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Agenda Item No

Meeting Board of Directors

Date 30 October 2014

Title BETTER CARE FUND

Executive Summary

NHS England announced the launch of the Better Care Fund in 2013 to ensure a transformation in integrated health and social care. The total value of Bolton's fund is £12.1m in 2014/15 rising to £20.7m in 2015/16. The Better Care Fund is set in the context of the Health and Wellbeing Strategy. The following schemes are well underway: Integrated Neighbourhood Teams, Intermediate Step up and step down care, Complex Lifestyles Service, Care Coordination Centre, Staying Well, Information Technology and Primary Care. The establishment of the Fund will challenge the Trust to develop a strategic response to the proposed integration of health and care.

Next steps/future actions

Discuss X Receive

Approve Note

For Information Confidential y/n N

This Report Covers (please tick relevant boxes)

Strategy X Legal Implications

Performance and Quality X Regulatory

Financial Implications X Stakeholder implications X

Workforce X Risk

Prepared by

Mark Wilkinson Director of Strategic and Organisational Development

Presented by Jackie Bene Chief Executive

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BETTER CARE FUND 1. PURPOSE

The purpose of this paper is to brief the Board on the Better Care Fund and set out some of the strategic implications for the Trust. 2. BACKGROUND

NHS England announced the launch of the Better Care Fund in the 2013 spending round, to ensure a transformation in integrated health and social care. It was described as one of the most ambitious ever programmes across the NHS and Local Government in creating a local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their well-being as the focus of health and care services.

Attached to this paper is a summary of Bolton’s Better Care Fund as submitted to NHS England at the end of September 2014. 3. CURRENT POSITION

The total value of Bolton's fund is £12.1m in 2014/15 rising to £20.7m in 2015/16. The Fund is designed to deliver integrated health and social care services for the adult population of Bolton. The Health and Wellbeing Board have recently submitted the latest iteration of the Better Care Fund to NHS England, and this Trust is a signatory to that submission. 4. STRATEGIC CONTEXT FOR THE BETTER CARE FUND

Bolton’s JSNA1 describes the health and wellbeing needs of local people and provides the key evidence for the commissioning of services to address and improve the populations’ health. Bolton’s Health & Wellbeing Strategy 2013-2016, is a three year plan setting out the key priorities to support Bolton people to live longer, healthier lives and address the health inequalities which exist within the Borough with specific focus on the key issues identified by the JNSA. These include; an increasing elderly population (with dementia & frailty), respiratory disease, cardiac disease, alcohol misuse and mental health issues. The approach of the Bolton Health & Wellbeing Strategy2 is to transform the current position of reactive care over time to proactive care to prevent hospital admissions and long term admissions to residential/nursing care through individual person-centred care planning. We aim to achieve this paradigm shift through investing in prevention and earlier intervention, reducing demand for hospitalisation and more complex care, further enabling reinvestment. This is demonstrated in the diagram below:

1 http://www.boltonshealthmatters.org/sites/default/files/JSNA%2020 13%20Executive%20Summary.pdf

2 http://www.boltonshealthmatters.org/sites/default/files/Health%20a

nd%20wellbeing%20strategy%202013-2016.pdf

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The NHS is facing an unprecedented financial challenge and this means that:-

Bolton CCG has to identify savings of £24m over the next 5 years to ensure that the commissioning plans can be delivered.

Bolton FT has to find efficiency savings of £73m over the next 5 years. In addition the CCG is planning to reduce the annual amount spent on hospital based care by £11.4m and make reinvestments in community and primary care. This means that the FT needs to downsize its activities on the hospital site.

Greater Manchester West FT has to find efficiency savings of £27.6m over the next 5 years. The CCG is planning to make further investments in mental health which may have an impact on GMW.

Local authorities are also facing budget reductions - Bolton council has to make savings of £59m over the next 3 years.

