The Bedfordshire CCG and Bedford Borough Council Better Care Plan Executive Summary: Our approach to Better Care planning

DRAFT Version 16 19 March 2014 The Bedfordshire CCG and Bedford Borough Council Better Care Plan Executive Summary: Our approach to Better Care planning Bedford Borough and Bedfordshire CCG s Better Care Plan sets out the progress we have made so far on our joint planning, how the plan and fund will help us to accelerate our work, where we will target our efforts, and the benefits we will expect to see as a result. The plan is based on all of the work we have done together to date, including the analysis and engagement on which we have based our Joint Strategic Needs Assessment (JSNA), Joint Health and Wellbeing Strategy (JHWS), our commissioning frameworks, corporate planning, and care redesign and delivery models. It is also based on our existing agreements across organisations to work together more effectively for the benefit of local people by pooling our commissioning resources. The Deputy Director for Integrated Care at the Department of Health Ed Scully confirmed at an NHS England event on the 23 rd of January 2014 that the only additional new money available is the increase in Section 256 monies to Local Authorities of 200M nationally. The other 3.8 billion nationally expected to be allocated into Better Care Funds to achieve integration has to come from within existing NHS resource allocations. Taking this into account this plan aims to describe our agreed vision for health and social care in the borough and the overarching delivery model that we have agreed for making that vision a reality. We have used the development of this plan as an opportunity to review our existing spend and match this to six key schemes or programmes that will help us to target this fund and our work together for the next three to five years. The six schemes identified in this plan align closely with the performance indicators identified in the guidance. They are: Reshaping our reablement and rehabilitation model for older people reviewing the services that provide support and get more of our older residents back on their feet, ensuring that we increase the proportion of older people at home 91 days after a hospital visit; Targeting our work with people with life limiting conditions identifying those at risk early, improving and coordinating support at home through increased domiciliary care, additional specialist nursing care, providing personalised choices within end of life care, reviewing the scope and use of community equipment and disabled facilities grants to avoid permanent placements; Improving our integrated care pathways across our provision by reviewing our current social care transfer monies and redesigning our processes, particularly around hospital discharge, so that we can reduce our delayed transfers of care; Redesigning our prevention model by delivering more comprehensive programmes of work aligned to our risk stratification and focussed on older people 1

DRAFT Version 16 19 March 2014 and people with mental health conditions who are at risk of emergency admission to hospital; Improving the user experience through different ways of working, challenging historic culture and practice within acute care, improving the availability of information regarding what information, services and advice is available to ensure the most appropriate and timely response. Integrating our commissioning arrangements taking a whole systems view, developing our joint commissioning arrangements and agreeing where to prioritise our resources so that we are better able to manage demand and respond more appropriately to people s needs. The plan includes our current draft action plan for delivering on the programmes of work and our benefit modelling so that we can ensure that the schemes of work deliver what is required. Our benefit modelling is based on a combination of managing increasing demographic demand; meeting productivity and efficiency savings; managing the number of people requiring services through early intervention and prevention; improving the impact of services by redesigning and specifying them; and driving through process and procurement savings in our current services and contracts. Underpinning all of these areas are our strong governance and accountability arrangements and the performance framework we have agreed, which will guide our understanding of the progress we are making across the programme. 2

DRAFT Version 16 19 March 2014 Better Care Fund planning template Part 1 Please note there are two parts to the template. Part 2 is in Excel and contains metrics and finance. Both parts must be completed as part of your Better Care Fund Submission. Plans are to be submitted to the relevant NHS England Area Team and Local government representative, as well as copied to: NHSCB.financialperformance@nhs.net To find your relevant Area Team and local government representative, and for additional support, guidance and contact details, please see the Better Care Fund pages on the NHS England or LGA websites. 1. PLAN DETAILS Summary of Plan Local Authority Clinical Commissioning Groups Boundary Differences Date agreed at Health and Well-Being Board: Bedford Borough Council (BBC) Bedfordshire Clinical Commissioning Group (BCCG) Bedfordshire CCG s boundaries are coterminous with Bedford Borough and Central Bedfordshire Councils. Bedford Borough is one of five recognised geographical localities in the CCG s delivery network. 1 April 2014 Date submitted: 4 April 2014 Minimum required value of BCF pooled budget: 2014/15 4.542m 2015/16 10.269m Total agreed value of pooled budget: 2014/15 4.542m 2015/16 10.269m Authorisation and signoff Signed on behalf of the Clinical Commissioning Group Bedfordshire Clinical Commissioning Group By Dr Paul Hassan Position Accountable Officer Date 1 April 2014 3

