BOROUGH OF POOLE Agenda Item 8 PEOPLE OVERVIEW AND SCRUTINY COMMITTEE (HEALTH & SOCIAL CARE) 22 nd JANUARY 2018 BETTER CARE FUND UPDATE STATUS OPERATIONAL 1. PURPOSE 1.1 The purpose of the report is to provide a half year update on the progress of the Better Care Fund 17/18. 2. RECOMMENDATION 2.1 The Committee is asked to consider the report and scrutinise the progress of the Better Care Fund plan. 3. BACKGROUND 3.1 The Better Care Fund (BCF) is intended to transform local health and social care services so that they work together to provide improved and joined up care and support. It is a government initiative, bringing existing resources from the NHS and local authorities into pooled/aligned budgets. 3.2 The Health and Wellbeing Boards have oversight of the BCF and are accountable for its delivery. The East Accountable Care System has been created which involves NHS organisations in the local area working together and in partnership with local authorities to take collective responsibility for resources and population. For the Bournemouth and Poole Health and Well Being area it is taking responsibility for the implementation of the BCF plan and for managing performance. 3.3 The BCF involves a total aligned budget between the Clinical Commissioning Group (CCG) and the 2 Local Authorities of 44.8m for 17/18. This budget has been created from funding for existing activity and supplementary funding announced at the Spring Budget specifically for the maintenance of Adult Social Care called the Improved Better Care Fund. The focus of the BCF is to change existing activity to improve outcomes and effectiveness. 3.4 In 2017/18 the plan is being seen as the joint operational plan for the new Sustainability and Transformation Plan (STP) Our Dorset which was co-developed with local NHS and Local Authority partners and is being aligned with the content and governance of the STP. The STP aims to build and strengthen local relationships, enabling a shared understanding of the system now and future ambitions towards 2021 and the steps needed to get there and are aligned with NHS England s own Five Year Forward View. 1
3.5 Chairs for the HWBB for Bournemouth and Poole had delegated responsibility to sign off the plan outside of a formal board meeting. The plan is due to be presented at the next Board. The final 2017/18 Better Care Fund plan was approved by NHS England in September 2017. 3.6 In the planning guidance released in July 2017 NHS England placed significant emphasis on reducing delayed transfers of care and for CCG and Local Authorities to set ambitious targets. For those areas poorly performing CQC have been instructed to undertake local system reviews and in November the Government was due to review 18-19 ibcf funding allocations for those Councils that are poorly performing in DToC. 4. THE IMPROVED BETTER CARE FUND 4.1 Supplementary funding for Poole was announced at the 2017 Spring Budget of 2,338,060, specifically for the maintenance of Adult Social Care called the Improved Better Care Fund (ibcf). 4.2 The funding has been used predominantly to retain hospital social work services, enhance market capacity, including reablement, and provide enhanced capacity within the Deprivation of Liberty Safeguarding (DOLS) service. 4.3 At the half year predominant planned spend of ibcf has been on domiciliary care hours, having market capacity in Poole is a key enabler in reducing delayed transfers of care. Good progress has been made in increasing capacity in reablement and using reablement hours to expedite discharge from hospital. Less developed is progress in increasing mental health social work capacity within the DOLS service to undertake Best Interests assessments. Recruitment has been completed during Qtr2, therefore the Council would envisage seeing the benefits of this increased resource over Qtr3. 5. REVISED SCHEMES AND THEMES PROGRESS The schemes for the BCF plan for 17/18 and 18/19 have been reduced from 12 to 5 and include: 5.1 Carers The Pan Dorset Carers steering group oversaw the development of the joint vision Valuing Carers in Dorset leading to services and solutions being coproduced. Carers get a real say in how resources are directed, and the level of support made available to support carers to maintain their caring role. After a review of carers services early in 2017, work is underway to ensure that a more targeted approach is taken to ensure that carers are receiving the services they need and use the most. 5.2 Integrated Locality Teams Teams are strengthening their focus on the most complex patients with an increased focus on frailty. Using the revised frailty specification the GP investment in over 75 s services are being reprofiled. Through Health Education England, Wessex frailty programme a toolkit has been developed to support identification for people at greatest risk of frailty. Integration National leads supported a care home workshop in November 17 to share approaches for teams to support reductions in hospital admissions. 2
5.3 Maintaining Independence The integrated equipment service continues to support individuals in the community. Joint working between health and social care practitioners is now embedded, and is seeing a consistency across the partnership in supporting people to remain independent. Work has begun to decommission My Life My Care on a Pan Dorset basis, with Bournemouth and Poole retaining the brand and much of the content to become a Bournemouth and Poole only brand by July 2018. 