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IMPLICATIONS AND OPPORTUNITIES FOR THE TRUST

The Better Care Fund has been established from a mix of some existing CCG and local authority budgets and additional investment from the CCG’s general budgetary allocation. There has been no new money to create the Fund, so funding now earmarked for the Fund would otherwise have been available to allocate to the other CCG priorities.

As with any pooled budget new and shared priorities will start to emerge for example, and in line with national guidance Bolton’s Better Care Fund earmarks £745k to respond to the financial implications of the Care Bill. National guidance on the Fund requires that it be established at a certain minimum financial value. For Bolton in 2015/16 that figure is £20m. It is at the discretion of the local organisations as to whether they wish to place more of their financial allocations into the Better Care Fund and operate it as a pooled CCG and Council budget. Bolton’s Better Care Fund meets the minimum requirement, and as such is it may almost be seen as a distraction from the big prize of influencing the combined public sector commissioning resource across the town which approaches c £750m. In other parts of the country this joint commissioning has been embraced more enthusiastically; Sheffield, Sunderland, and Salford all plan pooled budgets in excess of £100m3

The Fund, particularly if it grows in financial value over the next few years, will lead to a blurring of health and care and the hitherto relatively strict delineation between the two. Major political parties are keen to see much closer working between health and care organisations. It is therefore important that the Trust responds to this changing climate and considers for example how our services might become more integrated with those of the local authority and how that might improve health and care for Bolton people.

There is an opportunity for the Trust will to respond explicitly to the Council’s priorities and therefore position itself well in this changing environment.

The Better Care Fund brings with it a new performance management metric with a financial incentive i.e. reduction in non-elective admissions. Part of the investment the CCG is required to make in the Fund (c£1.6m) is conditional upon a reduction in non elective admissions. Should this reduction not be delivered the CCG would retain these funds – this would give them the funds to pay for the activity in providers such as this Trust.

The Health and Wellbeing Board was established as part of the 2012 Health and Social Care Act reforms and brings together key local partners to improve health and well being across the Borough. The Trust has the advantage of being a full member of the Board – providers aren’t full members of all Boards - and the opportunity to become an influential partner.

5. CONCLUSION

The Better Care Fund is significant, not in its current monetary value which is modest in overall budgetary terms, but in the signal about the increasing integration of health and care and the opportunities and challenges this presents to the Trust.

6. RECOMMENDATIONS

It is therefore recommended that the Executive Directors:

i. Note the report and consider the implications for the Trust ii. Support the development of a strategic response which sees the Trust becoming a more

actively engaged partner in the Bolton health and care system

3 http://www.hsj.co.uk/news/four-in-10-areas-to-pool-extra-health-and-care-cash/5069815.article

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SUMMARY OF BOLTON’S BETTER CARE FUND CASE FOR CHANGE The Bolton Programme for Integrated Care is set within the context of a wider review of Health and Social Care in Greater Manchester aimed at improving outcomes, at a lower cost. Specifically this involves Greater Manchester major strategic change programmes as well as locally agreed programmes. A set of consistent community based care standards have been agreed across Greater Manchester to set the expectation for the level of service required to support the overall transformation. The Bolton Vision partnership of private, public, voluntary and faith organisations has a strong track record of working together to improve the quality of life of our Bolton family. For a number of years the partnership has pursued twin aims of promoting prosperity and narrowing the gap around key outcome areas. Some of the successes of this strategy include an increase of 1 year in average life expectancy to 77.8 years, (the highest it has ever been) and a reduction in the life expectancy gap across Bolton from 15.2 years to 11.9 years. The borough has also seen improvement in educational achievement, and a reduction in crime and anti-social behaviour. Recent commitment from private businesses to invest in Bolton town centre will positively impact on regeneration. The Bolton Health and Wellbeing Strategy takes a life-course approach and for each of those life-courses we have set our goals for:

Helping people to stay well

Identifying and dealing with problems early

Ensuring the best quality care and experience for those with health and/or social care needs