DRAFT Version 16 19 March 2014 Signed on behalf of the Council Bedford Borough Council By Mayor Dave Hodgson Position Mayor of Bedford Date 1 April 2014 Signed on behalf of the Health and Wellbeing Board Bedford Health and Wellbeing Board By Chair of Health and Wellbeing Board Mayor Dave Hodgson Date 1 April 2014 a) Service provider engagement Please describe how health and social care providers have been involved in the development of this plan, and the extent to which they are party to it Bedford Borough Council and Bedfordshire Clinical Commissioning Group have well established mechanisms for provider engagement. Regular provider forums take place across commissioners and client groups. Open days, including the CCG s Provider Day, bring together providers to discuss emerging trends in the population, strategic and financial issues, and commissioning intentions. In adult social care, regular Provider Forums take place. Large events bring together providers across the borough, while more specific activity takes place focussed on client groups (such as older people), services (such as home care), and sectors (including targeted voluntary sector engagement, for example). Forums are followed up with other regular communication; including newsletters, further information, and consultation. Open communication is maintained throughout as a key part of the commissioning cycle. One-to-one leadership sessions with the acute providers and key providers in the area also take place. The content of our BCF has been discussed with providers, users, clinicians and carers as an integral part of our strategic planning processes. The starting point for all discussions has been our jointly-agreed JSNA and the priorities and plans agreed by the Health and Wellbeing Board. Through co-producing these documents, and basing our planning on evidence and feedback, we have worked hard to establish our engagement on the basis of partnership working over many months. In this context we have had many engagement events, including with GP leads on 1 May 2013 and service providers on 20 June 2013. We recognise the BCF as a significant opportunity to accelerate our progress to deliver on existing ambitions and plans, including our established programmes to improve services for older people. Integrating care in the borough around a shared evidence base and shared plans has been a key part of our provider engagement over the past twenty-four months at least. Specifically on the component schemes of the BCF we have shared our plan with key providers and stakeholders including through our Partnership Board, the Delivering for Patients Board, the Bedford Locality Board (which engages Bedford s clinical leaders), the BCCG Executive, third sector providers, the Performance Management Group, and the Joint Management Group. Providers are integral to all of these established governance groups and consultative forums. We have complemented this activity with specific meetings with the Luton and Dunstable Hospital Trust and Bedford Hospital, engaging our acute providers in the planning we have set out in this document as well as in the context of wider contract negotiations and the strategic review taking place across Milton Keynes and Bedford. We have also undertaken specific and targeted engagement with community based health and social care providers. We have used our GP networks 4

DRAFT Version 16 19 March 2014 to engage with practices and GPs. We have also had discussions with (SEPT Community Health Services (our main community health services provider), Bedford Locality Health (a group of twenty-five GP practices in North Bedfordshire with a combined patient list of over 170,000), SEPT Mental Health Services, independent care homes and home care agencies. We have discussed our plans with carers organisations that provide advocacy as well as services, including Carers in Bedfordshire and Advocacy for Older People. Our action plan for delivering on the contents of our BCF includes a dedicated and forward thinking programme of engagement focussed on working jointly towards common goals and, in particular, the priorities agreed by the Health and Wellbeing Board. b) Patient, service user and public engagement Please describe how patients, service users and the public have been involved in the development of this plan, and the extent to which they are party to it This plan incorporates what local people have told us is important to them. Through our on-going and targeted patient, service user and public engagement work, we have identified and discussed key issues of importance to older people, people with disabilities, residents with a caring role, people with mental health issues, and people with longer term conditions. We use a number of methods to engage with patients, service users, and the public. These include patient satisfaction surveys; patient, carers, and service user groups; information published on our websites and in newsletters; Healthwatch; lay members on partnership boards; links with community groups; and activities through voluntary organisations. Partnership boards have been a particularly important forum for this engagement and most recently the strategies have been discussed at: Learning Disability Partnership Board on 14 January 2014; Older People s Partnership Board on 19 September 2013; Physical Disability and Sensory Impairment Partnership Board on 12 December 2013; Carers Partnership Board on 18 July 2013; and Mental Health Partnership Board on 11 October 2013. Our Health and Wellbeing Strategy consultation in March 2012 told us there is a high level of local agreement about health and wellbeing priorities, with agreement scores as follows: Mental Wellbeing (93%), Independence (90%) Tobacco control (67%), Healthy Weight (80%) and Teenage Pregnancy (85%). Where relevant to the programmes included within our Better Care Fund pooled budget, these priorities are reflected in our submission. Additionally, BBC s Making your care home better consultation (January 2014) asked if people agreed with the Council s proposal that it should commission less residential care at the same time as commissioning more home care, extra care, and nursing care over the next twenty years as a result of the ageing population. Respondents expressed strong agreement with the proposals and this is reflected in the relevant schemes within our Better Care Fund plan. Specifically on the BCF, a newsletter will be published on both the BBC and BCCG websites. Paper copies will circulated widely to community groups and parish councils 5

DRAFT Version 16 19 March 2014 and patient representatives through Healthwatch. Additionally, Healthwatch will host a public meeting to receive comments on the draft plan and the feedback will be reflected in future iterations. Officers from the CCG and Council will continue to consult with patient participation groups, service users and the public including third sector organisations and carers through the upcoming Joint Commissioning Partnership Boards and the Delivering for Patients Boards. BCCG s Bedford locality has also run a session with its Patient Group around integrated care. Elected members have been central to engaging on the issues that are fundamentally important to our residents and this plan is discussed with the Portfolio Holder for Adult Social Care at weekly briefing meetings and the Health and Wellbeing Board Chair at regular meetings. c) Related documentation Please include information/links to any related documents such as the full project plan for the scheme, and documents related to each national condition. Document or information title Bedford Borough Joint Strategic Needs Assessment Bedfordshire CCG Commissioning Intentions Bedford Borough Health and Wellbeing Strategy Bedford Borough Joint Commissioning Strategies Bedfordshire CCG Plan for Patients Bedford Borough Council Inequalities Report Bedford Borough Council, Central Bedfordshire, and NHS Bedfordshire CCG Joint End of Life Strategy Synopsis and links www.bedford.gov.uk/health_and_social_care/bedford_borough_j sna.aspx www.bedfordshireccg.nhs.uk/home www.bedford.gov.uk/health_and_social_care/health_and_wellbe ing.aspx www.bedford.gov.uk/health_and_social_care/help_for_adults/joi nt_commissioning_strategies.aspx www.bedfordshireccg.nhs.uk/search/?zoom_query=delivering+fo r+patients www.bedford.gov.uk/health_and_social_care/idoc.ashx?docid=6 86640c9-7e53-457a-a096- This document is not currently online but is available on request. 6

