Berkshire Transforming Care Partnership

Berkshire Transforming Care Partnership

Introduction The Berkshire Transforming Care Partnership Board hold a shared vision and commitment to support the implementation of the national service model to ensure that children, young people and adults with learning disabilities, behaviour that challenges and those with mental health and autism receive services to lead meaningful lives through tailored care plans and subsequent bespoke services to meet individual needs. Berkshire Transforming Care Plan has 4 big aims: 1. Making sure less people are in hospitals by having better services in the community. 2. Making sure people do not stay in hospitals longer than they need to 3. Making sure people get good quality care and the right support in hospital and in the community 4. To avoid admissions to and support discharge from hospital, people will receive and be involved in a Care and Treatment Review (CTR) Dedicated web page with links to the TCP plan and Easy Read version - http://www.wokinghamccg.nhs.uk/component/edocman/berkshire-tcp-easyread-june16 2

Association of Directors of Adult Social Care NHS England Local Government Association Programme Governance Structure NHSE (South) Regional Transformation Board Representative Partner Boards Business Committees, etc. Berkshire Transforming Care Partnership Programme Board Experts by Experience Steering Group (Voluntary Appointments) Berkshire TCP Joint Operational Group (Berks East and Berks West) Berkshire TCP Work Streams and Project Groups LD and Autism Partnership Boards Health and Wellbeing Boards 3

i a tiu r Work streams and Project Groups Work Streams (Themes) 1. Demand and Capacity 2. Market Shaping Housing and Care Providers 3. Inpatients 4. Intensive Support Team 5. Communications and engagement 6. Children and Young People 7. Workforce Development and Culture 8. Co-Production 9. Joint Commissioning and Integration 10. Risk Management 11. Programme management 12. High Impact Actions Project Groups: 1. Finance and Activity 2. Housing and Accommodation 3. Autism 4. Intensive Intervention Service 5. Occupation and Employment 6. Community workforce 7. Berks East Capital Home Project 8. Co-production (People s Voice Service) 9. Experts by Experience Steering Group 10. Communications and Engagement 4 I s s u e 1 0 1. 0 8. 1 6 K e y Co n tac ts N e w s l e t t e r T r ans for mi ng C ar e P ar tner s hi p B er k s hi r e U m u t es t, c u lp a v eliq u a m n e q u a te o c c a tu r, ip it a b o. E t m o d i v o lo r ia n d a v o lu p - ta tu r e o m n im u s s u n t, q u e p la d o les d elis s i a b o. B ea t U m u t es t, c u lp a v eliq u a m n e eic a b o. B o r p o r e eu m q u is c il ip ic - q u a te o c c a tu r, ip it a b o. E t m o d i a c c u m q u e v en d is q u i s ita tu r v o lo r ia n d a v o lu p ta tu r e o m n im u s eh en tio m o l u p ta s ita tem r e n u s. s u n t, q u e p la d o les d elis s i a b o. U lp a r u m er u m f a c es p o r a lit, B ea t q u a m a u t la n d es t, is d o lu p ta - ev en ien tin t, ss u n tiu a m q u e a n i s tu r a lic tem v el m o c u s a e n u s. m illita tes t ip s u s d o lo r a e. B u s q u is N em u t q u o m a x im in c tu r r ec u s en es c id u s a p er o v id ea r u p ta t. s ec e tu r m a g n a tib a c o r r o r en t. Ob is r a e. U t et a u t d em o d it f u g it, V id et v o lo rm ia tiu a d i g en t a s a s q u a tio n es t eu m in to ip s a m, to ta - a r ite n o b it a t m a d o lu p ic ip ita ten - tu r a n d e p er u m h ilia tu r s in im in u m im n o n n i n ec a e v o lu p ta n a m in c to q u a s a c o n es et in t v id q u a m r es tem. F ic a tq u a e p lis im p ed i a d io s ellis v o lu p ta te p o r em p o r u m et, c u s a m o lu p ta m u s a e o d i s im i, et q u a m a u d ca es tin i t e t r ep ta tem d o lu t v el d o lo r es s e v eles t, u tem a u d a ec t d o llu p tu r m o les to es d o lo r es es - o ta s p id q u ia c o m n is a r c im a g n ia s u m a m f a c c ut p ti o ta tet q u a tu r? n o n c o r a u t et et d ou lu p ti s c i a es t I s v o lo m ar a ti m u s tia c u s d o l es ti m a g nn a m u s a m d o lu p ti u l liq u o d i o r io n etu r? c a b id er ep er u m in v er a ep ta n es - s u m a r c h illes m s it es tia a s v en ih ilis C o r s u n t, s u s iu m v o lu op ti s s e - et a s im q u o d is v er a c o n s eq u e q u o d ic i d o lu p ta tu s a m v o lu p ta tem n o n s ed i r er u n t v ita te c o n s eq u i eo s id es ev en t r ep e v er u n t, q u i r es ec te p a c o n c u s ex p er er a tet r em id i c o r u p ta v o lo b la m a u t in r eh en em q u id e v o lu p ta q u i u t f u g a. R u m f u g it h a r c h it v er e, s im i, q u a m ella c illo r i d en t a liq u i v el m il et a r c h it d o lu p ta c u s ea s a p id m o d q u a tu r es t a r u m a u t o f f ic m in c tu r? S ed it la q u is eu m q u e in v en t a m, a u te o d ita tu r, tem a u t eu m c o n s eq u e d o lo r e d o lo r io q u a m d o lu p ta s es tr u m v o lo r io s n s eq u id eliq u ia s a u t p a r c ia c o n p lig en is u ta tu s, u t a u tet et in t u ta tu r a b o r p o s a n d a m q u a e ea s in t. M a g n ih i liq u a s p ed elic ta q u id it m o d is ea r u m et la n d e n o n s ed io s t d o lla m s ita q u o q u i b ea te d u n d u c i r e, c o n c o r eh en d el es eq u i q u o eo s lla b o. U lla b im u s d a es t a s p ien i m in t. h ita tem in p o r es t etu s d a m q u i M a x im in c tem. I c iu m q u ia e v er - im q u i o d ita tec es t ti e v en t la b o. r o v id es t, n is q u ia q u a er is d o lu p - P ietu m a u t r e n i s v id ip id es tii es c i l ta tu r s in v el es eq u a t p r e eic iu r? K e y Co n tac ts TITL E H E RE TITL E H E RE U m u t es t, c u lp a v eliq u a m n e q u a te o c c a tu r, ip it a b o. E t m o d i v o lo r ia n d a v o lu p - ta tu r e o m n im u s s u n t, q u e p la d o les d elis s i a b o. B ea t q u a m a u t la n d es t, is d o lu p - ta tu r a lic tem v el m o c u s a e n u s. N em u t q u o m a x im in c tu r r ec u e s s ec tu r m a g n a tib a c o r r o r en t. V id et v o lo rm ia tiu a d i g en t a s a s a r ite n o b it a t m a d o liq u o d i

