Governing Body Meeting in Public

Agenda Item No: 6.1 Date of Meeting: 27 th March 2014 Governing Body Meeting in Public Paper Title: Out of Hospital Programme Board update Decision Discussion Information Follow up from last meeting Report author: Report signed off by: Jacqui Bunce Sheilagh Reavey Purpose of the paper: This paper summarises the workundertaken by the Out of Hospital Care Programme Board since the last update in January 2014 and the priorities that the Board is working on this year. Recommendations to the Board To note the progress to date

1 Purpose of the Paper OUT OF HOSPITAL CARE PROGRAMME BOARD UPDATE 27 th March 2014 1.1 This paper summarises the work programme undertaken by the Out of Hospital Care Programme Board (OoHC) since the last update in January 2014 and the priorities that the Board is working on this year and in 2014/15. 2 Appendices 2.1 Notes of January OoHC Programme Board minutes 1 2.2 OoHC Benefits Map 3 Terms / Acronyms Used in the Report this section is mandatory as papers are made available to the general public Initials AIHVS CHC HCC HCPA HCS IPA LLV NHS IQ OoHC SVV QIPP ULV In full Acute In Hours Visiting Service Continuing Healthcare Hertfordshire County Council Herts Care Home Providers Association Health & Community Services Integrated Point of Access Lower Lea Valley NHS Improving Quality Out of Hospital Care Stort Valley & Villages Locality Quality, innovation, productivity & prevention Upper Lea Valley Locality 4 Latest Summary Position, as at date: 18 th March 2014 5 Executive Summary and Main Body of Paper 5.1 The Out of Hospital Care Programme Board is responsible for the following schemes: Integration Home First IPA Prescribing Falls Primary Care Access These are regularly reviewed by the Programme Board. The notes of the January meeting is attached at Appendix A. The key issues for each project are as follows: 1 Meeting of 6 th March meeting currently in draft form to be agreed at OOHCPB 27 th March 2014

5.1.1 Home First At the OoHC Board meeting on 16th January the Board agreed to recommend North Herts Locality as the next area with Welwyn & Hatfield to roll out as soon as next as soon as early benefits had been seen in North Herts. This decision was ratified by the Governing Body on 30th January. Dr Fiona Sinclair has been nominated as the GP Lead for this project. An implementation group has been established with senior representation from the CCG, HCT, ENHT, HCC HCS and HPFT. The opportunity to implement discharge to assess model in North Herts which if successful could become part of the Home First model is being looked at. Home from Hospital (social care support) is currently being piloted in North Herts area already so would fit well with discharge to assess model. The aim is to have a fully costed model and specification agreed to include the social care and mental health elements by mid-april for approval by end. An implementation plan is being developed in parallel. 5.1.2 IPA At the NHSIQ workshop on 5 th March there was a presentation by HCT, HPFT and HCC on the opportunities for providers to deliver the integrated community model that the CCG and HCC has set out in its strategic plans. JAB will be meeting with Karen Taylor from HPFT to discuss a potential tripartite proposal coming forward for a single SPA/IPA for heath, mental health and social care community services. This would supersede the existing IPA model 5.1.3 Prescribing The OoHC Board had tasked Dr John Constable with leading a review of the Medicines Management Support Service provided by the CSU. At the meeting on March 6 th Heather Gray gave a précis of the work shared at the recent Medicines Management workshop. The report into effectiveness of the in house pharmacy pilots was discussed and it was agreed that this support should be incorporated into the core service specification from the Prescribing & Medicines Management team The Home First pharmacy support pilot proposal in LLV was endorsed and the OoHC Board recommended that money for this should come out of Transformational Funds. It was also agreed that this should be incorporated into the North Herts Home First business case that is being developed and directly links to the additional pharmacy support to Care Homes. The discussion regarding the proposed support to Care Homes recognised that whilst there was a need to see this support being rolled out across the CCG, it would be more appropriate for this team to be linked to localities but as the spread of care homes was not uniform across the CCG, it should be a core team to ensure appropriate economies of scale and flexibility not be allocated. The OoHC Board asked that the revised proposed specification also incorporated a requirement for the team to provide cost benefit analysis reporting using Eclipse Live or similar systems. All of these proposed changes to capacity support the CCGs Strategic and Primary Care strategies. The OoHC Board asked HG and JC to develop a revised proposed specification and offer that, subject to being affordable and agreed would incorporate the above services.