DRAFT Version 16 19 March 2014 Bedford Borough and Bedfordshire CCG Joint Strategies for: Carers Learning Disabilities Mental Health Older People Physical Disabilities and Sensory Impairments Dementia www.bedford.gov.uk/health_and_social_care/help_for_adults/joi nt_commissioning_strategies.aspx These joint strategies cover 2013-2017, apart from that for dementia, which covers 2011-2014. 7

DRAFT Version 16 19 March 2014 2. VISION AND SCHEMES a) Vision for health and care services Please describe the vision for health and social care services for this community for 2018/19. What changes will have been delivered in the pattern and configuration of services over the next five years? What difference will this make to patient and service user outcomes? Bedford Borough s Health and Wellbeing Strategy identifies our joint top priorities for promoting health and wellbeing in the borough. These priorities work towards a vision that: All adults are able to live healthy, safe lives, and are provided with the opportunities to realise their full potential; and all adults have the support they require to lead healthy and independent lives and timely access to high quality, appropriate health and social care. In support of this vision and to address health inequalities and ensure best use of resources, we have developed five cross-principles that underpin all services and interventions that contribute to our strategic priorities. These are: EQUITY provision of services should be proportional to need to avoid increasing health inequalities and targeted to areas which need them the most; ACCESSIBILITY services should be accessible to all, with factors including geography, opening hours, and access for people with disabilities considered; INTEGRATION service provision and care pathways should be integrated, with all relevant providers working together. This will maximise the benefits of delivery through the Health and Wellbeing Board; EFFECTIVENESS services should be evidence-based and provide value for money; and SUSTAINABILITY services should be developed and delivered with consideration of social, economic, and environmental sustainability. We understand the significant health and social care challenges we face. Our JSNA for 2013/14 sets out our expectation that our older population is forecast to increase by 12% in the number of people aged over 65 in the next 5 years and by 60% in those aged over 90. Looking to 2035, the over-85 population is set to increase by 135% and the number of people with diagnosed dementia is forecast to rise from just fewer than 2,000 now to around 3,500 by 2035. More people than ever are requiring services of us and we understand the national estimates that the cost of providing hospital and community services to a person aged 85 or more is around three times greater than for a person aged 65-74 years (Centre for Workforce Intelligence, 2013). We already expect there to be around 2,000 more people over 65 living in the Borough between now and 2016 and the Projecting Older people Population Information (POPPI) forecast tells us that failing to change quickly enough will mean we have an estimated 300 more people in care homes by 2020 (150 of those people funded by the local authority). 8

DRAFT Version 16 19 March 2014 These demographic issues and our resident s own expectations have led us to initiate programmes of change which this plan will support. We have already taken positive steps to deliver our vision and address these issues by, for example, developing our health and wellbeing planning and joint commissioning strategies and plans, as well as working hard to deliver more integrated community services and developing extra care housing. Our admissions to care homes reduced in 2012/13 as a consequence of more extra care housing now being available and the introduction of reablement for referrals. At the crossorganisational level we have taken a big step forward in the development of our integrated commissioning capacity by agreeing at the strategic level to work towards increasing integration across our organisations. Our overall model for integrating care for our residents, applicable to both health and social care, can be represented as follows: This agreed model of care is underpinned by our new delivery model, which describes a number of changes in the pattern, configuration and interaction of services. The delivery model will be fully embedded over the next five years. As this diagram shows, it places every individual at the centre of their interactions with the health and care system and focuses on self-care and keeping them well though good health decisions. This demonstrates our commitment to wellbeing, health promotion, and prevention. 9

DRAFT Version 16 19 March 2014 Emergency Care Obstetrics Emergency Medicine Emergency Surgery 24/7 Emergency Consultant Care Led Acute Services Social care Diagnostics Outpatients Dentistry Support for Carers Cancer Services GP Services Wellbeing Urgent Care Local Services Individual Self Care & Good Health Decisions Prevention District Nursing Diagnostics Specialist Care Pharmacy Health Promotion Day Procedures Step up/ Step Down Care Mental Health Therapy and Rehab Optometry Planned Care Health Visitor Allied Health Professionals Other Specialist Paediatrics Elective Inpatient Regional and National Services The diagram shows that wrapped around each patient and service user is a range of local services from both health and social care. This includes advocacy, advice and information, reablement, day care, assistive technology and disabled facility grants, GP, pharmacy, and dentistry services; outpatient and urgent care; community health services such as district nursing, health visiting, therapy and rehabilitation; step-up and step-down care; and support for carers. The multidisciplinary working that this model includes is a key facilitator of integrated health and social care services. Beyond these local services is emergency care, specialist care, and planned care. Our focus on prevention at the heart of the delivery model means that patients will require these higher end interventions less frequently, which is a key means both of improving both the health and wellbeing outcomes for patients as well as the financial sustainability of our local system. Overall, this model will mean that patients and users are able to access a range of services in a coherent way, with support based on the right skills and experience deployed at the right point in the patient pathway. More specifically to Bedford, the following diagram shows how we aim to place patients and service users at the heart of an integrated health and social care system with which they interact on three levels (working outwards from the middle of the diagram): 10

