Lambeth Better Care Fund (BCF) 2016/17 - narrative plan · The LUCR is now live across all general...

Lambeth Better Care Fund 2016/17 – narrative plan 1

Lambeth Better Care Fund (BCF) 2016/17 - narrative plan

Confirmation of funding contributions Local Authority London Borough of Lambeth Clinical Commissioning Group (CCG) NHS Lambeth CCG Boundary Differences No boundary difference Minimum required value of BCF pooled budget: 2016/17

£23,544,000

Total agreed value of pooled budget: 2016/17

£23,543,690 This figure is comprised of £1,145,265 from the London Borough of Lambeth and £22,398,425 from NHS Lambeth CCG. Within this allocation, the CCG and Local Authority can also confirm that the BCF plan is fully compliant with respect to allocations towards Disabled Facilities Grants, Care Act implementation, Carers’ funding, reablement funding, protecting Adult Social Care and NHS Out of Hospital services funding.

A narrative of BCF schemes can be found in Appendix I.

Local agreement to funding arrangements

Signed on behalf of the Clinical Commissioning Group

By Moira McGrath

Position

Director of Integrated Commissioning (Older Adults), Lambeth Council and NHS Lambeth CCG

Date 29 April 2016

Signed on behalf of the Council

By Cllr Jim Dickson Position

Chair, Health and Wellbeing Board and Co-Chair, Committees in Common, Lambeth Council

Date 3 May 2016


1. Introduction The Better Care Fund (BCF) was announced by the Government in the June 2013 spending round, to ensure a transformation in integrated health and social care. The Better Care Fund (BCF) creates a local single pooled budget to incentivise CCGs and local authorities to work more closely together around people, placing their well-being as the focus of health and care services. NHS Lambeth CCG and London Borough of Lambeth continue their commitment to develop integrated care and broadening the scope of integrated commissioning. In the 2015/16 BCF plan, Lambeth council and CCG collectively pooled £23.4million under a section 75 arrangement. The 2016/17 pooled BCF fund is £23.5million, consolidating our commitment to further integration. Additions to the plan for 2016/17 are: • Falls prevention and management service • New pharmacist support in care homes • Increased capacity in the reablement service • Independent Living 1.1 Review of BCF 2015/16 Lambeth’s 2015/16 BCF plan was approved without conditions as it demonstrated a commitment to, and a high level of integration across health and social care. Our plan sets out our commitment to improving outcomes for citizens in Lambeth whilst ensuring a financially sustainable health and care economy. In the 2015/16 BCF plan, Lambeth council and CCG collectively pooled £23.4million under a section 75 arrangement. Leadership In reviewing the Lambeth BCF Plan 2015/16 we feel confident that we have strong leadership from both council and CCG that supports the commitment to integrated care. To that end we have established a functioning and effective integrated relationship via monthly meeting of the Committees in Common where the two organisations bring together the decision makers to better align strategy and policy. Lambeth’s Committees in Common is the decision making environment for continuous embedding and developing integrated commissioning across adult health and social care. Person-centred care and citizen focused commissioning During 2015/16 we have continued to develop services that are centred on people and responding to their individual needs. Via contracting, service specifications and local CQUINs (Commissioning for Quality and Innovation payment to providers to incentivise improvements in quality and cost effectiveness), we have asked providers in primary, community and secondary care to focus on person-centred and integrated services. Our community multidisciplinary teams (CMDTs) provide a localised, integrated and person-centred approach to supporting people to remain independent and maintain their health and wellbeing. Lambeth continues to build community and patient and public involvement in commissioning. The Big Lambeth Health Debate in 2013 provided a benchmark for conversations with citizens across Lambeth


about their priorities for health and wellbeing in Lambeth. The outcome of this continuing conversation has informed commissioning and service priorities. In conjunction with Southwark CCG and council, Lambeth has continued to build on the person-centred and integrated approach established via the Southwark and Lambeth Integrated Care (SLIC) programme, a strategic and operational programme that included CCGs, councils, providers, citizens and voluntary and community groups. The SLIC programme finished on 31 March 2016 but work continues in the newly established Strategic Partnership Board. Lambeth Healthwatch is a regular partner, working with commissioners, patients and the public in establishing meaningful outcomes for people receiving health and care services. Lambeth is working with community groups, individuals and local charities to develop a strong and supportive community response to improving health and wellbeing. Lambeth has established Safe and Independent Living (SAIL) and Seasonal Health Promotion (SHP) via Age UK Lambeth, working with our local care networks (LCNs) of GPs to ensure true local response to supporting people to remain independent and well. In conjunction with local residents, Lambeth is developing a coproduced small grants scheme with residents and community groups to improve health and wellbeing at ward level. Additionally we are working with local individuals funding NVQ level training for them to create community connections between those needing help and support and the wealth of local services and community activities available to meet their needs. This project is being tested in one of our LCNs to continue development of the local response to supporting people. Data sharing to support care planning King’s Health Partnership (KHP), a collaboration of our three main local acute providers Guy’s and St Thomas’, Kings College and South London and Maudsley NHS Foundation Trusts (FTs), have been instrumental in developing our Local Unified Care Record (LUCR). In 2015/16 a shared patient record using NHS number was developed for the three FTs and is now live. The LUCR is now live across all general practices in Lambeth & Southwark. There are plans to extend this to community services and social care over the next year. Aligning systems Our BCF plan includes a set of services and a developing and responsive integrated health and care system where providers and commissioners share a local vision. Much of the delivery of the schemes in the BCF have been done in collaboration with our neighbouring borough Southwark as we have similar health and social care communities. These include very similar demographic and population needs, similar pattern of use of acute care, the majority provided by Guy’s and St Thomas’, Kings College, and South London and Maudsley NHS FTs. Contractual arrangements covering both boroughs include community and mental health services and existing partnership working between Lambeth & Southwark Councils. Collaboratively commissioned services have been designed to avoid admissions to hospital and facilitate discharge. These include an Enhanced Rapid Response team, GSTT @home, Supported Discharge team, intermediate care beds and Care Home Support team. Lambeth also has a reablement team currently