Making sure we better address the needs of the most vulnerable

The Vision Partnership and the Health and Wellbeing Board see working together to deliver integrated health and social care services as an essential enabler of these aims. Health and Social Care Integration is a standing item on the agenda for the Health and Wellbeing Board, where partners are updated on progress and given the opportunity to discuss developments. As the population of Bolton grows older, the health and social care system in the Borough is under increasing pressure from a combination of reduced resources and increasing demand for services. It is becoming increasingly clear that current models of service provision are rapidly becoming unsustainable. The population of Bolton is expected to grow by 3.8% over the next 5 years (to 2018/19). The number of people aged 65 and over in Bolton is expected to grow by 9.6% over the same period, from 46,000 to 50,000. We have applied population growth projections to 2013/14 secondary care activity (stratifying the activity using 5 year age bands) to calculate the amount of additional activity we expect to see for Bolton patients in a “do nothing” scenario. We have predicted that, due to demographic growth alone, there will be an additional 3,983 A&E attendances, 1,938 non-elective admissions, 2,085 elective and day case admissions, 4,486 first outpatient attendances and 11,555 follow up outpatient attendances over the next 5 years.

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Community services in Bolton are an asset and have the potential to form the building blocks from which a truly integrated system can be developed. General Practitioners and their teams are both providers and commissioners of health care in Bolton. General Practices have a track record in implementing population in health programmes delivered at pace and scale built upon year on year since the Big Bolton Health Check. Outcomes include increases in the diagnosis and evidence-based care of the people with long term conditions such as heart disease and diabetes in primary care. Resulting reductions in admissions to hospital and reductions in mortality have been achieved. Between 2009/10 and 2013/14 there was a 4.7% decrease in the number of heart disease non-elective admissions and a 15% decrease in the number of diabetes non-elective admissions. UK and international evidence suggests that integrating care can deliver better outcomes, improve individual experience and support cost containment, and that significant improvements can be made through a dual focus on redesigning services and supporting people to self-care (building on the assets around them). System level integrated care addresses the fragmentation of care, shifts the focus away from individual organisations and can provide powerful incentives to focus on prevention, self-care and cost reduction at a neighbourhood level.

MODEL OF INTEGRATED CARE To deliver the new system the health & social care partners across Bolton are designing a new model of integrated care which is detailed below. The aims of the Bolton Integrated Care Model are to deliver integrated health and social care services for the adult population of Bolton (230,000 adults registered with a Bolton GP).

Aim to keep patients well physically and mentally and independent and in their own homes (recognising the importance of family and community in promoting wellbeing).

Provide a good health and social care experience for patients and their families and result in better outcomes.

Meet the challenges of rising need for health and social care services within dwindling resources.

Are centred on the needs of the individual.

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The Bolton model for integrated health and social care is designed around the needs of populations of 20,000 to 30,000 people built from clusters of GP practices. This results in 10 clusters and each population cluster has been “risk stratified”. A multi-disciplinary health and social care team will serve each population cluster. District Nursing teams have already been aligned to the 10 clusters and currently work from 10 health centre bases. Therapists currently work from 3 ‘zones’ across the borough of Bolton, whilst the Social Care Teams work from 2 bases covering the North and South of Bolton. A phased implementation of the service commenced in early 2014 and enabled the Integrated Care model to be tested across a specific area of Bolton. The model is being continually evaluated and any necessary changes made so that the most effective model can be in place across the borough from April 2015. The model is centred on an Integrated Neighbourhood Team MDT and includes: the GP, practice nurse, district nurse, physiotherapist, OT, pharmacist, social worker and community psychiatric nurses.

LIST OF PLANNED BETTER CARE FUND SCHEMES

Integrated Neighbourhood Teams

Intermediate Step up and step down care

Complex Lifestyles Service

Care Coordination Centre

Staying Well

Information Technology

Primary Care These are described in detail in Appendix 1 BETTER CARE FUND RISKS The following risks have been identified to our Better Care Fund plans. In priority order:

Workforce culture - Pressure on teams/ staff who are required to work differently and under new management structures and workforce culture could impact on performance and service delivery

Contingency Planning - There is risk that non elective admissions will not be reduced and financial savings from integration not be delivered. This presents a risk to the overall delivery of CCG QIPP savings.