The OoHC Board expects the revised proposal to demonstrate appropriate flexibility in terms of workforce and the benefits of economies of scale. These proposals should be presented at the earliest opportunity and should include time line for implementation of the above proposals. A draft was requested for the next meeting 5.1.4 Falls A pan Herts task & finish group comprising the 2 CCGs, HCS and Public Health has been established to review the current falls related services and to develop a new strategy and service specification. This includes the Falls Car and Falls Liaison service. The initial service mapping has been completed and the costs associated with falls across health and social care are being collated. A countywide workshop is planned for 8 th May 5.1.5 Primary Care Access GP Access projects continue in Stort Valley & Villages and Lower Lea Valley localities. Early findings were reported to the 6 th March meeting. All 5 practices who are undertaking different models were all showing a level of reduction in A&E attendances during GP opening hours. The 2 practices in SVV had shown a positive increase in patient satisfaction scores. Stockwell Lodge and Warden Lodge had seen higher unplanned admission reductions compared to the other practices in the locality. The OoHC Board recognised the potential positive impact of these pilots and the potential benefits. However it was agreed that the sustainability of the pilots and approaches was as yet unclear as the capacity needed to deliver these appeared to be more than was currently available. It was agreed that these findings should be set out formally and shared with James Gleed who is leading the Primary Care strategy 5.1.6 Intermediate Care and Continuing Health Care (CHC) Performance overview of intermediate care services continue to be managed through the Intermediate Care Board, which has senior representation from the CCG and HCC and reports to the OoHC Board. An action plan for improvements to the CHC pathways is being actioned. A non-weight bearing pathway has been implemented this winter at a care home and will continue through to end of April 2014. The value and benefits of this pathways will be evaluated and presented through the Urgent Care Network. 5.2 Integration This continues to be is a key focus and priority for the OoHC Board. Members of the Board, colleagues from the CCG, HCC, the HWB and ENHT continue to participate in a national programme through NHS Improving Quality. This is a practical programme for commissioners leading large scale changes across organisational boundaries to improve outcomes for patients and achieve value through utilising resources as effectively as possible. Four of the seven workshops will have been completed by the end of March. 5.3 Support for Care Homes Business Case At the last meeting in Public the Governing Body approved funding of 766,600 to implement the proposed model of care across. The OoHC Board would need to clarify the metrics to be used and issue guidance to GPs and Nursing and Residential Homes on what was expected of them under the model of care.

Following this at the March 6 th meeting the OoHC PB considered the proposed service specification. The Board asked for a number of the details specification/expectations to be amended before circulating to localities. These included: Use of appropriate dementia tools Expectations regarding ward rounds Responsiveness of practices to calls from care homes Monitoring of admissions to include qualitative review of unplanned admissions of less than one day Links to prescribing support in MDT Benchmarking unplanned admissions prior to the service and post implementation Quantifying those patients where an advanced care plan had been initiated The case was updated and then shared with localities. Localities will now confirm their proposals for how they will manage the budgets and implementation locally. The OoHC Board had been asked by ULV to include flexicare/sheltered accommodation within the scope of the case. The OoHC Board recognised that this may need to be included in the future but agreed that the case should be confined to registered nursing and care homes initially. JAB confirmed that she had spoken to Sharon Davies from HCPA and a joint communique would go to care homes to share the proposals with them 5.4 Leg Ulcer Service in Upper Lea Valley At the 6 th March meeting the OoHC Board received a proposal regarding the development of an Upper Lea Valley community leg ulcer service which uses the practice nurses within each practice in the locality. This service will involve the practice nurses being up skilled in the treatment of leg ulcers to ensure all practice nurses are at the same level of competency plus ensuring every practice has the correct equipment to carry out the treatment of leg ulcers within the practice. The aim would be for the training to be carried out by a specialist nurse who would be available for 12 months. During this time the specialist nurse would provide face to face training and then attend each practice at least once a month for a clinical session with the practice nurse to support the management of complex cases. The practices would be provided with funds to backfill while the practice nurses attended both their face to face training, and also when the specialist nurse attended for management of complex cases. The business case was discussed and supported the use of Transformation Funds to cover the non-recurrent costs of the specialist nurse to provide the training and clinical review, the cost of backfilling practice nurses during the period of their upskilling/training and clinical supervision, the cost of additional equipment the practices might need.

