Mick Hancock, Assistant Director Joint Commissioning

Subject: Meeting: Better Care Fund NHS Milton Keynes CCG Board Date of Meeting: 25 th March 2014 Report of: Mick Hancock, Assistant Director Joint Commissioning Is this document: Commercially Sensitive For the Public or Private Agenda To be publically available via the CCG Website N Public Y 1. Background The Better Care Fund (BCF), formerly the Integration Transformation Fund, was announced in the government s June 2013 Spending Round. The BCF is viewed as an enabler to drive forward further integration of health and social care services. The fund will help provide sustainability and better manage local pressures. It seeks to ensure that people receive the right care, in the right place, at the right time, which includes a significant expansion of care in community settings. Each Clinical Commissioning Group in conjunction with it s local authority is required to submit a plan for the use of the BCF. 2. Issues Funding arrangements The BCF is to be deployed from April 2015. The fund will be made up of: 9.5m from the Milton Keynes Clinical Commissioning Group (MKCCG) allocation (including funding to deliver the requirements of the Care and Support Bill) 3.95m from the existing funding transfer from the NHS to social care 484k from the Disabled Facilities Grant 506k from the Adult Social Care Capital Grant For Milton Keynes this means the approximate total is 14.5m. Page 1 of 4

Conditions and statutory framework The following six national conditions must be met in local plans and delivery: Plans are to be locally developed and jointly agreed Protection for social care services 7 day working in health and social care to prevent unnecessary hospital admissions and facilitate timely discharge Data sharing based upon the NHS number Joint assessments and care planning, including an accountable professional Agreement on the impact on acute care An agreed BCF plan for 2015/16 must be in place to receive payment. In 2015/16 the fund will be allocated. It is expected that the fund will be pooled, between Milton Keynes Council (MKC) and MKCCG, under Section 75 arrangements of the NHS Act 2006. Performance framework In order to access 50% of the fund from 1 April 2015, local areas must be able to demonstrate progress against four of the national conditions and suitable performance against a number of nationally and locally determined metrics. The national metrics will be: Admissions to residential and care homes Effectiveness of reablement Delayed transfers of care Avoidable emergency admissions Patient service/user experience A local metric has also been determined that is based upon the uptake of telecare and telehealth. Access to the remaining 50%, in October 2015, will be conditional upon further progress against the national and local metrics. Page 2 of 4

Proposed use of the BCF It is recognised, given the complexity of the task, that across the health and social care system proposals are still being debated between partners. It is further recognised that engagement with providers and other stakeholders continues to take place. However, a number of themes have been put forward and these will provide the basis of the BCF plan. These are as follows: a) Integrated health and social care teams to avoid hospital admission and facilitate timely discharge b) Alternatives to permanent admission to residential/nursing care and more support to people in their own homes c) Additional schemes to avoid hospital admission 3. Next steps Timescales Timescales for the development of a plan have been challenging. Initial guidance was provided on 17 October 2013. A group from MKCCG and MKC met in early November 2013 to begin the planning required. The final national guidance was made available on 20 December 2013. Milestones: 30 January 2014 Milton Keynes Health and Wellbeing Board agreed to the first draft submission of the BCF plan 14 February 2014 First draft BCF plan submitted (see Annex A) 4 April 2014 - The final date for submission of the BCF plan. Feedback As part of the national assurance process the draft submission of 14 February 2014 is being aggregated with other plans, to provide a composite report to identify any areas of challenge. Formal feedback from the national assurance process on the draft BCF plan is still awaited. At this point, however, the NHS England Herts and South Midlands Page 3 of 4

Area Team have indicated a level of risk associated with the use of new schemes, which they would wish to see mitigated. Following feedback and further engagement on the draft submission, the BCF plan will be suitably amended prior to submission. It is then anticipated that further testing, refinement and discussion will take place during 2014/15 to ensure that Milton Keynes is in a strong position to meet the requirements of the BCF. 4. Recommendations The Board is asked to: note progress to date support the work to be undertaken regarding a) the submission of a final plan; b) ongoing work during 2014/15 to test and refine the plan Page 4 of 4

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 a) Summary of Plan Local Authority Clinical Commissioning Group Boundary Differences Date agreed at Health and Well-Being Board: Milton Keynes NHS Milton Keynes Clinical Commissioning Group No significant boundary issues. 30 th January 2014 Date submitted: 14 th February 2014 Minimum required value of ITF pooled 3,958,000 budget: 2014/15 2015/16 14,424,000 Total agreed value of pooled budget: 3,958,000 2014/15 2015/16 14,424,000 b) Authorisation and signoff Signed on behalf of the Clinical Commissioning Group By Jeannie Ablett Position Chief Officer Date 14/02/2014 Signed on behalf of the Council By Lynda Bull Corporate Director for Community Position Wellbeing Date 14/02/14 1