5.4 Early Supported Hospital Discharge Schemes Work with acute hospitals is ongoing in planning for safe discharge into community settings. The integrated hospital discharge hub is now well established in Poole Hospital since it s launch in May 2017. It has had a positive impact, introducing more efficient and co-operative ways of working by having all aspects of discharge coordination taking place within the hub for residents being discharged from Poole hospital. Poole Hospital have introduced the red bag scheme in order to improve transition from hospital back into the community in particular when working with nursing homes. The "Red Bag" keeps important information about a care home resident's health in one place, easily accessible to all staff involved in a patient s care. Ticket home and getting home leaflets are available and used in line with Discharge to Assess (in Poole) and Trusted Practitioner pathways. Staff at Band 3 level and above are trained in the use of the Trusted Practitioner model in conjunction with Dorset Healthcare Trust, this has been rolled out across the Dorset area. Trusted Practitioners are able to carry out straight forward assessments in order to restart packages of social care or by ordering equipment. The model has been adopted nationally and has proved successful in facilitation of speedy and safe discharge from hospital. Project plans are in place to increase activity and improve consistency in the acute settings. Reablement support has been retained and there has been an increase in activity levels and number of hours available to support adults maximise their independence on discharge from hospital using funding from the improved Better Care Fund. 5.5 Moving on from Hospital Living for Adult with Complex Learning Disabilities Commissioners have been working on several key development areas for the pooled budget on a Pan Dorset basis. These have included working in partnership to agree new and fair market hourly rates for the provider sector in relation to the national minimum wage and sleep in payments. Work has also been undertaken to scope out extending the pooled budget to allow for it to cover people who are 'stepping down' from out of area hospital provision to ensure they have a smooth transition and that there are no delays to the move on process with regards to the allocation of funding. Finally proposals are being drawn up for consideration by the joint commissioning board (that governs use of the pooled budget at present) to establish how best to utilise the pooled budget arrangements to enhance 24 hour crisis services for people with learning disabilities and complex needs requiring urgent housing and support to prevent people from needing to leave the county in these situations. 5.6 To enable further integration there are also 3 key strategic themes reflected within the plans, these are: 5.7 Strong and sustainable care markets 3
Bournemouth, Poole and Dorset CCG have completed a homecare tender and awarded a framework contract to 17 providers. This new framework will underpin and drive a more integrated approach to maintain people in their own homes. The framework sits within Proud to Care - a branded identity set up to engender partnership working amongst homecare providers. Work is also taking place to support and influence the Residential Care Market through developing a learning/training tool for new and existing managers. Through taking part in Action Learning Sets managers will build on their competencies, knowledge and experience to effectively lead the delivery of care within residential settings. Construction work on the new 80 bed care home, Figbury Lodge, will bring additional long-term capacity to the care market. Twenty of the beds are designated for intermediate care, jointly funded by the local authority and Dorset CCG, the remainder for dementia (with or without nursing) and challenging needs. 5.8 Advancing Locality Care Locality multi disciplinary teams are providing good outcomes for people and there is further development in consultant outreach from Poole hospital into care homes to prevent unplanned admissions. Increasingly locality care has a connected interface with acute hospitals in particular safe discharge into community settings and the establishment of the integrated hospital discharge hub in Poole has facilitated this. 5.9 Understanding Joint Expenditure Prior to consideration of further aligning NHS and social care budgets, financial information is being shared in order to better understand joint expenditure and common areas of spend. 6. PERFORMANCE AGAINST TARGETS 6.1 Appendix 1 summarises the performance information available for the half year 2017/18. One of the four key performance targets for the period is being achieved by the Bournemouth & Poole Health and Wellbeing Board area; reducing residential care admissions. 6.2 Performance in regards to emergency admissions to hospital still poses as a significant challenge both at a local and national level 6.3 Performance on delayed transfers of care (DToC) remains very challenging and targets have not been met in regards to all delays. However it should be acknowledged that there has been strong performance in regards to Social Care and jointly attributable delays over both quarters where those targets have either been met or exceeded. The key issues continue to be higher than anticipated levels of admissions and lack of capacity in the care market for nursing care. Health delays are also being attributed to care market issues for those funding their own care, however family and patient choice also play a significant contributing factor in causing discharge delays. 7. PLANS FOR IMPROVEMENT 7.1 Significant effort continues to be made to achieve performance improvement. Much 4