The discussion highlighted that there was no uniform service or provision across the CCG and there was a lack of equity across the CCG. The OoHC Board asked for an audit of leg ulcer services across the CCG. 6 Future Priorities The Board discussed the Strategic Projects to deliver the CCGs objectives and the attached Benefits mapping diagram at Appendix 2. It was confirmed that the integration and delivering, appropriate effective care was the key focus with the following projects delivering this objective: 1. Roll out of Home First & Home First Plus 2. The joint commissioning & integration of intermediate and enablement care and the review of provision (links to Better Care Fund) 3. Primary Care Strategy 4. Falls Strategy 5. Effective community prescribing 6. Enhanced Primary Care Support for Care Homes The board agreed that the links to Ageing Well and the self-management/prevention agenda needed to be strengthened and clarified. JAB to discuss with Frances Coupe in HCC what work should be shared and discussed at which forums 7 Conclusion Significant work has taken place to review existing services and schemes and to bring together a vision for integration. This work is being taken forward through the NHS IQ Programme and our priorities going forward.

Item 2 OUT OF HOSPITAL CARE/INTEGRATED CARE PROGRAMME BOARD Thursday 16 th January 2014 Notes 1. Apologies Chris Badger Attendees Deborah Kearns, Fiona Sinclair, Sheilagh Reavey, Ed Bosonnet, Alison Jackson, Jacqui Bunce, John Constable, Heather Gray, Frances Coupe 2. Matters arising from notes of last meeting (13 th December 2013) SIP feed GP volunteer to support procurement not yet found. JC asked to take this matter forward Confirmed support costs for Scriptswitch will be part of Medicines Mgt CSU specification review IPA this issue had been escalated through Execs and LW had met with David Law to discuss the matter. No response had yet been received. CCG continuing to withhold payment of transition funding until plan received. FC agreed to see what she could do from an HCS perspective ENHT CQUIN - revised version presented to ENHT, with response expected 20 th Jan. Discussed at unscheduled Care Workshop. Past medical history and drugs history shared for those older patients and those with 2+ LTC. Potential to incentivise through commissioning framework. FS discussed work to pilot/test different practice IT systems and ensure that data set can be provided easily. Requests will go to practice generic e-mails and therefore practices will need monitoring systems and response times need to be agreed. Accurate timely data can support effective discharges 3. Falls Further meeting of Falls Task & Finish Group took place 3 rd January Process map to simplify pathway has been drafted R.Jankowski leaving HCC PH tam and Raj Nagaraj taking over PH role in project Early views are that falls car may not provide optimum response to large enough cohort. More work to be done with Ambulance Trust to look at more universal coverage alongside how the service can more effectively link to Home First and integrated community services 4. Prescribing/Medicines Management update Poly Pharmacy o Antibiotic Prescribing & CDiff paper was discussed 85 cases in EN Herts, data on localities was needed. Discussed at Quality Committee, need to beef up Lead/Action JC JC FC FS/DK

approach with education and specific data. Agreed that compliance with antibiotic prescribing guidance should be part of commissioning framework and practices would be asked to undertake audit to demonstrate compliance Root cause analysis forms should be shared at locality prescribing meetings to ensure learning is cascaded and could to be part of prescribing dashboard. These proposals will be taken to Governing body for support and ratification Medicines Management CSU support o Specification for new service being presented to meeting on 28 th January, 2pm Charter House o Recommendations to come to next OoHC Board QIPP/Strategic Plan o Work has been undertaken to look at measureable targets and projects to deliver QIPP savings. HG to share these with NC and JAB o To be brought to next meeting 5. Ageing Well Strategy FC presented draft strategy that will go to HWB for ratification in March/April Key focus on outcomes, recognition of potential for integration and focus on emotional health and wellbeing There is a strategic commissioning group that JAB sits on and this group will work on outcomes and measures The Board were supportive of the outcomes and aims. There was concern that they were aspirational and in order to implement there was a need for some cultural changes and perceptions especially in some elderly who are reluctant to discuss care support for a variety of reasons, but do not see support as enabling them to live independently and increasing their capability for longer It was suggested that the health-checks should be focused on the 60-75 age group and that physical activity and emotional wellbeing could be included along with discussions regarding participating in volunteering etc. LLV carer support needs to make links to existing services. AJ and FC agreed to follow this up outside the meeting There is a staurtory responsibility for Carers Assessments in the new Care Bill 6. Commissioning of Home Care HCS currently commission home care through block contracts ending in 2015. Recognition that there needs to be a wider more flexible range of services. As with other areas nationally the proposal is for a lead provider model with the expectation that the lead provider will link with the voluntary sector and other providers in a locality There is a range of care needs and some of these do not necessarily need CQC registered care but may need befriending and other support which could be integrated with existing services JC/FS DK JC JC/HG HG FC AJ/FC FC