Signed on behalf of the Health and Wellbeing Board By Chair of Health and Wellbeing Board Cllr Debbie Brock Date 14/02/14 c) 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 All providers that Milton Keynes CCG and Milton Keynes Council contract with have been informed about the fund in writing and have been invited to provide input and ideas into the development of the plans for how the Better Care Fund (BCF) can be utilised in Milton Keynes. This included all the care homes in Milton Keynes; Central and North West London NHS Foundation Trust MK Community Services; Milton Keynes Hospital Foundation NHS Trust; Age UK; all voluntary and community services that MK Council contracts with; Domiciliary Care agencies. GPs have been involved in discussions about how integrated services need to develop through the CCG Board meetings; Clinical Forums and the Neighbourhood Group meetings organised by the CCG Milton Keynes has a long history of joint working, and has a number of integrated services: Intermediate Care; Mental Health; Learning Disabilities; Integrated Community Equipment services and a Joint Commissioning team. Work has been underway for some time to further develop integrated serves to better meet the needs of older people and those with long term conditions and/or physical disabilities. As part of this process, a number of workshops have been held with service providers and members of the public to discuss the development of integrated services. In February 2014, Milton Keynes CCG hosted a workshop to stimulate the planning and development of a pathway for Frail Older Adults. There was cross sector attendance at this workshop and a commitment to working together as a health and social care system to deliver improved care for older people. By working together in this way, the objectives of the MK Older People s Strategy and the Better Care Fund proposals will be delivered. Milton Keynes Hospital Foundation NHS Trust has indicated its support for the strategic direction within the plan. Discussions are on-going with all our provider colleagues to further refine our plans, and their impact, for the services we wish to develop. We are currently in the process of establishing our provider and stakeholder forum, who we will work with to help shape, commission and implement our plan for the new integrated services described in this planning template. 2

d) 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 As part of our on-going work to develop and improve health and social care services in Milton Keynes, we engage with our local population and the people that use our services to ensure that any developments reflect what they have told us. We have opened consultation and engagement with residents in Milton Keynes via the Milton Keynes Council and CCG websites to invite contributions and comments on the BCF and how it could be deployed. We will use this opportunity to invite all interested local residents to help work with us to develop and refine our plans going forward. Our local service providers regularly engage with their customers through focus groups, surveys and patient and service user involvement processes to ensure that the services provided meet the needs of the people that are using them. The CCG has an active Patient s Congress, and representatives are active members of each of the CCG s Programme Boards. The CCG Board Members of the local Healthwatch are also active participants in the governance structure of the CCG, and are members of the Health and Wellbeing Board. The Better Care Fund has been discussed at all these forums. In our learning disability services, we have an active Experts by Experience programme, and are seeking to develop this programme into other service areas to ensure that patients and service users needs, views and opinions are embedded in commissioning, service development and monitoring of service quality and effectiveness. Milton Keynes Council supports a range of community organisations through formal contracts and grants to ensure that all sectors of the local population have the opportunity to become involved and engaged in the work of the Council. The Better Care Fund will be discussed with the Milton Keynes Disability Action Group on 27 th February to ensure that the group members and their constituents are involved in the planning and implementation of the Better Care Fund. We are also discussing this at a formal meeting of the Physical Disabilities and Sensory Impairment Consultation Group and the Older Person s Forum in the next few weeks. 3

e) 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 Synopsis and links title Milton Keynes Joint Health & Wellbeing Strategy The Joint Health & Wellbeing Strategy sets out 3 key priorities and a series of actions which the Health and Wellbeing Board are planning to deliver. Milton Keynes CCG Strategic Plan 2012 2015 Milton Keynes Older People s Strategy 2014-2017 MKCCG Commissioning Intentions Milton Keynes Out of Hospital Strategy Milton Keynes Joint Strategic Needs Assessment Milton Keynes CCG Integrated Plan; QIPP Plans; Operational Plans Milton Keynes Council Corporate Plan 2012-2016 Milton Keynes Urgent Care Strategy 2013-2016 The strategic plan sets out the CCG s vision and key strategic pieces of work planned to be undertaken during the 3 years to meet future requirements. This strategy has recently been developed on behalf of the Milton Keynes Joint Health and Wellbeing Board and sets out the vision for services to meet the needs of older people in Milton Keynes. The proposals in this Better Care Fund submission are consistent with the objectives and deliverables outlined in this strategy. Currently being revised for 2014/15 this document indicates to our providers how we expecting to change the healthcare system and services in this year. This is currently under development and will be informed by the proposals in the Better Care Fund submission. Our JSNA has recently been refreshed and made available as a web based version to improve accessibility. Out of Hospital Care is one of the 3 strategic priorities for MK CCG. The objectives of the Better Care Fund are consistent with this and will ensure that we deliver effective community based services. This Council Corporate Plan outlines how the Council and its partners will work together to deliver the collective ambitions for Milton Keynes. This strategy has been developed with and will be implemented by stakeholders and partners across the local health and social care economy, and sets out specific actions to address the pressures currently experienced in the Urgent Care sector. All the proposals in our Better Care Fund submission support the objectives of this Urgent Care Strategy. 4