DRAFT Version 16 19 March 2014 Through services provided only through localities, such as assessment and care planning, case management, and their accountable professional; Through services provided either through localities or borough-wide the system will be able to flex locality and borough teams depending on locality and borough populations/needs; and With services provided only borough-wide, as determined by population needs and economies of scale. The system has various enablers, including early identification, assistive technology, and a shared health and social care record. Our ambition is that this model will be developed for all client groups, across both health and social care. This will drive the achievement of an integrated care system that is: person-centred, focussed on the outcomes I want to achieve ; more connected; more targeted; delivered through localities where appropriate; flexible and evidence-based; based on multi-disciplinary working; deliver support to carers promote social inclusion and independence; and Focussed on prevention, early intervention, patient self-management, and minimising unnecessary hospital admission. There are a number of primary changes that will be delivered in the pattern and 11

DRAFT Version 16 19 March 2014 configuration of services over the next five years. These are cross-cutting themes across all our BCF schemes. There are a number of critical changes to be delivered in the pattern and configuration of services across health and social care over the next five years. Health and social care services will be re-designed to support people to live in their own home, not in a home. The continued availability of universal services like housing, transport and environment management will provide the foundation, at individual household and community level, for social care and health services to build their personalised model upon. Health and social care related information, advice and advocacy to help people stay independent and in good health for longer, will be freely available to the population at large and specifically targeted towards those in greatest need. The overriding goal will be to prevent wherever possible the onset of disability, ill health or adverse social circumstances and the associated negative impact on a person s independence. When the prevention of disability, ill health or adverse social circumstances is not possible then early intervention to prevent deterioration will be put in place. During the intervention period the promotion of independence will continue with people supported to self-manage their support needs to the maximum degree possible. The availability of practical support and comfort obtainable from minor adaptations to people s homes will be facilitated by increased investment in handy-man services. People who need enhanced levels of care and support will be offered the support to maintain independence in Extra Care housing with residential and nursing care provision only being considered as options of last resort. Care and Support Planning for Maximum Independence. Multi-disciplinary care planning will be implemented across the health and social care system. This involves health and social care risk profiling for communities and individuals with proactive case management, especially in the achievement of medication concordance. A strong culture of self-management and prevention of aggravating factors (such as flu and unhealthy lifestyles) will manage down the demand for services. Carer s support services will be addressed in the integrated care and support plan. There will be increased availability of short term respite breaks to prevent carer breakdowns leading to long term admissions to residential care. An integrated (multi-disciplinary) health and social care system will promote the culture of self-management to prevent avoidable admissions to care homes and hospitals. BCCG and BBC currently have services in place to prevent patients being admitted to hospitals and care homes. However these are commissioned and delivered independently by contractors operating without due co-ordination between each other. Contractors are drawn from across the voluntary sector, primary care and community health providers and both statutory and private social care providers. The whole system provided by these services will be re-designed in co-production with local residents and then commissioned jointly by BBC and BCCG together. We already have organisational approval to integrate our commissioning resource across the CCG and Borough and have used the process of developing this plan to identify the resources each of our organisations will put into services in the 6 areas identified for investment through BCF. 12

DRAFT Version 16 19 March 2014 Within the integrated system above, General Practitioners will proactively manage patient s health and wellbeing in order to reduce demand for reactive interventions from other social care and health services when ill health occurs. The system will include preventative interventions available via General Practitioners to people at high risk of developing an illness. People who become ill with a high risk of becoming disabled will be identified through joint health and social care risk stratification. GP s will take case-holding responsibility and signpost to a range of general and specialist health and social care services that align with the patient s pathway. GP practices will work together across the patch to ensure improved access to care both in and out of hours. They will leverage the primary care network and provide improved access to care 7 days a week and out of hours. A key part of the prevention sub-system will be the expansion of Bedford s Lifestyle Hub, which provides primary and secondary prevention advice and support to people at risk of, or suffering from, long-term conditions. Appropriate access to specialist multi disciplinary teams (nursing, social care and therapies). Providing access to specialist multi-disciplinary teams in the community will help prevent patients visiting A&E inappropriately. That in turn will reduce hospital admissions and that in turn will reduce residential care placements. Multi-disciplinary clinics will be in place to support and advise people in the community in partnership with primary care. We will accelerate the work that is already underway to develop integrated pathways of care for patients suffering from stroke, cancer, neurology and cardiology issues. Hospital Discharge Planning If people need to go into hospital then it is important that they leave with support to maximise their independence back in their own home. This calls for integrated rehabilitation and enablement services with access to equipment, aids and adaptations. The aim is to review the current discharge pathway and re-commission a more integrated and effective pathway through the BCF. End of Life an integrated pathway Quality end of life care depends on integrated planning by health and social care to support people in a seamless way. Improvements in End of Life care will be delivered by our stepped improvement programme. Building on the success of the Partnerships for Excellence in Palliative Support (PEPS) pilot, all End of Life care will be managed by one jointly commissioned care organisation. This will ensure improved communication and coordination of care supporting people to die in their preferred place of death. b) Aims and objectives Please describe your overall aims and objectives for integrated care and provide information on how the fund will secure improved outcomes in health and care in your area. Suggested points to cover: What are the aims and objectives of your integrated system? How will you measure these aims and objectives? What measures of health gain will you apply to your population? The overall aims of the integrated system are to improve health and wellbeing 13

