changes to different service areas: Neighbourhoods (Healthy communities and Core Neighbourhood Services) Intermediate Tier Services Acute Interface Ambulatory Care Acute Interface Outpatients The purpose of this document is to look in detail at the practical and operational impacts of proposed changes to the Intermediate Tier services. Actions arising from this impact assessment will be embedded into the Intermediate Tier implementation plan and monitored as part of delivery by the Stockport Together Programme Management Office. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 222 and Viaduct Health (a federation representing all Stockport GPs) 3

223 4. Equality Impact Assessment Name of the Strategy / Policy / Service / Project Champion / Responsible Lead What are the main aims? Intermediate Tier EIA Stockport Together - Intermediate Tier Business Case Margaret Malkin, as Director of Integrated Care for SNC, supported by: Dr Liz Elliott, Associate Medical Director Paula Friggieri, Associate Director Jane Ankrett, Associate Director of Nursing Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current fragmented form, the health and social care system is financially unsustainable. If no changes are made, by 2010/21 there will be a combined deficit of 156m across Stockport s health and social care services. The Intermediate Tier of services is defined as those services that: promote faster recovery from illness; prevent unnecessary acute hospital admission and premature admission to long-term residential care; support timely discharge from hospital; and maximise independent living. In Stockport there are over 20 such services which have developed in isolation over the past ten years. While each service has significant strengths, collectively the Intermediate Tier is fragmented and difficult to navigate. The current range of services has been designed to manage the effects of the system, rather than tackling its causes. The majority of staff and financial resources are spent on facilitating a hospital discharge - or step-down from secondary care. Much less capacity is used for step-up activity intensive support to prevent unnecessary hospital admissions. This means that there is not a strong alternative offer to respond to people in crisis and prevent hospital admissions, placing additional demand on the hospital and the Emergency Department in particular. And many patients receive intermediate care interventions in a hospital bed due to the lack of capacity in the community. Most of the budget is spent on delivering care in community facilities and not an individual s home, reducing independence. As a result, people spend longer in intermediate tier beds than patients in other parts of the country. A point prevalence study of Intermediate Care beds in 2015 found that 33% of patients did not need an intermediate tier bed at that moment in time resulting in 1,257 excess bed days. The knock on effect can be seen in the simultaneous review of 6 hospital wards, which found that 44.53% of people no longer required a hospital bed, but could not be discharged due to a lack of capacity in Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 223 and Viaduct Health (a federation representing all Stockport GPs) 4

224 4. 5. List the main activities of the project: What are the intended outcomes? community services. The longer patients spend in a bed, the harder it can be for them return home and live independently. Table 1: Point Prevalence Study of Patients in Intermediate Tier Beds Bed Based Service No. of patients No. who did not need an Intermediate Tier bed Blue Bell ,126 Saffron Ward Marbury Berrycroft Total ,257 Resulting Excess Bed Days Fragmentation of the 20+ services means that many service users rely on multiple teams and referrers are unsure of the availability of services or the criteria for access. Patients report multiple assessments being duplicated by different services. In addition, the current range of services lacks enough mental health and dementia input to support the needs of service users. This situation will only intensify as Stockport s population continues to age. By 2020, the number of people aged over 65 will increase from 55,700 in 2014 to 61,000. Currently 51% of the total adult population of Stockport are known to have one or more long-term conditions. By the age of 85, 87% have at least one and 53% have two or more. And by 2030 dementia prevalence will rise by 50%. Implementing a fully integrated team to deliver care at place of residence and/or community intermediate tier beds Implementing a single point of access (intermediate tier hub) Implementing a crisis response model Implementing an active recovery model Implementing the model of transfer to assess Implementing an integrated transfer team Ultimately, Stockport Together aims to develop a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bedbased care. The Intermediate Tier work stream of Stockport Together will: Create an Intermediate tier Hub that provides a streamlined single point of access/triage function and enables better co-ordination of care. Shift resources within system to build greater capacity to support in peoples own home at less cost than a hospital bed. Review and develop the rapid response function of intermediate care to create a service that is designed and better equipped to prevent avoidable acute admissions. Form a fully integrated team with a common purpose, shared values, protocols and a single competencies framework. Develop one holistic assessment and joint care planning (supported Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 224 and Viaduct Health (a federation representing all Stockport GPs) 5

225 6. Who currently uses this service? by technology) that avoids duplication and fragmentation. Make more effective use of resources to enable 24/7 service provision based on the needs of individuals. Arrange in-reach by aligned specialist practitioners to support rapid assessment, diagnostics and rehabilitation. To ensure that the future number of intermediate care beds matches demand. IMPACT ON SERVICE USERS Predominantly people over 65 who are in transition and would benefit from short term support to regain or maintain their level of independence. The services in scope of this business case and current usage for 15/16 are shown in the table below: Service name Service Description Activity 15/16 Adult Community Treatment Team (ACTT) Assessment& recovery Beds (19 Newlands & 9 Meadway) Bluebell Ward (The Meadows) Community Assertive In Reach (CAIR-ID) Community beds in residential care homes Equipment & Adaptations Services GP cover to intermediate tier beds Community Rehabilitation Workers Intermediate Care bed based (Marbury & Berrycroft) Intermediate Care home based (East & West teams) IV Therapy (Mastercall) Short-term community therapy intervention (OT & Physio) Community beds for recovery & assessments regarding longer term care needs Continuing health care and end of life care Facilitating hospital discharge up to 72hrs after discharge Spot purchases to support recovery and carer breakdown (SMBC) Equipment, home adaptations, moving & handling for independent living Medical support to patients in Intermediate tier Supporting patients with transfer from bed based to home based intermediate care Intensive rehabilitation in high dependency 24/7 care facility Clinically led therapeutic intervention & rehabilitation IV antibiotics in the home up to 3 times a day 8415 ftf contacts 301 telephone contacts 3264 referrals Weekly ward rounds 120 admissions Newlands, LOS 46days 9,125 bed days 5231 ftf contacts 33 telephone contacts 2428 referrals Estimate: 400 placements spot purchased Variation of daily and weekly ward rounds Step up home 74 admissions Step up bed 53 admissions Step down home 300 Step down bed 459 LOS step up 26 days LOS step down 32 days 645 referrals; 530 accepted of which 377 GP referrals; 3781 visits; 3448 bed days saved (average of 7 per Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 225 and Viaduct Health (a federation representing all Stockport GPs) 6

226 patient) NWAS Pathfinder (NWAS & Mastercall) Rapid Response Assessments (in hours 9am-5pm and out of hours4:30pm-8.30pm; weekends and BH 12: pm) 20 Rapid Response hub beds (4 localities) Re-ablement / REACH 7am-10pm 7d; limited night support Saffron Ward 23 beds (The Meadows) A10 Ambulance redirect to community provision Assessments in the community to prevent hospital admissions Recovery beds where unsafe for patients to stay at home or carers breakdown Support after care to regain independence (incl. night cover) Community beds for intermediate mental health care Hospital ward 2042 referrals; deflection rate 88%; average referral 5 a day 527 referrals in hours; 45% admitted to hub bed 789 referrals (13-14 OOH) 1184 episodes (1050 referrals), avg length 29 days 9125 bed days; average length of stay 29 days The new model is targeting two population cohorts. 1. People in crisis that are at high risk of acute admission (step up). Population size: 14, People in hospital who are medically optimised but require additional time and rehabilitation to recover (step down). Population size: 14,079 + proportion of elective admissions The future commissioning arrangements for a population based weighted capitation contract will look to commission specific outcomes for specific population segments. The approach being taken to this is built on the Bridges to Health approach identifying 8 population segments. These are described diagrammatically below. At any given time nobody is in more than one of the six upper segments and can exacerbate from any of these to the Acutely ill segment (3). Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 226 and Viaduct Health (a federation representing all Stockport GPs) 7

227 Evaluation of Whole Population Segmentation and an Implementation Approach for the Bridges to Health Segmentation Model (OBH, August 2016) 7. Are there any clear gaps in access to this service? (e.g. low access by ethnic minority groups) The Intermediate Tier business case when considering step-up functions will be predominantly dealing with significant exacerbations of people in Segments 4 and 5 (chronic Conditions) and Segment 7 (Limited reserve & exacerbations), but may also occasionally support people in Segments 6 and 8. When it is looking at step-down it will be focussed on how it transfers individuals back home from an acutely ill state (Segment 3) in such a way as to minimise their decline towards limited reserve and further exacerbations (Segment 7) or towards frailty and dementia (Segment 8). Further information on protected characteristics within Stockport s population can be found in the full Equality Impact Assessment of the Stockport Together Strategy: A breakdown of local service users and their needs can also be found in Stockport s Joint Strategic Needs Assessment: The current service is open to all patients who reside in Stockport. Access is via referral into the Step-Up services from GP or community service, or Step Down on discharge from hospital. However the current situation is that people have difficulty in accessing the existing services due to lack of clarity what is on offer and services not working together. It is envisaged that in the new situation people will have one clear single point of access and receive a response based on an integrated, person-centred action plan. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 227 and Viaduct Health (a federation representing all Stockport GPs) 8

228 8. 9. Are there currently any barriers to certain groups accessing this service? (e.g. no disabled parking / canteen doesn t offer Kosher food / no hearing loop) How will this project change the service offered? (is it likely to cut any services?) Currently, the service is predominantly step down and predominantly bed based instead of home based many people, especially people with cognitive impairment are disadvantaged. This patient cohort would benefit from receiving treatment in their own familiar place of residence when possible. One significant barrier to access is in the provision of bed-based care. Many of the care homes providing intermediate tier beds do not have capacity to support patients with dementia who require support overnight. As a result, dementia patients are mainly accommodated on the Bluebell ward or must stay in hospital. The number of care homes with nursing facilities is also limited, creating an access barrier for patients with ongoing care needs or disabilities. The proposed changes in the intermediate tier services will result in: - An increased workforce supporting more people in their own place of residence - Preventing unnecessary hospital stays and by doing so preventing complications related to a hospital stay (infections, muscle weakness, reduced confidence / skills) - A more pro-active and responsive approach in case of (non-acute) emergencies - More joined up working between health and social care and with third sector - Avoiding duplication - 24 hour crisis response service - A new build or existing care home building location to be determined - Support workers in the home to reduce need for hospital stay and support for carers 10. If you are going to cut any services, who currently uses those services? (Will any equality group be more likely to lose their existing services?) 11. If you are creating any new services, who most likely to benefit from them? (Will any The only reduction will be a shift in usage and a reduction in the bed based service but this is a safe and preferable option because there will be more staff available to support people in their own home during day and night and thereby preventing an admission to a community bed. Beds can still be spot purchased if required. By increasing capacity in the crisis response service and the community based active recovery model, more older and frail people who otherwise would have been admitted to hospital will be able to stay at home and receive their treatment there. By creating an integrated transfer team and by implementing the transfer to assess model it is envisaged that the discharge process of each person leaving Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 228 and Viaduct Health (a federation representing all Stockport GPs) 9

229 equality group be more or less likely to benefit from the changes?) 12. How will you communicate the changes to your service? (What communications methods will you use to ensure this message reaches all community groups?) 13. What have the public and patients said about the proposed changes? (Is this project responding to local needs?) hospital will be better prepared and coordinated. By introducing more mental health professionals in the service people with mental health needs will receive an improved service offer. The implementation of the service is combined with communication to various groups to inform them how and when to access intermediate tier services. This will be done through newsletters, staff engagement sessions, attending GP locality meetings, partnership working with ambulance service, ED and hospital, meetings with expert patient groups and patient reference groups, meeting with HealthWatch, patient stories to highlight change, information at GP practices and information at website and social media. As the access is predominantly through referral, most attention goes into informing professionals rather than the public. The case for change was built based on engagement with the public and professionals. Public engagement and consultation included meetings with local groups representing protected characteristics to ensure that all voices were heard and all concerns / impacts understood. Information was disseminated in a range of formats: Online survey Paper surveys Public events Fliers and consultation documents handed out in clinics and displayed in Libraries, Pharmacies and GP Practices The consultation document included a message explaining how information could be obtained in an alternative format. Events were undertaken in accessible local venues across each area of Stockport, offering interpretation where required. The key messages from engagement activity were: - Services are not clear on what is on offer and how to access - Disconnect when being referred from one service to the other, duplication of tasks like assessments - Treatment is broken down in steps delivered one at the time by different teams rather than integrated and interdisciplinary Based on JSNA and other local data our current system is more step down than needed. A full write up of engagement can be found on the Stockport Together website at: Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 229 and Viaduct Health (a federation representing all Stockport GPs) 10

230 14. Is this plan likely to have a different impact on any protected group? Age Carers Can you justify this differential impact? If not, what actions will you add into the plan to mitigate any negative impacts on equality groups? IMPACT The service is likely to impact the elderly the most, as those most likely to require intermediate care. However, service access will be based on need not age with no age restriction other than 18+. The new service model is predicted to reduce hospital attendances, which will mean patients do not have to travel into hospital for their appointment. MITIGATION This represents a positive impact on a protected group, reducing the length of stay in hospital, increasing independence and delivering more care close to home. This positive impact is objectively justifiable under the Equality Act. This is likely to have a positive impact on carers, whether the carer looks after the patient or is the patient themselves. This is because they will not have to take time out of their lives to attend a hospital appointment. Disability Carers who need to visit patients in the new unit could potentially be disadvantaged by the new location. With fewer sites it will make it harder to visit a relative or friend. The majority of service users are likely to have a disability or long-term condition. As such, disabled people will be more impacted by the change than others. Potential difficulties with communication and in understanding changes that are to be made, such as how to make care at home accessible, for example through the ability to send and receive texts to cater for deaf individuals rather than telephone conversations or using BSL apps. Carers needs will become integral to the care plan. The new system will be designed to be more responsive and provide more support in the home environment and community. There should be carer and public views taken into account in the planning of the new location. Transport options should be widely publicised to family and carers. This represents a positive impact on a protected group which is objectively justifiable under the Equality Act. If certain technology is not accessible to disabled groups, we will provide direct support to the individual. SNC will develop a plan on how to implement the Accessible Information Standard to ensure that patients receive Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 230 and Viaduct Health (a federation representing all Stockport GPs) 11

231 Gender Reassignment Marriage / Civil Partnership Pregnancy & Maternity Race Religion & Belief Dependant on individual needs, home care may not be an option for some patients. Access to same-sex accommodation in the patient s chosen gender. Some private care homes may not provide shared living accommodation for same sex couples The proposed changes may have a negative impact on any individual who does not speak English proficiently. This is because individuals may not understand documentation explaining the purpose of any changes. Increased care in the patient s home may raise issues for those with religious-based cultural differences, such as care providers taking off shoes in the home or requirements for gender specific care staff. Bed based care may not cater for different dietary needs, quiet space for prayers, or information in the format that is right for them. For those people with disabilities as with all people who access the services, assessments will be made at the homes to identify requirements. Where a more supportive environment is needed patients can be transferred to a temporary placement such as a community bed, or a transitional placement such as extra care housing, until such time the person can be supported to return home. Contracts with care homes to include the requirement to comply with the Gender Recognition Act. Contracts with care homes to include the requirement to comply with the Equality Act and provide equal access. It is recommended that leaflets explaining the service are available in the most common languages spoken in the Stockport area. SNC to ensure that the integrated service provides clarity on access to interpretation services. SNC to ensure that staff training plans include equality and diversity and how to access interpretation services. Staff training plans to include equality and diversity, with staff working in patients homes given a good understanding of cultural and religious diversity to meet local needs. Contracts with care homes to include the requirement to comply Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 231 and Viaduct Health (a federation representing all Stockport GPs) 12

232 Sex Sexual Orientation 15. How many staff work for the current service? facilities for ablutions. with the Equality Act. Life expectancy is greater among women, This represents a positive impact who constitute a greater percentage of the on a protected group, which is over 65 group who will most benefit from objectively justifiable under the these changes. Equality Act. The proposed changes may have a Staff training plans to include negative impact on individuals who are equality and diversity, so that all concerned about experiencing stigma staff have a good understanding based on their sexual orientation. This has of diverse local needs. been reported as a potential barrier to individuals accessing healthcare, or revealing information that may benefit their care. IMPACT ON STAFF The number of staff who currently work for the service is Whole-Time Equivalents. The proposal is to increase this to WTE as part of the Intermediate Tier Business Case. It is envisaged that the new intermediate tier service will broadly operate within the existing financial envelope of in scope services, however there will be an increased workforce and a shift towards increased step up capacity to enable people to remain at home and avoid admission into hospital. Detailed workforce modelling has been undertaken taking into consideration anticipated demand on the service and the skill mix required to support the new model, in summary the staffing will look as follows: Pathway Current Staffing WTE (%) Future Staffing WTE (%) Step down (74%) (38%) Step up (26%) (62%) Total (100%) (100%) The additional capacity will enable a greater number of people to be cared for at home, for example once all permanent Home Support Workers are in post within Active Recovery this will enable a total of 13 teams across the borough, each team supporting up to 7/8 people, based on 4 visits per day between the hours of 7am -10pm this equates to approximately 100 people on any given day. 16. What is the potential impact on these employees? (including potential The additional capacity will enable a greater number of people to be cared for at home, for example once all permanent Home Support Workers are in post within Active Recovery this will enable a total of 13 teams across the borough, each team supporting up to 7/8 people, based on 4 visits per day between the hours of 7am -10pm this equates to approx people on any given day. This change will result in a shift of staff from step down work to step up roles, Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 232 and Viaduct Health (a federation representing all Stockport GPs) 13

233 redundancies, role changes, reduced hours, changes in terms and conditions, locality moves) with place of work more dominantly in the community. Plans to roll out 7 day working will also create changes in working patterns, with extended hours and weekend working required. However, any changes to roles would be subject to staff consultation and all employees would have equal employments rights under their HR policies, including: TUPE, flexible working, reasonable adjustments. 17. Is the potential impact on staff likely to be felt more by any protected group? Age Carers Disability Gender Reassignment Marriage / Civil Partnership Pregnancy & Maternity Race Religion & Belief If so, can you justify this difference? If not, what actions have you put in place to reduce the differential impact? IMPACT Members of staff with young families/childcare responsibilities may struggle with shift patterns and job rotation Staff with carers duties may struggle with shift patterns and job rotation Working more in patients homes may not be accessible for staff with a disability No negative impact expected No negative impact expected Working more in patients homes may create a health and safety risk for pregnant staff More working in a patient s home could present cultural difficulties for minority groups Sex The majority of employees are female as such women are more likely to be impacted by changes Sexual Orientation 18. What communicatio n has been undertaken with staff? MITIGATION Any changes in roles will be subject to staff consultation and will be managed under HR policies, offering equal opportunities for TUPE, reasonable adjustment and flexible working rights. A range of staff have been involved in design sessions for Stockport Together representing a wide range of roles. Staff engagement sessions, team briefs, newsletters, 1 to 1s have been used to communicate changes with staff as well as HR support, team building and culture change sessions. 19. Do all affected workers have genuinely equal opportunities Yes this is part of the work force development plan Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 233 and Viaduct Health (a federation representing all Stockport GPs) 14