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? Our Health and Wellbeing Strategy in Milton Keynes sets out 3 key strategic objectives, and the development of integrated services is integral to the achievement of all 3 of these objectives. We aim to: Improve Wellbeing to enable residents to lead longer and healthier lives Reduce earlier deaths and tackle major diseases by focusing on prevention, early diagnosis and the quality of treatment services, including improved integrated services Reducing health inequalities by addressing poverty, unemployment, education provision, transport and housing issues in view of their direct influence on physical health and mental health. Implicit in the Joint Health and Wellbeing Strategy is the empowerment of Milton Keynes residents to be supported to help manage their own health and wellbeing through the commissioning and delivery of person centred services, which place the individual at the heart of service delivery. Through our health and social care teams we will work with local people in Milton Keynes to further develop our plans for integrated care and support to enable people to maintain their independence. Our vision for health and social care services in Milton Keynes is for services that are configured to support people to live independently in their own home, within their local communities, wherever possible. This will be our default option for service delivery. The aim of any intervention, especially acute care, will be to support people to realise this objective. Capacity will be developed in community health and social care services to meet the delivery of this objective and will be provided by a full range of statutory and voluntary and community organisations. More effective partnerships will be developed with housing providers, employment services, transport and leisure services to enable people to improve their quality of life and improve wellbeing. This isn t just about integrating health and social care services, but also looking to develop new links with new agencies and organisations that can help to support the delivery of health and social care objectives. GPs will be central to organising the co-ordination of people s care and will work in a seamless integrated way with health and social care providers to better manage care and treatment of patients. Self-care and self-management of an individual s health will be encouraged and people will be supported to develop strategies for managing their health and independence, including access to a range of preventative, early intervention services to support people to pro-actively manage their health. Supporting services such as telehealth, telecare and community equipment will be strengthened to support independence. 5

Rehabilitation and re-ablement will be offered to everyone. We are clear that everyone has the potential for restoring some level of physical and mental functioning. There will be integrated commissioning of services through a single pooled budget and delivered through integrated health and social care teams. These teams will be configured so that they support people either on a short term basis i.e. to deliver rehabilitation and re-ablement to help people regain confidence and previous levels of functioning or to provide support for physical health at home until reablement can be commenced. or on a longer term basis for people with more complex health and social care needs that may require more intensive support over a longer timeframe especially when they have an exacerbation of their condition. In the next five years it is expected that the demand for high cost secondary care (acute hospital) services will reduce as the service offer delivered in primary care, community care and social care settings will increase. Through the development of self-management and preventative services, ill health can be better managed at an earlier stage, and linked in to community based rehabilitation and reablement services to provide intensive support over the short term with a view to restoring people to independence. 6

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? We aim to configure services that support people in their own homes and local communities wherever possible, delivered on a 7 day a week basis. The use of services in the secondary care (acute) sector is essential for those people that need them where community, primary and social care services cannot meet the (acute) healthcare need. We aim to deliver services with the following objectives: Focused on improved outcomes not solely on activity Promote individual independence for all Improving the experience of patients/service users and carers Reduce delayed transfers of care by the development of a range of community based services that can meet a range of needs for post-hospital support. The extension of rehabilitation and reablement to people with dementia The links between physical health and mental health are well known, although our services continue to work in silos. Services (Relationships) will be strengthened to deliver the objective of no health without mental health A reduction in the rate of emergency admission to hospital and the number of permanent placements to residential and nursing care Support early intervention, identifying people who may need support before a crisis Case management and co-ordinating care to ensure people are cared for in the most appropriate environment by the most appropriate professional In order to measure these aims and objectives and track outcomes, we will develop the following: Opportunities to share data across health and social care, using robust information sharing protocols Have clearly defined outcome focused service specifications which focus on what difference the commissioned service will make to the person receiving that service. Is the service doing what we want it to do? Have outcome focused individual care and support plans with specific, measurable and time limited goals and targets Develop patient/ service user led monitoring of commissioned services Develop robust patient/service user reported outcome measures for each service and integrate these into the contract monitoring process. Use the national and local key performance measures outlined in the Better Care Fund guidance to monitor the impact of our planned service changes. (More detail in appendix B) 7