being transformed to provide fully integrated health and social care. All of these schemes have been mainstreamed, have service specifications and contracts in place and receive recurrent funding. Measuring success We developed a BCF dashboard that reported performance against the key metrics in the BCF return for the Committees in Common – non-elective admissions, number of permanent admissions to residential home, number of people at home 90 days discharged from hospital into rehabilitation/ reablement, and the number of delay transfers of care. We can report success of our 2015/16 BCF plan with excellent performance in reducing the number of non-elective admissions (NAE) in Lambeth, and at Q3 2015/16 our NEA had been reduced by 4.2% against a target of 2%. Against a target 653 per 100,000, forecast outturn for permanent admissions to a residential home is 648.8. Against a target of 96% of older people still at home 90 days after being discharged from a hospital into reablement/rehabilitation, our forecast outturn of 94.3%. Although we have had a low level of delayed transfers of care (DTOC) compared to the average for CCGs in England (53.4% of the England average December 2015, HSJ1), further reduction in DTOC remains a challenge, especially for working aged adults who are inpatients with our mental health provider South London and Maudsley NHS FT. Relationships to support integration Lambeth council and CCG established integrated commissioning for older adults and adults with mental health needs in 2010. This has enabled true collaboration and integration for related services and positioned Lambeth well to use the BCF to great effect. The Committees in Common brings commissioners, councillors, GPs, and the public around the table to consider and agree strategy and service delivery across health and social care. An example of using integrated commissioning to support effective integration is the process of transforming our reablement service. This will include workforce development around the creation of integrated roles in the service, able to manage both health and social care need, whilst having the ability and autonomy to make decisions in real time with the person they are supporting. A case study of the reablement service can be found in Appendix II. The future Lambeth is in a strong position to continue and consolidate integration of services to residents and patients receiving health and social care. Our BCF plan performance during 2015/16 has confirmed the matrix working across commissioners, providers and the public makes for a strong platform in which to deliver effective person-centred, integrated services that provide a system-wide response to managing acute demand. Our BCF plan will support delivery and transformation of integrated services in a continuing challenging financial climate.

1 http://www.hsj.co.uk/topics/quality-and-performance/analysed-the-best-and-worst-regions-for-delayed-

transfers-of-care/7002382.article

http://www.hsj.co.uk/topics/quality-and-performance/analysed-the-best-and-worst-regions-for-delayed-transfers-of-care/7002382.article

http://www.hsj.co.uk/topics/quality-and-performance/analysed-the-best-and-worst-regions-for-delayed-transfers-of-care/7002382.article


The excellent and mature relationship between CCG and council is making integration ‘business as usual’. We are confident Lambeth BCF plan for 2016/17 will continue to deliver cost effective integrated services to people in their home and community, supported their articulated desire to remain independent, to know who they can turn to for advice and support and in a crisis, and to maintain their health and wellbeing in a community where they feel welcome and safe.


2. The local vision for health and care services Strategy The Lambeth Health and Wellbeing Strategy 2013-23 sets the vision for continuing progress in achieving the best possible health and wellbeing for its citizens. The Health and Wellbeing Board, Lambeth Council and Clinical Commissioning Group are working to embed health and wellbeing equity and equality in all polices (from licensing to workforce), with a vision of Lambeth being a place where:

Health and well-being is improving for all, and improving fastest for those communities with the poorest health and wellbeing

People are able to reach their full potential and to feel good about themselves

Everyone is able to make a contribution and to feel valued

People are safe from harm

Citizens and services working together as equal partners (coproduction)

