Part 1 meeting of the Castle Point and Rochford CCG Governing Body held on 29 th September 2016 Agenda item 16 Marginal Rate Emergency Threshold Submitted by: Prepared by: Status: Robert Shaw, Joint Director of Acute Commissioning and Contracting Robert Shaw, Joint Director of Acute Commissioning and Contracting Approval Executive Summary i) Recommendations The Governing Body is asked to approve the report. ii) Overview The purpose of this paper is to inform the Governing Body of the requirement to publish all plans for reinvestment as a result of the Marginal Rate Emergency Tariff, as set out in the 2016/17 National Tariff Payment guidance. 3. Key Issues The 2016/17 National Tariff payment guidance includes the requirement to publish all plans for reinvestment as a result of the Marginal Rate Emergency Tariff (MRET) and readmissions. MRET, the marginal rate emergency rule, was introduced in 2010/11 in response to a growth in emergency admissions in England which exceeded that which could be explained by population growth and growth in A&E attendances alone. The purpose of the MRET is twofold; To incentivise lower rates of emergency admissions, and To encourage Acute providers to engage with other organisations within the local health economy to reduce the demand for emergency care. The marginal rate rule sets a baseline (set at 2008/09 actual activity levels) from which, any 1
activity exceeding this level, is chargeable at 30% of tariff by the relevant provider with the remaining 70% being reimbursed to the commissioner. Upon reimbursement, it is the responsibility of the commissioner to reinvest these funds into schemes/services that will contribute to reducing the demand on emergency/urgent care across the local health economy. This does not necessarily have to be reinvested into the Trust that has reimbursed the funding (e.g. it could be reinvested into primary care). These reinvestment plans are mandated to be shared with relevant providers, communicated to the public via the CCG website and to be shared with NHS Improvement and NHS England. The 30 day readmission rule was introduced in 2011/12 in response to a significant increase in emergency readmissions in the previous decade. The rule aims to incentivise Acute Trusts to reduce the number of emergency readmissions by, for example, investing in more effective discharge planning and community interventions. The rule stipulates that, where a patient is readmitted within 30 days, the cost of the spell is absorbed by the original provider. In practice, there are variations to the way that this is reimbursed and work is undertaken annually to ensure that the correct process is being followed by all parties. In line with guidance, CCG s must also publicise plans for reinvestment of these funds, demonstrating the monies are being invested to help support Trusts in reducing emergency readmissions. Plans for reinvestment together with other schemes relating to delivery of the A&E Recovery plan are presented to the CCG Systems Resilience Group (SRG) on a monthly basis and monitored fortnightly. The SRG is being transitioned into the A&E Delivery Board, therefore schemes will continue through this meeting. In addition it has been agreed that these schemes will be included within the Programme Management Office (PMO) reporting schedule and fed into the SUHFT Contract Management Group. Current guidance states that, to receive the funds for reinvestment, the CCG must comply with the following: Properly prepared plans with clear evidence on how the scheme(s) can reduce demand on urgent care; Plans must be co-ordinated with overall commissioning decisions regarding demand management; Plans must be developed with constructive engagement; Plans must be communicated to all relevant stakeholders; via the CCG website, to Chief executive s at all relevant Trusts and to be shared with NHS England and NHS Improvement; Plans must be reviewed for effectiveness. It has been recognised that significant investment was required into schemes outside of the acute hospital in order to reduce what were previously high levels of Non-elective admissions. Therefore the CCGs have invested Marginal Rate Emergency Threshold and Readmissions monies, along with QIPP and other sources, into a range of schemes to tackle non-elective admissions and re admissions. The total MRET and readmissions monies removed from the contract for The Southend University Hospital NHS Foundation Trust for 2016/17 is 1,198,000 for Marginal Rate and 2,677,000 for Emergency Readmissions. The following table provides a summary of the schemes together with levels of investment made by NHS Southend and NHS Castle Point & Rochford CCGs. Details of associates can be found on their respective websites. 2
Scheme Care Co-ordination Primary Care Support for Care Homes Community Geriatrician Description The aim of the service is to significantly improve the delivery of health and social care services required to support people living with frailty or complex needs, to maintain their optimum level of independence and wellbeing, through the provision of effective and co- ordinated services. The service will be delivered by a range of health and social care professionals, with support from the voluntary sector. The delivery model will comprise of three main elements being Care Coordinators, Independence Workers and Medical (GP) leadership. The Care Co-ordination Service will support Accountable GPs to manage complex and/or frail patients within their own homes and consequently reduce A&E attendances, hospital admissions and readmissions and admission to long term residential care. The provision of clinical primary care support for care homes. To reduce the number of people living in care homes who attend A&E and who are admitted to hospital. Each patient will receive a coordinated proactive care and Care homes will be supported to deliver better care for patients which should see a better use of GP time and a reduction in their workload. Each care home will have access to a multidisciplinary primary care team. The Community Geriatrician service will ensure consultant level clinical leadership for frail and vulnerable people within our population who are at risk of hospital admission and require a consultant led comprehensive assessment. The assessment will lead to an individualised plan of care that will enhance patient experience through 3 CP&R CCG Planned Investment ( ) Southend CCG Planned Investment ( ) Total Investmen t 922,560 922,560 273,350 441,202 714,552 60,000 60,000 120,000