234 for retraining or redeployment? 20. Who are the stakeholders for the service? 21. What is the potential impact on these stakeholders? IMPACT ON STAKEHOLDERS Key stakeholders are: The public The Ambulance Service NHS 111 Service Stockport GPs Stepping Hill Hospital (A&E and wards) Stockport Care Homes Extra Care Council Social Services Targeted Prevention Alliance Ambulance service / 111 will have an alternative offer for patients. GPs / Care homes / extra care housing can use the crisis response team instead of sending someone to A&E. Hospital receives support from the intermediate tier services to plan for a timely and successful discharge to place of residence or community bed and A&E has more choice to refer someone to the community instead of admitting someone. 22. What The approach to developing the new intermediate tier service model and communicationbusiness case has engaged a number of stakeholders between June 2015 and has been June 2016, these include the following activities: undertaken Patient survey intermediate care (July 2015) with Staff / stakeholder online survey intermediate tier (July 2015) stakeholders? GP consultation via pin board at various meetings (July 2015) GP consultation on rapid response via online survey (March 2015) A series of one-to-one discussions with key individuals to inform and help identify the key issues and any critical issues from either a particular organisational or professional perspective. (June 2015 to June 2015) Task & Finish group work with service managers/staff (August - November 2015). Stakeholder workshops at key stages of design: Current state validation Design workshop Check-in & Interface workshop with other workstreams to define boundaries and understand key questions to be addressed. Presentation of outline model to the Stockport Together Practitioner Design & Steering Group (June 2016) Presentation and discussions at Citizens Panel (June 2016) Engagement events with all staff within scope of Intermediate Tier (September 2016) Engagement at Neighbourhood leadership event (September 2016) Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 234 and Viaduct Health (a federation representing all Stockport GPs) 15

235 As the project moves into implementation further engagement is required. The project will engage face to face with stakeholders (including service users) with a significant interest in the project and with those stakeholders where alternative communication methods are more appropriate, e.g. newsletters, briefings, etc. A communications & engagement plan will be developed to ensure that there is effective two way communication with all those affected by the changes to the intermediate tier. The project will seek to empower staff groups who will be delivering a new capability and a new patient-centred service so that the design, development and implementation has the full involvement and engagement of health and social care professionals, as well as end users of the intermediate tier services. It is also anticipated that given the proposed changes to the provision of bed based services, that the intermediate tier service changes may require public consultation and the implementation plan has been developed on that basis. 23. What support is being offered to frontline staff to communicate this message with service users / family / carers? 24. How will you monitor the impact of this project on equality groups? 25. Action Planning New uniform to mark the change, new patient leaflet, new format for an individual health and wellbeing plan, patient stories to highlight change and improvements There is regular support from the operational delivery teams to support them in their discussions. Equality data is collected by providers including: deprivation (postcode), age, disability, ethnicity; gender; religion; sexual orientation. This will be mapped against the equality data for Stockport as a borough as part of the public sector equality duty. If this highlights potential underrepresentation of certain groups, further analysis will be undertaken to understand the reason and an action plan will be developed to improve equality. Patient and carers surveys might also highlight inequalities which will then be acted upon. An action plan has been set out at the end of this document to capture all actions identified through the course of this Equality Impact Assessment required to: Mitigate any potential negative impacts Take advantage of opportunities to reduce inequalities Respond to patient and public engagement. Actions in this plan will be included in the implementation plan for delivery of the Intermediate Tier changes. At a strategic level, progress on the EIA action plan will be monitored regularly by the Stockport Together Programme Management Office as part of the Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 235 and Viaduct Health (a federation representing all Stockport GPs) 16

236 governance framework for delivery of the work stream. EIA SIGN OFF 26. Sign off EIAs should be approved by the work stream s Senior Responsible Officer and sent to an equality specialist for quality assurance before sign off. Final EIAs should be attached to the final Strategy / Policy / Business Case before being presented to the relevant decision making Board. a. SRO Name: Margaret Malkin b. Quality Assurance Quality Assured by: Angela Dawber Date: 20/12/2017 c. Board Approval EIA considered by / Date: Joint Commissioning Board 04/01/2018 Scrutiny Committee 16/01/2018 SMBC Cabinet 17/01/2018 CCG Governing Body 31/01/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) 236 and Viaduct Health (a federation representing all Stockport GPs) 17

237 5. INTERMEDIATE TIER Equality Action Plan Ref. Action Lead Deadline IT01 Equality Actions to be included in the Intermediate Tier Implementation Plan Margaret Malkin 31/01/2018 IT02 Intermediate Tier programme to send monthly updates on implementation (including Margaret Malkin 28/02/2018 progress on equality actions) to Stockport Together PMO IT03 Develop future engagement strategy for the work stream, identifying key Margaret Malkin 31/03/2018 stakeholders (including protected groups) and optimal communications methods (including translation and interpretation requirements) IT04 Patient engagement and complaints to be monitored by protected groups to ensure there are no adverse impacts on any groups Margaret Malkin & SNC management 31/03/2018 IT05 IT06 Stockport Neighbourhood Care to outline the process for meeting the Accessible Information Standard in the new service model: Agreement on Interpretation service (currently 3 services at SMBC, Primary Care and SFT) Collating data on formats required by patients Equality monitoring process System for sending patients communications in the correct format (e.g. Braille, large print) Service Level Agreements in place for translation information into other formats (Braille, BSL videos, audio format, other languages) Alternative contact methods to phone for deaf patients (e.g. Text-Relay service; text messaging; ; face-to-face) Contracts with care home / bed-based care providers to set out the legal requirements to follow duties under the Equality Act and Accessible Information Standard, including: Equality monitoring & reporting Interpretation and translation services Accessible facilities team Margaret Malkin & SNC management team Lesley Brown & Gillian Miller 31/03/ /03/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

238 Ref. Action Lead Deadline IT07 Patients and carers views to be sought in the planning of the new location. Margaret Malkin & Estates IT08 Patients and carers views to be sought in the planning of the new location. Margaret Malkin & Estates IT09 Venue of new bed based facility assessed to ensure full access, including: Margaret Malkin & Disabled parking Estates Disabled toilets Changing facilities Hearing loops IT10 IT11 IT12 Communications plan for roll-out of the service changes, including: Map of stakeholders (including protected groups) Communications formats to meet needs to stakeholders Leaflets and other publicity to use inclusive images and language to demonstrate accessibility to all community groups Transport options for accessing the new bed based facility should be widely publicised to family and carers. IT plan developed to include: Training on how to use any self-care technology Alternative options for patients who are unable to use self-care technology Training on how to use skype technology for virtual appointments Alternative options for patients who are unable to access virtual appointments Margaret Malkin & Comms Margaret Malkin & IT IT13 Equality Impact Assessment of how the new service model will affect staff Margaret Malkin & HR IT14 Staff consultation on new service model and any changes to roles / places of work Margaret Malkin & HR IT15 Develop a staff training plan, including: Margaret Malkin & Equality & Diversity Training HR Use of interpretation and translation services Equality monitoring to comply with AIS 31/03/ /03/ /03/ /03/ /03/ /03/ /03/ /03/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

239 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

240 Stockport Together NEIGHBOURHOODS BUSINESS CASE Equality Impact Assessment Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 240 1

241 1. Introduction The partner organisations across Stockport (Stockport NHS Foundation Trust, NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust, Stockport Metropolitan Borough Council and Stockport s GP federation, Viaduct Care) are working alongside GPs and voluntary organisations to develop a single strategic plan to improve health and social care services across the borough Stockport Together. Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current fragmented form, the health and social care system is financially unsustainable. If no changes are made, by 2010/21 there will be a combined deficit of 156m across Stockport s health and social care services. The Stockport Together programme aims to create a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bed-based care. In doing this, we want to ensure that our plans are fair and support all community groups. 2. The Public Sector Equality Duty The Public Sector Equality Duty, as set out in the Equality Act 2010, requires public authorities, in the exercise of their functions, to have due regard to the need to: eliminate unlawful discrimination, harassment and victimisation advance equality of opportunity between different community groups foster good relations between people who share a protected characteristic and those who do not. The Act explains that having due regard for advancing equality involves: removing or minimising disadvantages suffered by people due to their protected characteristics taking steps to meet the needs of people from protected groups where these are different from the needs of other people encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Having due regard to the need to foster good relations between persons who share a relevant protected characteristic and persons who do not share it involves having due regard, in particular, to the need to: tackle prejudice, and promote understanding. Compliance with the duties may involve treating some persons more favourably than others; but that is not to be taken as permitting conduct that would otherwise be prohibited by or under the Equality Act Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 241 2

242 The characteristics given protection under the Equality Act 2010 are: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation Equality Analysis is a way of considering the effect on different groups given protection under the Equality Act. There are a number of key reasons for conducting an Equality Analysis, including: to consider whether the policy will help eliminate unlawful discrimination, harassment and victimisation to consider whether the policy will advance equality of opportunity between people who share a protected characteristic and those who do not to consider whether the policy will foster good relations between people who share a protected characteristic and those who do not to inform the development of the proposed policy. 3. Scope of this Impact Assessment A full equality impact assessment of the Stockport Together programme has been undertaken and can be found on our website at: The high level Strategy is backed up by four detailed work streams, which each address changes to different service areas: Neighbourhoods (Healthy communities and Core Neighbourhood Services) Intermediate Tier Services Acute Interface Ambulatory Care Acute Interface Outpatients The purpose of this document is to look in detail at the practical and operational impacts of the implementation of the Neighbourhoods proposal. Actions arising from this impact assessment will be embedded into the Neighbourhood implementation plan and monitored as part of delivery by the Stockport Together Programme Management Office. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 242 3

243 4. Equality Impact Assessment 1. Name of the Strategy / Policy / Service / Project 2. Champion / Responsible Lead 3. What are the main aims? Neighbourhoods EIA Stockport Together Neighbourhood Business Case Margaret Malkin, as Director of Integrated Care for SNC, supported by: Dr Liz Elliott, Associate Medical Director Paula Friggieri, Associate Director Jane Ankrett, Associate Director of Nursing Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current form, Stockport s health and social care system is unsustainable. If working practices do not change, the financial position is set to deteriorate so that by 2020/21 there will be a funding gap of around 156m. 27% of the population (84,700) have at least one long-term condition. By age 60 this rises to 50% and by age 85, 88% of the population have at least one long-term condition. The number of Stockport residents aged 65 and over is set to rise from 55,700 to 61,000 by It is therefore estimated that the number of people living with a long-term condition will increase by 53% in the next decade, which will challenge the traditional way of delivering services and managing disease. Rising prevalence of dementia has also contributed to increasing complexity in social care. We know that there are 2,850 people in Stockport who have dementia, with a further 1,000 people undiagnosed this is higher than the national average and increasing. By 2030 dementia prevalence will be 50% higher than it is currently. Emergency admissions for dementia have doubled in the last 8 years with 2,200 emergency admissions for dementia per year. For many years, Stockport has had a much higher rate of emergency hospital admissions than peers or the England average. Unnecessary or overlong stays in hospital are neither good for individuals nor the finances of the system. If a person over the age of 80 spends 10 days or more in hospital then it leads to the equivalent of 10 years ageing in their muscles and makes subsequent independent living difficult. High rates of expensive non-elective admissions have resulted in a chronic underfunding of primary and community services. Stockport spends 5.43 a head less on primary care than Greater Manchester colleagues. Compared to the national average, Stockport over-funds hospital care and underfunds both Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 243 4

244 physical and mental health out of hospital. If working practices do not change, the financial position is set to deteriorate so that by 2020/21 there will be an economy deficit of around 156 million. The current system is also unsustainable in terms of workforce capacity, with significant recruitment challenges for: Consultants; GPs; nurses; and social workers. Even if we had the resources to fund growing demand, it is unlikely that we would have the professional workforce to run an enlarged version of the existing system. 4. List the main activities of the project: 5. What are the intended outcomes? 6. Who currently uses this service? Implementing neighbourhood teams Implementing multidisciplinary teams Implementing seven-day services (primary care and wider neighbourhood services) Implementing neighbourhood hubs / treatment centres Implementing new models of care for primary care and collaborative general practice. Ultimately, Stockport Together aims to develop a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bedbased care. The Neighbourhoods work stream of Stockport Together will: 1. Create 8 neighbourhood teams with primary care at the centre 2. Deliver increased capacity in community and primary care to enable the shift in care from the acute setting 3. Align resources into multidisciplinary teams to provide focused and personalised support for those most at risk of admission to hospital 4. Implement a reshaped primary care team, able to defect activity from GPs thus releasing time to care (additional support for those most at risk of admissions) and ensure safe and sustainable general practice 5. Implement find and prevent, self-care and lifestyle based support for those at risk of developing a long -term condition 6. Services (physical and mental health and social care) wrapped around the needs of people 7. To ensure neighbourhood capacity meets the local need 8. To align resources to where they are most needed 9. To facilitate the move to early intervention and prevention 10. IMPACT ON SERVICE USERS The current services include primary care, community care, mental health and adult social care services. The principle service areas directly in scope of this business case are: All adult services provided by Stockport NHS Foundation Trust through its community contract. All adult services provided in the community by Pennine Care NHS Foundation Trust, excluding Learning Disabilities and drug and alcohol Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 244 5

245 services. All non-core services provided through general practices in Stockport and through their local GP Federation Viaduct Care. Several pertinent services provided by the Targeted Prevention Alliance (TPA.) The model will be developed for the whole GP adult registered population, however, the focus of the new neighbourhood model is predominantly people over 65 with complex needs / one or more long-term condition: 70% of all health and social care spend goes on long term conditions 50% of GP appointments and 7 out of 10 hospital beds are utilised by people with one or more long-term conditions Over 4,000 patients overdue for an appointment for a long-term condition on the Stockport Foundation Trust Outpatients waiting list. The table below details the eight most prevalent long-term conditions in Stockport. Long-term condition Number of people Hypertension 44,745 Anxiety 30,085 Depression 29,100 Asthma 20,545 Obesity 20,050 Diabetes 15,700 Coronary heart disease 12,230 History of falls 12,150 Source: Stockport JSNA , Long Term Conditions October Conditions.pdf 27% of the population (84,700) have at least one of these eight conditions and this increases with age, from 2% in the 0-4 age band, to 88% in those aged 85 and over. By age 60, half of the people have one or more of these conditions and 15% of the population have two or more of eight key long-term conditions. Many more may also have a condition which is currently undiagnosed. It is estimated that the number of people living with more than one long-term condition will increase by 53% in the next decade, which will challenge the traditional way of delivering services and managing disease. For us in Stockport this will equate to an additional 47,700 people living with a condition. Prevalence of dementia has contributed to increasing complexity in social care. We know that there are 2,850 people in Stockport who have dementia, with a further 1000 people living with dementia who have not had a diagnosis. Dementia prevalence is higher than the national average and increasing. By 2030 dementia prevalence will be 50% higher than it is currently. Emergency admissions for dementia have doubled in the last 8 years with 2200 emergency admissions for dementia per year. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 245 6

246 Further information on protected characteristics within Stockport s population can be found in the full Equality Impact Assessment of the Stockport Together Strategy: A breakdown of local service users and their needs can also be found in Stockport s Joint Strategic Needs Assessment: 7. Are there any clear gaps in access to this service? (e.g. low access by ethnic minority groups) 8. Are there currently any barriers to certain groups accessing this service? (e.g. no disabled parking / canteen doesn t offer Kosher food / no hearing loop) 9. How will this project change the service offered? (is it likely to cut any services?) Current services are open to all community groups who reside in Stockport. However, we know that: men are less likely to attend their GP practice, with inflexible opening times often given as a reason Refugees, asylum seekers and new residents who are unaware of primary and community services tend to rely on hospital care Homeless people have noted issues registering with a GP practice. The current services are fragmented with variable access. Those with complex needs often find it difficult to navigate between providers and services. It is envisaged that people and carers will be support by multidisciplinary teams to access the required services and have a single care plan. This will reduce the complexity of navigating the system and improve first time access. Stockport s over-reliance on hospital care can be difficult for people with multiple and complex care needs and their carers this business case aims to support the delivery of more care close to home, reduce this access issue. The proposed changes in neighbourhood services will result in: An increased workforce supporting more people in their own place of residence An increase in workforce based in neighbourhoods Increase local access to primary care and extended primary care services Provide seven-day access, tailored to meet the needs of local people A shift in place of care from the acute to neighbourhood setting Reduction in duplication More joined up working between health and social care and with third sector More choice of appointment times for GP and extended services More choice of first contact professional Greater coordination of services for those most at risk of admission to hospital Increased system leadership from GP s A shift in focus from illness management to early intervention and identification and prevention Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 246 7

247 10. If you are going to cut any services, who currently uses those services? (Will any equality group be more likely to lose their existing services?) 11. If you are creating any new services, who most likely to benefit from them? (Will any equality group be more or less likely to benefit from the changes?) 12. How will you communicate the changes to your service? (What communications methods will you use to ensure this message reaches all community groups?) 13. What have the public and patients said about the proposed changes? (Is this project responding to local needs?) Improved accessibility for people not registered with a GP (homeless / no fixed abode, travellers) The only reduction will be a shift in usages and a reduction in the bed based service but this is a safe and preferable option because there will be more staff available to support people in their own home during day and night and thereby preventing admissions. No equality group will be more likely to lose their existing service. Capacity in neighbourhoods will be increased based upon need and weighted for deprivation. The multidisciplinary approach will support those most at risk of admissions. The overall impact will be increased support and provision for the most vulnerable and disadvantaged with reduced variation in quality and access. Older people, carers, hose with a disability, complex care need or mental health requirement will benefit the most. There will also be increased opportunities for people who are not registered with a Stockport GP but part of the Stockport health and care system to access services. The implementation of the service is combined with communication to various groups to inform them how and when to access services. This will be done through newsletters, staff engagement sessions, attending GP locality meetings, partnership working with ambulance service, ED and hospital, meetings with expert patient groups and patient reference groups, meeting with HealthWatch, patient stories to highlight change, information at GP practices and information at website and social media. The case for change was built based on engagement with the public and professionals. Public engagement and consultation included meetings with local groups representing protected characteristics to ensure that all voices were heard and all concerns / impacts understood. Information was disseminated in a range of formats: Online survey Paper surveys Public events Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 247 8

248 Fliers and consultation documents handed out in clinics and displayed in Libraries, Pharmacies and GP Practices The consultation document included a message explaining how information could be obtained in an alternative format. Events were undertaken in accessible local venues across each area of Stockport, offering interpretation where required. The key messages from engagement activity were: Services are not clear on what is on offer and how to access There is currently significant repetition and need to repeat a story is commonplace Services are disconnected There is significant duplication (e.g. assessment) People would like more services closer to home People would like to access services at convenient times, reflecting their working and home lives A full write up of engagement can be found on the Stockport Together website at: Is this plan likely to have a different impact on any protected group? Age Can you justify this differential impact? If not, what actions will you add into the plan to mitigate any negative impacts on equality groups? IMPACT Services are designed predominantly for 65+ so the service is likely to impact the elderly the most. MITIGATION Service access is based on need not based on age so there will be no age restriction other than 18+. Carers All age groups will have a reduced number of hospital appointments, thereby reducing time taken out of their lives to attend appointments and the associated costs for travel and/or car parking. Positive impact expected as the service is predicted to reduce attendances, which will mean patients do not have to travel into hospital for their appointment. Extended hours will enable working carers to attend evening and weekend appointments However, this focus on over 65s represents a positive impact on a protected group, which is objectively justifiable under the Equality Act. This is likely to have a positive impact on carers, whether the carer looks after the patient or is the patient themselves. This is because they will not have to take time out of their lives to attend a hospital appointment. Again, this represents a positive impact on a protected group, which Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 248 9