2016 TCP Achievements Regular TCP Briefings to all partners and communication teams to keep them up to date with national and local news Secured 2016 2017 funding from NHS England for Shared Housing provision in Royal Borough of Windsor and Maidenhead for up to three individuals from across Berkshire with complex LD and challenging behaviours 2016 2018 from Department of Health for 10 x Hold Ownership Schemes for people with Long Term disability 2017 2018 national funding for interim intensive support service and respite Co-opted Carer and Family Experts by Experience into the programme on Voluntary Appointment Contracts, as members of the Finance and Activity Project Group, Capital Home Project Group, and TCP Board, with further appointments planned in 2017 Commenced Experience Based Co-Design Project with Point of Care Foundation weekly BHFT led group with service users Undertaken a desk top gap analysis of local authority LD and ASD strategies and, reviewed capacity and demand projections until 2019, to inform prioritizing of the work plan for 2017/18 Started to map local authority and CCG work streams already in place for Children and Young People, to avoid duplication in work Developed a repatriation timetable for NHS England specialist commissioned patients and Clinical Commissioning Group (CCG) out of area placements 5

(1) 2017/18 TCP Programme Plan Overview Work streams and group responsible for leading the work 2017/18 Q1 Q2 Q3 Q4 Finance & Activity (Project Group) Review inpatient block contract and IST financial model New opportunities for joint Commissioning arrangements defined and plans developed to implement, and cascaded to TCP Partners for consideration and feedback New opportunities for pooled budget arrangements developed and cascaded to TCP Partners for consideration and feedback Capacity and Demand Stock take of TCP projections completed New joint commissioning arrangements implemented ready for 2018/19 Reduce the number of separate funding streams that users have to access New opportunities for pooled budgets arrangements implement ready for 2018/19 Capacity and Demand Stock take review Heath & Social Workforce (Joint Operational Group) Agree core LD and ASD workforce structures in local authorities to retain expertise Standardise local workforce tool kits across all local authorities Start recruitment of shared lives staff and carers in Berks East (subject to business case approval) Hold workforce event with health and wellbeing partners and providers to develop new ways to recruit and retain LD and ASD skilled and specialist staff TCP Carers by Experience (Expert by Experience Steering Group) partner with two care providers and use Berks TCP Workforce Assurance Framework to check staff competencies and behaviours Start training of Shared Lives Carers in Berks East Match Service Users and Shared Lives Carers Start to develop career progression structures for public sector staff in line with private sector Develop training modules for primary care and third sector staff on LD and ASD. Linked to Autism and CYP work streams TCP Carers by Experience (Expert by Experience Steering Group) partner with two care providers and use Berks TCP Workforce Assurance Framework to check staff competencies and behaviours Housing & Accommodation (Joint Operational Group) Transition of up to three clients into RBWM Secured Tenancy Property as part of Berkshire East Capital Home Project Share learning from Capital Home Project Berkshire wide to inform 2017/18 capital bid submissions Establish Berkshire wide housing list for people with short, medium and long term LD needs Share learning from Reading and Slough local authority HOLD Schemes to roll out to other localities to enable up to 6 people to buy their own home Share learning from Slough local authority housing technology schemes to roll out to other localities to enable more people to access technology grants in 2018/19 Review and align local authority strategies and build capital business cases to access NHSE and DoH grants in 2018/19 Autism (including Children and Young People) (Project Group) Develop joint commissioning standards around age. Cascade to TCP Partners for consideration and feedback. Align work stream objectives with Thames Valley Network, Future in Mind and SEND Groups to avoid duplication on priorities Develop informational sharing criteria across education and health for LD and ASD people at high risk of admission. Cascade to TCP Partners for consideration and feedback. Implement joint commissioning standards Berkshire wide Develop training and support tools for: Health Visitors, GPs, Paediatrics, Perinatal Mental Health- SPA (CPE) Implement informing sharing standards Berkshire wide across health and education Increase access to Pre-Assessment Specialist Support 6