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 All our proposals are consistent with the assessment of health and social care need outlined in our JSNA, and meet the strategic objectives and actions in our Joint Health and Wellbeing Strategy. The CCG commissioning plans and local authority plans for social care have also been developed in the context of the JSNA and the Joint Health and Wellbeing Strategy, so there is a golden thread linking the health and social care high level strategic documents with the BCF service proposals. We will utilise the Better Care Fund to deliver a range of services that will help us achieve the aims and objectives outlined about in paragraph 2b as follows: 1. Integrated health and social care teams Two Complex Needs teams organised on a virtual basis, operating 7 days a week, involving a range of local authority, NHS and voluntary sector staff. These teams will offer on-going support to people with complex health and social care needs, identified by risk profiling, and managed by person centred care planning and case management using a virtual ward model by an applicable professional. Active involvement with this team will not be time limited, but patients will be discharged to receive the appropriate level of care and support, once the exacerbation of their illness has been managed effectively. The team will also provide 24/7 support to people who require support at the end of life. Extension of Intermediate Care Services to deliver effective reablement and rehabilitation 7 days a week for a period of up to 6 weeks by a team of therapists, nurses and reablement workers. This will be available for people following a period of acute hospital provision or as an alternative to emergency hospital admission and aims to restore confidence and levels of functioning following illness or injury. The rehabilitation and reablement will be delivered in a range of community settings, including the patient s home, and is currently being delivered on this basis. The BCF will be used to extend 24/7 working by this team Assertive Inreach and Supported Discharge Team to work on a time limited basis to inreach into acute settings and support the discharge of patients who don t yet meet the criteria for intermediate care and require a period of convalescence at home prior to rehabilitation e.g. non-weight bearing patients, those patients requiring support with wound care and nursing interventions. This service will be available 24/7 and will work with patients for a period of up to six weeks. Recruitment of Community Geriatricians and rehabilitation specialists to support the integrated health and social care teams Recruitment of additional social care staff to provide social care input into the completion of CHC assessments. These staff will work across the integrated health and social are teams above. 8

Development of Community equipment, telehealth and telecare to be utilised by the integrated health and social care teams above as a tool to help support people at home. 2. The development of additional extracare housing schemes for older adults with dementia to provide longer term support as an alternative to permanent admission to residential/nursing care, and offered on a tenancy basis with additional care support. 3. The provision of an alcohol liaison service to support people presenting at A&E and who have an alcohol problem. This will focus on ensuring their physical health needs are met and that they are signposted on to a range of services that can help manage their alcohol need. 4. The development of a High Impact Team to support residential and nursing homes to manage the fluctuating health needs of their residents, thereby avoiding admission to hospital. This team of nurses will work with those care homes identified as high referrers to A&E and higher than average ambulance call outs. 5. Investment in the falls prevention pathway to ensure the correct mix of lower level support and specialist services so that people who have fallen or are at risk of falling can access the relevant level of support. 6. Care Funding Calculator delivery through a sustainable team reviewing learning disability care packages and negotiating funding levels with providers. 7. Development of dementia pathway to support the implementation of the dementia strategy in Milton Keynes. 8. Create an Autism Diagnosis Service to ensure appropriate diagnosis, signposting and information. 9. Enhance our current approach to Experts by Experience in Learning Disability Services and roll out into other service areas. 10. Undertake social isolation research to measure the effects on older people. This research will then inform future commissioning. 11. As an alternative to secondary (acute hospital) care we will ensure we have suitable and sufficient community nursing and residential care. This will be based around the provision of community beds supported by nursing and appropriate therapies. 12. We will review all services currently funded by s256 funding to ensure that they remain consistent with the aims and objectives, and are delivering the outcomes we wish to deliver through the BCF. 9