Integrated Stroke ESD Service End of Life Overnight Support interventions appropriate to their care needs. To ensure frail elderly patients are cared for in their home and community settings, improving the patient experience and outcomes and prevent inappropriate admissions to hospital. The wider Stroke project will look at the whole Stroke pathway, from prevention to end of life, with an initial focus on rehabilitation. The primary objective is to improve patient flow through the entire length of the stroke pathway, with particular focus on provision of rehabilitation services. This will ensure prompt access to efficient and high quality services at each stage of the patient journey. Activity assumptions and quality metrics: Reduce variation in stroke mortality, with reduction overall Patient outcomes (independence) Patient experience Reduction in social care packages Reduce LOS Reduce re-admission rates Reduce tertiary care referrals Release capacity in the acute sector (links to development of other services) There is a need to strengthen community partnerships and promote integration in order to further improve the quality of patient EOL care, with a focus on improving identification of patients on the EOL pathway and patients who choose EOL in the community/ at home. To improve early identification of patients on the EOL pathway, simplify and clarify access to the full range of community EOL care, and develop services in line with the gold standard framework. The overnight support model is an awake-night domiciliary support package, provided by paid carers to adults either in hospital who are 208,784 285,977 494,761 14,000 100,000 114,000 163,800 163,800 4
Complex Care Priory House medically fit awaiting discharge or for those adults in the community who are at risk of hospital admission (typically lasting 1-2 days). The service will enable: A reduction in non-elective admissions by providing an alternative place of safety step-down residential placements sourced by SUHFT Patients to remain in familiar surroundings and a positive patient experience Through individualised care planning, asset management and review: contacts with GP primary care services for high frequency users. A&E attendances non-elective re-admissions into hospital; residential placements and high cost care packages sourced following a hospital stay. An increase in the number of individuals who maintain independence. Reduced complexity of domiciliary/reablement packages put in place for this cohort. Improved patient/family/carer experience Collation of data to reflect need and facilitate future commissioning decisions. Discharge to assess model providing 24-hour care, assessment, enhanced rehabilitation therapy and reablement in a care home setting for an initial period of 6 months. 255,000 255,000 156,000 156,000 Avoid an increase in care needs of patients being discharged from hospital demonstrated through audit of needs assessed when 5
medically fit and those on discharge from Priory House. To reduce re-admissions to hospital Enable patients to return to preexisting functional ability as demonstrated by clinical outcome measures To improve patient and family confidence on discharge home demonstrated by survey on discharge home. Uplands Discharge to Assess model of 17 Rehabilitation beds within a nursing home for patients from the acute hospital who have been identified to have a high potential of CHC need on discharge and are deemed to have potential to improve interdependence. 1,910,000 1,910,000 To enable these patient to go home with or without a nursing or care package. Reduce readmissions and prevent admissions by enhanced rehabilitation to support patient to remain in their own home with lower or no CHC package. Domiciliary Regaining This project will provide patients identified needing CHC domiciliary packages with up to 8 weeks 433,847 Independen rabblement and stabilization ensuring a period of intensive ce Service support through which patients 433,847 (RIS) will be empowered to regain their optimal levels of independence. prior to CHC assessment. Total 1,912,541 3,371,979 5,284,520 iv) Associated papers None. 6
Governing Body monitoring information Internal governance None. Stakeholder and community engagement None. Resource implications Failure to adhere to the 2016/17 National Tariff Payment guidance would result in reputational and financial implications for the CCG. Legal implications Failure to adhere to statutory guidance could result in legal challenge. NHS Constitution This report supports the following NHS Constitution principles: Principle 1: The NHS provides a comprehensive service, available to all Principle 2: Access to NHS services is based on clinical need, not an individual s ability to pay Principle 3: The NHS aspires to the highest standards of excellence and professionalism Principle 4: NHS Services must reflect the needs and preferences of patients, their families and their carers Principle 5: The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population. Principle 6: The NHS is committed to providing best value for taxpayers money and the most effective, fair and sustainable use of finite resources Principle 7: The NHS is accountable to the public, communities and patients that it serves. Equality and diversity implications N/A Further information For further information about this report, please contact: Michelle Angell, Head of Performance and Corporate Services on 01268 464621. 7