Financial Context and benefit realisation - Partner organisations are working against financial constraints and a requirement to make cost savings. Financial allocations are only confirmed for one year ahead. Stakeholders fail to agree benefit apportionment and share of risk.

Data Sharing - The current legislative framework does not allow certain types of data to be shared between health and social care organisations. Integrated services rely on the ability to share patient information.

Workforce – failure to ensure the correct skill mix and development of staff to support new model of care and service delivery.

Implementation – Integration programme is based on a number of interrelated work streams for MDT care planning and delivery, service response and supporting infrastructure. Coordination of and timeliness of each component presents risks to implementation.

Community Services Redesign - The CCG and acute trust are working on a redesign programme for Community Services. Community Services are a key element for the health and social care integration agenda. The outcome of the service review could affect the integration programme and its ability to access an appropriate level of capacity to deliver MDT planning and

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service response.

NATIONAL CONDITIONS NHS England required certain statements in Better Care Fund submissions. These mandatory requirements and our responses to them is set out in the table below:

Condition Our Response

Outline your agreed local definition of protecting adult social care services (not spending)

Adult Social Care Services will be protected where they contribute to the desired outcomes, provide good outcomes for service users, and would otherwise be reduced due to budget pressures in local authorities. The Local Authority will maintain its eligibility criteria at substantial until replaced by the level mandated under the Care Act 2014.

Specify the level of resource that will be dedicated to carer-specific support

Submission includes £650,000 for support to Carers. This includes the provision of funding to a number of carer focussed third sector organisations and a contribution to costs incurred in providing respite services.

Describe your agreed local plans for implementing seven day services in health and social care

Bolton already has seven day services in place across health and social care to support people being discharged from hospital and to prevent unnecessary admissions and there has always been a joint commitment in Bolton to ensure seven day access to Intermediate Tier services. These services include, a step up Rapid Response service, Intermediate Care at Home service, Intermediate Care beds and Home Support Reablement.

There are also seven day social work services in place which ensure seven day social work assessment support to A&E and other assessment areas in the acute trust.

There is a recognition locally that although Bolton has good seven day services in place these services are fragmented across health and social care and there is a joint local commitment to integrate what Bolton has in place already in order to reduce duplication and ensure services are seamless but also to enhance what is in place now by increasing the level of community based support to ensure more people are able to have their needs addressed at home preferably by avoiding an admission in the first place or by supporting a timely discharge.

Set out the plans you have in place for Bolton’s partners are using the NHS

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using the NHS Number as the primary identifier for correspondence across all health and care services

Number as the primary identifier for correspondence across all health and care services to which it delivers an integrated health and social care service. Documents and assessment templates have been changed to reflect this.

The NHS number will be collected and used for all new service users. Work has progressed over the past 5 months and there are now approximately 70% of records that contain the NHS number as the unique identifier. The remaining 30% are problematic and not easy to match, however a process is being developed between the Local Authority and the CCG to increase the uptake as much as possible.

Describe how patients, service users and the public have been involved in the development of this plan to date and will be involved in the future.

In April 2014 over 150 patients from across Bolton came together for a one day event structured around ‘Changing our NHS’. One of the main discussion topics was Integrated Care in Bolton. Participants had the opportunity to take part in a number of interactive exercises and discussions. Pre consultation on the Healthier Together programme began in Bolton in January 2013, consisting of public meetings (with over 120 members of the public in attendance), presentations to voluntary sector organisations, and involvement of the local Healthwatch.

Structured interviews and satisfaction surveys were gathered during the pilot phase of the Staying Well project and results have been used to inform service developments. The communications strategy ensures there is a framework to support clear and consistent communication. A quarterly bulletin “Bolton Scene” is sent to every household in Bolton and contains an in depth update on our Integration Plans.