The Board recognised the workforce issues and the recruitment and retention pressures. The potential to include care for CHC patients, especially fast track patients was discussed with the recommendation that this was looked into as the resources could be potentially pooled through the Better Care Fund. Suggestion for FC to ask Alison Sansom to join working group 7. Home First Roll Out DK had write to localities to ask them for the rationale for them to be next - 2 responses received, one from WelHat and the other from North Herts. WelHat had provided a short e-mail but JC provided a verbal response as to why they should be the next in the roll out. NHerts had provided a 2 page case. JC and FS left the meeting and the Board considered the proposals. On balance it was agreed that North Herts should be the next area for roll out and this recommendation would go to the Steering Group and the Governing Body. WelHat would be next as soon as early benefits had been seen in North Herts The Board still wished to see a proposal regarding the roll out to all localities as the pace of change was important for the delivery of the CCGs objectives Recognition that there are two risks workforce availability and management capacity. The Board reiterated its view that the Project Manager should be brought into the CCG and linked to IC commissioning manager for additional support Stevenage locality had contacted DK to seek support in principle for looking at alternative community provision and a devolved budget. The principle was agreed although a detailed business case would need to be presented to the OoHC Board. DK to feedback to locality leads. Care Track data potentially less robust data in North Herts, related to provider coding. There is a change in the way that ENHT will be coding that may improve this. OoHC Board to continue to monitor this. 8. Primary Care Strategy Concerns raised that unless there was a clear strategy the CCG would not achieve its ambitions and deliver its objectives Nicky Williams had attended a meeting with AT to discuss primary care strategies and JAB agreed to meet with her to follow this up and report back to next meeting 9. Support for Care Home Business Case JAB and NC highlighted that there were some revisions to the financial section that needed to be made, but they did not affect the costs of the case HG agreed to add in more KPIs to link the case with the prescribing support to care homes work With these amendments the case was supported by the Board and would go to the Governing Body 10. CHC Care Pathway This was shared for information. In light of the above case, the expectation was that the nominated GP practice would FC AJ DK JAB NC/JAB HG

support the temporary CHC patients that would be assessed in Care Homes rather than in an acute setting. 11. HC420 This proposal for a pilot was agreed. It had previously been agreed in principle The proposal would be to use Transformation funds for the pilot which would costs around 25,000 for the CCG It was supported by the LMC and LPC The pilot was likely to be in one locality HG will bring forward implementation recommendations as to which pharmacies would pilot the proposal 12. Date and Time of Next meetings The next scheduled date of 13 th February is the Governing Body Members meeting. An alternative date needs to be agreed. Future dates for the year were shared HG DK / Julie Andrews

Out of Hospital Care Programme Board: Benefits map Enablers Projects Outcomes Benefits Strategic Objectives Better Care Fund Falls Liaison service Reduction in variation Reduction in non-elective Consistent, high-quality (eg by locality, by GP practice) admissions for over 75s patient experience NHS improving quality Support for care homes programme Joint posts Integrated services Clearer navigation and points of access (for patients, carers and clinicians) Increased number of care plans for over 75s Right care, right time, irrespective of place Prevention of falls strategy Home First Integrated health and social Improved patient satisfaction Empowering self- management Care homes business case Integrated care project board Home First steering group Integrated points of access Primary care access Medicines Management care community services Jointly commissioned enablement and intermediate care, better aligned to secondary care Reduced non-elective admissions cost Reduction in staff absence rates in community services Controlled costs Co-ordinated and personalised service linked to planned care Accessibility: equal and Integrated Point of Care Improved information on Reduction in incidence of appropriate for all users negotiations activity, cost and outcomes in adverse effects for patients on Community IT CCG Associate Director: non-hospital settings multiple medications Improving health and social care outcomes (NHS Outcomes Framework) Quality, Innovation, Productivity and Prevention Jacqui Bunce All localities have reported an increased workload from care homes over and above The Programme Board has supported the development of a new model, with locality devolved budgets, to match Effective strategic and operational clinical leadership Primary care access projects the standard GP contract. care homes with just one practice. Proposals have been welcomed by the Competent and Often, care homes are looked after by Herts Care Homes Providers compassionate workforce more than one GP practice, all with their Association. different ways of doing things, leading to difficulties for the home and potential From Spring 2013, this aims to improve continuity of care issues. We are also the way that care homes, GPs and seeing a rise in the number of emergency pharmacists work together and to Chair: short stay hospital admissions from care reduce the number of unnecessary Deborah Kearns homes. In 2012/13 there were 2,300+. admissions to hospital through better, more targeted falls prevention work.