DRAFT Version 16 19 March 2014 outcomes for local residents by: Eradicating fragmentation and silo working across health and social care; Ensuring every part of the system is working effectively; Achieving maximised health and wellbeing outcomes within available resources; Minimising health and wellbeing inequalities across the area; Improving the capacity of the local population to self-care, in particular minor ailments and long-term conditions; Improving the ability of the local population to implement lifestyle choices that reduce future demand for health and social services; Avoiding unnecessary admissions to hospitals and care homes; Ensuring that nobody stays in a hospital or care home longer than they need to; Maximising the knowledge and skills of all staff; and Making Every Contact Count (MECC) to: o o o Systematically utilise the thousands of contacts that people have with health and social care staff (such as GP, outpatient appointments, day services etc.) to deliver brief advice on healthy lifestyle behaviours and signpost people where they can get help to change their behaviour; Increase the prevalence of healthy lifestyle behaviours amongst NHS and social care staff as well as the population they serve; and Reduce inequalities in health outcomes associated with lifestyle behaviours. Our objectives are to effectively deliver the continuum of care for local people described in our Joint Non-Acute Community Health and Social Care Services Review (September 2013). In the review, we described beginning the continuum at one end with the independent self-caring person and at the other end the heavilydependent person. Our objective is that along the continuum a range of services will be provided, from prevention and early intervention to patients and service users in need of high end and acute interventions The continuum will be delivered through: 1. Patient Self-management Prevention of illnesses will continue to be a priority with early support available and easily accessible through the Lifestyle Hub. More practices will be able to refer and a greater range of support will be made available to local residents especially those at risk of, or already suffering from a long term condition. 2. Risk Stratification The CCG and Council are agreed on the need for a shared risk stratification approach. Professionals already share information about their higher risk cases but there is a need to do this more systematically with a consistent response to the prevention of deterioration in high risk patients. From primary care to specialist services, multi-disciplinary teams will have risk stratification tools in place to identify individuals who will most benefit from preventative interventions. 3. Case Management and Integrated Care Pathways The Council and CCG already operate integrated approaches in a number of areas. 14

DRAFT Version 16 19 March 2014 For example, support is provided at the time of dementia diagnosis, leisure and physiotherapy services work together in stroke rehabilitation and the Council s Care Standards Teams and the CCG s Quality Team raise standards in local care homes. Integration will continue to grow from these foundations and the areas of Cardiology, COPD, Stroke, Diabetes, Neurology, Dementia and End of Life have been identified as key priorities. Integrated Care Pathways will improve access and flow through services delivered by Integrated Community Multi-Disciplinary Teams (CMDTs) with health and social care staff working together to support local people. The CMDTs will access shared patient and service user information utilising the NHS identifiable number within information governance guidelines. Named coordinators will be assigned to patients to ensure greater coordination and active monitoring of individual care plans. This plan has been based on a shared understanding across our organisations of the pressures and issues we are facing in our performance. Our next steps plan includes setting up a performance management approach based on a dashboard of measurable changes to health and wellbeing at both the individual and demographic level, managed and reported through our governance structure. The measures of health gain we will be applying to the population shown in the table below. Part two of our submission shows both our level of ambition and the baselines from which we will be working. For full details of our baselines and targets, please see part two of our submission. Measure Outcome Baseline Permanent admissions of older people (aged 65 and over) to residential and nursing homes, per 100,000 population Reducing inappropriate admissions of older people (65+) into residential care The 2012/13 baseline (outturn) is 663.6 which is a rate per 100,000 populations for those aged 65+. The rate is calculated by dividing the number (numerator) of council supported permanent admissions (65+) by the (denominator) size of the older people population (65+) Numerator 173 Denominator 26,069 Proportion of older people (65 and older) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services Increase in effectiveness of these services whilst ensuring that the number of those offered services does not decrease The 2012/13 baseline (outturn) is 83% this is the percentage of older people (65+) still at home 91 days after discharge. 15

DRAFT Version 16 19 March 2014 The percentage is calculated by dividing the number (numerator) of older people (65+) who are still at home 91 days after discharge by the (denominator) i.e. number of older people (65+) offered rehabilitation services Delayed transfers of care from hospital per 100,000 population (average per month) Effective joint working of local partners (acute, mental health and nonacute) community-based care in facilitating timely and appropriate transfer from all hospitals for all adults Numerator 78 Denominator 94 This indicator gives the monthly average delayed transfers of care per 100,000 population aged 18+ The baseline for the periods April to December 2013 indicates that the average per month was 308.5. Avoidable emergency admissions (average per month). The numerator is the total count for the 12 month time period. Reduced emergency admissions which can be influenced by effective collaboration across the health and social care system. This is a composite measure of 1) Unplanned hospitalisation for 16 There were 3418 delayed transfers of care from April to December 2013. This is then divided by the 18+ population of 123,100 and then by the number of months in the baseline period to give the average per month. Numerator 3418 Denominator 123,100 The 2012/13 baseline of 1865.7 is a crude rate of avoidable emergency admissions per 100,000 population which equates to 154.73 average per month.