Investing early to enable people to stay healthy and maintain good wellbeing

Whole person / whole family care

Collaborative commissioning

Health and wellbeing equity and equality in all polices

Safeguarding children and adults from abuse and neglect The Lambeth Health and Wellbeing Board comprise representatives of Lambeth’s citizens and the main organisations with responsibilities and funding to protect and improve health and well-being in the borough. It brings together Lambeth Healthwatch, Council, NHS Clinical Commissioning Group, NHS National Commissioning Board and King’s Health Partners (a collaboration of our three main local acute providers Guy’s and St Thomas’, Kings College and South London and Maudsley NHS FTs), to work with local people to improve health and wellbeing in the borough. Lambeth BCF is an integral part of our Five Year Forward View, in taking decisive and collaborative steps to break down the barriers in how care is provided. In 2016/17, BCF continues flagship projects implementing reablement, rapid response and @home (hospital at home). BCF supports moves to the full implementation of our vision for an Integrated Community Independence Service, a service that breaks down the barrier between health and social care, with professionals from across health, care and voluntary and community groups, working together to maximise the independence of our older residents, preventing and responding to acute events. Lambeth BCF supports and is integral to our Sustainability and Transformation Plan (STP), in addressing the need for a whole system approach to health and social care planning, working together to produce a sustainable plan that both meets quality and performance standards and ensures financial sustainability, and aligned commissioner and provider plans for activity and finance, supporting service quality and performance. Using integrated commissioning for change In the Lambeth Health & Wellbeing Strategy 2013-23 there is a specific and collective commitment from the council and CCG to ‘integrate’ commissioning, with an explicit focus on outcomes throughout and:

Making the citizen central to everything

Recognising citizens for what they can bring, not just what they need

Making co-production with citizens the default way of working for all organisations

Ensuring all organisations opening up their data and information and making their decision making as transparent as possible


Working to develop the market of providers to ensure there are enough of the right kinds of organisations with the right skills to deliver the services that are required now and in the future

Encouraging innovation by becoming risk-aware rather than risk-averse. The Lambeth Health and Wellbeing Strategy 2013-2023 can be found in Appendix III. BCF underpins the commitment to integrated commissioning enabling citizens to remain healthy, well and independent in their community. Schemes included in BCF avoid the need for individuals to be admitted to hospital if their health deteriorates, enabling responsive and intensive care in a person’s home or usual place of residence. Schemes support individuals leaving hospital earlier and return to their home or community and being well supported and cared for. BCF schemes recognise the vital role carers, family and the local community play in improving health and wellbeing, as well as the importance of housing, environment and equipment as part of person-centred health and care provision. Our joint scale of ambition in developing integrated commissioning over future years extends beyond the scope of the BCF. We are committed to improving outcomes for citizens in Lambeth whilst ensuring a financially sustainable health and care economy.


3. An evidence base supporting the case for change Our work as partners of Southwark and Lambeth Integrated Care (SLIC) has included a detailed programme that has examined the case for change. This work has been supported by all the key local commissioners and providers of acute, primary and community based care services who were involved as the business case has developed. This work has shaped the approach to the pooling budgets in the BCF which is very much the first step in a wider integration agenda. The analysis was based on detailed data on the population needs, current services, demographic projections of need and finance and evidence about what models work. The full analysis of the case for change is available in Appendix IV. A key conclusion of the case for change work is that the current system is financially unsustainable without transformative change. The evidence shows that integration can help bridge that gap by shifting the balance of care towards more preventative community based care, and in so doing improve outcomes. All partners agree that there is scope to improve services and reduce costs by better integrating services. Our risk stratification and population segmentation approach has led to an initial focus on older people and long term conditions, and this has informed the focus of the BCF. Headline information from the case for change outlines that Lambeth is a vibrant inner London borough that has a culturally diverse and relatively young population. Mobility and migration levels remain high and the borough faces numerous challenges including deprivation, higher than average unemployment and population density, poor quality housing and crime. The resident population recorded in the 2011 Census was 303,100 people. The number of people registered with a Lambeth GP is 386,965 (January 2016). Lambeth’s JSNA is reflected in the 2015/16 submission and together with SLIC data provides the following key population facts:

Young – 50% aged 20-44 years

Growing – 15% increase by 2028 from 2011 numbers

Mobile – 22% move each year

Diverse – 42% ethnic minority, 150 + languages spoken

Densely populated – twice London average Segmentation tells us that Lambeth needs to focus on supporting older people to manage their health, specifically those long term conditions (LTCs) and serious mental illness. Changing the dynamic of delivering integrated support and services proactively to this specific group of people in their home and/or community setting will drive down associated costs and move away from an emergency admission dependant population. Refer overleaf for population and per capita spend based on segmentation taken from the SLIC case for change. Segmentation has provided understanding where and how we need to integrate and deliver services differently. For example, we are using information gleaned from segmentation to change how we deliver reablement services. Transformation will support a more streamlined and tailored reablement service that is responsive to health and care need of the older population requiring support on discharge from hospital, so they are better able to recover in their home environment. The scope of transformation will include workforce development so that practitioners are integrated decision makers


working at a higher level of responsibility, reducing management costs (refer Appendix II Case Study Reablement). SLIC segmentation for Lambeth and Southwark

SLIC spend per capita x population segment for Lambeth and Southwark


4. A coordinated and integrated plan of action for delivering that change Governance arrangements for BCF and integrated commissioning in Lambeth