249 Disability The needs of carers will be assessed at the same time as the patient This service is targeted at residents with multiple and complex care needs, who are protected under the characteristics of disability. is objectively justifiable under the Equality Act. The new model aims to take a proactive approach to managing disabilities and long-term conditions, preventing deterioration and improving independence. Care and support will be coordinated by a Multi-Disciplinary Team, reducing the need for repeating their story and improving patient experience. Gender Reassignment Marriage / Civil Partnership Pregnancy & Maternity Race Some patients with disabilities may experience greater difficulties in understanding the changes or less able to benefit from new technologies for self-care at home. The proposed changes may have a negative impact on any individual who does not speak English proficiently. This is because individuals may not understand documentation explaining the purpose of any changes. Religion & Belief Increased care in the patient s home This represents a positive impact on a protected group, which is objectively justifiable under the Equality Act. Stockport Neighbourhood Care will set out a plan of how it will meet the Accessible Information Standard, providing information in the correct format for aptients, such as the ability to send and receive texts to cater for deaf individuals rather than telephone conversations or using BSL apps. If certain technology is not accessible, assessments will be made as to whether carers could support the use of this technology and traditional support in a GP practice or community clinic will be made available to those who cannot use the technology.. The NHS and Council already provide an interpreting service for anyone who does not speak English proficiently. Stockport Neighbourhood Care will assess the best use of interpretation as an integrated service. Staff training plans to include Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

250 Sex Sexual Orientation 15. How many staff work for the current service? may raise issues for those with religious-based cultural differences, such as care providers taking off shoes in the home or requirements for gender specific care staff. Life expectancy is greater among women, who constitute a greater percentage of the over 65 group who will most benefit from these changes. The proposed changes may have a negative impact on individuals who are concerned about experiencing stigma based on their sexual orientation. This has been reported as a potential barrier to individuals accessing healthcare, or revealing information that may benefit their care. equality and diversity, with staff working in patients homes given a good understanding of cultural and religious diversity to meet local needs. This represents a positive impact on a protected group, which is objectively justifiable under the Equality Act. Staff training plans to include equality and diversity, so that all staff have a good understanding of diverse local needs. IMPACT ON STAFF Over 1500 Full-Time Equivalent staff are currently employed across primary care, community care, adult social care and mental health in Stockport: 490 FTEs in Primary Care 462 FTEs on Community Care 631 FTEs in adult social care 489 FTEs in mental health, though many are hospital-based. In Primary Care: 84% of employees are female 76.87% are White British The average age of staff is 47 52% work in admin; 29% are GPs; 11% are nurses; and 8% are other direct care practitioners In Community Care: 78.05% of employees are female 82.42% are White British The average age of staff is % are Christian 32.2% work in nursing; 27.9% admin or estates; 20% are clinical; 7.7% are medical; 8% are other direct care practitioners; 6.2% are Allied Health Professionals; and 5.51% are healthcare scientists. In Adult Social Care: 74.35% of employees are female 89.27% are White British The average age of staff is % are Christian 48% are support workers; 20% work in admin; 20% are social workers; Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

251 1% occupational therapists; 0.23% are nurses; 0.21% are dieticians. In Mental Health: 79.85% of employees are female 86.27% are White British The average age of staff is 46 33% work in nursing; 27% are clinical; 15.75% admin and estates; 12% prof scientific; 5% allied health professionals; 4.5% medical / dental; and 1.3% healthcare scientists. 16. What is the potential impact on these employees? (including potential redundancies, role changes, reduced hours, changes in terms and conditions, locality moves) 17. Is the potential impact on staff likely to be felt more by any protected group? Age Carers Disability Gender Reassignment Marriage / Civil Partnership Pregnancy & Maternity The neighbourhood business case provides for an increase in workforce of over 20%, therefore more career opportunities will be created. Most of the services will be 24/7: staff will therefore be asked to work more flexibly. Staff will be expected to work in multidisciplinary / integrated teams, with changes to venues so that different teams can work together to support shared patients. It is not envisaged that there will be redundancies at this stage. However, any changes to roles would be subject to staff consultation and all employees would have equal employments rights under their HR policies, including: TUPE, flexible working, reasonable adjustments. If so, can you justify this difference? If not, what actions have you put in place to reduce the differential impact? IMPACT Members of staff with young families/childcare responsibilities may struggle with shift patterns and job rotation Staff with carers duties may struggle to work new shift patterns as part of the extended hours plan. Staff with disabilities may require reasonable adjustments, including accessible venues and disabled parking Working more in patients homes may create a health and safety risk for pregnant staff MITIGATION Any changes in roles will be subject to staff consultation and will be managed under HR policies, offering equal opportunities for TUPE, reasonable adjustment and flexible working rights. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

252 Race Religion & Belief More working in a patient s home could present cultural difficulties for minority groups Sex The majority of employees are female as such women are more likely to be impacted by changes Sexual Orientation 18. What communication has been undertaken with staff? 19. Do all affected workers have genuinely equal opportunities for retraining or redeployment? 20. Who are the stakeholders for the service? A range of staff have been involved in design sessions for Stockport Together representing a wide range of roles. Staff engagement sessions, team briefs, newsletters, 1 to 1s have been used to communicate changes with staff as well as HR support, team building and culture change sessions. Yes this is part of the work force development plan IMPACT ON STAKEHOLDERS Key stakeholders are the GPs, community health, adult social care, mental health, hospital, care homes. 21. What is the potential impact on these stakeholders? GP s will receive significant additional funding enabling safe and effective general practice, delivery of GM standards and provision of extended services across seven-days. GPs will be expected to work in MDTs. AHPs, nurses and social workers will be expected to work across seven-days and within MDTs. Some hospital provision will be reduced / stopped to enable funding for increased provision in the neighbourhoods. Increased provision for mental health in neighbourhoods Potential increase in activity for community and primary care staff Potential decrease in activity for secondary care staff Changes to the service delivery could impact place of work and changes to job plans. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

253 22. What communication has been undertaken with stakeholders? 23. What support is being offered to frontline staff to communicate this message with service users / family / carers? 24. How will you monitor the impact of this project on equality groups? 25. Action Planning Various presentations have been given to stakeholders, meetings have been planned to discuss and align pathways, information sheets, leaflets and other promotion material (pens and business cards with telephone number) have been developed. New uniform to mark the change, new patient leaflet, new format for an individual health and wellbeing plan, patient stories to highlight change and improvements. Equality data is collected by providers including: deprivation (postcode), age, disability, ethnicity; gender; religion; sexual orientation. This will be mapped against the equality data for Stockport as a borough as part of the public sector equality duty. If this highlights potential underrepresentation of certain groups, further analysis will be undertaken to understand the reason and an action plan will be developed to improve equality. Patient and carers surveys might also highlight inequalities which will then be acted upon. An action plan has been set out at the end of this document to capture all actions identified through the course of this Equality Impact Assessment required to: Mitigate any potential negative impacts Take advantage of opportunities to reduce inequalities Respond to patient and public engagement. Actions in this plan will be included in the implementation plan for delivery of the Neighbourhoods changes. At a strategic level, progress on the EIA action plan will be monitored regularly by the Stockport Together Programme Management Office as part of the governance framework for delivery of the work stream. EIA SIGN OFF 26. Sign off EIAs should be approved by the work stream s Senior Responsible Officer and sent to an equality specialist for quality assurance before sign off. Final EIAs should be attached to the final Strategy / Policy / Business Case before being presented to the relevant decision making Board. a. SRO Name: Margaret Malkin b. Quality Quality Assured by: Angela Dawber Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

254 Assurance Date: 20/12/2017 c. Board Approval EIA considered by / Date: Joint Commissioning Board 04/01/2018 Scrutiny Committee 16/01/2018 SMBC Cabinet 17/01/2018 CCG Governing Body 31/01/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

255 11. NEIGHBOURHOODS Equality Action Plan Ref. Action Lead Deadline N01 Equality Actions to be included in the Neighbourhood Implementation Plan Margaret Malkin 31/01/2018 N02 Neighbourhood programme to send monthly updates on implementation (including Margaret Malkin 28/02/2018 progress on equality actions) to Stockport Together PMO N03 Develop future engagement strategy for the work stream, identifying key Margaret Malkin 31/03/2018 stakeholders (including protected groups) and optimal communications methods (including translation and interpretation requirements) N04 Patient engagement and complaints to be monitored by protected groups to ensure there are no adverse impacts on any groups Margaret Malkin & SNC management 31/03/2018 N05 N06 Stockport Neighbourhood Care to outline the process for meeting the Accessible Information Standard in the new service model: Agreement on Interpretation service (currently 3 services at SMBC, Primary Care and SFT) Collating data on formats required by patients Equality monitoring process System for sending patients communications in the correct format (e.g. Braille, large print) Service Level Agreements in place for translation of information into other formats (Braille, BSL videos, audio format, other languages) Alternative contact methods to phone for deaf patients (e.g. Text-Relay service; text messaging; ; face-to-face) SNC Contract to set out the legal requirements of the new integrated organisation to follow duties under the Equality Act and Accessible Information Standard, including: Equality monitoring & reporting Interpretation and translation services Accessible facilities team Margaret Malkin & SNC management team Lesley Brown & Gillian Miller 31/03/ /03/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

256 Ref. Action Lead Deadline N07 Venues of new neighbourhood teams assessed to ensure full access, including: Disabled parking Disabled toilets Changing facilities Hearing loops Margaret Malkin & Estates 31/03/2018 N08 N09 Communications plan for roll-out of the service changes, including: Map of stakeholders (including protected groups) Communications formats to meet needs to stakeholders Leaflets and other publicity to use inclusive images and language to demonstrate accessibility to all community groups IT plan developed to include: Training on how to use any self-care technology Alternative options for patients who are unable to use self-care technology Training on how to use skype technology for virtual appointments Alternative options for patients who are unable to access virtual appointments Margaret Malkin & Comms Margaret Malkin & IT N10 Equality Impact Assessment of how the new service model will affect staff Margaret Malkin & HR N11 Staff consultation on new service model and any changes to roles / places of work Margaret Malkin & HR N12 Develop a staff training plan, including: Margaret Malkin & Equality & Diversity Training HR Use of interpretation and translation services Equality monitoring to comply with AIS 31/03/ /03/ /03/ /03/ /03/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

257 Stockport Together OUTPATIENTS BUSINESS CASE Equality Impact Assessment Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 257 1

258 1. Introduction The partner organisations across Stockport (Stockport NHS Foundation Trust, NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust, Stockport Metropolitan Borough Council and Stockport s GP federation, Viaduct Care) are working alongside GPs and voluntary organisations to develop a single strategic plan to improve health and social care services across the borough Stockport Together. Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current fragmented form, the health and social care system is financially unsustainable. If no changes are made, by 2010/21 there will be a combined deficit of 156m across Stockport s health and social care services. The Stockport Together programme aims to create a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bed-based care. In doing this, we want to ensure that our plans are fair and support all community groups. 2. The Public Sector Equality Duty The Public Sector Equality Duty, as set out in the Equality Act 2010, requires public authorities, in the exercise of their functions, to have due regard to the need to: eliminate unlawful discrimination, harassment and victimisation advance equality of opportunity between different community groups foster good relations between people who share a protected characteristic and those who do not. The Act explains that having due regard for advancing equality involves: removing or minimising disadvantages suffered by people due to their protected characteristics taking steps to meet the needs of people from protected groups where these are different from the needs of other people encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Having due regard to the need to foster good relations between persons who share a relevant protected characteristic and persons who do not share it involves having due regard, in particular, to the need to: tackle prejudice, and promote understanding. Compliance with the duties may involve treating some persons more favourably than others; but that is not to be taken as permitting conduct that would otherwise be prohibited by or under the Equality Act Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 258 2

259 The characteristics given protection under the Equality Act 2010 are: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation Equality Analysis is a way of considering the effect on different groups given protection under the Equality Act. There are a number of key reasons for conducting an Equality Analysis, including: to consider whether the policy will help eliminate unlawful discrimination, harassment and victimisation to consider whether the policy will advance equality of opportunity between people who share a protected characteristic and those who do not to consider whether the policy will foster good relations between people who share a protected characteristic and those who do not to inform the development of the proposed policy. 3. Scope of this Impact Assessment A full equality impact assessment of the Stockport Together programme has been undertaken and can be found on our website at: The high level Strategy is backed up by four detailed work streams, which each address changes to different service areas: Neighbourhoods (Healthy Communities and Core Neighbourhood Services) Intermediate Tier Services Acute Interface - Ambulatory Care Acute Interface - Outpatients The purpose of this document is to look in detail at the practical and operational impacts of proposed changes to the way Outpatient appointments are managed. Actions arising from this impact assessment will be embedded into the Outpatients implementation plan and monitored as part of delivery by the Stockport Together Programme Management Office. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 259 3

260 4. Equality Impact Assessment 1. Name of the Strategy / Policy / Service / Project 2. Champion / Responsible Lead 3. What are the main aims? OUTPATIENTS EIA Stockport Together - Outpatients Business Case Karen Snelson, Outpatients SRO / Andrea Stewart, Outpatients Programme Manager Like many areas across the country, health and social care services in Stockport are subject to growing demand from an ageing population with increasingly complex care needs. In its current fragmented form, the health and social care system is financially unsustainable. If no changes are made, by 2010/21 there will be a combined deficit of 156m across Stockport s health and social care services. Since 2008/09 the rate of first outpatient appointments has risen by 26% nationally. Outpatient attendances have grown by 17% locally a 15% growth in GP referrals and 20% growth in referrals from other professionals, including hospital consultants. These trends are likely to be magnified in future by demographic and epidemiological pressures. In our current model, people are referred to hospital and receive specialist advice and support, often followed by recurrent follow-ups. Around 40-50% of outpatient appointments in Stockport result in advice and / or pharmaceutical treatment only, without the need for the patient to physically visit the hospital. Alternative approaches to the traditional model could deliver more effective solutions outside of the hospital setting, using technology to enable communications, advice and treatment between patients, GPs and specialists. The outpatients work stream of Stockport Together aims to reduce the number of unnecessary outpatient attendances over the next 3 years by providing alternatives to the traditional way in which they are currently delivered. 4. List the main activities of the project: Active support for patients to enable them to take more control of their condition including decision making and self-care and provision of advice Support for GPs in clinical decision making Appropriate clinical triage of referrals and diagnostics Alternative mechanisms for traditional appointments and support to enable discharge from outpatient clinic Identifying outpatient activity that can be stopped Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 260 4

261 Coordinated support for complex patients 5. What are the intended outcomes? 6. Who currently uses this service? Ultimately, Stockport Together aims to develop a sustainable health & care system for the people of Stockport delivering improved health outcomes, reduced health inequalities, greater independence and a lower need for bedbased care. The Outpatients work stream of Stockport Together should reduce the number of unnecessary hospital appointments, ensuring that: Patients access self-help, signposting and support at the earliest opportunity. Patients are confident and supported to take control and make positive decisions about their conditions and planning their care. Primary Care has access to specialist advice and support to encourage and enable management of conditions in a local, neighbourhood setting. GPs have access to appropriate training and education to manage patients in primary care that might otherwise have been referred to secondary care. Referrals are triaged systematically and specialists provide suitable advice to ensure that patients are managed in the most applicable setting by the most appropriate health professional. Diagnostic tests take place at the earliest opportunity in a patient pathway to inform the most appropriate treatment. This includes discharge with advice for patient and GP, and review by allied health professionals in non-acute settings. The amount of traditional outpatient activity is reduced by up to 38% over a 4 year period (2017/ /21) including the identification and removal of unnecessary outpatient activity. Patient pathways are optimised and streamlined. Alternatives models of outpatient care are developed to move away from traditional specialist outpatient face-to-face appointments where appropriate. Patients have more flexible access to a specialism rather than having to attend traditional face-to-face appointments. Patients receive care in a hospital setting only when it is needed. Patients receive one-stop coordinated care where possible. Unnecessary urgent care is reduced through strengthened planned and urgent OP care. IMPACT ON SERVICE USERS In theory, any person registered with one of Stockport s GP practices can be referred into the hospital for an outpatient appointment. Outpatient attendances have grown by 17% locally a 15% growth in GP Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 261 5

262 referrals and 20% growth in referrals from other professionals, including hospital consultants. In total, there were 101,315 first outpatient appointments for Stockport residents in 2016/17 and 243,005 follow-up appointments. Activity is particularly high among older residents and people with long-term conditions. The latest Joint Strategic Needs Assessment (JSNA) indicates that around 51,000 of the first appointments (FA) and 175,500 of the follow up appointments (FUs) are attributable to the cohort all adults over the age of 18 that are in the 15% of the registered adult population identified as most at risk of emergency admission. A more detailed breakdown of patient demographics by protected groups has been requested as part of this EIA s action plan and will be monitored to ensure that all protected groups have equal access to services in the new model of care. The top five specialties by first outpatient attendance volume together account for over 40% of the total first attendances. They have remained stable in the last four years: Outpatient Activity at Stockport NHS FT**: First Appointments Follow-up appointments 2015/ / / /17 Trauma & Orthopaedics 12,206 12,378 19,710 19,324 General Medicine * 9,386 10,609 4,800 14,968 Ophthalmology 6,130 6,300 7,719 17,067 Ear Nose & Throat 5,992 5,993 8,557 7,164 General Surgery 5,875 6,047 6,647 6,430 Anti-Coagulant ,259 40,902 * General Medicine includes Cardiology, Respiratory, Gastroenterology, Diabetes and Endocrinology ** This activity only relates to outpatient appointments commissioned at Stockport FT. Further information on protected characteristics within Stockport s population can be found in the full Equality Impact Assessment of the Stockport Together Strategy: A breakdown of local service users and their needs can also be found in Stockport s Joint Strategic Needs Assessment: 7. Are there any clear gaps in access to this service? (e.g. low access by ethnic minority The current service is open to all patients registered with a GP in Stockport. That said, we know that: Men are less likely to attend their GP Practice, where initial referrals into secondary care are made Outpatient referrals rates are higher in more affluent areas of the borough Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 262 6

263 groups) Patients with limited mobility, people in deprived areas, adults in fulltime employment, and those with caring responsibilities have noted issues attending multiple appointments at the hospital As noted above, more detailed monitoring has been requested as part of the action plan to this EIA so that the impact of changes to the service can be tracked. 8. Are there currently any barriers to certain groups accessing this service? (e.g. no disabled parking / canteen doesn t offer Kosher food / no hearing loop) 9. How will this project change the service offered? (is it likely to cut any services?) 10. If you are going to cut any services, who currently uses those services? (Will any equality group be more likely to lose their existing services?) 11. If you are creating any new services, who most A number of residents have raised issues with the cost of car parking at Stepping Hill Hospital, particularly for those on low incomes and people with multiple long-term conditions who need to attend more than one clinic. Older patients, people with disabilities and those with English as a second language have raised issues around communications from the hospital with appointment letters sent by post in a standard format that does not consider requirements for Braille, large print, Makaton or translation into other languages. It is recognised that technology based solutions will need to be accessible to all patients and alternative, traditional access methods available for those patients who are unable to use technological solutions. The proposed changes in the outpatient service will mean that people will be supported to manage health by the most appropriate professional in the most appropriate setting by the most appropriate way to meets their clinical need. This will mean a reduction in unnecessary trips to hospital and more care closer to home, such as in a local GP practice or community clinic. It will also include options such as follow-up appointments by phone or skype. There will be a reduction in the number of unnecessary outpatient appointments in a hospital setting; however the changes will not prevent people from accessing services. The service users will still receive the care that is needed, however it may be that it is delivered in a different way such as a follow-up in the local GP Practice. Where a patient s condition requires input from specialist consultants, they will continue to receive this level of care, though this may be in a community setting, rather than in the hospital. The move of routine follow-ups into the community will reduce waiting times for these higher risk patients for seeing a specialist. These changes will apply to any patient who is registered with a Stockport GP, however, given the higher use of elective services among women, older people and those with a disability or long-term condition, the impacts of more proactive care, reduced hospital trips and care closer to home will be of most Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 263 7