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Appendix 1 – Detailed Scheme Description

Scheme name

Integrated Neighbourhood Teams

What is the strategic objective of this scheme?

The strategic objective is closer Integration of Health and Social Care to provide a focus on prevention, self-care and cost reduction at a neighbourhood level. The main objectives are to:

Keep people well and independent at home

Provide good experience of care and ensure better outcomes

Meet the twin challenges of rising demand and reducing resource base

Provide care tailored to the needs of the individual.

Overview of the scheme

Existing teams will be redesigned to take on the new and existing work identified from the risk stratified population and the GP practice over 75s register. The borough has been patched into 5 neighbourhoods and the teams will be aligned to GP practices in each neighbourhood. Each practice will have dedicated support from a clinical facilitator who will be a member of the Integrated Neighbourhood Teams and will be the link between the GP and the team. A systematic approach will be used to work through the risk stratified population and the over 75s list to take a proactive approach to case finding and to undertake a comprehensive multi- disciplinary assessment, hold MDT meetings where required and develop personalised care plans. There will be a primary focus on self-management and personalised care plans will include specialised admission avoidance plans. The teams will have close links with other integrated services such as intermediate tier, staying well and the complex and challenging lives service. The team will also work with people who have not been risk stratified or defined as elderly who the GP is concerned about. These referrals will be made to the team by the GP. The team do not provide a crisis response service but are closely aligned to a 24/7 admissions avoidance service which forms part of the menu of services offered in the intermediate tier. Existing teams will be redesigned to take on the new work associated with the risk stratified population. Five hubs will be created, based in close proximity to the GP Practice sites identified as being in the first phase. A systematic approach will be used to work through the risk stratified population to undertake comprehensive MDT assessment, MDT meetings where required and the development of personalised care plans.

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Scheme name

Intermediate Tier Services

What is the strategic objective of this scheme?

Bolton will invest in Intermediate Tier Services in order that we promote well-being and prevent, reduce and delay the need for long term health and care services within our population. Our goal is that people should receive adequate rehabilitation and reablement when needed, to prevent permanent disability; greater reliance on care and support, avoidable admission to hospital or care homes and delayed discharge. A key aim is for people to be able to re-engage in the community following a period of intermediate care. All these services will operate 7 days per week in order to meet the 7 day requirement to support discharge.

Overview of the scheme

The following services will be commissioned as part of our Better Care Fund Plans: Admission Avoidance Service – Community and Hospital Based, additional home-based Intermediate Care, and 7 day hospital discharge

Bolton will not be investing in Intermediate Care Bed Services or Reablement Services further as we have recently carried out a whole system reconfiguration that saw over £1.5million invested into these services. Admission Avoidance Services When the health or social situation of a person, especially if they are older, rapidly deteriorates they should have rapid access to care including an effective alternative to hospital. Bolton’s Admission Avoidance Service will provide a rapid intervention in response to a health or social care crisis that will allow a person to be supported and treated at home safely and therefore avoid an unnecessary admission to hospital or residential care. It seeks to maintain and/or help the person regain their maximum independence and to support carers, as a crisis can threaten the stability of care and support arrangements. An integrated admission avoidance team of both health and social care professionals ensures that tailored interventions are offered to people to enhance their quality of life and prevent inappropriate, unplanned admissions. Provision of immediate treatment.

To provide a multidisciplinary assessment in the patients’ own home to determine the level of support required.

To allow the patient to be supported in the comfort of their own home during an episode of illness

Provision of urgent equipment

Rapid access to Intermediate Care at home and Reablement Support, personal care, night services.

To provide rapid access to Intermediate Care beds if required as an alternative to hospital admission when the patient cannot be maintained in their own home.

The service will support a wide range of acute and chronic conditions in a crisis.