DRAFT Version 16 19 March 2014 Patient and service user experience Attendance at leisure facilities chronic ambulatory care (all ages) 2) Unplanned hospitalisation for asthma, diabetes and epilepsy in children 3) Emergency admissions for acute conditions that should not usually require hospital admission (all ages) and 4) Emergency admissions for children with lower respiratory tract infection. To demonstrate local population / health data, patient / service user and carer feedback has been collated and used to improve patient experience. To provide assurance that there is a co-design approach to service redesign, delivery and monitoring, putting the patients in control and ensuring parity of esteem To demonstrate an increase in the proportion of people attending the Borough s leisure facilities and to realise a positive impact on health through physical activity. The rate per 100,000 is calculated by dividing the total number of emergency admissions (2956) by the Bedford Borough population (159,207), expressed as a rate per 100,000 per month. Numerator 2956 Denominator 159,207 This national indicator is as yet undetermined. The 2013/14 baseline is a rolling figure for the past 12 months (January to December 2013). The baseline for 2013/14 is 1,199,629 Our performance dashboard will be underpinned by a number of NHS, social care, and public health indicators, which may at include: Before and After comparisons to assess and monitor the impact on individuals and the system; Reduced outpatient visits; Reduced unplanned or unnecessary admissions to hospitals and care homes; Number of individuals who have a coordinator and a care plan; Increasing independence; Relief from pain/discomfort and other debilitating symptoms of long term conditions and disabilities; Increasing confidence in self-management evidenced by an increase in outcomes 17

DRAFT Version 16 19 March 2014 achieved via the Lifestyle Hub and other sources of information and advice including third sector groups and community pharmacies. Narrowing health inequalities; and Patient satisfaction surveys and other goal attainment measures to monitor service user health improvement and quality of service experience. c) Description of planned changes Please provide an overview of the schemes and changes covered by your joint work programme, including: The key success factors including an outline of processes, end points and time frames for delivery How you will ensure other related activity will align, including the JSNA, JHWS, CCG commissioning plan/s and Local Authority plan/s for social care Our joint work programme has been devised to make full use of the BCF. Each of the programmes aligns closely with our shared performance targets and pressure points. We have already started work, sharing our budgets and information in an open book manner so that we can apply the benefits we expect to see to the whole commissioning budget in each area. Each programme is made up a smaller number of projects and tasks (see Appendix 1) which will deliver our aims. The programmes and projects are as follows: 1. Reshaping our reablement and rehabilitation model for older people This programme will aim to get more of our older residents back on their feet. Our primary measure for delivering this will be ensuring that we increase the proportion of older people at home 91 days after a hospital visit. The programme will be made up of the following projects: 1a. Maintaining the current reablement service and approach and reviewing existing services that would enable increased capacity, impact and reach; 1b. Reviewing existing rehabilitation beds and services within the community and recommissioning our community health services in line with a redesigned reablement/intermediate care model. and 1c. reviewing and reshaping our high-end rehabilitation, including the use of specialist residential units. 2. Targeting our work with people with life limiting conditions This programme will aim to improve the impact of our support at home and in high end services such as end of life care settings. Our primary measure for delivering this will be avoiding permanent placements. The programme will be made up of the following projects: 2a. reviewing and redesigning the domiciliary care model to reduce reliance on more expensive alternatives by helping people to return home more quickly; 2b. Increasing the capacity and responsiveness of 24/7 services that help keep people at home, including equipment and Assistive Technology; 2c. Reviewing and redesigning end-of-life care to support people staying in their own homes at the end of their lives; and 2d. Redesigning care pathways of specialist health interventions, including strokes, heart issues, and neurology to ensure more nursing support is available in the community to prevent visits to out-patients and avoidable hospital admissions. 2e. Reviewing the use and scope of the community equipment service and the 18