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. There is a strategic review of healthcare services across both Bedfordshire & Milton Keynes underway, with support from Monitor, Trust Development Agency & McKinsey. The review will: Generate options for the delivery of sustainable, high quality (hospital and out of hospital) services for the people of Milton Keynes & Bedfordshire Help TDA & Monitor to make regulatory decisions with regard to Bedford Hospital NHS Trust and Milton Keynes Hospital NHS Foundation Trust Develop a locally led model of healthcare This review will form a central part of informing the 5 Year Strategic Plan for Milton Keynes CCG, and will need to consider the activity implications driven by the local BCF plan within its demand modeling. This will ultimately have a bearing on the acute service configuration proposals that will be made as part of the review in early summer 2014. The aim of the MK BCF plan is to improve health outcomes for people with long term conditions, frail older people (75+) and their carers. The developments described in section c will strengthen services outside the hospital, including both primary and community health & social care services for those patient groups. They will enable more people to be managed at home or close to home supporting our planned shift in activity away from reliance on the acute hospital. The planned changes are expected to deliver NHS savings through reducing local secondary care non elective activity by 4,449 with additional follow up and outpatient impact. There will be a reduction in A&E attendances, first outpatient and follow up appointments. This equates to 9.5m. The changes will see a reduction in length of stay down to the NHS tariff trim point for particular conditions. Secondary care capacity cannot be capped; therefore the budget shift is dependent on activity not taking place in the acute hospital. The impact of delivery of the plan on the local urgent care/unplanned care system is significant. A 20 bedded ward running at 100% occupancy equates to approximately 2.5m of CCG funds. To save 9.5m requires a reduction equivalent to approximately 60 secondary care beds (including on costs), this equates roughly to 19 %of the local Hospital Foundation Trust bed stock. The savings will come from urgent care and unplanned care budgets. The CCG is in early discussion with providers about the introduction of a year of care tariff for frail older people. This arrangement will see a risk sharing mechanism in place and providers of the new services taking ownership of both deliverables and savings. The CCG will be working with practices and supporting them to develop practice plans that enable the transformation of services for people aged over 75 and reducing avoidable admissions. These services are to be funded by the CCG at a rate of approximately 5 a head in 14/15 and must improve the quality of care and complement the MK BCF plan. 10

The BCF is to be top sliced from the CCG allocation; 75% of funds will be made available from 1 April 2015 and the additional 25% awarded as the system hits agreed KPI s. THE BCF group will consider options for implementation including prioritisation of schemes. The additional 25% will be available for use in schemes as performance targets are met throughout the year or will be used as part of the contingency funds if targets are not met. Non delivery of the activity reduction and/or the savings will result in failure to meet key national and local targets including A&E waiting times, trolley waits, 18 week pathway, cancer waits, ambulance times to respond and handovers, mixed sex accommodation, IAPT. The pressure on the system will impact on patient and carer experience and result in poorer health outcomes. The BCF challenges all parts of the system to work together to deliver a sustainable Health and Social Care System. 11

e) Governance Please provide details of the arrangements are in place for oversight and governance for progress and outcomes Following implementation of the Better Care Fund, the Health and Wellbeing Board will retain oversight of progress, and monitor performance and achievement of outcomes. Reports will be produced on a quarterly basis to outline progress, identify risks to delivery and outline mitigation action to ensure delivery remains on track. The CCG and Local Authority will satisfy themselves through their individual governance arrangements that they are meeting the BCF requirements and monitor performance and outcomes, and report any issues, risks, achievements to the Joint Commissioning Board The current Section 75 monitoring arrangements between Milton Keynes Council and Milton Keynes CCG to oversee Joint Commissioning will be reviewed to ensure that they are robust and able to meet the financial and governance requirements of the new fund. The Joint Commissioning Board will have the responsibility for ensuring the BCF proposals are delivered, risks identified and mitigation action specified and implemented. The JCB will also oversee the risk share agreements and monitor the progress on key specified performance indicators and report this to the Joint Health and Wellbeing Board. We aim to establish a Better Care Fund Working Group (title to be confirmed) which will comprise of commissioners, service providers and key stakeholders. This working group will be responsible for the day-to-day management of the implementation of the proposals within the BCF and will report on progress to the Joint Commissioning Board, using established Programme and Project Management tools and techniques. It is also proposed to establish individual work streams for each of the proposals to ensure focused, dedicated effort to implementation. Proposed BCF Governance Arrangements 12