Access to out of Hours GP support

Access to sessional Geriatrician cover

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Additional Intermediate Care at Home The focus is on a shift from bed based to home care where clinically safe to do so. Intermediate care at home will support individuals to regain their optimum independence and mobility following an episode of ill-health, injury or an exacerbation of a long term condition through personalised care planning and care delivery. Benchmarking and comparison of Bolton’s Intermediate Care at home services with other high function services has identified shortfalls in our provision, especially with regard to the management of medicines and access to medication reviews. We are therefore increasing the following elements. The following establishment will be added to our intermediate care/reablement at home services in order that we are able to deliver a more effective service.

Advanced Nurse Practitioner - 1.0 WTE

Senior Pharmacist - 1.0 WTE

Pharmacy Technician - 1.74 WTE

AHP (OT or PT) - 3.48 WTE

Reablement Support Worker - 3.52 WTE

The additional investment required = £448,000. Prior to these investments Bolton was implementing a whole system review following identification of a significant over use of beds having 29% more than the national average whilst at the same time having 69% less referrals to Intermediate Care at home and 32% less than the Greater Manchester average for Reablement. Reablement is important as it has been evidenced to deliver 62% of people to the point where they no longer need services compared to 5% of a control group.

As a result of this benchmarking and prior to BCF submission Bolton had agreed to release £1m of funding used for underutilised respite and intermediate care beds and invest this in reablement. This will see the numbers of people receiving reablement rise from 1200 per year to over 1800 per year or a rise of 600 episodes.

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Scheme name

Complex Lifestyles Service

What is the strategic objective of this scheme?

To reduce inappropriate and/or unplanned (crisis/emergency) presentations and admissions to health and social care provision for people defined as having complex lifestyles.

Overview of the scheme

The Complex Lifestyles programme aims:

To provide a responsive, coordinated, proactive, individual client specific and focused service to improve outcomes for adults with a sub-set of complex needs in Bolton. This sub-set is defined as individuals presenting with a combination of substance misuse, mental health and deprivation needs who do not currently consistently engage with existing service provision.

To provide a holistic response to some of the most vulnerable individuals in our communities and to work flexibly and proactively to engage them in service provision, reducing the likelihood of them being at further risk of harm to themselves and, where applicable, to others.

Currently there is no single agency or service with responsibility for co-ordinating care and facilitating access to services for people with complex lifestyles. A new team of Engagement and Support workers is envisaged across the borough to link with the Integrated Neighbourhood Teams. The aim of the Complex Lifestyles programme is to facilitate behaviour change so that clients with complex lifestyles reduce their presentations to inappropriate services. Additionally the programme seeks to provide intensive support to assist clients in navigating health and social care systems with the aim of enabling access to appropriate services. The Complex Lifestyles model will take a holistic approach to understanding and responding to individual client need whilst fostering increased self-care and reduced dependence on services that are currently unable to respond effectively. The proposed model will focus on those clients defined, within the overall complex needs cohort, as having complex lifestyles. These clients are expected to have a combination of issues/conditions, particularly in relation to:

Active misuse of drugs and/or alcohol

At risk of self-harm or further self-harm

At risk of harming others

Depression and/or anxiety

Social deprivation (e.g. financial problems, worklessness)

Housing/homelessness

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Scheme name

Care Coordination Centre

What is the objective of this scheme?

The scheme aims to deliver Care Co-ordination via one single point of access to Integrated Health and Social care Services in Bolton.

Overview of the scheme

Community referrals will be made through a Care Coordination Centre, where an agreed set of information will be collected about the individual and their circumstances. CCC advisors will provide signposting or referral to the appropriate support services. If a clinical service is indicated e.g. Intermediate Tier, the referral will be clinically triaged by a registered health care practitioner (usually a nurse) to determine the level of response required.

The patient cohorts being targeted by the scheme are: adults over the age of 18 who have complex care needs requiring an integrated health and social care provider response. This will include patients nearing the end of life, patients with long term conditions requiring active intervention, the frail elderly and patients with dementia.

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Scheme name

Staying Well

What is the strategic objective of this scheme?

The aim of the Staying Well programme is to enable and increase opportunities for individuals to stay healthy, happy, maintain independent, connected to their communities and to reduce dependence on expensive secondary healthcare and social services.