LambethCCG and Council

Health and Wellbeing Board

Integrated Commissioning Committee

‘Committees in Common’

Joint Programme Board

Joint Director

Joint commissioning

Team

IPSA Team

London Borough of Lambeth and Lambeth CCG have been working closely to align commissioning of services for older adults and adults with mental illness since 2010. The two organisations have established an integrated commissioning team and have brought together the decision makers to better align strategy and policy. Lambeth have devolved the governance and management of the BCF including decision making for integrated care and commissioning to the Committees in Common (CiC). The CiC and Health and Wellbeing Board are chaired by the same lead member, ensuring a collective understanding of Better Care Fund. The CiC objectives are:

To improve outcomes for older adults and adults with mental illness in Lambeth and their carers.

To optimise the use of resources for these care groups across the commissioning responsibilities of the council and CCG

To agree commissioning strategy and policy for commissioning of services for older adults and adults with mental illness

To govern use and manage of the pooled budgets for the Better care Fund and Integrated Personal Support Alliance

To prioritise and guide the work of the Integrated Commissioning team

To own and assist in the resolution of risks and issues

To advise the Cabinet and CCG Governing Body Membership of the CiC is:

Councillors, including the Lead member for Health & Wellbeing and the Lead member for Adult Social Care

CCG Clinical leads for mental health and older people

A CCG lay member


CCG Chief Financial Officer

Head of Finance, Corporate Resources, London Borough of Lambeth

Director of Integrated Commissioning (Adults)

Assistant Director of Commissioning for Older Adults

Assistant Director of Commissioning Mental Health

Lambeth Healthwatch representative (co-opted) (non-voting) As part of the Better Care Fund, the council and CCG pooled elements of funding for adult services from April 2015. This builds upon the already strongly aligned commissioning for older people. In addition the council and CCG have chosen to pool budgets associated with mental health to enable the commissioning of a common service offer. Each organisation has separately agreed the amounts of resource to be pooled through CCG Governing Body and council cabinet – refer to BCF submission template. The agreement to work together is set out in detail in the section 75 agreement signed by the CCG and the council. The value of pooled budget Lambeth BCF plan is £23,543,690, comprising £1,145,265 from the London Borough of Lambeth and £22,398,425 from NHS Lambeth CCG. The CiC is accountable to London Borough of Lambeth Cabinet for the council and the CCG Integrated Governance Committee respectively. The CiC reports at least six monthly to the Health & Wellbeing Board. Performance against BCF metrics are reviewed at each Committees in Common meeting and consideration and agreement to any remedial action is agreed and reviewed. Committees in Common reviews and agrees all related integrated commissioning business cases.


5. A clear articulation of how Lambeth plan to meet each national condition 5.1 Plans to be jointly agreed

Local Authority London Borough of Lambeth

Clinical Commissioning Group (CCG) NHS Lambeth CCG

Boundary Differences No boundary difference

Minimum required value of BCF pooled budget: 2016/17

£23,544,000

Total agreed value of pooled budget: 2016/17

£23,543,690

This figure is comprised of £1,145,265 from the London Borough of Lambeth and £22,398,425 from NHS Lambeth CCG

Confirmation of specific areas of expenditure within BCF plan: (Note for detailed expenditure against all schemes contained in BCF, please refer to the management template that

accompanies the narrative plan)

2015/16 £

2016/17 £

Disabled Facilities Grants (DFG)

615,000 1,145,265

Care Act implementation

865,000 865,000

Carer’s funding 572,000 572,000

Reablement funding 2,163,000 2,663,000

Protecting adult social care 6,916,000 6,916,000

NHS out of hospital services funding 8,150,000 8,415,000

Lambeth’s pool fund reflects the Spending Review. Provider participation in decisions regarding services included in the BCF is part of continuous contract monitoring, including an agreed transformation programme. Lambeth’s submission reflects a ‘steady state’ in 2016/17 against an assumption of increasing activity. The BCF plan will maintain stability and further embed and transform services.

We confirm DFG will be allocated through BCF in the amount of £1,145,265. Lambeth Council is a unitary organisation which has housing authority responsibility and outcomes across health, social care and housing have been considered in developing the BCF plans. 5.2 Maintain provision of social care services Protecting social services means ensuring that there are sufficient resources for social services that promote health and wellbeing and reduce demand on health services, in particular those at the


interface of health and social care where seamless services are required to improve user experience and promote efficient use of resources. This means focusing BCF on areas that would otherwise be vulnerable under current funding reductions facing local authorities, combined with rising demand for services due to demographic factors. This includes maintaining current levels of eligibility criteria at substantial and critical needs, provision of assessment, care packages and personal budgets for home based care, reablement, intermediate care and hospital discharge and support to carers, and signposting to prevention and community support services for those below the eligibility threshold. Lambeth’s adult social care services continues to be supported, the value in 2016/17 is £6,916,000 described in the following table.