Work streams and group responsible for leading the work (1) 2017/18 TCP Programme Plan continued 2017/18 Q1 Q2 Q3 Q4 Market Shaping (Joint Operational Group) Review results of ADASS South marking scoping exercise to inform the development of a range of marketing management exercises across TCP partners to increase the utilisation of local authority and CCG resources Establish links with Thames Valley Network for Forensic Pathways to ensure alignment Develop programme plan for High Impact Actions: Respite Care, Day Centres, Residential Living Accommodation, Independent Living Schemes Undertake a strengths based review of LD and ASD provision with providers to identify where high needs register of service users needs are not matched to local supply (sharing the results with all TCP partners and groups) Review CYP in transition plans Cascade recommendations to TCP Partners for opportunities to implement joint procurement exercise for housing and workforce providers for consideration and feedback Implement joint procurement exercises ready for 2018/19 Inpatients (TCP Board and BHFT Board) Ongoing monthly review throughout year for: Specialist Commissioning Care and Treatment Review Timetable and outcomes CCG commissioned beds in Berkshire and Out of Area timetable and outcomes BHFT Assurance reports on admissions and discharge planning Children and Young People in 52 week placements and transition Reduce OOA adult placements to 25 Community transition arrangements in place to avoid inappropriate admission to hospital and support timely discharge from hospital Reduce OOA adult placements to 20 Community transition arrangements in place to avoid inappropriate admission to hospital and support timely discharge from hospital Reduce OOA adult placements to 18 Community transition arrangements in place to avoid inappropriate admission to hospital and support timely discharge from hospital Intensive Intervention an d Support (CCG Commissioners and Joint Operational Group) Monitor and manage transition arrangements in the community due to the consolidation of inpatient services at Campion Unit, Prospect Park from March 2017 Decommissioning of beds at Little House as part of block contract Commissioning of new Phased recruitment of staff to the Intensive Support Team Service Phased roll out of Intensive support team by milestone date October 2017 (TCP Board ambition) Employment & Occupation (Project Group) Project Group established with Undertake stock take to review employment and occupational opportunities Berkshire wide Identified barriers and solutions to remove those practical barriers that disabled people face in work, such as provision of specialist aids and equipment in the workplace, a communicator, support worker, travelling costs, etc. Work with service user advocacy groups and Partnership Boards to identify where there are gaps in service provision Create Berkshire wide on-line directory for work-based supported employment, work preparation training and work related job experience Align local authority strategies to increase social inclusion and skills Hold an event for voluntary services to promote a directory of services Build infrastructure in local authorities to support employers and disabled people accessing employment of > 16 hours Build support to enable people to undertake work trails in actual job vacancies Communications & Engagement (TCP Board) Commission People s Voice Service (Co-production) Commission Communications and Engagement resources to support programme Publish quarterly TCP briefing to partners Expert by Experience Steering Group established, chaired by Service User and LD and ASD Clinician(s) Experts by Experience Steering Group review progress against the milestone plan and make recommendations to the TCP Board on behalf of service users of where improvements need to be made Steering Group uses to Benefit Realistion criteria to monitor health and quality outcomes of service users during the changes Primary Care (Joint Operational Group) Workstream established with PHE and Carer Expert by Experience involvement Undertake stocktake to make sure all people with LD and ASD have annual physical health check; and quality of checks improved Align project group with CYP and SEND work streams Berkshire wide Campaign to promote STOMPwLD best practice started Campaign to reduce inequalities in access to oral care started Campaign to reduce inequalities in access to diabetes services started 7