Overview of the scheme

The Staying Well service offer will include three elements: 1. Proactive Staying Well (‘Staying Well’): extension of the original pilot approach to all areas of the

Borough, using the care needs index to risk stratify and target through practice lists and utilising the Staying Well Tool.

2. Reactive Staying Well accessed by people who approach Social Care services through Access Bolton, but aren’t eligible for services such as reablement or intermediate care; using the opportunity of this contact and the Staying Well Check Tool to provide preventative support and offer early, time-limited intervention if appropriate. Offer early, brief intervention to Staying Well clients when longer term service support is not required, reducing or delaying future demand on health and social services.

3. Community Capacity Building: Underpinning the individual Staying Well offer, delivered through the Staying Well service, a specific work stream will stimulate and develop community capacity to support older people’s health and wellbeing. This community capacity building work stream is absolutely essential to fully realise the potential of communities, neighbourhoods and their residents to assist in the delivery of prevention and early intervention, and to address the many inequalities in outcomes for older people across the borough.

The service will be targeted at the following customers:- 1. There are over 44,000 people aged 65 and over in Bolton. Using the Potential Care Need Index

(PCNI) 13,064 people are at risk of developing future health and social care needs have been identified as being eligible for a Staying Well Check. Staying Well will undertake a phased roll out aiming for borough wide coverage by April 2015.

2. The Combined Predictive Model (CPM) is a risk stratification tool which aims to predict the likelihood that a patient will be admitted to hospital in an emergency in the next 12 months. The risk score is a probability score between 0 and 100, where 100 is the highest risk score. A further 11,236 people aged 65 and over score over 20, which means there is a 20% likelihood of them being admitted to hospital in the next 12 months, but fall below the threshold of 50 eligibility for an Integrated Neighbourhood Team response.

3. Social services front door. An estimated number of up to 4000 will be eligible for the Staying Well Check who currently despite approaching social services every year are not subsequently provided a service as they fall below Fair Access to Care Criteria.

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Scheme name

Information Technology

What is the strategic objective of this scheme?

Overview of the scheme

There is currently a wide variety of IT systems in use amongst the key organisations. Within organisations, teams use different systems for different purposes, and in the majority of cases, these systems are not joined up nor have the ability to communicate with each other. However, this presents a very real opportunity to identify improvements and start to define a system that meets the emerging needs of the new health and social care system. Discussions to date give confidence that all organisations recognise the need to have interoperable systems that support and underpin clinicians, clinical pathways and patients. The IT will not drive the process, the process will inform the required IT. There are opportunities emerging in the shape of existing procurements that are already in progress, i.e. the acute trust EPR project. The emerging service requirements will be key to informing the way that new systems are implemented; including new ways of working.

Scheme name

Primary Care

What is the strategic objective of this scheme?

To ensure General Practice is at the centre of the integrated care model and can deliver the required shift in emphasis to more proactive care of high risk patients.

Overview of the scheme

This work stream provides the capacity to general practice, at the centre of the integration model General Practice is the major initiating point for integrated care working due to them holding the list of registered patients and identifying those most at risk of hospital admission through the following cohorts:

2% highest risk of hospital admission (risk stratification)

>75s with application of frailty index (6-7% of Practice population)

vulnerable patients identified by Practices including complex children

Ad hoc support to patients following recent hospital admissions.

Time for care planning is provided through the National 2% DES and additional CCG Investment. The model of care involves identification and Practice based MDT care planning of patients, with options to:

manage the patient with greater input from Practice

involve the wider integrated neighbourhood team in management of patient

clinical facilitator led referral onto more specialised services depending on need

Having only developed to date the practice involvement in care planning, this scheme will specify a greater involvement of General Practice capacity in

detailed review of patients (requiring lengthy appointments and or home visits)

intervention from the primary care team with these patients, whether in terms of medication review or practice nursing support

MDT discussion/ case conferences with the integrated neighbourhood team

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