BCF adult social care schemes

7 day working for social workers in hospital supporting discharge from hospital

Health care support to care homes including training and care planning for people with dementia

Integration of admission avoidance schemes and reablement for streamlined provision of health and social care

Development of single point of access including self referral, to community based services for faster access, especially when people are being discharged from hospital

Continued development and implementation of fully integrated model of reablement providing health and social care practitioners re help people remain independent

Implement new model of provision of community support for adults and older people, promoting personalisation and preventative approaches, utilising the CarePlace web based e-brokerage system

Develop joint health and social care approaches to personal budgets, including direct payments

Improve digital access where appropriate to assist people in being able to access information and participate in society

Develop community assets working with local communities and the third sector to improve the support offer to people and carers, creating a strong and confident community response

Our intent is to ensure stability for social care. For example we have addressed provider failure for reablement services by putting additional resource into developing a fully integrated service host by Guy’s and St Thomas (GSTT) Adult Community Service (Refer Appendix II Case Study Reablement). We have agreed an uplift in tariff to home care providers to ensure the London Living Wage is available for carers, recognising the importance of the carer role, as well as providing stability in our home care market. The implementation of the Care Act 2014 has bought significant changes to service delivery, including improved systems and a redesigned ‘Customer Pathway’ with new assessment tools to ensure staff meets their duties under the Act. Improvements include:

New Care Act compliant assessment tool for Adults and Carers

New Care and Support Plan/Support Plan Templates

New resource allocation system

Improvement in assessment quality and equity in provision of support

Improved offer for carers


Increased Advocacy services

Improved customer pathway

Provision of information and advice

Streamlined Direct Payment Pathway

Support for self-funders

5.3 7-day working to prevent admission and facilitate discharge Lambeth has already established a range of community based services operating 7 days a week across health and social care to prevent unnecessary non-elective (physical and mental health) admissions to acute settings, and to facilitate transfer to alternative care settings when clinically appropriate. These are outlined in the next table.

7 day services included in Lambeth BCF

Enhanced rapid response team

GSTT@ home (now including PAL@home providing a 24/7 district nursing service to end of life patients)

Reablement

Community equipment

Supported discharge

Intermediate care beds

Other 7 day services not included in BCF

Community nursing

Specialist palliative care services

Extended GP services available in four hubs operating 8am to 8pm weekdays and 10am to 6pm at weekends and bank holidays (Prime Minister Challenge Fund pilot)

24/7 mental health crisis support line

Mental health home treatment teams for working age and older adults

Liaison psychiatry based at Guy’s and St Thomas’ and King’s College Hospitals

Home care services

Lambeth has established 7 day integrated working within our two local acute hospitals Guy’s and St Thomas’ and King’s College Hospitals. These services are ensuring patients are discharged safely over the weekend. These include:

7/7 hospital based social workers

Additional consultant ward rounds

Pharmacy and transport

Additional therapy support to plan and facilitate discharges

Community equipment satellite stores in both hospitals Strong progress has been made in ensuring that all local partners meet the milestones associated with the Clinical Standards for 7 Day Services. This has been a core principle of the Our Healthier South East London work, with providers collaborating to see where individual providers need to make progress, and what the interdependences are for services. The requirement to meet these standards has also been included in provider contracts and as such any risk associated with providers being non-compliant will be addressed through strong contractual management.


We plan to establish a regular review of 7 day working in partnership with providers via Lambeth and Southwark Urgent Care Working Group (UCWG). This will set new stretch targets for weekend discharges from Guy’s and St Thomas’ and King’s College Hospitals, and agree KPIs to ensure timeliness of discharge for patients requiring social care support either at home or in a residential placement. This will also ensure that BCF schemes are joined up across the partnership working at UCWG, and support winter planning. Action plan for 7/7 working:

5.4 Better data sharing between health and social care, based on the NHS number A local shared patient record that incorporates health and social care enables services to work in a more streamlined and constructive way for people they support. Local health and care systems have struggled to share meaningful information in real time that is timely and has sufficient governance incorporated into the process. An integrated care record supports an holistic understanding of the individual receiving health and care for all professionals involved, and provides a platform for effective and efficient health and care provision that all providers understand. Residents and patients assume that there is already a process in place to share information and are often frustrated by the lack of a ‘joined up’ approach, answering similar questions with each practitioner that provides an intervention. The NHS Number has always been identified as the preferred unique identifier for patients / users. All health providers use the NHS Number with excellent progress having been made to maintain data quality. The council went through a NHS number cleansing process in 2015/16 and 95% of records now have the NHS number identified. Lambeth CCG provides information about how GPs and the CCG use an individual’s data, and the person’s right to choose whether they want their personal health data is shared. This is available on the Lambeth CCG website (http://www.lambethccg.nhs.uk/your-health/Information-for-patients/Pages/default.aspx). The website provides a comprehensive explanation of how and why data is used, as well as a description and purpose of the Local Unified Care Record (LUCR) being developing in Lambeth and Southwark – see below for details regarding LUCR. The patient choice not to share their record, expressed to any one or all of the partner organisations (King’s, Guy’s, SLAM or Primary Care), will be recorded in the partner organisation system and will exclude ALL record sharing for the patient between the partners. In 2015/16 we established our LUCR (Local Unified Care Record). This has enabled the real time sharing of clinical information between Kings Health Partners (Guy’s and St Thomas’, King’s College, and South London and the Maudsley NHS FT) and primary care across the boroughs of Lambeth and Southwark. It recognises the complexity of the various information needs and the technical difficulty of developing integrated systems.