(1) 2018/19 TCP Programme Plan Overview Work streams and group responsible for leading the work 2018/19 Q1 Q2 Q3 Q4 Finance & Activity Identify opportunities for pooling commissioning resources across health and social care Capacity and Demand Stock take Capacity and Demand Stock take Heath & Social Workforce Expand Shared Lives Scheme to local authorities Berkshire wide Facilitate providers in developing an 24/7 occupational health model and peer support network for staff Facilitate providers in developing a salary retention incentive to reduce turnover/sickness absence rates Housing & Accommodation Shape private rented sector market place Identifying sites for new purpose built units Expand domiciliary care and short stay residential breaks provision Autism Introduce Autism Support Navigators in health and education Establish social communication and friendship groups for all ages Increased access to ADS services for youth offending providers Market Shaping Align milestones to activities in workforce, housing accommodation and employment and occupation work streams Inpatients Repatriation Programme continues Reduce OOA placements to 16 Reduce OOA placements to 14 Reduce OOA placements to 12 Intensive Support Team Intensive Support Team in place Monday to Friday 0900 1700hrs Start to implement plans to increase services 24/7 in line with capacity and demand projections forecast by Finance and Activity Group Employment & Occupation Implement supported employment models in partner organisations with partners leading by example Communications & Engagement Experts by Experience Steering Group review progress against the milestone plan and make recommendations to the TCP Board on behalf of service users of where improvements need to be made Steering Group uses to Benefit Realistion criteria to monitor health and quality outcomes of service users during the changes Primary Care Campaign to reduce inequalities in access to nutrition education and sport activities Campaign to promote access to cancer services 8

(1) TCP Programme Outcomes (approved by TCP Board November 2016) 9

Intensive Support Team All TCPs nationally are looking to commission a new service model in the community called an Intensive Support Team (IST) or Intensive Intervention Service. An Intensive Support Team will provide proactive community based support for people with a learning disability and/or autism who have associated mental health needs and/or present with behaviour that can challenge. Offering support to people in their own homes and preventing in-patient admissions where possible, the IST will provide access to specialist health and social care support. The service will use intensive, safe, responsive and non-invasive strategies, including Positive Behaviour Support (PBS). Focusing on improving a person s quality of life and reducing behaviours that pose a risk to self and others, the Team will provide intensive support that is person-cantered on the needs of the individual and their families. In conjunction with social care teams, the IST will minimise the risk of people with learning disabilities being taken into specialist inpatient health services for assessment and treatment (unless clinically warranted). The TCP Board is currently in the process of drafting a service specification for the IST. The TCP Board will update partners on progress following the January Board meeting. 10