3) NATIONAL CONDITIONS a) Protecting social care services Please outline your agreed local definition of protecting adult social care services. Our local definition of protecting social care services in Milton Keynes is that we ensure that those local people in need of care and support continue to receive this by looking to develop innovative, integrated services to enable people to remain in their own homes and local communities wherever possible. We will need to ensure adult social care can respond to growing demands due to demography especially with regard to older people and dementia. We will need to ensure that the provision developed by the BCF enables Milton Keynes to continue to provide local innovative approaches that enable people to remain independent at home e.g. housing with care for people with dementia. We will retain and develop local models of integrated services such as those reflected in new section 75s, whilst not compromising the contribution of social care to 24/7 working. We will look to future proof, for example, through ensuring we have capacity to deliver the Care Bill requirements. This includes new responsibilities around funding social care (Dilnot), portable assessments, national eligibility criteria etc. We will ensure capacity to retain and further develop the social care model of personalisation. This model is person centred, utilises personal budgets (increasing direct cash payments where appropriate), continues to deliver support services, focuses on targeted prevention and increases support for carers, We will maintain and further develop market diversity on a local scale. This will involve closer working relationships with the voluntary and community sector and the development of more responsive providers at scale. Please explain how local social care services will be protected within your plans. Funding currently provided will be maintained, and where appropriate extended to enable social care services to develop. This is to ensure that the increasing numbers of people who will require assessment, care/case management and review receive it. We will commission services for residents who require support to meet their critical or substantial needs. We will target investment to meet the needs of people who do not qualify for funded support, but who may require advice and guidance and signposting to agencies who could help meet their needs. This is particularly important given the requirements of the Care Bill and also to expand the offer to self-funded clients. The extended working hours presented by the need to implement 7 day working will also require additional resources 13

b) 7 day services to support discharge Please provide evidence of strategic commitment to providing seven-day health and social care services across the local health economy at a joint leadership level (Joint Health and Wellbeing Strategy). Please describe your agreed local plans for implementing seven day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends. We are committed to developing seven day health and social care services to ensure that people in hospital can be discharged safely into the community or their own homes following an episode of acute care. Our aspiration in Milton Keynes is to go further and use the BCF to support the development of 24/7 working in some of our proposed integrated health and social care teams, in line with the principles in the NHS Services Seven Days a Week Forum report. Already in 2013-14 some of our winter pressures funding has been used to extend working hours for our services. We aim to continue and build upon this in 2014/15, using the Better Care Funding to support this delivery. The CCG has identified 7 day working as one of its priority commissioning intentions for 2014-15. 14

c) Data sharing The agreement to use of NHS number needs to be confirmed by MKC Please confirm that you are using the NHS Number as the primary identifier for correspondence across all health and care services. All health services use the NHS number as the primary identifier, and this is used where available for social care services. Approximately 40% of social care records have the NHS number manually recorded, and there is a work plan in place to improve this through automated batch trace upload to ensure that as many social care records as possible have the NHS number embedded by December 2015. If you are not currently using the NHS Number as primary identifier for correspondence please confirm your commitment that this will be in place and when by All health services use the NHS number as the primary identifier, and this is used where available for social care services. Approximately 40% of social care records have the NHS number manually recorded, and there is a work plan in place to improve this through automated batch trace upload. Please confirm that you are committed to adopting systems that are based upon Open APIs (Application Programming Interface) and Open Standards (i.e. secure email standards, interoperability standards (ITK)) There is commitment from both health and social care organisations to adopting interoperable systems that facilitate efficient and effective integrated services. The CCG is currently investigating and has placed an initial bid for funding to support the ability to interface with other systems that are ITK compliant or through the use of Open API s. The Local Authority is working with NHS partners to ensure all existing and new procurements of case management systems are ITK compliant. Secure e-mail (nhs.net and GCSx) is deployed amongst all relevant staff groups. Please confirm that you are committed to ensuring that the appropriate IG Controls will be in place. These will need to cover NHS Standard Contract requirements, IG Toolkit requirements, and professional clinical practise and in particular requirements set out in Caldicott 2. There is commitment from both health and social care organisations to ensuring appropriate IG Controls are in place. All health services are compliant with NHS Standard Contract requirements, minimum IG Toolkit Level 2 and relevant professional clinical standards. The Local Authority is compliant with IG Toolkit Level 2 for the Public Health Directorate, and is working towards Level 2 for the organisation as a whole, expected to be in place by April 2015. 15