264 likely to benefit from them? (Will any equality group be more or less likely to benefit from the changes?) 12. How will you communicate the changes to your service? (What communications methods will you use to ensure this message reaches all community groups?) benefit to these protected groups. The implementation of the service is combined with communication to various groups to inform them how they will receive outpatient care. This will be done through newsletters, staff engagement sessions, attending GP locality meetings, partnership working with ambulance service, ED and hospital, meetings with expert patient groups and patient reference groups, meeting with HealthWatch, patient stories to highlight change, information at GP practices and information at website and social media. Public engagement and consultation included meetings with local groups representing protected characteristics to ensure that all voices were heard and all concerns / impacts understood. Information was disseminated in a range of formats: Online survey Paper surveys Public events Fliers and consultation documents handed out in clinics and displayed in Libraries, Pharmacies and GP Practices The consultation document included a message explaining how information could be obtained in an alternative format. Events were undertaken in accessible local venues across each area of Stockport, offering interpretation where required. 13. What have the public and patients said about the proposed changes? (Is this project responding to local needs?) Initial consultation across a sample of Outpatient clinics reflects broad support for the planned changes with the caveat that standards of care are maintained. Patients were asked a range of questions relating to their experience in the clinic they attended and their views about possible alternative approaches: 81% would consider seeing other appropriate healthcare professionals within the community. 54% would be happy for your care to be delivered in other ways rather than face to face. 90% would be happy to become involved in ways of directly managing/ monitoring your own health. A full write up of engagement can be found on the Stockport Together website at: Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 264 8

265 14. Is this plan likely to have a different impact on any protected group? Age (Can you justify this differential impact? If not, what actions will you add into the plan to mitigate any negative impacts on equality groups?) IMPACT Older people are more likely to use elective outpatient services MITIGATION This impact will be a positive one, reducing unnecessary hospital appointments, moving more care to a local setting and reducing waiting times for patients who require specialist input. This positive impact on a protected is objectively justifiable under the Equality Act. Carers Disability Some older people struggle with the use of technology for alternative appointments or self care monitoring Local carers have noted issues taking patients to multiple appointments and the cost of parking in hospitals People with one or more long-term condition are more likely to require elective procedures. Local disability groups have noted issues with the format of communications from the hospital Additional access requirements at any new community venues People with physical or learning disabilities may struggle with the use of Training should be made available on how to use any self-care equipment or technology such as skype for virtual appointments and alternative options should be given for those who struggle to use new equipment This impact will be a positive one, reducing unnecessary hospital appointments, moving more care to a local setting and reducing waiting times for patients who require specialist input. This impact will be a positive one, reducing unnecessary hospital appointments, moving more care to a local setting and reducing waiting times for patients who require specialist input. Contracts for the new neighbourhood services will include requirements to ensure that patient communications are undertaken in the most appropriate format for the individual. Venues for new community clinics will be required by contract to meet access standards. Training should be made available on how to use any self-care Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs) 265 9

266 Gender Reassignment Marriage / Civil Partnership Pregnancy & Maternity Race Religion & Belief Sex technology for alternative appointments or self care monitoring The service could have a negative impact on individuals with a learning disability or dementia, who may be less able to initiate a follow-up appointment. The service will likely have a positive impact on parents with young children, due to a reduced requirement for parents to arrange childcare around hospital appointments. It is likely to have a positive impact for pregnant women who may find it harder to travel into hospital for their appointment. While interpretation is provided for most hospital appointments, local residents have reported appointment cancellations due to a lack of interpretation and issues understanding communications sent from the hospital. Women are more likely to use elective outpatient services than men and, as such, will be more impacted by changes. Men are less likely to attend their GP Practice, as such they are less likely to equipment or technology such as skype for virtual appointments and alternative options should be given for those who struggle to use new equipment Consider alternative methods of communication such as how to make telephone services accessible, for example through the ability to send and receive text to cater for deaf individuals. This represents a positive impact on a protected group, which is objectively justifiable under the Equality Act Contracts for the new neighbourhood services will include requirements to ensure that patient communications are undertaken in the most appropriate format for the individual and interpretation services are provided. This represents a positive impact on a protected group, which is objectively justifiable under the Equality Act - reducing unnecessary hospital appointments, moving more care to a local setting and reducing waiting times for patients who require specialist input. Evidence suggests that flexible opening hours and improved Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

267 Sexual Orientation benefit from the changes. The proposed changes may have a negative impact on individuals who are concerned about experiencing stigma based on their sexual orientation. This has been reported as a potential barrier to individuals accessing healthcare, or revealing information that may benefit their care information available online could be levers that could make use of the service more accessible for men. Demographics should be measured to ensure that similar proportions of men and women are accessing follow-ups. Leaflets would also benefit from including images of men and the leaflet should be written in a gender neutral format. Staff training should include equality and diversity. Engagement plan should include work with LGBT groups. Patient data monitoring should include sexual orientation to ensure equal access and that no group receives a worse service. 15. How many staff work for the current service? Consideration should be given to use of imagery in publicity / leaflets to demonstrate accessibility. IMPACT ON STAFF The current service is delivered across a wide range of specialties based at provider sites. Currently, Full-Time Equivalents work in Outpatients at Stockport NHS FT: 36.6% are nurses; 23.53% work in admin; and 39.87% are classed as additional clinical services 96.73% are female and 3.27% are male 7.84% were in their 20s; 18.95% were in their 30s; 16.99% in their 4s; 38.56% in their 50s; 16.34% in their 60s; and 0.65% were in their 70s 85.62% are White British; 3.92% come from a White Minority background; 1.96% are Asian; 2.61% are Black; and 5.88% have not stated their ethnic origin 56.86% were Christian; 11.76% atheist; 6.54% reported following another religion; and 24.84% did not declare their religion or belief 7.84% reported a disability; 71.9% reported no disability; and 20.26% did not declare 74.51% reported being heterosexual; 1.31% were LGB; and 24.18% did not declare their sexual orientation. In addition, FTEs work in surgery; and FTEs are employed in trauma & orthopaedic surgery, who may also be impacted by the changes. As Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

268 part of the staff consultation on changes, all employees affected by the changes will have a chance to give their views and any impacts will be assessed by protected group. 16. What is the potential impact on these employees? (including potential redundancies, role changes, reduced hours, changes in terms and conditions, locality moves) Stockport Together aims to reduce the number of outpatient appointments at Stepping Hill Hospital by 38% - 107,513 fewer appointments - by 2020/21. The new model of care for outpatients depends upon a more integrated and aligned approach. The redesigned pathway moves away from a traditional approach where a patient is passed from GP to specialist to involve a wider spectrum of health professionals, who may be better placed to provide different aspects of patient care throughout the patient journey. This will inevitably require a more flexible, responsive and potentially complex approach to bring the right skill-mix of people together, at different points across the pathway e.g. community support, specialist nurses, pharmacists, GPwSI. GPs, specialists and other health professionals as required. The workforce may be required to work in an alternative setting and will require changes to job plans to enable them to work in a different way to traditional service delivery of outpatients. In order to deliver the model to the ambitions described a review of the existing workforce will be required to inform the development of a detailed workforce plan which describes the sequence of the proposed service changes and the associated impact on the workforce across the services. This proposal should include plans to deliver: Clear clinical governance New job roles Training and development programme It is not envisaged that there will be redundancies at this stage. However, any changes to roles would be subject to staff consultation and all employees would have equal employments rights under their HR policies, including: TUPE, flexible working, reasonable adjustments. 17. Is the potential impact on staff likely to be felt more by any protected group? Age If so, can you justify this difference? If not, what actions have you put in place to reduce the differential impact? IMPACT The average age of SFT employees is 45. There are more employees in their 40s or 50s than in their 20s or 30s. Older employees are more likely to work part-time and in nursing roles, which may limit options for potential job changes. MITIGATION Any changes in roles will be subject to staff consultation and will be managed under HR policies, offering equal opportunities for TUPE, reasonable adjustment and flexible working rights. Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

269 Carers Disability Gender Reassignment Marriage / Civil Partnership Pregnancy & Maternity 49.57% of SFT employees work parttime. Those with caring responsibilities may be limited in their ability to move or in working hours 2.89% of SFT employees report having a disability. Changes in roles may require reasonable adjustments for those with a disability No data is recorded by SFT on gender identity, however HR policies will apply ensuring that all staff have equal opportunities. No SFT HR policies follow national legislation on legal rights for employees during pregnancy and maternity Race 82.42% of SFT employees are white, with higher rates of BME staff among consultant roles and auxiliary positions. Religion & Belief 52.49% of SFT employees record their religion as Christian Sex 78.05% of SFT employees are female 96% of outpatients staff. Representation of men is higher in medical roles (64.52%) and particularly low in nursing roles (7.4%). Sexual 1% of SFT employees record their Orientation sexual orientation as homosexual and 18. What communication has been undertaken with staff? 19. Do all affected workers have genuinely equal opportunities for retraining or redeployment? 0.39% as bisexual A range of staff have been involved in design sessions for Stockport Together representing a wide range of roles. Staff engagement sessions, team briefs, newsletters, 1 to 1s have been used to communicate changes with staff as well as HR support, team building and culture change sessions. Yes this is part of the work force development plan Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

270 20. Who are the stakeholders for the service? 21. What is the potential impact on these stakeholders? 22. What communication has been undertaken with stakeholders? IMPACT ON STAKEHOLDERS It is recognised that the proposed new model of care for outpatients is complex and involves a range of stakeholders whose engagement and active participation will be key to the successful delivery of this business case. Key stakeholders include: Patients are central to the proposed model of care in relation to becoming activated and taking greater control of their own care and in accepting the proposed changes to their care. GPs will work in closer partnership with specialist clinicians to manage the care of their patients with appropriate advice and support from clinicians and healthcare professionals. Specialist clinicians will be expected to work differently providing specialist advice, guidance, protocols and care management plans so that where appropriate patients can self-manage or be managed by other healthcare professionals. Their knowledge, expertise and specialist clinical judgement is vital to informing the feasibility of future plans. Appointment booking teams will be required to operate potentially more varied and flexible approaches to provide patient access to the most appropriate clinical support. This will require more streamlined approaches and flexibility to adapt to changing pathways. Neighbourhood and borough wide teams and other health professionals will be responsible for delivering different aspects of patient care including specialist nurses, pharmacists, physiotherapists etc. in addition to the provision of an effective contact, access and triage infrastructure to enable the ongoing care of patients with longterm conditions. Third sector and community support groups are essential to providing a support mechanism for patients to share experiences, learning and support. Potential increase in activity for community and primary care staff Potential decrease in activity for secondary care staff Changes to the service delivery could impact place of work and changes to job plans. Consultation exercises with clinicians and patients have been undertaken to test and identify opportunities to support and enable this approach. Clinicians noted a wide range of areas where outpatient activity could be managed differently, through GP and nurse-led clinics, one-stop clinics, virtual appointments and more joint working. 81% of patients said they would consider seeing different healthcare professionals in the community for follow-up appointments. 54% would be happy for care to be delivered in other ways rather than face-to-face. 90% would be happy to become involves in directly managing / monitoring their Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

271 own health. Key findings can be found in Appendix 3 of the Outpatients Business Case. In addition, regular meetings, presentations and s have been used to keep stakeholders up to date on progress. 23. What support is being offered to frontline staff to communicate with service users / family / carers? 24. How will you monitor the impact of this project on equality groups? 25. Action Planning There is regular support from the operational delivery teams to support them in their discussions. Equality data is collected by providers including: deprivation (postcode), age, disability, ethnicity; gender; religion; sexual orientation. This will be mapped against the equality data for Stockport as a borough as part of the public sector equality duty. If this highlights potential underrepresentation of certain groups, further analysis will be undertaken to understand the reason and an action plan will be developed to improve equality. Patient and carers surveys might also highlight inequalities which will then be acted upon. An action plan has been set out at the end of this document to capture all actions identified through the course of this Equality Impact Assessment required to: Mitigate any potential negative impacts Take advantage of opportunities to reduce inequalities Respond to patient and public engagement. Actions in this plan will be included in the implementation plan for delivery of the Outpatients changes. At a strategic level, progress on the EIA action plan will be monitored regularly by the Stockport Together Programme Management Office as part of the governance framework for delivery of the work stream. EIA SIGN OFF 26. Sign off EIAs should be approved by the work stream s Senior Responsible Officer and sent to an equality specialist for quality assurance before sign off. Final EIAs should be attached to the final Strategy / Policy / Business Case before being presented to the relevant decision making Board. a. SRO Name: Karen Snelson b. Quality Quality Assured by: Angela Dawber Assurance Date: 20/12/2017 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

272 c. Board Approval EIA considered by / Date: Joint Commissioning Board 04/01/2018 Scrutiny Committee 16/01/2018 SMBC Cabinet 17/01/2018 CCG Governing Body 31/01/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

273 5. OUTPATIENTS Equality Action Plan Ref. Action Lead Deadline OP01 Equality Actions to be included in Outpatients Implementation Plan Karen Snelson / 31/01/2018 Andrea Stewart OP02 Outpatients programme to send monthly updates on implementation (including Karen Snelson / 28/02/2018 progress on equality actions) to Stockport Together PMO Andrea Stewart OP03 Develop future engagement strategy for the work stream, identifying key stakeholders (including protected groups) and optimal communications methods (including translation and interpretation requirements) Karen Snelson / Andrea Stewart 31/03/2018 OP04 OP05 OP06 Patient engagement and complaints to be monitored by protected groups to ensure there are no adverse impacts on any groups Stockport Neighbourhood Care to outline the process for meeting the Accessible Information Standard in the new service model: Agreement on Interpretation service (currently 3 services at SMBC, Primary Care and SFT) Collating data on formats required by patients Equality monitoring process System for sending patients communications in the correct format (e.g. Braille, large print) Service Level Agreements in place for translation information into other formats (Braille, BSL videos, audio format, other languages) Alternative contact methods to phone for deaf patients (e.g. Text-Relay service; text messaging; ; face-to-face) SNC Contract to set out the legal requirements of the new integrated organisation to follow duties under the Equality Act and Accessible Information Standard, including: Equality monitoring & reporting Karen Snelson / Andrea Stewart & SNC management team Karen Snelson / Andrea Stewart & SNC management team Lesley Brown & Gillian Miller 31/03/ /03/ /03/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

274 Ref. Action Lead Deadline Interpretation and translation services Accessible facilities OP07 OP08 OP09 Venues of new clinics assessed to ensure full access, including: Disabled parking Disabled toilets Changing facilities Hearing loops Communications plan for roll-out of the service changes, including: Map of stakeholders (including protected groups) Communications formats to meet needs to stakeholders Leaflets and other publicity to use inclusive images and language to demonstrate accessibility to all community groups IT plan developed to include: Training on how to use any self-care technology Alternative options for patients who are unable to use self-care technology Training on how to use skype technology for virtual appointments Alternative options for patients who are unable to access virtual appointments Karen Snelson / Andrea Stewart & Estates Karen Snelson / Andrea Stewart & Comms Karen Snelson / Andrea Stewart & IT OP10 Equality Impact Assessment of how the new service model will affect staff Karen Snelson / Andrea Stewart & HR OP11 Staff consultation on new service model and any changes to roles / places of work Karen Snelson / Andrea Stewart & HR OP12 Develop a staff training plan, including: Equality & Diversity Training Use of interpretation and translation services Equality monitoring to comply with AIS Karen Snelson / Andrea Stewart & HR 31/03/ /03/ /03/ /03/ /03/ /03/2018 OP13 Establish baseline figures for people accessing the services from protected groups Karen Snelson / 31/01/2018 Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

275 Ref. Action Lead Deadline then monitor these levels as the service changes are implemented. Andrea Stewart Stockport Together is a partnership between NHS Stockport Clinical Commissioning Group, Pennine Care NHS Foundation Trust (mental health services), Stockport Metropolitan Borough Council, Stockport NHS Foundation Trust (Stepping Hill hospital and community health services) and Viaduct Health (a federation representing all Stockport GPs)

276 Appendix 1 Transcript of questions and answers relating to Stockport Together consultation report at Adult Social Care and Health Scrutiny Committee Q: One of my concerns is something that was raised in the report page 20: fear of possible lower standards of care if less qualified staff started to undertake tasks that should only be done by qualified staff. I would be seeking assurances from you that that would not happen. A: The workforce planning that we have engaged in has looked at who does what at every level so there is a piece of work around outpatients which looks at what is the balance of what a consultant should do in a hospital as a follow up, or what might be transferred to a GP or practice nurse. What is the most appropriate use of skills? When we get into neighbourhoods, we have talked extensively to GPs about some of the tasks that they do, which in their view could be better done by a pharmacist, a therapist or a nurse. So how can we put those additional resources into their neighbourhoods so that they can be freed up to do those things that only a medically qualified doctor can do. At the next level down we have looked at the skill mix to support people at home. There are many people who have practical tasks done for them at the moment with something like self care or any additional help, who are seen by a district nurse who could in fact be seen by someone slightly less qualified. And given the shortage of nurses there is in the system, our plan is to try and get that skill mix much stronger in localities. At every point the decisions about who should do what is driven by two things: One is there a statutory element to this whereby only someone with a particular qualification can do i.e. prescribing for example, or mental health assessments. Secondly, what is the skillset required to carry this out: not what is traditionally how we have delivered this service. I can give you an assurance that at every point in planning, and with all the conversations we ve had about how to change the way we deliver services at the heart of that has been who is the best person to deliver this care or carry out this task, and not how can we get this done cheaper. We have had a comprehensive view of how we use our resources. Our analysis at the outset showed that a lot of what we do was being done because that s the way we ve always done it. But the professionals and the people receiving services we ve spoken to have all said that that has got to change. Q: I was reading this and convinced myself that when the steady state is reached, the system will work. But when steady state is reached that s fine as 276

277 long as it remains steady. But if something occurs like some terrible pandemic sweeps across the country and the hospital provision has contracted, how does it then rapidly expand to deal with that? A: The hospital building has all sorts of sections which are well used, and sections which are less well used because it has been adapted over time to meet all sorts of different purposes. There has always been the capacity up at Stepping Hill to open up a bit of mothballed building; that can be done quite easily. We ve had these conversations in Stockport Together planning and as part of winter planning about where are the spare beds, how quickly can they be got out of storage, what condition are they in? So your question about pandemics is part of the way we always plan our care, and is not really affected by the changes we re talking about in Stockport Together they happen on top of the day job whatever the day job is. We have got emergency and contingency plans to deal with those issues. The tests we ve been trying to establish and how we measure if we re ready to make a change all have at least two parts to them. One: is the system ready? Is the steady state well enough for us to disengage a part of our system, whether it s to stop using a residential home or to stop using a chunk of the hospital are we there yet? And if so, how long do we leave it before we make any decisions permanent? How long do we let the system operate at a new level before we make a change permanent? And that s the second test. And what s hardest for us as a system is not finding physical localities to care for people, it s finding the staff. At the moment we are really struggling: our system is pulling us in directions where we have to use a lot of non-permanent staff just to cover what we re doing. We see a contraction of that core of the system providing us with a more stable and effective workforce, particularly in the hospital, than we have at the moment. That is our thinking. Before we reduce, set ourselves some very clear criteria When we reduce, don t make decisions permanent until we re sure that the changes we ve made are sustainable Always have that capacity to mobilise for any kind of epidemic. As an example, a flu outbreak in any hospital can take out a huge chunk of the operating capacity in order to isolate patients we already have systems that would have to deal with this on an ongoing basis and that won t change. Q: My concern is: I think most people would agree that if you put care into the community, people want the care in their own home, but would need to have a network of support to back that up, or else they could end up having to go into hospital. Can we be sure that we would have that network of support to keep people out of hospital? A: That is the proposal that we have put in place. Within the business case it describes a whole new set of services to provide that level of community services. We have identified some more intermediate care services; a new model of 277