DRAFT Version 16 19 March 2014 allocation of disabled facilities grants to ensure we maximise independence. 2f. Implementing outstanding actions within the Carer and Physical Disability and Sensory Impairment strategies 2g. Integrated out of hospital care 3. Improving our integrated care pathways across our provision This programme will review our current social care transfer monies and redesign our processes, particularly around hospital discharge. Our primary measure for delivering this will be reducing our delayed transfers of care. The programme will be made up of the following projects: 3a. Reviewing the NHS to social care transfer monies and build on the successes achieved through increased hospital social work teams and reablement. Review the services within the current community contract to ensure multi-disciplinary teams and coordinated responses to patients/people. Increase housing interventions, and targeted voluntary sector support, with the aim of maximising spending and outcomes across health and social care based on evidence about what works; 3b.Promoting self-care, integrating the role of primary care services (GPs, Pharmacists, Dentists and Opticians ) with other services available within the locality that provide appropriate support to people at home and within the community 3c. reviewing hospital discharge procedures and policies in order to improve Improving discharge planning processes and team operations. 3d. Review current and future residential and nursing home bed provision 3e. Maximise the use of rehabilitation and Reablement provision to enable people to return to independence and their own home as much as possible 3f. Ensure that patients discharge from hospital is as coordinated and integrated as possible across the system 3g. Provide strategic advice and support to Care Homes in Bedford Borough 4. Redesigning our prevention model This programme will deliver more comprehensive programmes of work aligned to our risk stratification and focussed on older people and people with mental health conditions. Our primary measure for delivering this will be emergency admission to hospital. The programme will be made up of the following projects: 4a. Linking risk stratification within primary care to early preventative services available within the community across health and social care with GPs taking on the lead coordination role. 4b. Develop and procure a comprehensive and equitable mental health model of care for both adults and children. Through the implementation of our joint Mental Health Strategy that commits to ensuring more people with mental health problems stay in good physical health, receive positive experiences and support and reduced experience of stigma and discrimination. Child and Adolescent Mental health Services will be aligned to Community Services to ensure that children s physical and mental health needs are met in line with our joint Children s Strategy of ensuring an Early Offer of coordinated services that involves all partners across the system including education. 4c. Further develop the existing falls programme into a comprehensive service across the CCG, Bedford Borough Council and Community Services. 4d Our redesign will account for the changes made by, and any implications of, the Care Bill 19

DRAFT Version 16 19 March 2014 5. Improving the user experience This programme will deliver a change in the culture in our workforce and improve the quality of our information, advice and signposting. Our primary measure for delivering this will be service user and patient reports of a better experience of what we do. The programme will be made up of the following projects: 5a. Developing an engagement model and approach for the development of shared outcomes and KPIs to inform redesign and commissioning; 5b. Creating a differentiated engagement model for clinicians, carers, and users through the use of local networks. 5c. Providing information and signposting to services through a single source and supporting website services 5d. Effective and targeted messages and communications designed to change the culture of A&E usage and thereby divert unnecessary A&E attendances to more appropriate services (e.g. primary care, pharmacies). 6. Integrating our commissioning arrangements This programme will take a whole systems view, developing our joint commissioning arrangements and agreeing where to prioritise our resources so that we are better able to identify weaknesses in the system and respond to them quickly. The programme will be made up of the following projects: 6a. Creating a joint approach to the full commissioning budget, prioritising areas where joint commissioning can have the most impact. 6b. Creating a targeted resource model for task-and-finish commissioning. These schemes have been discussed and agreed at the Health and Wellbeing Board, which will continue to be involved in ongoing discussions about prioritisation, timeframes, and benefits as we work up our final submission. This will take place in addition to the governance arrangements detailed below. We have already completed a great deal of work to ensure that we are aligned in our objectives and planning. In September 2013, the Council and CCG undertook a Joint Review of Non-acute Community Services. A number of commitments were made and agreed. From the CCG, these included: Changing service specifications in 2014/15 to deliver more integration and closer working with GPs and hospitals; Introducing Consultants specialising in Care for Older People in the community setting; Commissioning an assessment tool and process that will help us to identify people at risk of hospital admission; Establishing better information sharing between health providers and between health and social care which will allow us to better support people; Working with Bedford Borough Council to commission additional beds in residential and nursing homes to use when fixed supply of beds is full; Working with Bedford Hospital to develop a funding model that facilitates the redirection of resources currently spent on hospital care into community alternatives; Moving towards population-based budgets for frail older people across hospitals and community providers. This will allow money to be more effectively spent on preventing hospital admissions and will drive innovation locally; and Appointing specialist nursing services and nurse prescribers that support Stroke, 20

DRAFT Version 16 19 March 2014 Cancer, Cardiology and Neurology. In turn, the Council agreed to: Maintain Joint Commissioning Plans and Partnership Boards for the provision of services to all care groups; Work jointly with BCCG on the re-provision of residential care and in particular agreeing the nature and type of specialist and non-specialist residential care and nursing home beds to be provided in the future; Develop integrated locality based health and social care assessment, and reablement, services removing all duplication with NHS Community Health Services; Ensure that appropriate health care facilities are available in extra care and residential care facilities; Re-commission a range of flexible step up step down residential/nursing home beds with a focus on rehabilitation and return to independence; and Work jointly with BCCG to raise awareness of healthy life choices and promote health checks amongst vulnerable older groups to prevent long term condition development. In the joint action plan that followed from the Joint Review of Non-acute Community Services we take a whole system approach to deliver positive outcomes for our population over the next five years and quality services to the highest standard within the resources available. This is just one example of our joint work together and the basis on which this plan and our programmes are based. At the more strategic level, the JSNA continues to be a live document, kept under constant review by a joint group including health, social care, public health, housing, community intelligence, Healthwatch and the third sector. The Council and CCG have Joint Commissioning Strategies in Learning Disability, Older People, Mental Health, Physical and Sensory Disability and Carers. Each Joint Commissioning Strategy has a smart action plan that is implemented by Joint Commissioning Partnership Boards reporting to the Health and Wellbeing Board and Overview and Scrutiny Committees on a regular basis. d) Implications for the acute sector Set out the implications of the plan on the delivery of NHS services including clearly identifying where any NHS savings will be realised and the risk of the savings not being realised. You must clearly quantify the impact on NHS service delivery targets including in the scenario of the required savings not materialising. The details of this response must be developed with the relevant NHS providers. The developments described in this Better Care Fund submission will strengthen primary and community health and social care services and thereby enable more patients with urgent care needs to be managed at home or close to home. Our investment in these services will reduce reliance on the hospital sector for emergency care and present an opportunity to re-invest a significant element of the spending currently directed towards the acute sector. Although the focus is very much on releasing funds from the hospital sector, improved ways of working should also achieve greater productivity in primary and community services but this is unlikely to generate significant savings. The scale of the change required is described in paragraph 18 of Everyone Counts: Planning for Patients 2014/15 to 2018/19: The funding and implementation of the Better 21