Domain

7/7 working Q1 Q2 Q3 Q4

Agree KPIs with providers that demonstrate effective weekend discharging

Establish reporting of 7/7 working in URWG

Establish regular review of 7/7 KPIs and consequential actions in UCWG

Review

http://www.lambethccg.nhs.uk/your-health/Information-for-patients/Pages/default.aspx

http://www.lambethccg.nhs.uk/your-health/Information-for-patients/Pages/default.aspx


The main health providers are committed to their EPR systems and have instead a clinical portal (across acute, community and mental health). With all GP practices using EMIS Web this is an ideal opportunity to make the ‘link’. LUCR allows Primary Care clinicians to view all KHP vital clinical information, including community services from within their EMIS Web. It builds upon local IM&T strategies. It is a portal, based on NHS numbers, follows IG, is fully auditable, ITK compliant, easily accessed from the existing partner EPRs. Via the newly established Strategic Partnership Board that has replaced the SLIC programme, LUCR will to extend into social care and NHS adult community services during 2016/17. With common goals of patient centred care and patient empowerment, the final stage would look to integrate into a local patient/public portal. Data sharing agreements with all partners is approved. LUCR aligns to the work underway with the MIG (Medical Interoperability Gateway) for the viewing of primary care records across the patch. Work continues in developing an overarching Data Sharing Agreement (DSA). This has been via a Local Unified Care Record Data Sharing working group, comprising of Caldicott leads, LMC GP leads, and IG leads. Key principles are:

A framework to share between the organisations who are subject to the agreement (in accordance to the DPA and Caldicott principles)

An agreement to share clinical information. The actual data set of information shared will be constrained by the system design and capability.

A programme of communication to inform patients that in the course of their care data will be shared between clinicians with a legitimate reason to access their records

Mechanisms to establish and record patient opt out preferences

Appropriate system logic to exclude patient information on the basis of expressed opt out. Feedback from GPs and practice staff during roll out of LUCR February 2016

As part of our Quarter 3 2015/16 BCF submission, we confirmed the following position for NHS number and APIs across the system for Local Unified Care Record (LUCR):


Action plan for Local Unified Care Record (LUCR)

5.5 Ensure a joint approach to assessments and care planning and ensure that, where funding is used

for integrated packages of care, there will be an accountable professional Using risk stratification in individual practices, primary care offers identified older adults/frail elderly a proactive, holistic health assessment (HHA) to support early identification of issues and risks. Risk stratification is led by primary care using EMIS-Web. Currently 3,543 adults have been identified through risk stratification. Patients identified will be supported by GPs or Integrated Care Managers (ICMs). Care management and co-ordination ensures people are engaged in their own care and that a full range of support is made available to improve overall wellbeing and outcomes, and reduce the need for unplanned hospital admissions. GPs and ICMs are supported by Community Multi-Disciplinary Teams (CMDTs) meetings. These meeting provide additional advice and support, help to unblock service issues and problems, and ensure holistic care is being offered. CMDTs are based in each of the three Lambeth localities. CMDTs consist of professionals from acute trusts, mental health, social care and adult community health services. At February 2016, the level of HHNA provided to individuals was 5441 with 836 receiving case management. Both have exceeding our 2015/16 target of 3939 and 659 respectively. Lambeth will continue to fund both HHA and CMDTs, and will be commissioning the three Lambeth GP Federations to manage this outcomes focused programme. Through SLIC we commissioned an

GP Hospital Social Care Community Mental health Specialised palliative

NHS Number is used as the consistent identifier on all relevant

correspondence relating to the provision of health and care services

to an individual Yes Yes Yes Yes Yes Yes

Staff in this setting can retrieve relevant information about a service

user's care from their local system using the NHS Number Yes Yes Yes Yes Yes Yes

Please indicate across which settings relevant service-user information is currently being shared digitally (via Open APIs or interim solutions)

To GP To Hospital To Social Care To Community To Mental health To Specialised palliative

From GP Shared via Open API Shared via Open API

Not currently shared

digitally

Shared via interim

solution Shared via Open API

Shared via interim

solution

From Hospital Shared via Open API Shared via Open API


digitally

Shared via interim


Shared via interim

solution

From Social Care


digitally


digitally

Shared via interim

solution


digitally


digitally


digitally

From Community

Shared via interim

solution

Shared via interim

solution


digitally

Shared via interim

solution

Shared via interim

solution

Shared via interim

solution

From Mental Health Shared via Open API Shared via Open API


digitally

Shared via interim


Shared via interim

solution

From Specialised Palliative

Shared via interim

solution

Shared via interim

solution


digitally

Shared via interim

solution

Shared via interim

solution

Shared via interim

solution

In each of the following settings, please indicate progress towards instillation of Open APIs to enable information to be shared with other organisations

GP Hospital Social Care Community Mental health Specialised palliative

Progress status Installed (not live) Live In development In development Live In development

Projected 'go-live' date (dd/mm/yy) 30/06/16 Complete 31/03/17 30/06/16 Complete 31/03/17

Is there a Digital Integrated Care Record pilot currently underway in

your Health and Wellbeing Board area?