278 community based support within the neighbourhoods; and particularly looking at people who are more vulnerable to admission, and perhaps need more care wrapped around them, and identifying additional medical, nursing and support services that would enable people to be cared for within community settings and reduce the need for hospital provision and admission where we can. Obviously there will always be times when people require hospital admission, but the proposals are designed to support people to maintain them in their own homes and also for those people who do need to be admitted for a short-term, provide that support to enable them to be discharged quicker than they would have ordinarily. The business cases that you ve considered previously set out those service models for putting that range of community services in place across primary care, community services and social care. Q: I was concerned a lot of the public s response was fear of loss of beds, moth-balling beds or disposing of the beds too soon I still can t get my head around the idea that we can reduce admissions to hospital. But are we predicting that there will be an increasing need for the hospital, so by reducing once we get to the steady state the beds will still be needed or are we actually looking to reduce the need for beds? And if so, if we moth-ball wards is this an expensive process: keeping them just sitting there while the system sets itself up. A: The plan is to deal with some of the growth in the system, and to go beyond that. When we compare our system to similar boroughs across England, we currently have about 30% higher urgent and non-elective admissions than our peers. So we think there is some room to make these changes. It s really important that we plan and invest 16m in out of hospital services, and don t leap to moth-balling bed, but we have a clear set of processes by which we would then bring that about. We have a set of set of measures that test truly, along with the Simon Stevens Fifth test that the NHS has produced, that the services are in place and operating, and we would be looking to have some measures in place to check that that is the case. We then need to keep a check on what impact this has on demand over time and to monitor that closely. If we did then make a decision to moth-ball resources, one of the things we would look at doing is look at the three levels of resource: 1. variable costs (equipment/resources) 2. semi-fixed costs (staff/agency cover) 3. fixed costs (estates/buildings) Our planning is that it ll take at least three years to get through releasing all of those to be really clear that we re not rapidly taking the capacity out that we will need at a later date. There is a three phase approach to make sure we re doing it as set out in our economic plan. 278

279 Q: In the report it mentions that feedback from the consultation is that the more articulate middle class people would demand better services and that would disadvantage the less affluent areas of the borough. We do know that in communities those that shout the loudest do get the better care. What are the checks and balances in place to make sure that doesn t happen? A: Interesting comment that was made: yes, some sections of the population are better at having their voice heard than others. It was quite clear that when I went to the Poets Corner Action Group, those members were quite clear about what they wanted out of their system, and likewise we have tried to find ways of communicating with different groups in our community: we went out in the streets in each part of the borough to collect people s views. That was the worry that those voices would dominate the consultation process, and we have done everything we can to prevent that being the case: and I think successfully. When it comes to designing services, we are a very polarised borough and one of the reasons we ve gone to an eight neighbourhood model is because that s the sort of size of population where we can start to see real differences. In some areas, the way people live leads them to need a particular type of designed services when they re in their late 80s or 90s and in other parts of our borough they don t live that long, and their needs are quite different in their 60s and 70s. And our neighbourhood approach is designed very explicitly to be adaptable to the requirements of the population and ultimately, in that question how do we organise our services and plan for them? we have been very upfront in saying we need to do things differently, both at a preventative level and a reactive level in all our communities, because their needs are different. We have built in a way of managing that and the scrutiny processes of implementation will I m sure regularly ask questions about who is getting what about sort of care. What we hope to do in our implementation is build in different community responsiveness and engagement of people who use the services in the design and development of service than we have at the moment. Because at the moment, people are not very engaged. One of the real strengths is the neighbourhood model, because we all know that the different communities differ quite significantly across Stockport, but as well as the design of this and having those neighbourhood teams looking and monitoring the service delivery at a neighbourhood model. From a commissioning point of view, it is very important that through these proposals we will focus less on the inputs and more on the outcomes and how are these new service models addressing the inequalities that we might see both for different groups and different communities. Supporting those integrated service models might be a way of looking at whether these have made the difference we want and that will be a change to the way we do some of the commissioning activity. 279

280 Q: The sharing of the electronic records which mentions the third sector. Can you clarify what is meant by that, as the assumption could be that any volunteer is going to have access to the electronic records... I m sure that s not the case, but for the purposes of clarity could you just expand on that? A: One of the challenges we face of involving the third sector adequately in the proposals is that the information governance constraints are more significant when we do. We have involved the third sector, we use a consent model so that people are giving consent before any information is shared, and clearly we can t go beyond that. What is really important to understand when we talk about working with the third sector which we want to do, and have had feedback we should do more of the information governance constraints are even more of an issue. The last thing we will do is just share with anybody, the challenge is sharing with those groups who it would be recognised as working effectively with us. The challenge around information governance is less about just sharing with anybody, as sharing with the right people. And this is one of the big issues we have to constantly work through in an appropriate way. And at the moment we re basing it on individual consent as a mechanism for doing that. 280

281 Stockport Mental Health Investment Plan 2016/ /21 NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group 7th Floor Regent House Heaton Lane Stockport SK4 1BS Tel: Fax: Text Relay: Website: 281

282 Executive Summary What decisions do you require of the Governing Body? Governing Body is asked to: (i) Discuss and review the proposed Mental Health Investment Plan (ii) Approve the investment plan as a high priority for inclusion within the 2018/19 CCG plan. (iii) Note that the scope of this plan excludes both the CQC action plan and PCFT underlying financial position. Please detail the key points of this report Investment into Mental Health services is a key local and national policy. This paper sets out an investment strategy for 9.7m into Stockport services across a five year period. What are the likely impacts and/or implications? These are identified in the report How does this link to the Annual Business Plan? The Investment Plan is consistent with the CCG s Annual Business Plan What are the potential conflicts of interest? There are no potential conflicts of interest Where has this report been previously discussed? Joint Commissioning Board 4 th January 2018 Wider Leadership Team 6 th December 2017 and 17 th January 2018 Clinical Executive Sponsor: Dr Ranjit Gill Presented by: Mark Chidgey Meeting Date: 31 st January 2018 Agenda item: Reason for being in Part 2 (if applicable) Compliance Checklist: Documentation Cover sheet completed Y / N Statutory and Local Policy Requirement Change in Financial Spend: Finance Section below completed To follow Page numbers Y / N Service Changes: Public Consultation Completed and Reported in Document n/a 282

283 Paragraph numbers in place Y / N Service Changes: Approved Equality Impact Assessment Included as Appendix n/a 2 Page Executive summary in place (Docs 6 pages or more in length) n/a Patient Level Data Impacted: Privacy Impact Assessment included as Appendix Y / N All text single space Arial 12. Headings Arial Bold 12 or above, no underlining Y / N Change in Service Supplier: Procurement & Tendering Rationale approved and Included Any form of change: Risk Assessment Completed and included Any impact on staff: Consultation and EIA undertaken and demonstrable in document Y / Na n/a Y / N 283

284 Introduction When approving the Stockport Together Business Cases in July 2017, the CCG Governing Body highlighted that the Stockport Together models of care would not, by themselves, fully deliver the required levels of improvement and access for Mental Health services. The Governing Body was assured that a significant piece of work was underway to consider Mental Health investment priorities and this is now presented to the Governing Body for consideration. Process The investment plan has been developed by the CCG clinical and commissioning leads for Mental Health through engagement with people who access services, carers, service providers and other stakeholders. The following reference points have also informed the plan:- local needs assessment. current performance against national key performance indicators. National and Greater Manchester policy priorities. The plan sets out a prioritised proposal that delivers a significant element, but not all of, the potential for improvement. The plan specifically references those areas of potential investment that, at this stage are not recommended to progress. Scope & Phasing The scope of the investment plan is not intended to address all of the challenges of Mental Health services. In particular, no assumptions are made as to CCG investment to either address issues raised in the most recent CQC assessment of Pennine Care NHS FT or their underlying financial position. Greater Manchester CCGs are working with PCFT to quantify these issues and agree how they should be reflected within 2018/19 plans. The phasing of the proposed investment is:- Year Additional Recurrent Investment m Cumulative Investment m 2016/ / / / / Note that of the 2.793m planned investment in 2017/18, 1.496m relates to the Stockport Together business cases and was endorsed in July Summary The proposal is to invest an additional 9.7m into Mental Health services across a five year period, Governing Body is asked to: (i) Discuss and review the proposed Mental Health Investment Plan (ii) Approve the investment plan as a high priority for inclusion within the 2018/19 CCG plan. 284

285 (iii) Note that the scope of this plan excludes both the CQC action plan and PCFT underlying financial position. 285

286 Stockport Mental Health Investment Plan 2016/ /21 To improve the mental health and wellbeing of the people of Stockport 286 1

287 Mental Health Investment Plan Introduction How We Will Do This? This Investment Plan sets out how Stockport Health and Care Organisations aim to improve mental health services for the population of Stockport across a life course by 2020/21. The organisations want the population of Stockport to receive high quality mental health services by ensuring that: - Local mental health needs are met, so that our most vulnerable residents can receive NICE recommended treatment, care and support The Investment Plan will have a strong focus on: - Preventing and promoting mental wellbeing We assign additional investment to deliver the best service model for sustainable and high quality services We achieve and exceed national standards on mental health The plan is in response to the Mental Health Five Year Forward View (5YFV), which identifies three key areas: - Quality Access and crisis High Quality 7- day services for people in crisis Prevention Integrating physical and mental health care The 5YFV must do priority areas include: All age 24/7 Mental health crisis Eliminating out of area placements Suicide Prevention Acute Hospital MH Liaison service Early Intervention for Psychosis Children & Young Peoples Mental Perinatal Mental Health Health including eating disorders Dementia Diagnosis Improving Access To Psychological Therapies 287 Health and Care Organisations will invest an additional 9,672,000 over a five year period (2016/ /21) in mental health services for the whole population To realise parity of esteem we will work towards a new service model for integrating mental and physical health as a cross cutting theme 2

288 Mental Health Investment Plan Vision Statement Our vision of mental health services for all Stockport residents is a bold one. We want everyone to find it easy to access the support they need to enable them to maximise their mental health and wellbeing. We will strive to prevent mental ill health, promote wellbeing and ensure access to services that are in the right place, at the right time and through involving the right people. We can realise this vision through smooth pathways into, through and out of specialist and non-specialist services. This means a system of services that communicates effectively with everyone involved and provides safe and high quality care, interventions and treatments based upon the most up to date knowledge and research. We want to see a future where having a mental health condition is not stigmatised by society, and where equal life chances are made available to all. In our vision, people who have experienced, or are living with a mental health condition play an important role in helping us improve how services are delivered and commissioned. This also applies to carers. We acknowledge that mental health service users and their carers have expertise through their own experience. We shall make it our business to ensure that prevention, intervention and recovery are well resourced so as to put mental healthcare on a par with physical healthcare. Stockport Mental Health Stakeholder Forum Core Principles 1. Our services are based on the belief that everybody has the capacity to recover and to live a fulfilling life 2. Parity of Esteem is defined by the Royal College of Psychiatry as valuing and funding mental health equally with physical health. It is characterised by equal access to the most effective and safest care and treatment; equal efforts to improve the quality of care; allocation of time, effort and resources on a basis commensurate with need; equal status within healthcare education and practice; equally high aspirations for service users; equal status in the measurement of health outcomes. 3. User-friendly pathways for diagnosis, assessment support, treatment and intervention, informed by evidence where available, are recognised as essential. Professionals to work joint with users and their carers in a timely manner and seek to reach recovery as soon as possible. 4. Prevention of poor mental health and prevention of relapse; promotion of recovery and mental health and wellbeing; reduce isolation and maximise social inclusion to support clinical and personal recovery through a wide range of approaches 5. Provide safe and effective services that meet the needs of the population of Stockport; ensure that staffing levels are sufficient in numbers and have appropriate interpersonal, professional skills and competencies to deliver high quality services in a caring and compassionate way. 6. Local partners plan and develop appropriate and responsive services for all mental health conditions and for people of all ages

289 Mental Health Investment Plan Investment Secondary Driver Primary Driver Aim Increasing physical health checks and lifestyle interventions for people with severe mental illness Supporting people bereaved by suicide Providing suicide prevention training Increase mental health community access for children and young people Expand acute hospital mental health liaison services Expand community mental health care teams Perinatal and infant parent mental health services Develop a 24/7 crisis for children and young people Develop a 24/7 crisis for adults Exceed the national standards for people experiencing first episode psychosis (EIP) Expand IAPT services to support people with long term conditions Promoting physical health and interventions for people with SMI Suicide Prevention Early intervention/resilience/ self care for children and young people 24/7 access to support when in crisis Faster and better access to IAPT/EIP/ Core CAMHS/ Perinatal More people seen Prevention and Wellbeing Access and Crisis Improve the mental health and wellbeing of the people of Stockport Acute mental health in-patient pathway (including female PICU) Dementia care and post-diagnostic support Best practice care Safe services Better experiences for all Quality Integration Parity of Esteem Psychological Medicine Service in Stockport Neighbourhoods Mental Health Liaison 289 and Intermediate Care for Older People Neighbourhood mental Wellbeing Navigators 4 4

290 Promoting physical health checks and interventions for people with serious mental illness Reduce the rate of deaths due to suicide Promote early intervention, resilience and self-care Core Themes Drivers Case for Change Mortality rates are almost 4 times higher for people in Stockport with serious mental health conditions, than the Stockport average. The rate of mortality from suicide in Stockport has increased People tell us that more support should be available for those bereaved by suicide Our approaches to self help, promoting resilience and early support for children and young people are not well coordinated There are gaps in provision for children and young people with mental health concerns whose needs are not met by the specialist services Prevention and Wellbeing Reduce the inequality in mortality rates between people with a serious mental illness and the rest of the population Stockport will have a multi-agency plan for suicide prevention to deliver a 10% reduction in deaths from suicide To improve access to a range of mental wellbeing services and opportunities for children and young people Commitment Investment Areas Physical health checks and access to lifestyle interventions for people with serious mental illness Enhance and develop an early help offer for children and young people Commission suicide prevention training package for Neighbourhood staff Commission support for those bereaved by suicide 290 5

291 Core Themes 24/7 access to support when experiencing a mental health crisis Faster and better access to mental health services More people to access services when they need treatment, care and support Drivers Case for Change Access & Crisis National policy inform that services for people experiencing a mental health crisis should be available 24/7 There are high rates of children and young people and adults attending the emergency department because there are no other alternatives for support National policy informs waiting time standards across mental health services should be achieved More children and young people and adults should receive evidence based treatment and care to promote mental wellbeing. This includes better and faster access to services 24/7 access for people of all ages when they experience a mental health crisis, with the aim of providing an alternative to the emergency department and/or hospital admission Access to all-age acute hospital mental health liaison services Exceed national standard for early intervention in psychosis services An increase in access to psychological therapies More children and young people will access evidence based interventions and will access them earlier More women will access specialist perinatal mental health support Commitment 291 Investment Areas Develop a 24/7 crisis pathway for both children and young people and adults Expand the acute hospital mental health liaison service Expand early intervention in psychosis services Expand core CAMHs services, ensuring alignment with GM crisis response Develop perinatal and infant parent mental health services Enhance community mental health teams 6

292 Core Themes Best care practice - Effectiveness Safe Services for all Better experiences for all Drivers Case for Change The quality and safety on in-patient mental health wards need to improve There is no access for females who require psychiatric intensive care The people of Stockport tell us that they would like staff who are able to build trust The results from Friends and Family show that most people would recommend mental health services, but improvement is needed Quality People who use services will report that they are safe, effective and they have a good experience Eliminate out of area placements for non-specialist in-patient mental health care People will have confidence in all services that they are in contact with New GM CAMHS specification embedded locally Commitment Investment Areas Dementia care and post diagnostic support Safer staffing on in-patient mental health wards Commission local female psychiatric intensive care beds Investment in specialist CAMHS to ensure reliance of service 292 7

293 Cross Cutting Theme To bring mental health and physical health services closer together in the neighbourhood model Drivers Case for Change National policy suggests that integrating physical and mental health care improves outcomes People tell us that they want a holistic approach to care People of Stockport want an equal approach to both physical and mental health Integration Continued engagement with people who use services, their carers, our key partners and other key stakeholders A programme of organisational development and training for the entire workforce A continued focus on improving information systems and data quality Pathway development and re-design Co-location of services, wherever possible Commitment Investment Areas Psychological Medicine Service in Stockport Neighbourhoods Mental Health Liaison and Intermediate Care for Older People Neighbourhood mental Wellbeing Navigators 293 8

294 Mental Health Financial Investment Plan Proposals Area for Investment Existing investment and Delivering National and GM Policy Recognising Local need above National and GM Policy Proposed Investment Additional Investment to fully meet National expectations for each service Additional Investment to fully meet identified Local needs Increase mental health community access for children and young people 1,000K 1,000K Prevention and Wellbeing Improve physical health of people with severe mental illness 150K 200K 350K Suicide Prevention including supporting people bereaved by suicide 33K 55K 88K Workplace Health Stigma & Discrimination K Expand acute hospital mental health liaison services 1067K 1067K 888K Achieve and exceed the national standards for people experiencing first episode psychosis (EIP) 821K 821K Access and Crisis Expand IAPT services to support people with long term conditions 773K 773K Develop a 24/7 crisis offer for adults 704K 704K Develop a 24/7 crisis offer for children and young people 370K 55K 425K Perinatal and infant parent mental health services 436K 436K 194K Expand community mental health care teams 350K 350K 383K Quality Acute mental health in-patient pathway (including female PICU) 400K 186K 586K 114K Dementia care and post-diagnostic support 285K 285K Integrated Mental Health Services/Mental Health - Stockport Together Other Commitments Psychological Medicine Service in Stockport Neighbourhoods 705K 705K Mental Health Liaison and Intermediate Care for Older People 665K 665K Neighbourhood mental Wellbeing Navigators 451K 451K Mental Health Placements 575K 575K Other Commitments- Inflation on mental health contracts 391K 391K Total 6039K 3633K K 562K 294 9