d) Joint assessment and accountable lead professional Please confirm that local people at high risk of hospital admission have an agreed accountable lead professional and that health and social care use a joint process to assess risk, plan care and allocate a lead professional. Please specify what proportion of the adult population are identified as at high risk of hospital admission, what approach to risk stratification you have used to identify them, and what proportion of individuals at risk have a joint care plan and accountable professional. Work is underway to put in place an accountable lead professional for those people at high risk of hospital admission. In our Intermediate Care service we have lead professionals for the delivery of care and/or treatment, with common assessment paperwork and an agreed process for assessing risk which we intend to roll out across community services. Two risk assessment tools have been trialled in MK since 2009 including the EARLI Tool plus clinical view and ACG. The evaluation the ACG tool is expected shortly. Locally discussions are underway exploring the potential use of SystmOne currently being rolled out in primary care added to local authority information to better understand the needs of patients requiring support from an integrated team. Each GP practice in Milton Keynes has access to the ACG tool to use to predict risk and have been incentivised to do so by the Quality Premium and latterly the Direct Enhanced Scheme relating to risk profiling and MDT assessment and care management of those identified as at higher risk of hospital admission. Health and social care partners are currently debating where to target the care planning and co-ordination activity to make most impact on the individual and the system. A growing belief that targeting the top 5% or those who are currently utilising significant hospital resources will not deliver the best outcomes. As our thinking develops, it is likely that we will extend predictive risk tools to the next 15% in the hierarchy of risk, and we will be testing out the impact of targeting activity towards this cohort. This will include integrated teams, joint care planning and a lead professional to manage the care for that individual. Integration and care co-ordination will require significant organisation to ensure that care delivered is person centred and meets individual needs. We are working to develop a specification for a specialist administrative role of care co-ordinator, who will be responsible for organising MDT meetings for the patient, acting as a point of contact. We have been working on developing a model of integrated care in Milton Keynes, and we will use the Better Care Fund to develop and enhance this model and focus on those local people who are at risk of hospital admission. Current use of the ACG tool suggests that approximately 2,000 patients in Milton Keynes are at risk of hospital admission. This relates to the top 5%. We are also working closely with our acute care colleagues to better understand who is using acute hospital care, and which patients are driving the CCG costs. Once this work is completed, we will be able to target any activity by our integrated teams towards meeting the needs of this cohort of patients. 16

4) RISKS Please provide details of the most important risks and your plans to mitigate them. This should include risks associated with the impact on NHS service providers Risk Redirecting resources to support the development of community based services could de-stabilise acute sector CCG will experience financial pressures if the funding can t be released in the acute sector The need to continue with the day to day work whilst undergoing service transformation is always a challenge Uncertainty regarding the true costs and impact of implementing the Care Bill Securing clinical support for the service changes will be vital. This engagement has thus far been a challenge to secure Implementation of the service changes proposed by the BCF will fail to translate into the required reductions in acute care and residential and nursing home activity Available workforce with the right skills TUPE issues Risk rating HIGH HIGH HIGH HIGH HIGH HIGH HIGH Mitigating Actions 25% funding held back Services paid 75% at start of 14/15 and 24% linked to delivering targets Develop risk sharing agreement with current and future providers Need to develop joint working group with joint commissioning & FT Joint working with other CCGs exploring future options for acute care Contract negotiations to gain agreement to reduced activity in MKHFT Risk sharing agreement with providers and commissioning partners in the system Contingency in place Effective project and programme planning and clear responsibilities and criteria for developing projects and services agreed Investment in BCF implementation team Workforce training and development Impact assessment required Work with clinical commission leaders to influence and lead these discussions 25% of funding held back Contingency in place Workforce review to be undertaken Recruit specialists for Older People Skills audit, training needs analysis Workforce training 17

BCF Planning Template Finance - Summary DRAFT Organisation the Better Care Fund pooled budget in 2015/16. Spending on BCF schemes in 14/15 Holds the pooled budget? (Y/N) Finance - Summary For each contributing organisation, please list any spending on BCF schemes in 2014/15 and the minimum and actual contributions to Minimum contribution (15/16) Actual contribution (15/16) Milton Keynes Council tbc 3,987,000 990,000 990,000 Milton Keynes CCG tbc 13,434,000 13,434,000 CCG #2 Local Authority #2 etc BCF Total 3,987,000 14,424,000 14,424,000 Enc No 14/09 Approximately 25% of the BCF is paid for improving outcomes. If the planned improvements are not achieved, some of this funding may need to be used to alleviate the pressure on other services. Please outline your plan for maintaining services if planned improvements are not achieved. The 2014-15 spending relates to the S256 funds. The 2015-16 spending is based on the NHS England allocation notifications Contingency plan: 2015/16 Ongoing Planned savings (if targets fully achieved) -9,150,000-9,150,000 Maximum support needed for other Outcome 1 services (if targets not achieved) 9,150,000 9,150,000 Planned savings (if targets fully achieved) Outcome 2 Maximum support needed for other services (if targets not achieved) DRAFT Better Care Fund Template Part 2 14.2.14