of this is focused through the health and social care partnership arrangements looking at urgent and emergency care. Examples of improvement work where performance measures are in exception are listed below: 7.2 Performance Measure Plan for Improvement Emergency admissions to hospital 5 1. Emergency/unscheduled admissions; there is an established screening process in place for most wards and work to case find patients to develop plans for discharge. 2. CCG information teams have developed reporting that identified homes that utilise 999 emergency services for targeted health and social care intervention. 3. National leads supported a care home workshop in November to share approaches for teams to support reductions in hospital admissions. Delayed Transfers of Care (DTOC) 1. Trusted practitioner training level 1 completed for all localities to assist with discharge planning within all acute and community hospital sites. 2. For emergency/unscheduled admissions a screening process is in place for most wards and work to case find patients to develop plans for discharge. Good working relationships with wards and daily contact assist in early discharge planning. 3. Hospitals flex capacity when necessary to manage patient flow. Concentrated and focussed work undertaken with Dorset Healthcare has enabled a reduction in delays that has supported flow within acute hospitals and community health and social care teams. Stranded patient meetings and CCG led case conferences to focus on complex delays and RCAs carried out for learning. Reablement 8 CQC SPECIAL REVIEWS 1.Variable data capture issues are recognised locally and work is still to being undertaken to resolve this. 8.1 The Department for Communities and Local Government and Department of Health have written to Councils expressing the urgency of the combined work needed to
reduce delayed transfers of care to no more than 3.5% of all occupied bed days across the country. 8.2 They also expressed their commitment to challenge entrenched poor performance by conducting reviews of ibcf allocation to those Councils performing in the bottom quartile in regards to managing delayed transfers of care. Due to Poole s good performance there has been no impact to Poole s ibcf allocation so far. 8.3 Alongside this, CQC have been tasked with conducting a series of special reviews in 20 Local Authority areas to look at local health and social care systems; looking specifically at how older people move through these systems with a focus on how services work together. CQC data profiles predominantly from 16/17 data sets have been used to determine which areas to review, Poole s data profile can be found at appendix 2. 8.4 The reviews will look at the variation in local systems to identify the reasons why some struggle to work together. An interim report on the first 6 reviews was released in late December 17 and is attached at appendix 3. The key message from the initial findings was that there was too much focus on individual organisations drivers rather than the whole system; system leadership was not always easy to identify; that Health and Wellbeing Boards wider system oversight was variable and that coordination of strategies at local, regional and national level is essential. Once the 20 reviews are completed a national report on the key findings will be available outlining recommendations for change. 9 RISK AND FINANCIAL IMPLICATIONS 9.1 It should be noted that although delayed transfers of care attributable to social care have consistently remained low in Poole, there is more variation across the health system. Greater emphasis on joint work needs to take place to reduce the variation in performance between health and social care delays for Poole; both the Systems Leadership Team and the Health and Wellbeing Board have a significant role to play in driving this forward. As a council we should be mindful that a CQC special review could take place if performance is found wanting as a whole system and that ibcf funding conditions could be imposed if there is not whole system improvement. Therefore there is the potential of significant financial risks for the BCF in 2018/19 and beyond. 9.2 Although the overall value of the BCF has increased, the level of funding to directly protect adult social care activity has decreased by 228,000. This is because the financial pressures in the healthcare system are so great that the CCG was unable to maintain the full amount of additional, discretionary funding that they made available for adult social care in 16/17. 6
9.3 The financial contributions to the Better Care Fund for Poole are as follows: Scheme Description CCG Contribution Borough of Poole Contribution Total 000 000 000 Maintaining Independence 3,329 2,670 Early Supported Hospital Discharge 842 927 Carers 599 - Moving on From Hospital Living Integrated Health & Social Care Locality Teams 2,277 385 7,166-5,999 1,769 599 2,662 7,166 Total 14,213 3,982 18,195 The integrated community services pan Dorset pooled budget included in the Maintaining Independence scheme is currently showing a budget pressure of 146,000 pan Dorset wide. The moving on from hospital living pan Dorset pooled budget is currently showing a budget pressure of 103,000. All partners are actively working together to manage the above pressures. All other Better Care Fund schemes are expected to be managed within budget. 10. EQUALITIES IMPACT 10.1 An overall Equalities Impact Assessment (EqIAs) was completed when the BCF was agreed. As the plan is implemented, full EqIAs will be carried out for any proposed changes to policy or service delivery. 11. CONCLUSION 11.1 The Better Care Fund has enabled partners to align health and social care resources to benefit residents and several initiatives are starting to have an impact on lengths of stay in hospital and reductions in admissions to care homes. However, our efforts continue to be focused on effective community services that avoid unnecessary hospital admissions and support people effectively in their own homes. 7
Report of Jan Thurgood, Strategic Director 01202 633207 Contact Officers David Vitty, Head of Adult Social Care - Services 01202 261132 Phil Hornsby, Head of Commissioning and Improvement, People Theme 01202 261030 Elaine Stratman, Principal Officer, Quality Assurance and Planning, Commissioning and Improvement- People Services 01202 261158 8
Appendix 1 attached. Bournemouth & Poole Health & Wellbeing Board half year Performance Dashboard Appendix 1 Appendix 2- attached CQC Local System Reviews- Poole data summary Appendix 2 Appendix 3- attached CQC Local System Reviews- Interim report Appendix 3 9