295 Risks and Mitigation of Proposed Investment Risks Workplace Health, Stigma and Discrimination - No investment opportunity to address stigma and discrimination as part of workplace MH Expand Acute Hospital Mental Health Liaison Services - Reduced effectiveness of an acute hospital mental health liaison service as the investment proposed is below the maximum potential level. Perinatal/Infant Parent Mental Health - Risk of national scrutiny as investment proposed for perinatal/infant parent mental health is less than national proportionate allocation ( 630K) Community Mental Health Care Teams - Assuring effective support to people with serious mental illness in the community Dissatisfaction from local stakeholders about the reduced investment Acute mental health in-patient pathway - Assuring quality and safety on the acute in-patient mental health wards Local mental health trust progressing to a good CQC rating Mitigation Greater Manchester will co-ordinate a work stream to deliver on Population Health and other Transformation Board work streams as part of the Taking Charge strategy, this will include overcoming mental health stigma and discrimination and work and health. The requirement to invest at the maximum level into an acute hospital mental health liaison service for Stepping Hill Hospital is not recommended at this stage. 1,067K represents a significant investment into the acute hospital MH liaison service and this should not be seen in isolation from the enhanced community offer providing support to people in the Neighbourhoods. In addition, the investment proposed to develop a 24/7 mental health crisis response will provide a much needed offer as an alternative to people using the Emergency Department. Following implementation and evaluation of both Stockport Together and the crisis offer the scale of the MH Liaison service will need to be reviewed. The investment proposed to support acute hospital mental health liaison service will provide additional consultants, other medical staff and a range of mental health practitioners which will enhance the current offer. Greater Manchester Perinatal and Parent Infant Mental Health Model comprises 3 key elements: - 1. Specialist Perinatal Community Mental Health Team (CMHT) 2. Early Attachment Service 3. Fast Track IAPT The model proposed by GM will provide funding to establish the Specialist Perinatal CMHT, which will be prioritised following 2020/21. Through the Stockport Perinatal Forum and existing investment Stockport has already made good progress on both the development of an early attachment and the fast track IAPT offer. Investment has been identified to support further re-design of the CMHT model this will focus on understanding the competing pressures and to align the model with Stockport Neighbourhoods. The CMHT Pathway will be re-designed, this will be led by Pennine Care and involve local stakeholders. An existing acute pathway group is in place to review the demands on the mental health acute wards. The CCG is working closely with Pennine Care NHS FT to review both in-patient utilisation and review alternatives to in-patient admission, including the review of STEM (Stockport Team for Early Management) model and development of 24/7 crisis response

296 Next Steps The following work streams have been identified to deliver the commitments in the investment plan: Prevention and Wellbeing Access & Crisis Quality Integration Children and young people mental health and wellbeing to develop the early help offer and implement the 24/7 crisis response Physical health and well-being interventions for people with Severe Mental Illness To develop a comprehensive physical health offer for people with severe mental illness. The work stream will include developing an effective system for completing physical health checks as well as providing evidence based lifestyle interventions for people with severe mental health conditions. Review of Mental Health Crisis Pathway To undertake a review of the mental health crisis pathway to create an integrated offer for people both known or unknown to mental health services. Secondary Care Mental Health Provision To ensure that secondary care mental health services are adequately resourced to meet local need and deliver quality services. The areas included in this work stream are Early Intervention Treatment for first episode psychosis and support to people with complex needs. Review of Acute Pathway Review of the mental health Acute Pathway to improve quality and safety, provide alternatives to in-patient care, commission female PICU in order to eliminate out of area placements Integration with Neighbourhoods To work towards the integration of a clear mental health offer in Stockport Neighbourhoods, this will involve working with the existing mental health services Other investment areas identified will be delivered within established areas of work. A detailed implementation plan will be developed to track progress and outcomes

297 Locality Chairs Report Report to January 2018 Governing Body NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group 7th Floor Regent House Heaton Lane Stockport SK4 1BS Tel: Fax: Text Relay: Website: 297

298 Executive Summary What decisions do you require of the Governing Body? This is a report for discussion and no decision is required Please detail the key points of this report There is a new format of meeting and a number of issues have been discussed Crisis Response Service Flu Long Term Conditions What are the likely impacts and/or implications? How does this link to the Annual Business Plan? What are the potential conflicts of interest? The GPs are commenting upon services that they deliver however the decisions are made at the primary care committee to alter the provision of service. This is therefore a consultation design process not a decision making process. Where has this report been previously discussed? Nil Clinical Executive Sponsor: Dr Gill Presented by: Dr Hardern Meeting Date: 31 January 2017 Agenda item: 11 Reason for being in Part 2 (if applicable) 298

299 Locality Chairs report to Governing Body 1. Introduction 1.1. Locality Chairs meet on a monthly basis to discuss relevant issues for General Practice. Themes discussed and the agenda for the next meeting are shared with member practices to encourage feedback on any issues. This has ensured that member feedback is incorporated into the meeting cycle Themes highlighted for discussion by Locality chairs have to date included Crisis Response Service Flu Long Term Conditions 2. Crisis Response Practices were asked for feedback on the changes in the Crisis Response Service. Member practices reported a mixed response prior to the changes but the changes had not improved this. General member concern was that the service has insufficient capacity and a lack of medical input. Locality Chairs are hopeful that the bid for funding for an ANP into the service will improve the situation. 3. Flu Practices continue to maintain high uptake figures and data has been shared with practices and localities to support this. Levels are higher than this time last year. An issue was raised regarding Midwifes not coding flu vaccinations for pregnant ladies particularly those done whilst in the practice although Midwifes have EMIS access. This will be picked up in discussions with the Midwifery service 4. Long Term Conditions Data is currently being reviewed by Locality Chairs in relation to the increase in admissions for long term conditions. This is being further refined to determine whether this is a trend or a brief episode, the reasons for increased admissions and which long term conditions are specifically involved. Data will be fed back to the locality chairs for discussion with their practices 5. Conclusion Members are asked to note the report. 299

300 Chief Operating Officer s update Chief Operating Officer s update to the January 2018 meeting of the Governing Body NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group 7th Floor Regent House Heaton Lane Stockport SK4 1BS 300 Tel: Fax: Text Relay: Website: 1

301 Executive Summary What decisions do you require of the Governing Body? This report provides an update on a number of issues. Please detail the key points of this report Provides an update on: Working Well Project Re-location of CCG Offices to Stopford House Stockport Town Centre Ambassador What are the likely impacts and/or implications? How does this link to the Annual Business Plan? Supports delivery and meets statutory requirements. What are the potential conflicts of interest? Where has this report been previously discussed? Leadership Team Clinical Executive Sponsor: Ranjit Gill Presented by: Gaynor Mullins Meeting Date: 31th January 2018 Agenda item:

302 Chief Operating Officer Update 1.0 Purpose 1.1 This is the report of the Chief Operating Officer to the Governing Body for January Working Well Early Help Programme 2.1 There is a co-dependent relationship between health and work. Good quality work supports good health and economic growth relies on a healthy, productive workforce. In Greater Manchester there are 236,400 people out of work and claiming benefits. Of these, 64% (150,800) people are claiming benefits as a result of a health condition. The number of people with longterm health conditions in employment is 59% compared to 65% in the rest of England. Greater Manchester Health and Social Care Partnership and the Greater Manchester Combined Authority have agreed to develop a joint programme to provide: An effective early intervention system available to all GM residents in work who become and are at risk of falling out of the labour market, or are newly unemployed due to health issues; Better support for the diverse range of people who are long-term economically inactive to prepare for, find and keep work; Development to enable GM employers to provide good work and for people to stay healthy and productive in work. Why is this Programme Needed? 2.2 Currently there is no systematic early intervention pathway to prevent people with health conditions falling out of work within Greater Manchester. General Practitioners spend significant time supporting people via the current sick note system, and the National Fit for Work programme GPs previously referred to has recently been stopped. There is therefore a gap in the support for this group of people and for GPs who need to refer patients for additional support. Objectives of the Programme 2.3 The proposed objectives of the programme are to: Provide additional support for GPs, employers and the population; Reduce the number of days lost to sickness absence for those in employment; Prevent GM residents with health conditions from leaving the labour market; Support businesses to retain employees and better manage health in the workplace; Reduce the amount of time spent on non-clinical work clinicians in primary care; Support newly unemployed people with health conditions to access an enhanced health support offer to facilitate an early return to work

303 How would this work? 2.4 The programme aims to ensure that it fits with local models of support and pathways of care. So for example, in Stockport links would need to be made to neighbourhood direct access to physiotherapy services. GPs and health professionals will be able to refer employed people who have been off sick for two weeks and likely to be off for four weeks to the new service for a biopsychosocial assessment, action planning and case management. Patients will receive advice on how to manage their condition, self-care advice and will have rapid access to physiotherapy and mental health treatments. There will also be self-referral or via employer for those at work but struggling with health conditions and require an intervention to remain effective and productive in work. The new service will integrate with local existing health and work support services. Support will also be targeted at employers and their employees to improved workplace health practice. 2.5 Whilst the Early Help Programme will build on existing local integration of services, such as Work Clubs, Stockport Advice, and Stockport Family, there are some health and wellbeing related services that will be a key focus as part of the local offer. These include: Healthy Stockport, the Stockport Prevention Alliance, Stockport Psychological Wellbeing Service, Stockport Healthy Minds, the PARiS scheme (Physical Activity Referral in Stockport), Stockport NHS X-pert Patient and the GP based Direct Access Physiotherapy programme and Mental Well Being and self-care programme. Partnership work with Stockport Homes will also continue. 2.6 Greater Manchester have identified an 8.5 million investment fund for this service over three years. A service is already running in Manchester and there is some early evidence that the approach works. The procurement is planned for early 2018 with a pilot go live date predicted for the end of How are we approaching the pilot in Stockport? 2.7 Councillor Tom McGee, the Stockport Council Cabinet Member with responsibility for Health and Wellbeing in Stockport and Councillor Kate Butler, the Council Cabinet Member covering Work and Skills are supporting the development of the Stockport pilot. The Deputy Director of Public Health is providing strategic support and ensuring full Public Health involvement in Stockport, working closely with the Work & Skills Leads in the Council. 2.8 Within Stockport CCG, Dr James Higgins has agreed to be the lead GP on the programme and Dr Diane Jones, the Director of Service Reform will be the lead Director for the CCG and providing strategic support. A small task and finish team to support the delivery of the pilot has been established between the Council and the CCG. This group will report into the CCG Leadership Team and the Working Well Local Integration Board. 2.9 As the pilot can only be made available to 6-7 practices in the first instance, the team have agreed to commence with one neighbourhood to test the 303 4

304 service. Engagement with practices will commence in February and if insufficient interest is shown further practices will be contacted to achieve the 50,000 population size required Key next steps include: GP engagement is planned for February 2018; A workshop with local employers In Stockport is planned for February 2018; The GM procurement will commence in March 2018; A paper has been submitted to the Health and Wellbeing Board to seek endorsement of this work programme. 3.0 Re-location of CCG Offices to Stopford House 3.1 With the Regent House lease due to expire on 15th March 2018 the CCG has over the last 12 months undertaken a review of office accommodation options. Due to the limited availability and access to capital funding only two options were considered: 1. Renew Regent House lease 2. Co-locate with SMBC on the 4thFloor of Stopford House 3.2 The strategic context of the developing integrated commissioning function with the Council was an important consideration within the process, as was suitability and value for money. 3.3 Management Team has reviewed both options and agreed at the January 2018 meeting that the preferred option is to co-locate with the Council on the 4 th Floor Stopford House. This option delivers benefits of co-location alongside SMBC to deliver closer working and integration of CCG and Council commissioning functions, with the aim to improve services and outcomes for patients. Management Team were assured that the Stopford House option represents the best value for money because it is both a lower price option than the current lease and has been tested against current market prices. 3.4 It is proposed to enter into a ten year lease with the Council with an option to break at year 5. If the CCG exercised the option to break at year 5 a penalty payment would be payable. The penalty payment would be equal to unrecovered capital costs which have been amortised over the 10 year lease period and charged as part of the annual rent. 3.5 Lease arrangements include the CCG having full use of Council building services including, reception, porterage, post room, domestics and meeting room facilities. 3.6 The area to be leased is 433m 2 which is below area currently occupied at Regent House. However Regent House includes a significant area for 304 5

305 meeting rooms which will be provided across Stopford House and shared with SMBC. The CCG also intends to continue and further develop its approach to flexible working (in line with many other organistations), and will reduce the amount of fixed desks available within its Headquarters. This move will require a change in our working arrangements and a significant increase in flexible working, and we are doing a lot of work with staff to ensure that the transition to these new arrangements. 3.7 A staff consultation will be undertaken during February regarding changes to terms and conditions resulting from a change in base and the office move is anticipated to take place in early June Stockport Town Centre Ambassador 4.1 Stockport MBC have developed a town centre ambassador programme. This was launched in December 2017 at an event to showcase the town centre ambitions and plans to GM Mayor Andy Burnham. Stockport MBC have approached a number of organisations to ask if senior leaders would be interested in joining the programme, and undertake a role in promoting Stockport in the course of their daily life and work. As a commissioner of health services and with an important role in improving health, the CCG will participate in this programme, and is very keen to work with the Council and other bodies as part of this programme. 5.0 Action requested of the Governing Body 1. The CCG Governing Body are asked to note the report and confirm their endorsement of Stockport s engagement in the Working Well Early Help Programme 2. Request that the Chief Operating report to the Governing Body any material changes to lease terms. 3. Delegate authority to the Chief Operating Officer to enter into a 10 year lease for the 4 th Floor Stopford House subject to the final negotiated lease cost remaining value for money

306 Chief Clinical Officer s update Chief Clinical Officer s update to the January 2018 meeting of the Governing Body NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group 7th Floor Regent House Heaton Lane Stockport SK4 1BS 306 Tel: Fax: Text Relay: Website: 1

307 Executive Summary What decisions do you require of the Governing Body? The Governing Body is requested to consider and discuss the information contained within the report. Please detail the key points of this report This report provides an update on the following matters: (a) Healthier Together (b) What are the likely impacts and/or implications? The implications and impact of is outlined within the body of the report. How does this link to the Annual Business Plan? Regional and sector based work forms a key part of the delivery of the Stockport Plan. What are the potential conflicts of interest? None Where has this report been previously discussed? The individual reports have been discussed at their development bodies. Clinical Executive Sponsor: Ranjit Gill Presented by: Ranjit Gill Meeting Date: 31 January 2018 Agenda item:

308 Implementation of Healthier Together in the South East Sector: update on progress January 2018 Business Case and Financial Position NHS Improvement (NHSI) have requested additional information from all sectors within Greater Manchester regarding the content of their capital projects. On the basis of this, it is understood that the final approval process will involve both NHSI and HM Treasury. The South East Sector Healthier Together schemes are modest in comparison to other Sectors at 9.9 m. Two key changes to the estate are the expansion of A&E capacity and theatre capacity at Stepping Hill Hospital and the upgrade of a currently decommissioned ward to provide capacity for the increased activity expected to flow into Stockport from Tameside and Glossop. Initiation of the capital schemes is dependent upon the approval date for capital. With regard to recurrent funding for Healthier Together, sector leads met with Jon Rouse, the Chief Executive at the Greater Manchester Health and Social Care Partnership in December to agree a route for local partners to progress to final agreement. Sector Directors of Finance held a workshop on 16 th January where an agreement in principle was set out for endorsement by each organisation.. A further meeting with Jon Rouse is planned for February and it is intended that the basis of the final agreement will be drafted at that point. Improved Outcomes for Bowel Cancer in the South East Sector The latest National Bowel Cancer Audit (2017) has been released and shows high survival rates for patients who have surgery and treatment at both Stockport NHS Foundation Trust and Tameside Integrated Care Foundation Trust Data (Patients diagnosed between 1 April 2015 and 31 March 2016) Ca s e ascertainment No. patients having major s urgery Observed 90 day mortality Adjusted 90 day mortality Observed 2- year mortality Adjusted 2- year mortality 2017 SFT 98% % 1.1% 19.7% 17.5% TGICFT 100% % 1.4% 17.5% 22.3% 2016 Data (Patients diagnosed between 1 April 2014 and 31 March 2015) Ca s e ascertainment No. patients having major s urgery Observed 90 day mortality Adjusted 90 day mortality Observed 2- year mortality Adjusted 2- year mortality 2016 SFT 102% % 1.5% 15.1% 13.8% TGICFT 97% % 2.2% 27.4% 42.9% The overall 90 day mortality figure for patients treated at Stepping Hill Hospital is 1.1% which is an improvement from the previous year which was 1.9%

309 Similarly improvement has been seen at Tameside General Hospital where the current mortality is 1.4% which has improved from 2.8% in the previous year. These are the lowest ratings in Greater Manchester and well below the national average of 3.2%. Two year mortality from bowel cancer has also continued to improve and Stockport remains the lowest in Greater Manchester. This is a reflection of the hard work by many health professionals within the Multi-Disciplinary Cancer Team who working together to follow up cancer patients and prevent recurrence. This is excellent news for people accessing care within the two Trusts in the sector and sets us in good stead for the change to a single service for South East Sector Healthier Together. A press release related to this is attached for information. Bowel cancer safety success Stockport and Progress on Key Areas Despite the uncertainty over the commencement of estates changes the South East Sector continue to move forward with a wide programme of work to finalise plans in readiness for implementation. This includes: Finalising clinical pathways to enable prompt assessment and diagnosis and ensure that, where possible, patients are directed early into the appropriate route, avoiding inappropriate inpatient admission; Finalising arrangements for the Sector Colorectal Cancer Multidisciplinary Team (MDT). Plans are also being put in place to undertake a mock MDT to allow lay representatives from Public Voice, the South East Sector Patient and Public Engagement Group to observe and comment on the proposed new model; Finalising rota plans for the proposed expanded surgical consultant workforce and identification and planning for HR implications of the changes for other staff groups; Identification of a suitable IT solution which will enable access to essential clinical data across organisations; Continued work on developing the patient journey including an event focussing on the paediatric pathway which was undertaken in December A multi-specialty event has been scheduled for February 2018 to ensure that all associated specialties have been able to input into the planned changes. Members of Public Voice have been invited to attend all such events

310 The South East Sector Healthier Together Programme Board approved the use of the Design Ethos developed by Public Voice within the development of the new patient journey at their meeting in January. This set of design characteristics developed by patients and the public will now be used by all of the clinical sub groups within South East Sector Healthier Together ensuring that public and patient voices at the heart of these changes

311 Safeguarding Annual Report NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to live healthier, longer and more independent lives. NHS Stockport Clinical Commissioning Group 7th Floor Regent House Heaton Lane Stockport SK4 1BS Tel: Fax: Text Relay: Website: 311

312 Compliance Checklist: Documentation Cover sheet completed Page numbers Paragraph numbers in place 2 Page Executive summary in place (Docs 6 pages or more in length) All text single space Arial 12. Headings Arial Bold 12 or above, no underlining Y Y Y Y Y / N Statutory and Local Policy Requirement Change in Financial Spend: Finance Section below completed Service Changes: Public Consultation Completed and Reported in Document Service Changes: Approved Equality Impact Assessment Included as Appendix Patient Level Data Impacted: Privacy Impact Assessment included as Appendix Change in Service Supplier: Procurement & Tendering Rationale approved and Included Any form of change: Risk Assessment Completed and included Any impact on staff: Consultation and EIA undertaken and demonstrable in document Y / N Y / Na Y / N 2 312