Pilot currently

underway

2. Proposed Metric: Availability of Open APIs across care settings

3. Proposed Metric: Is there a Digital Integrated Care Record pilot currently underway?

Domain

Develop underpinning, integrated datasets and information systems Q1 Q2 Q3 Q4

Senior project team established to extend local unified care record (LUCR) to

include social care

Implementation of project to share LUCR between council and health partners

Review


independent evaluation from RAND/University of Cambridge. The first stage evaluation showed a small but statistically significant impact from practices undertaking the processes on emergency admissions and increased used of planned care. This was compared with comparable CCGs elsewhere in London and England. We will be receiving further evaluation reports over the next year based on a larger data set. Lambeth has an estimated prevalence of 1513 people living with dementia and has exceeded the NHSE target of estimated prevalence via QOF recording, currently at 85.3%. Services provided following diagnosis include Alzheimer's Society providing support to people with dementia and their carers via a local Dementia Advisor and Dementia Support Worker, working closely with primary care services. Integrated commissioners will continue to work closely with community groups, Alzheimer’s Society, Healthwatch, statutory services to review services and coproduce effective use of local dementia services budget. 5.6 Agreement on the consequential impact of the changes on the providers that are predicted to be

substantially affected by the plans Health and social care providers Our local acute trusts have been key members of the Southwark and Lambeth Integrated Care (SLIC) programme and are part of the newly established Strategic Partnership Board. They have been closely involved in producing and delivering the integrated care strategy to date, as well as being involved in delivering some of the new integrated service models, for instance the admission avoidance programme. Regular reports on the BCF go to contract meetings with acute providers, and the findings are discussed to ensure that all parties are not only sighted, but actively involved in the design and delivery of BCF plans. In conjunction with Southwark, we are introducing a CQUIN to support coordination of care across key health and care provider partners as this is recognised as fundamental to improving quality of care and improving effective utilisation of resources. The ‘Care Coordination’ shared contract incentive seeks to provide high quality integrated care for Lambeth & Southwark citizens. The key enabler for this incentive will be the five primary care Local Care Networks (LCNs) across Lambeth and Southwark. LCN provider partners have committed to work together to define and agree care processes relating to management of people with complex needs. Specifically, all five LCNs will develop and implement proactive and person-centred care coordination for people with complex needs; the precise definition of this target cohort will be based on complex needs rather than age, with the number of Long-term Conditions (including Mental Health and Frailty diagnoses) and care-based factors (e.g. housing status, social isolation) used as markers of need. It will be a two-year incentive scheme. Our detailed proposals for integration in Lambeth, including the schemes to be funded from the BCF, have been shared and discussed with acute providers at Committees in Common, SLIC meetings, and a Southwark and Lambeth joint planning meeting which includes CCG and Local Authority commissioners as well as representatives from our local acute providers (Guy’s and St Thomas’, King’s College and South London and Maudsley NHS FTs). Service providers have also been active participants in a number of change programmes and consultations that together help form our local integration programme. For instance, home care providers are working with hospital social workers to ensure discharge to home can be supported during


weekends for some social care packages. We are also working with our main care home provider to ensure discharges occur seven days a week. Primary care providers are CCG council members and key members of the SLIC and Strategic Partnership programme, actively involved in shaping our approach to integration and BCF. As part of the PMS review, Primary Care will also be incentivised under the system wide CQUIN. We have included a cast study describing how collaborative work with GSTT Community is driving transformation and integration of reablement services – refer Appendix II Case Study Reablement. Public, patient and service users The plan is underpinned by a vision for improving services in the community through better integrated working and is shaped by a range of engagement and collaborative activity. The Big Lambeth Health Debate previously mentioned together with our integration project (SLIC), has developed much of the thinking behind our approach. SLIC has actively consulted with the public through its Citizen's Forum over the past 30 months. For example, Lambeth and Southwark commissioners, working with the SLIC team, held engagement events with residents to identify what people wanted as outcomes from integration and to help us articulate those outcomes from a resident’s perspective and shape BCF schemes. Citizens Forum told us:

That they wanted all their needs looked at, with physical and mental health and social care needs all taken into consideration

That they wanted more time to talk to a professional at their GP practice, who understood their needs

That they wanted support to stay fit and healthy for as long as possible

That they wanted to stay out of a care home or hospital as long as possible but if they had to go to hospital, they wanted to be assessed and treated as quickly as possible and return home

That they wanted their care to be coordinated better, particularly when living at home in the community or being discharged from hospital