BCF Planning Template Finance - Schemes DRAFT BCF Investment Scheme 1 - Integrated Health and Social Care Model Implementation Lead provider Recurrent Non-recurrent Recurrent Non-recurrent Recurrent Non-recurrent Recurrent Non-recurrent 1,250,000 CNWL/ MKC/community sector provider 207,000-180000 Scheme 2 - Assertive Inreach and 1,000,000 Discharge Team CNWL & MKC 200,000-180,000 reduction in 500,000 Scheme 3 - Community Millbrook excess bed days Equipment Healthcare 150,000 Scheme 4 - Social Isolation Research TBC 50,000 Scheme 5 - Alcohol Liaison 50,000 100,000 Scheme 6 - Project Management TBC 100,000 100,000 Existing S256 Investment Please list the individual schemes on which you plan to spend the Better Care Fund, including any investment in 2014/15. Please expand the table if necessary. Scheme 7 - Additional supported housing for adults with dementia Scheme 8-7 day working for existing intermediate care Scheme 9 - High Impact team for care homes Scheme 10 - Additional Telehealth Various 3,230,000 2014/15 spend 2014/15 benefits 2015/16 spend 2015/16 benefits Already embedded in 13/14 3,230,000 Already embedded in 13/14 1,100,000 1,000,000 350,000 500,000 Scheme 11 - Falls Prevention 200,000 Scheme 12 - End of Life Care 250,000 Scheme 13 - CHC team & care 350,000 funding calculator Scheme 14 - dementia service 700,000 Scheme 15 - LD Experts by 100,000 experience 590,000 Scheme 16 - Community Nursing Scheme 17 - Autism Diagnosis 270,000 Service 200,000 Scheme 18 - continence service Social Care grants 990,000 Contingency 1,134,000 Care Bill Implementation 510,000 Reductions in Acute Sector Emergency Activity -9,150,000 Total 3,937,000 50,000-180,000 0 14,424,000 0-9,150,000 0 DRAFT Better Care Fund Template Part 2 14.2.14

BCF Planning Template Outcomes & Metrics DRAFT Outcomes and metrics For each metric other than patient experience, please provide details of the expected outcomes and benefits of the scheme and how these will be measured. Permanent admissions - with an exponentially increasing older population, the level permanent of admissions will reduce through increased capacity in intermediate care and integrated health and social care teams, increased telelcare/telehealth and specialist continence services, as well as provision of alternatives to residential care. Internal monitoring is undertaken on a monthly basis to monitor impact. 91 day discharge - from an established high baseline, this will be maintained and increased against a backdrop of increasingly frail and older clients through increased capacity in Intermediate Care services. Internal monitoring is undertaken on a quarterly basis to monitor impact. Delayed transfers of care - this will be reduced through integrated health and social care teams,, increased capacity in equipment provision, increased capacity in intermediate care. Internal monitoring undertaken undertaken on a weekly basis to monitor impact. For the patient experience metric, either existing or newly developed local metrics or a national metric (currently under development) can be used for October 2015 payment. Please see the technical guidance for further detail. If you are using a local metric please provide details of the expected outcomes and benefits and how these will be measured, and include the relevant details in the table below n/a - awaiting national metric For each metric, please provide details of the assurance process underpinning the agreement of the performance plans Each metric has a comprehensive data quality and audit process so there is assurance that the baseline figure. Permanent admissions - agreed at senior management level as part of routine business planning. 91 day discharge - agreed at senior management level as part of routine business planning. Delayed transfers of care - agreed at senior management level as part of routine business planning If planning is being undertaken at multiple HWB level please include details of which HWBs this covers and submit a separate version of the metric template both for each HWB and for the multiple-hwb combined n/a - one HWB in Milton Keynes. Metrics Permanent admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services Delayed transfers of care from hospital per 100,000 population - measured in average days delayed per month Avoidable emergency admissions (composite measure) per 100,000 population Current Baseline (as at.) Performance underpinning April 2015 payment Performance underpinning October 2015 payment Metric Value 779.9 723 Numerator 230 236 N/A Denominator 29,490 32,652 ( April 2012 - March 2013 ) ( April 2014 - March 2015 ) Metric Value 91.5% 93% Numerator 215 224 N/A Denominator 235 240 ( April 2012 - March 2013 ) ( April 2014 - March 2015 ) Metric Value 289 278 266 Numerator 559 544 529 Denominator 193078 195,737 198424 (Jun 2013 - Nov 2013) ( April - December 2014 ) ( January - June 2015 ) Metric Value 954 931 888 Numerator 2463 2444 2368 Denominator 258,213 262,419 266,549 (April 2013 - Sep 2013) ( April - September 2014 ) ( October 2014 - March 2015 ) Patient / service user experience - national metric to be used N/A ( insert time period ) ( insert time period ) Telecare / telehealth - number of people supported both community alarm Metric Value 204 n/a 223 and one or more additional sensor, as a proportion of all new community Numerator 204 223 alarm users - year to date figure used. To be developed to show proportion of Denominator 957 766 telehealth user. (Apr 2012 - March 2013 ( insert time period ) ( October 2014 - March 2015 ) DRAFT Better Care Fund Template Part 2 14.2.14