313 Executive Summary What decisions do you require of the Governing Body? 1. To acknowledge that the CCG is not fully meeting its safeguarding responsibilities, accept the level of assurance provided and the residual risk. 2. To acknowledge the gaps/risks in the system and the actions in place to address them. Please detail the key points of this report 1. Identifies how the CCG is meeting the statutory safeguarding requirements. 2. It reports on our providers compliance with the CCG safeguarding standards. 3. It incorporates the statutory requirement for the CCG to produce a : - Safeguarding Children Annual Report - Looked After Children Annual Report 4. As good practice it also includes reference to the Safeguarding Adults activity Please note that whilst this report is later being presented this year, the regular safeguarding reports presented to the Quality Committee have kept the members appraised of the issues being raised around safeguarding What are the likely impacts and/or implications? The CCG is not fully meeting its statutory safeguarding duties. How does this link to the Annual Business Plan? Safeguarding is integral to all aspects of the SCCG business plan What are the potential conflicts of interest? None Where has this report been previously discussed? Quality Committee Clinical Executive Sponsor: Anita Rolfe Executive Nurse Presented by: Anita Rolfe Executive Nurse Meeting Date: 31 January 2018 Agenda item: 15 Reason for being in Part 2 (if applicable) 3 313

314 Safeguarding Annual Report Purpose The purpose of this report is to review the safeguarding activity that has taken place in the 12 months from April April 2017 and benchmark it against the statutory requirements that Stockport Clinical Commissioning Group (SCCG) is required to meet. Safeguarding forms part of the CCG compliance framework. NHS England assures compliance through an annual self-assessment audit and the CCG s participation in the safeguarding nursing collaborative. Safeguarding for the purpose of this paper includes; Children, Adults at Risk and Looked After Children. 2.0 Safeguarding Requirements of Stockport CCG 2.1 Statutory Requirements The following are the statutory requirements as identified in Safeguarding Vulnerable People in the NHS: Accountability and Assurance Framework June 2015, and a summary describing how the organisation is meeting these requirements CCGs must gain assurance from all commissioned services, both NHS and independent healthcare providers, throughout the year to ensure continuous improvement. [Partially Met] The CCG safeguarding standards are included in a schedule contained within all clinical contracts for which SCCG is the lead commissioner. Within this schedule, there is a requirement for each provider to complete an annual audit based on the safeguarding standards specified in the contract. The audit is reviewed by the safeguarding team and RAG rated. All action plans resulting from the audit findings are monitored by the safeguarding team. Quarterly meetings are held with our main providers and less frequently with others. Although the CCG is not the lead for Pennine Care NHS FT, quarterly reviews are undertaken jointly with the Designated Nurses from the six CCGs. Failure to progress action plans in a timely manner results in escalation to the Quality Committee who then agree on the next steps. It should be noted that the above process was extended to seeking assurance not only from our main providers but also from: Care homes with nursing Specialist placements providers A number of small contracts including Beacon Counselling, Homestart. The Women s Centre, Neuro physiotherapy. However the process with these organisations was limited to receiving and reviewing of the self-assessment due to team capacity. The CCG should be informed by a lead commissioner if a provider in its area has been identified as not meeting its safeguarding standards and the CCG commissions services from there. This process is robust around Care Homes with Nursing who are commissioned using the North West framework

315 The Quality Committee received a quarterly exception report in 2016/17 and additional reports in respect to specific areas which are highlighted later in the main body of this report. The committee has brought to the Governing Body s attention, via the quality report, any issues that it has deemed that the Governing Body require to be sighted on prior to this Annual Report. The 2015 version of the accountability framework extended the assurance requirement and as a consequence the safeguarding team has been unable to fully meet the required standard. This is identified on the corporate risk register To be a member of Stockport Safeguarding Children Board (SSCB), engaged with Stockport Safeguarding Adults Board (SSAB) and work in partnership with local authorities to fulfil their safeguarding responsibilities. [Partially Met] These requirements are fulfilled as follows: SSCB Working Together to Safeguard Children clarifies that the Board representative should be at executive level and the Designated Doctor and Nurse attend as specialist advisors. The Stockport Safeguarding Children Board (SSCB) expects 80% attendance by members. The Designated Professionals and a CCG executive Nurse have met the required attendance The Designated Nurse fulfils the partnership requirements by chairing the SSCB Quality Committee and attends a further 6 sub-groups, all bi-monthly. The Designated Nurse is also the CCG strategic lead for Domestic Abuse and attends the Supporting Families Executive Steering Group which includes Domestic Abuse as one of its terms of reference. Safeguarding Adults the Stockport Safeguarding Adult Board (SSAB) representatives are the CCG Executive Nurse and Designated Nurse Safeguarding Adults also attends three board sub groups to fulfil partnership requirements. Looked After Children Statutory Guidance on Promoting the Health and Wellbeing of Looked After Children 2014 and underpinned by Children Act 2004 requires the CCG to work in partnership with the Local Authority to meet the needs of Looked After Children. The Designated Nurse attends the Integrated Looked After Children Board (ILAC) quarterly and the Health Steering group monthly. Attendance at the Health Partnership Board and CAMHS Partnership Board also ensure that the health needs of Looked After Children are considered in all the relevant strategic forums. Whilst the last quarter of 2016/2017 saw reduced capacity in the safeguarding team; representation at the Boards has remained good To have in place robust processes to learn lessons from cases where children and adults die or are seriously harmed and abuse or neglect is suspected. [Fully Met] The designated professionals are required to be involved in any review that the Safeguarding Boards commission or Stockport Safer Partnership, who commission Domestic Violence Homicide Reviews (DVHR). Progress against health provider s action plans are monitored as part of the assurance processes 5 315

316 with the safeguarding leads/senior representatives. The learning is disseminated to the wider health economy and also to GPs via the GP Safeguarding Leads briefings. There have been 2 DHR s in 2016/17 completed and awaiting a decision from the Home office about publication. The Designated Professionals along with the Named GP are proactively progressing the learning from these reviews Clear policies in place (fully met) The Safeguarding Policy was updated in November 2017 to ensure it reflected current statutory guidance and a section around PREVENT was included. In addition the wording in the safe recruitment, the serious incident, whistle blowing and complaints policies has been strengthened to make safeguarding more explicit Training [Fully Met]. The SCCG safeguarding training strategy was updated in March 2016 to reflect changes in statutory guidance. Safeguarding is part of the mandatory training requirements for all SCCG staff and compliance is managed via the CCG e- learning portal. For a small number of staff, CHC and Medicine Optimisation, there are additional training requirements. Work has been undertaken to ensure these are captured in individual learning profiles and in face to face sessions have been provided by the safeguarding team to ensure the staff are meeting their required competencies. Additional training for mental capacity has been delivered to the continuing health care team, GP adult safeguarding leads and the wider health economy using funding from NHS England to ensure that the Mental Capacity Act is fully embedded in practice across the Stockport health economy. PREVENT training is a statutory requirement, however a more proportionate response to the level of training required has been agreed nationally and the CCG PREVENT lead has ensured that the appropriate materials are available on the CCG e- learning portal. The CCG closely monitors mandatory training uptake so there is no risk anticipated in maintaining the organisations compliance Accountability [Fully Met]. There is a clear line of accountability reflected in the SCCG governance arrangements (Appendix 1) Co-operation with Partners [Fully Met]. The SCCG co-operates with the Stockport Metropolitan Borough Council (SMBC) in the operation of the SSCB and SSAB, outlined previously, and the Health and Well-being Board Information Sharing [Fully Met]. The SCCG has a Caldecott Guardian, Dr Vicci Owen-Smith, to ensure there are effective arrangements for information sharing. This is also addressed in the safeguarding policy

317 Designated Posts [Partially Met]. A new Designated Nurse Safeguarding Children/Head of Safeguarding commenced in January 2017; there was no gap in service provision when the previous post holder retired. The SCCG has had partial compliance around the Adults post in the last quarter of 16/17 and into 17/18. The adult lead left the organisation; recruitment for replacement was successful and post holder commenced at the end of October The Designated Nurse for Safeguarding Adults is the Mental Capacity Act Lead and the Designated Nurse LAC is the PREVENT lead. The CCG has a 0.5 wte deficit in the capacity of the Designated Nurse Looked After Children role as mapped in intercollegiate guidance however there are no identified risks associated with this. 3.0 Specific Provider Issues The following issues were escalated to the Quality Committee in and where deemed appropriate were included in the monthly Quality Report to the Governing Body. 3.1 Stockport NHS FT Safeguarding Adult Training The Trust achieved compliance. CQC visits demonstrated that whilst staff had undertaken the relevant training in MCA/DOLS, the application of the assessment principles with individuals required improvement. This finding does demonstrate that attending training is only one way of embedding learning hence the Trust adopting a more coaching based model. PREVENT became a focus in 16/17 due to national requirements. The organisation worked closely with the Designated Nurse around MCA/DoLS and, with funding from NHS England, specialist training was put in place to achieve compliance, which was achieved by March 16. Looked After Children The Trust s performance in respect to compliance with statutory time scales to complete initial and review health assessments is an issue. Children coming into care in Stockport from out of area is a significant factor around the performance. The committee received a detailed paper from the Designated Nurse Looked after Children which highlighted that the root problem to this dip in performance was multi-faceted, not all within the FT s scope to resolve. The committee was updated throughout the year about plans to resolve the issue which still remain ongoing. 3.2 Pennine Care NHS FT There has been some progress and from July 2016, Pennine Head of Safeguarding is meeting quarterly with each CCG s safeguarding lead to report directly about the local picture. A deep dive into the safeguarding standards has been commenced led by the Designated Nurse for Heywood Middleton and Rochdale; she invited the other co-commissioning CCG s to offer lines of enquiry 3.3 Care Homes with Nursing Any issues with care homes with nursing have continued to be highlighted in reports presented to Quality Committee this year. The reports have highlighted 7 317

318 homes which have been subject to action plans following inspections by the Care Quality Commission and/or closed to admissions by the SMBC Quality team. Some of these concerns have been due to safeguarding issues. The committee has been assured that the Continuing Health Care Team (CHC) review any patients placed by the CCG whenever concerns are raised. CHC also communicate any concerns to the SCCG safeguarding team and receive support and guidance on appropriate responses and escalation of potential safeguarding incidents. The Local Authority Safeguarding and Quality Team always invite the CCG and Provider health nurses to strategy meetings where there are clinical areas to consider in any safeguarding incidents; this collaboration works well to analyse and consider risk areas. The appointment of a Band 6 nurse into the quality team will also enhance this collaboration. 3.4 Out of Area Providers This primarily covers Mental Health and Learning Disability providers where individual packages of care are commissioned for Stockport patients. The safeguarding team contacts these providers directly and each completes our selfassessment tool. The commissioners use the information provided in the safeguarding standards audit when deciding the suitability of individual out of area placements. The level of oversight of these providers in has been a paper review. Where safeguarding concerns have been notified to the CCG commissioner/chc case manager, discussions have taken place with the safeguarding team and advice given. 3.5 Third Sector Providers There has been some focus on this sector this year. Self-assessments were requested and the majority returned some safeguarding information, however due to reduction in team capacity these were not given the attention required. The CCG therefore had limited assurance in respect to the robustness of safeguarding in our third sector providers that the CCG contracts with. 3.6 Independent providers Including:- BMI Alexander Priory Cheadle Royal St Ann s Hospice Beechwood Cancer Care Centre Mastercall Each of these providers was visited and their compliance with safeguarding standards monitored St Ann s Hospice A very comprehensive safeguarding strategy has been produced in March 2017 by the provider which gives assurance around safeguarding processes and standards. The safeguarding lead has asked that her job description is now reviewed as it shows additional responsibilities

319 4.0 Other Areas 4.1 Looked After Children 2016/17 These will be outlined in the Looked After Children Annual report appendix General Practitioners The Named GP took up post in September 2015 as part of the agreed model with NHS England to comply with the CCGs requirement to have a post holder. This has strengthened the safeguarding provision for General Practice and supports the CCG who became delegated commissioners for General Practices in April 16. Since taking up post the Named GP has: - Produced briefings/summaries of new guidance e.g. FGM - Produced high quality reports for serious case reviews and domestic homicides which are also shared with the coroner as appropriate - Shared learning from serious case reviews with GP safeguarding leads - Represented and supported GP s at safeguarding review practitioner events - Facilitated training - Produced model policies - Provided advice and support to practices The Designated Nurses continue to facilitate briefings for the GP safeguarding leads both children and adults to ensure they are provided with up to date information both nationally and locally and provide advice and support. 4.3 NHS England Safeguarding Collaborative There is a requirement in Safeguarding Vulnerable People in the Reformed NHS, for the designated professionals to work with NHS England to drive improvements in safeguarding practice across the health economy. Nurses attend the collaborative meetings and assist in progressing pieces of work by being members of Task and Finish groups. 5.0 Current Challenges/Risks 5.1 Adult safeguarding The CCG capacity to meet this agenda posed a risk to the organisation in This is partly due to the Care Act putting this agenda on a stronger statutory footing, which has raised both profile and demands and the increasing issues within the care home with nursing sector. Stockport Together provides new opportunities to reinvigorate the joint assurance work with the local authority 5.2 PREVENT The requirement for monitoring compliance with this agenda was transferred to CCGs in April 2014 and included in the standard NHS contract. Holding the providers to account has been extremely challenging, as the requirements have been changed nationally several times creating uncertainty about what level of information/training has to be provided. There has been some progress in ensuring the workforce across the health economy has received the appropriate level of training but full compliance has not been achieved. With the ever increasing profile of radicalisation, achieving full compliance in this area has to be a priority for

320 5.3 CCG statutory and authorisation safeguarding requirements including Looked After Children The non-compliance with the requirements has created a corporate risk and plans are in place to reduce this risk. 5.4 Primary care It does appear that funding from NHS England for the one PA a week (incorporating adults and children) is not to be continued longer term. The CCG will need to consider the future funding shortfall. 6.0 Future Opportunities Integrated Commissioning To explore synergies with the CCG and local authorities statutory responsibilities Service Development To develop a comprehensive safeguarding web site to ensure information is easily available and the use of digital technology is maximised i.e. pod casts. 7.0 Quality Committee The Quality Committee in October 2016 agreed that: 1. The information provided demonstrated that the SCCG is meeting the majority of its statutory and authorisation safeguarding requirements and has an action plan in place to address the gaps. 2. This annual report is a statutory requirement and will be presented to the Governing Body, both the Stockport Safeguarding Children and Stockport Safeguarding Adult Boards and the Integrated Looked After Children Board. The committee asks that the Governing Body endorses point 1above and in addition: The Governing Body confirms that the Designated Professionals will continue to coordinate the safeguarding children, safeguarding adults and looked after children agendas on behalf of the CCG, by providing strategic and clinical leadership both to members of the CCG and to partner agencies across the Stockport economy. The following sections will address specifically the work undertaken by the designated professionals in their specific areas of work and identify any risks and future plans: Section 1: Safeguarding Children Section 2: Safeguarding Adults Section 3: Looked After Children It must be noted that this report is primarily a position statement at end of March 2017 for and that work across all three areas is progressing

321 Section 1: The Safeguarding Children Annual Report 8.0 Purpose 8.1 To fulfill the statutory requirement, as per section 11 of the Children Act 2004, to produce an annual report 8.2 To advise the Governing Body in respect to the level of assurance provided from services commissioned by the CCG in respect to their safeguarding arrangements for children. 8.3 To update the Governing Body on its safeguarding activity during Context 9.1 All health organisations have a statutory responsibility to safeguard children - Children Act 1989, The statutory responsibilities are outlined in Working Together to Safeguard Children 2015, and are expanded on in Safeguarding Vulnerable People in the NHS: Accountability and Assurance Framework, 2015.Safeguarding Children and young people: roles and competencies for health care staff, inter collegiate document 2014 also provides the statutory guidance relating to training and the roles and responsibilities of named and designated professionals. 9.3 As part of the CCG s statutory responsibilities it must: Ensure that the providers from which services are commissioned, deliver a safe and effective system that safeguards children Ensure robust systems are in place to learn lessons from cases where children die or are seriously harmed and abuse or neglect is suspected Be a member of the Stockport Safeguarding Children Board (SSCB) It should be noted that the CCG no longer commissions Health Visitors and School Nurses, both key in providing services to children Background 10.1 There are 67, year olds in Stockport (2014) making up 23.5% of the population 10.2 The multi-agency safeguarding and support hub (MASSH), the front door service into children s social care received 22,047 contacts in Of these, 3268 required social work assessment, 7825 required an early help offer and 11, 093 were dealt with through existing case provision, information and advice. The way referrals are triaged in the MASSH has changed and so it is not possible to compare the figures to the previous year. Stockport does have a higher number of contacts into the MASSH than all its neighbours and this inevitably puts pressure into the system which needs understanding. A revised dataset into the SSCB Quality Assurance sub group (chaired by the Designated Nurse) will assist this analysis At the end of March 2016, 239 children were subject to a child protection plan, an increase of 48 since Emotional abuse and neglect continue to account for the majority of child protection plans. Whilst there has been no obvious explanation for

322 the moderate rise, audit activity by the LA Safeguarding Unit has evidenced that cases held at child protection plan level are appropriate The numbers of domestic abuse incidents which were referred to the MASSH because of safeguarding concerns for children by Greater Manchester Police dropped in the last year from 2063 incidents in to 1800 this year. The reason for this drop is not yet understood. The impact on both children s and adult s health is seen across a wide range of health services, including general practice, mental health services and accident and emergency. Domestic abuse therefore remains a key issue for the safeguarding team. The Designated Nurses are members of a newly formed Domestic abuse Steering group chaired by a senior representative from the police Serious Case Reviews In 2016/17 the Stockport Safeguarding Children Board did not commission any new serious case reviews although did complete an independent learning review involving a 15 year old male child who completed suicide. The focus in was to progress the single and multiagency action plans formulating an overall multiagency serious case review improvement plan. The themes within the plan for all agencies to consider are Supervision, Meetings Plans and Assessment. NHS Stockport CCG has submitted evidence around how these themes are being embedded into practice. There has been evidence that GP s have intervened effectively to safeguard children The Designated professionals and the Named GP are actively involved in the whole SCR process from the commissioning to completion and closely monitor the responses from the health providers. The Designated Nurse has been involved in a podcast to disseminate the key learning as an alternative training method; this has been evaluated well Domestic Homicides There was one new homicide involving children commissioned in 16/17 although remains unpublished to date Designated Doctor The Designated Doctor alongside the Named Doctor at Stockport NHS FT has trained the medical staff on the paediatric and neonatal unit around assessment of risk and high quality report writing. The Designated Doctor also continues to provide expert advice to both the Child Death Overview Panel and the Serious Case Review Panel and attends the Safeguarding Children Board Resources The resources for safeguarding children are: Head of Safeguarding / Designated Nurse 1wte Designated Doctor 2 PAs/week. Shared 0.8 administrative support with Safeguarding Adult and Looked After Children Nurses Named GP 1PA a week covering adult and safeguarding children

323 The Executive Nurse has safeguarding in her portfolio providing support to the team. The CCG Chief Clinical Officer is ultimately responsible for safeguarding Equalities The safeguarding team strives to ensure that all service users, whatever their disability, sexual orientation, age, race, culture, religion or gender receive the same level of protection from abuse from all our commissioned services Report Context 13.1 NHS Stockport FT (acute and community) At the March 2017 assurance meeting, 4 out of the 24 safeguarding contractual standards remained on amber. There is an action plan in place to address these issues: - The standard relating to documenting parents/carers has fluctuated throughout the year. This is monitored via the Trust s record keeping audit and is also part of a Domestic Homicide Review action plan - The Trust is not fully compliant in meeting the PREVENT agenda but has provided a trajectory to achieve compliance. - There have been delays in the writing up of serious incident reports including those where safeguarding issues - The Access policy is not comprehensive to include children who are not being brought for appointments this is a preferred term to did not access as young children are reliant on carers to engage with health appointments The FT Named safeguarding professionals engage well with the Designated Nurse and Doctor. The Named Nurse accesses supervision from the Designated Nurse and likewise the Named Doctor from the Designated Doctor Child Protection Information Sharing Project (CPIS) SFT implemented this national project in September 2015 which ensures ED services are aware of children on child protection plans or who are Looked After at the point of contact with the service and the information is then automatically shared about their attendance with their lead professional in their home local authority. There is a plan in 2017/18 to implement fully in the other unscheduled care departments (midwifery and children s assessment) in the Trust Pennine Care NHS FT Assurance for this organisation is led by Heywood, Middleton and Rochdale CCG but scrutinised jointly by all the Designated Nurses from the CCGs who commission from them. In March 2017 Pennine were declaring full compliance in their safeguarding assurance apart from the standard for a policy around children s attendance at A and E departments. Several polices were due for review. A thematic deep dive audit methodology is planned for January Stockport shares a Named Nurse for Safeguarding with Tameside, who is supported by an adult nurse practitioner; she is an active member of the safeguarding sub-groups and reviews as they are commissioned