DRAFT Version 16 19 March 2014 Care Fund has the potential to improve sustainability and raise quality including by reducing hospital admissions. Hospital emergency activity will need to reduce by 15% and CCGs will need to make significant progress towards this in 2014/15. This clearly has important implications for the hospitals serving the population of Bedford Borough. Across all Bedfordshire there were approximately 66,000 urgent admissions spells by patients of all ages, at a value of 100m in 2012/13. This equates to an average admission spell cost of approximately 1,500 (across all ages and admissions). Of these, admission spells for patients over the age of 75 were 10,000, at an approximate value of 30m and an average cost of 3,000. Within these overall totals for Bedfordshire, approximately 40% is attributable to Bedford Borough. This equates to 22,400 spells for patients under the age of 75 and 4,000 spells for patients over the age of 75. At an average of 1,250 per spell for patients under the age of 75 and 3,000 for patients over the age of 75, this equates to 40m. To respond to NHSE guidance, the health and care system will need to re-structure care pathways in such a way that 15% of 40m which equals 6m is released from hospital spending. To avoid admissions we will focus on the implementation of Ambulatory Emergency Care (AEC) Pathways. We will be implementing new high impact pathways in Bedford Hospital A&E for identified illnesses and symptoms which can be more easily managed. We will reduce waiting times for treatment and avoid admissions in line with NICE guidelines and best practice studies. We will be introducing an integrated Frail Elderly model to reduce length of stay and support hospital navigation teams. We will be building on successful winter pressure initiatives, such as pharmacy and therapy weekend working and additional junior doctors supporting discharges. This work will continue through 2014/15 and beyond to improve the flow of patients in and out of Bedford Hospital. The impact of this work upon future capacity and workforce is detailed within the appendices of the BCCG two year operational plan Bedfordshire Plan for Patients 2014 2016. It is anticipated that the focus of changed patterns of care will be upon the sub-acute care of older patients, i.e. the over 75s. Releasing the necessary proportion of the current spend on this age group will require a reduction both in the number of patients admitted and lengths of stay. These potential savings will be identified in a number of ways: Through the re-procurement of existing services across acute and community, working with Monitor and the Trust Development Agency to reconfigure the patient pathway across hospitals, community, and local authority services in line with the Strategic Review covering Milton Keynes and Bedfordshire; A revised pricing structure currently being developed by Monitor, potentially through a reduced tariff; Through the programmes and projects detailed in this submission, there will be a reduction of duplication within service delivery and identification of areas of inappropriate activity and associated savings; More effective management of caseloads within the community, including selfmanagement, which will reduce the need for out-patient appointments and unplanned admissions to hospital; and 22

DRAFT Version 16 19 March 2014 Our single hospital discharge process across acute and community services will link seamlessly into rehabilitation and reablement, facilitating early discharge planning and reducing the number of blocked hospital beds. Our plan is based on improving the management of existing capacity as well as creating additional capacity. In the context of this type of change, the CCG and BBC adult social care commissioners have a successful track record in engaging clinicians across all sectors in the co-design and delivery of new ways of treating patients. All health and care systems have a similar agenda, driven by the national Better Care Fund programme and targets. So although many of the hospitals serving the residents of Bedford Borough are outside of the Bedfordshire system, commissioners in Hertfordshire, Cambridgeshire, Milton Keynes and Buckinghamshire, will almost certainly be taking forward aligned programmes. We anticipate that our NHS England Local Area Team will support co-ordination of programmes across a wider area. The current strategic review of services in Milton Keynes and Bedfordshire is also relevant here. e) Governance Please provide details of the arrangements are in place for oversight and governance for progress and outcomes Oversight and governance of this Better Care Fund plan will be provided by the Joint Commissioning Officer Group (JCOG), which comprises representatives from both BCCG and BBC. As this diagram shows, the JCOG: Reports to Bedford s Health and Wellbeing Board, which in turn reports on to the Bedford Partnership Board; Receives reports from BCCG s Delivering for Patients Board, into which the CCG s individual programme boards report; and Is reported to by a series of steering groups and partnership boards on which BCCG and BBC are both represented. The specific responsibilities of the JCOG, to which oversight of the BCF is a natural complement, are to: Ensure that, through effective and joined-up commissioning, high-level outcomes are secured for the population of Bedford Borough; Ensure that the weaknesses in services identified both by the sub-groups of the wider Health and Wellbeing structure (shown at the bottom of the diagram above) and through the JSNA are effectively met; 23