324 13.3 Mastercall From a child safeguarding perspective, the organisation is fully compliant with the required safeguarding standards. The improvement in reporting of incidents where practice was not optimum is noticeable; for example a locum doctor was followed up rigorously when the prescription of emergency contraception was prescribed to a child where the correct risk assessment had not been completed Independent Providers BMI Alexander Whilst SCCG does not commission services for children from this provider, we do commission adult care. Adult-facing staff are required to be appropriately trained in respect to children s safeguarding and the organisation has appropriate policies in place. Other Greater Manchester CCGs do commission care for children from BMI therefore as lead commissioner we have a responsibility to inform them if the organisation s safeguarding standards as per contract are not being met. The organisation is fully compliant with all the required safeguarding standards applicable to children and following the appointment of a new children s service lead, safeguarding pathways have been further strengthened. A number of good practice examples relating to safeguarding children have been identified this year Priory Cheadle Royal SCCG has no children or young people placed at this hospital but as a provider on our footprint which provides NHS services, the Designated Nurse has a responsibility to audit their safeguarding standards. The organisation has completed the annual selfassessment and provided supporting evidence that demonstrates it is good compliance with the required safeguarding standards The Adult only providers, St Ann s Hospice, Beechwood Cancer Care Centre have been visited and supported to gather evidence for their safeguarding assurance. Adultfacing health staff are required to have a level of safeguarding children training

325 Section 2: The Safeguarding Adults Annual Report /17 saw excellent examples of joint working with the Adult Social Care Quality Team and the continuing healthcare team (CHC) in care homes where the CQC have found the home to be inadequate. There have been very good examples of collaboration between all agencies to ensure positive outcomes were achieved for residents, families and providers The Care Home Awards 2016/17 took place in February 2017 and gave staff in this sector a deserved recognition for their dedication and commitment to this sector. This is planned again for 2017/ React to Red training was facilitated by the safeguarding team in ; training designed for care home staff to identify the first signs of pressure area damage and to react appropriately. 9 training sessions have taken place at venues across Stockport; some of these have been within care homes for in-house staff only and others have been open to all care home/domiciliary care staff across the Borough to attend. The evaluations were very good and Stockport CCG saw a drop in high grade pressure ulcers in the care home sector. The integrated health and social care quality team will take this further in 2017/ Serious Adult Reviews During 2016/17 the SSAB commissioned two Safeguarding Adult Reviews and one Comprehensive Learning Review. The reviews and resulting lessons learned plans have been disseminated widely using the 7 minute briefing format which has been well evaluated. These are hosted on the CCG s safeguarding website. In 2017/18, it is important to be able to provide detail as to how lessons learned are being embedded and ultimately improving safeguarding outcomes for adults across all the Stockport health economy Opportunities for 2017/18 Safeguarding Adults To ensure there is a clear template used in all Mental Capacity Assessments and to audit how clinicians assess and document decision based assessments To engage fully with the SSAB sub group work and activity. This will be easier to achieve on the appointment of the Designated Nurse for Adult Safeguarding. To embed the learning from the recent safeguarding adult reviews and to consider a variety of means alongside formal face to face training- podcasts and webinars are a good way of disseminating learning. To focus on the Prevent agenda and ensure staff are being trained according to their role alongside meaningful contribution at Channel Panel where GP information would be extremely useful To work closely with the Local Authority team and the CCG quality Nurse based in the team around safeguarding issues relating to poor quality care/acts of omission and neglect

326 Section 3: The Looked After Children Annual Report 17.0 Purpose This is the annual report for Stockport Clinical Commissioning Group (SCCG) in respect to Looked After Children (LAC). The purpose of this report is to: 17.1 Advise the Governing Body on the delivery of services for LAC during Assure the Governing Body of the extent to which the services commissioned by the organisation are meeting their statutory functions and delivering best practice Outline the Governing Body s statutory responsibilities for LAC and SCCG s compliance Context 18.1 All health organisations have a statutory responsibility to promote the Health and well-being of Looked After Children Framework The statutory responsibilities are outlined in: Statutory Guidance Promoting the Health and Well-Being of Looked After Children DH The specific duties for health are explained in Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework Looked after children Knowledge, skills and competences of health care staff. Intercollegiate Role Framework 2015 provides clear recommendations and expectations for all staff working with LAC The SCCG s statutory responsibilities are: To cooperate with the local authority in fulfilling its duties towards looked after children, including the commissioning of statutory health assessments and reviews. To have a Designated Doctor and Nurse for Looked After Children. To commission most secondary health care, including for those originally from the CCG area but now placed outside, even where the child registers with a GP practice in the new CCG area in which they have been placed Background 19.1 A looked after child is a child who is looked after by the local authority. There are four main groups: Those who are accommodated through a voluntary arrangement with the child s parents Those who are subject to a legal order Those who are compulsory accommodated via the judicial system Unaccompanied asylum seekers and children who are in a family and friends placement. The CCG is responsible for meeting the health needs of all these groups

327 19.2 At the time of reporting Stockport have 328 ( report) Looked After Children of which 91 (86) are placed outside Stockport. This is a dynamic population and these figures do not reflect the total numbers of children and young people who have been accepted into care then discharged over a 12 month period. As a CCG we are responsible for commissioning sufficient resources to meet the identified health needs of the LAC population, including those placed in our area by other local authorities. As part of the responsible commissioner guidance, the placing authority can be asked to pay. Stockport has introduced this system for children from areas outside GM however the GM Directors of Finance have agreed that no cross charging would be introduced and thus Stockport is a net looser. This agreement is due to be reviewed in January In addition to Stockport s own LAC, an additional 366 LAC from other local authorities currently reside here. There is now an effective online reporting system in place with the local authority which has resulted in a significant improvement in the accuracy of this data The availability of placements for children from other areas is mainly due to the 40 plus residential units that have been granted planning permission in Stockport. These homes are operated by a number of independent providers and are regulated by Ofsted. The young people residing in these units are some of the most vulnerable and challenging and often access multiple services across organisations including health The Designated Nurse LAC benched marked LAC provision in as part of NHS England s pilot into CCG commissioning compliance. The standards were RAG rated according to compliance with statutory guidance and an action plan formulated. The majority of actions have now been completed resulting in a service that is in a better position to meet the health needs of LAC. The CCG Quality Committee has received updates on the action plan throughout the year. The outstanding actions are linked to producing a health profile for our LAC to inform the JSNA. Profiling has commenced but there is insufficient data available at present Resources 20.1 The CCG has a statutory responsibility to have designated health professionals for LAC. We continue to be compliant with authorisation requirements by having the following in post: A 0.5wte Designated Nurse LAC the current post holder was new into post in February A medical resource for Looked after Children - a Designated Doctor who is a paediatrician with 2PAs / week to fulfil this role. This role is now shared between two paediatricians to promote development and succession planning. Administrative support of 0.85 wte is shared with safeguarding children, vulnerable adults lead and the Named GP Stockport NHS FT is commissioned to provide a dedicated resource for Looked after Children which sits alongside the universal services of Health Visiting and School Nursing which are commissioned by the Local Authority. The organisation has recently appointed a Named Nurse for LAC in line with Looked after Children: Knowledge, skills and competences of health care staff March

328 Together these services fulfil the aim of reducing inequalities and ensuring Looked after Children s health needs are met, in accordance with statutory guidance SCCG statutory responsibility 1. Within the specialist team there is also a Care Leavers resource which is offering a drop in for those that have now left care advising and signposting them to appropriate health services. The team also offer all care leavers a Health passport which contains the young person s childhood health history. The Paediatric Block contract requires the FT to undertake Initial Health Assessments for all LAC received into care. This assessment has to be undertaken by a medical practitioner, currently a paediatrician. This resource is over and above the 2pa s commissioned to undertake the Designated Doctor function, which is a statutory CCG post. Pennine Care NHS FT is commissioned to provide mental health services for all children, including LAC. LAC have benefited from a small but dedicated resource commissioned by the CCG which compliments an increase in resources for all children, including those year olds who are in transition, from transformation funding. However until April 17 this resource was predominantly for Stockport LAC, only offering crisis assessments for those LAC placed here from other authorities. There has been an acknowledgment by the provider that is not in line with Statutory Guidance. A GM agreement has ensured that LAC in Stockport from another GM Boroughs now receive ongoing treatment as would Stockport children placed in GM and scoping is being undertaken to assess the capacity required to extend this to any LAC living in Stockport. Having access to specialist services will improve the outcomes for these very vulnerable young people and hopefully divert them away from emergency services, including ED, were they present frequently in crisis Equalities 21.1 Looked after Children and young people share many of the same health risks and problems as their peers, but often to a greater degree. They often enter care with a worse level of health than their peers, in part due to the impact of poverty, abuse and neglect. This statement reinforces the need to have in place a process for capturing the health profile of LAC living in Stockport to inform the JSNA and influence future planning of services for LAC The vision across Stockport is that Looked after Children will access universal health services in the same way as other children and young people. Additional needs will be met through targeted interventions and specialist services. Furthermore, children and young people who are cared for by any Local Authority, but living in Stockport, will also receive the same opportunities to access health services within the borough irrespective of their originating CCG. It should however be acknowledged that this can cause difficulties due to commissioning arrangements for these children within some services Report Context Services should continue to be developed in response to the need to improve the quality of assessments and outcomes for LAC and take into account the requirements of national guidance and the findings of CCG compliance benchmarking

329 22.1 Assurance Stockport NHS Foundation Trust Provide a dedicated resource for LAC which works alongside universal services. Specific standards have now been included in the annual safeguarding assurance audit and are monitored via the quarterly assurance meetings. There are quantitative KPI s that are reviewed quarterly. A quarterly performance report is provided by the trust and reviewed by the Designated Nurse. There is an on-going quality assurance process in place to ensure all health assessments meet the required standard. Stockport has adopted the GM model which is being used consistently in Payment by Results (PBR). The specialist team is now co located with local authority staff who work with LAC; this has improved communication and addressed some performance issues. There is a planned programme to seek opinions of young people with regard to their experience of health assessments; however this has not yet been achieved due to capacity within the service Pennine NHS Foundation Trust This year has seen a small increase in dedicated resources for LAC within Healthy Young Minds alongside a general increase in capacity for all children through the transformation monies. There is now a 0.4wte dedicated resource for care leavers and a wte in the Access/RAID team providing advice and support for all year olds. The LAC psychologist provides consultation appointments for foster carers, particularly when children placed with them have challenging behaviour. This can prevent placement breakdown and research shows LAC achieve better outcomes when they are cared for in stable long term placements SCCG statutory responsibilities CCGs and NHS England have a duty when fulfilling their Commissioning roles to have regard to the need to: a) Reduce inequalities between patients with respect to their ability to access health services, for the CCG this is access to secondary care and NHS England, primary care, dental care, pharmacy, optometry and specialist services such as tier 4 CAMHS. b) Reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services Currently there are some access issues to some services for LAC, most notably around timeliness of health assessments and access to Healthy Young Minds (HYM) both could impact on outcomes Risks 23.1 Funding There has still been no progress on a national agreement on the implementation of the national tariff for LAC with some holding the view that LAC, irrespective of their origin, should be funded in the same way as any other person registered with a GP. As a consequence there continues to be no consistent way in which PBR is being

330 implemented within CCG s locally and nationally all choosing to implement the tariff arrangements as they see fit. We are currently in a position in which we are being charged for Stockport children placed out of area with a system in place to ensure the quality of these assessments. Stockport Foundation Trust has implemented a charge for any assessments undertaken on children from other local authorities, with the additional income being used to supplement the additional nurse time required. Due to an agreement, which was renewed in January 2016, that there would be no cross charging across GM the CCG has been underwriting the FT for GM assessments. This will be an ongoing pressure until the directors of finance review their agreement, at which time the funding arrangements for the commissioned service will need reviewing to take into account the impact of any decision made Access to Services There are two areas where there are difficulties: Timeliness of assessments This poses a significant risk to the CCG as there are statutory time scales for assessments to be completed. Throughout the KPI s which monitor this have consistently been missed. The performance around IHA s has been particularly concerning and regular reports / updates have been presented at Quality committee and information included in the Quality report to the Governing Body. LAC placed from other areas access to mental health services Pennine NHS FT has been engaging in a GM piece of work around access to services for out of area LAC. There has been some positive progress however this remains a moderate risk to the CCG Access to data and information This is predominantly a risk for Stockport NHS Foundation Trust; however, there is an impact on the SCCG which creates a moderate risk when planning services as health profiling data is not available. This was highlighted in last year s annual report as a risk and though there has been some progress the inclusion of a programme in the new IT system to make collection more efficient and effective has not yet been achieved Service Delivery The specialist LAC team has now been expanded with a Named Nurse taking up post in September Unfortunately due to sickness and maternity leave the team continues to struggle to deliver its KPI alongside escalating demands to support the increased numbers of IHA clinics. The team is delivering the Care Leavers offer which the CCG has commissioned Initial Health Assessments are delivered as part of the paediatric block contract. Increase demand is putting a severe strain on the current capacity and work is being undertaken with the Children s commissioner to explore options to meet this demand SCCG has the duty to commission statutory health assessments, but does not commission health visitors or school nurses that carry out the majority of review health assessments. The Designated Nurse works closely with the LA and NHS England to ensure there is on-going scrutiny of the service specifications to ensure this role is included in both service specifications

331 25.0 Progress to date 25.1 The Designated Doctor LAC post is now shared by two paediatricians. The advantage to this arrangement is resilience, development and future planning. Consideration needs to be given to the Named Doctor and medical advisor roles identified within the intercollegiate framework and the capacity and expectations required to fulfil the roles There is a specialist looked after children health team service specification in place. The team strive to deliver best practice and review this as new guidance is published. Restructuring of the team has introduced a Named nurse role and some additional skill mix. There are processes in place to ensure that the Designated Professional s roles and provider services work together to meet the health needs of LAC in accordance with statutory guidelines Service user involvement remains important to help shape service delivery. The Children in Care Council have been approached to help design a new Health passport, however due to competing demands on the Care Council this has not yet been produced The Designated Nurse represents the SCCG at a number of multiagency forums which monitor and drive service improvements, the focus being improving outcomes for all Looked after Children SCCG statutory responsibility Work needs to be continued in conjunction with public health in creating a health profile for LAC in Stockport. A template has been developed but there remains the need to be considering the best way of collecting this data in light of IT systems and change in service structuring Ongoing audit and training needs to be embedded into an improvement program. As a feature consistently within action plans this will provide the evidence required so assuring the CCG that desired improvements are embedded Training has been implemented by Stockport NHS FT in line with new guidance that was released in March 2015 setting out the knowledge skills and competencies required by health professionals The Designated Doctors have completed an audit of the quality of IHA s and delivered further training as a consequence. The Doctors are now regularly dip sampling assessments and Peer reviewing each other s The Designated Nurse and Doctors for LAC are active members of the GM Designated LAC forums. This involvement promotes the sharing of good practice and standardisation of processes across GM e.g. Screening for blood borne viruses has been standardised as well as good practice when undertaking assessments on LAC who are unaccompanied asylum seekers Next Steps 26.1 Funding To provide the Director of Finance with information re the cost of out of area children on the CCG prior to the reconsideration of the GM agreement, due January

332 26.2 Access to services To work with the Children s commissioner and Public Health to support the CAMHS transformation project, specifically in relation to service access for all LAC, irrespective to origin Access to data LAC health profiling data needs to be recorded consistently to enable the needs of LAC living in Stockport to inform the JSNA, benchmark service provision and inform future commissioning. This will be supported by work been undertaken at GM level by the Designated Nurses Service delivery To ensure that the health needs of Stockport Looked After Children placed outside of the area are having their health needs identified and met SCCG statutory responsibility 3. To benchmark Stockport s progress against the quality standard for the Health and Well-Being of Looked After Children and Young People (NICE quality standard 31 April 2013) and identify any gaps that the SCCG may need to consider To identify if a formal agreement is required with health visitor and school nurse commissioners in respect to the completion of review health assessments. The GM Designated Nurses are developing model service specifications and will engage with commissioners in public health to encourage them to recognise the importance of being specific about these services involvement with LAC in future contracts. Without the involvement of these services with LAC the CCG would not be meeting SCCG statutory responsibility 3 and positive outcomes for LAC would not be met To work with the Children s commissioner to ensure there is sufficient capacity to undertake IHA s with statutory timescales Conclusion Looked after Children and Care leavers are some of the most vulnerable young people who access our health services however as a % of our population they make up less than 1%. As a CCG we have a statutory duty to ensure that we commission sufficient capacity to meet their needs. The increasing numbers of children being received into care has been an upward trend in and 2017 is already seeing that trajectory continuing to rise. This demand is putting a real strain on our commissioned services to deliver timely, quality services which will support these children and young people to achieve positive outcomes. This is the challenge for Sue Gaskell Designated Nurse LAC

333 In summary Primary Care remains an ongoing risk with NHS England and SCCG continue to work on a clear agreement in respect of completing the safeguarding assurance framework. As a result, there is limited safeguarding assurance audit data available. Some mitigation is that all GP practices have received CQC inspections; the one practice that was deemed inadequate on inspection has moved to good and the safeguarding processes were substantially strengthened with support. The Named GP continues to be very proactive in promoting good practice and there is notable improvement in communication around safeguarding. A business case submitted to the Primary Care Commissioning Committee by the Named GP will look at safeguarding administrative support in the neighborhoods in 2017/18. There has been an increased expectation on GPs to be more actively involved in safeguarding processes. An increased awareness for GPs as they access available training has seen a rise in the number of calls to the safeguarding team to discuss cases. This is positive and demonstrates the commitment of GP s to safeguard children and adults at risk. NHS Stockport CCG has a strong history of working closely in partnerships; strong collaborative safeguarding relationships are evident and there are good opportunities to be developed further in 2018 as we move closer to an integrated commissioning model. Julie Parker Designated Nurse Safeguarding Children 30 th November

334 Appendix 1 Governance Arrangements Quality and Performance Contract Meeting CCG Governing Body Annual reports - Children, LAC and Adults Exception reports Quality report monthly (safeguarding headlines) Medical Director Named GP for Safeguarding Quality Committee Bi-Monthly safeguarding reports NHS England Safeguarding Designated Nurse Safeguarding Children CCG Safeguarding Lead Designated Nurse LAC Prevent lead Executive Nurse Management/Executive Lead for Safeguarding Monthly meeting Designated Doctor Designated Nurse Safeguarding Adults MCA/DOLS Lead