Translated into ‘I’ statements this is what our population say they want for themselves:

I live the life I want

I am part of a community

I am as healthy as possible

I am at the centre of my care and support: it is organised around me

I can manage my own condition and get support to do this if I need it

I live independently

I have as small a disruption as possible to my life when a crisis happens

I feel safe and respected, my dignity is maintained and I do not experience any discrimination or harassment

BCF responds with services that:

Shift support from ‘doing for’ to ‘doing with’,

Promote self-care

Focus on prevention and early support


Promote physical and mental wellbeing

Support the critical role of carers

Foster more resilient communities able to provide to people and carers co-produced with the third sector and local communities

Engagement regarding schemes contained in the BCF is iterative rather than a stand-alone process. Lambeth has a number of key partnerships between citizens, commissioners and local providers of care. Excellent collaborative working with Lambeth Healthwatch and Age UK Lambeth provide service user and public insight and influence into BCF focused services. Additionally we are using outcomes focused indicators to improve quality, informed by service users. Healthwatch have been closely involved through the various BCF and integration discussions at HWB, HWB workshops and CCG Boards and other events and also providing service user and patient feedback to a number of individual schemes included in the BCF. The response from citizen’s has also ensured our local performance metric focuses on people with a long term condition feeling supported by their GP to manage their health. It has also informed the development of our quality metric with Guy’s and St Thomas’ adult community services where we are seeking to understand satisfaction and confidence with the @home service that provides intensive medical support for a short period of time so patients can remain at home. Community and voluntary sector We continue to work closely with Age UK Lambeth and commission them to provide the successful Safe and Independent Living (SAIL) service, and Seasonal Health Promotion (SHP). SAIL aims to support older people to maintain their independence, safety and wellbeing by providing a quick and simple way to access a wide range of local services. The service receives a high proportion of referrals from GPs, as well as other health services, housing and police. SAIL ensures people are links to support that helps them maintain independence and health and wellbeing for example a handy person to carry out repairs, link a person to a befriending service. SHP carries out health promotion campaigns during winter (Warm and Well in Winter) and summer (Cool as a Cucumber) seasons. SHP aims to reduce social isolation, improve well-being amongst older people in Lambeth through promoting community activities where people can access information and practical measures on keeping warm and well or staying cool during summer. Project Smith has been established to test working at ward level with communities and individuals to support strengthening community connection and support. All of Project Smith’s workstreams are co-produced with local citizens. Project Smith is based on ‘I statements’ identified by Lambeth citizens as important to them:

I can manage my own condition and get support to do this if I need it

I live independently

I feel part of a community The project has three workstreams - (1) an outcomes based small grants scheme focusing on improving health and wellbeing; (2) provision of training (PH NVQ level 2) and local infrastructure to local individuals who will become ‘community connectors’ supporting and linking individuals with statutory


services and community group to improve their health and wellbeing; and (3) a live map of local and statutory assets available to all who live in the area. The Independent Living and Carers’ Partnership brings together a partnership of Age UK Lambeth, Disability Advice and Support Lambeth, Help for Carers and Lambeth Mencap to provide support and advice to carers in Lambeth. These four organisations provide a range of services that promote independence as well as improving quality of life and are being delivered in partnership with the London Borough of Lambeth and Lambeth Clinical Commissioning Group (CCG). Specialised staff with appropriate skills and knowledge, support older people (55+), disabled adults, adults with long term conditions and all carers including young carers (5-18 years). 5.7 Agreement to invest in NHS commissioned out of hospital services, which may include a wide

range of services including social care Lambeth continues critical investment of £8,415,000 in out of hospital services. As with all other parts of our plan, this expenditure has been jointly agreed between the Council and CCG. NHS commissioned out of hospital services from 2015/16 will continue at the same level for 2016/17 ensuring consistency of approach, and it is hoped will yield further benefits given that schemes are now better established. The main out of hospital schemes in our BCF plan are:

@home offers more intensive medical support for a shorter period of time (usually two to seven days). This service enables patients either to avoid coming into hospital at all, or to help them return home sooner with extra support.

Enhanced rapid response and supported discharge provides home based rehabilitation and support targeted at adults and older people with a physical or sensory disability, with the aim of them regaining or maintaining independent living within the community and preventing unnecessary hospital admission. The rapid response service carries out a holistic assessment of needs, within two hours if required, and put support in place to prevent unnecessary hospital admissions. Referrals are accepted from a range of areas including GPs, Community Matrons, District Nurses, community therapists, London Ambulance Service, A&E and other acute wards, and acute assessment units.

Intermediate care in Lambeth is provided to patients requiring a step down service on discharge from hospital. The service supports patients aged 18 and over, and is designed to promote faster recovery from illness, prevent unnecessary acute hospital admission and premature admission to long-term residential care, support timely discharge from hospital, reduce delayed transfers of care, and maximise independent living.

Analysis of these schemes has shown that:

Over 500 LAS conveyances to hospital have been averted thanks to the use of the Alternative Care Pathway established between @home and London Ambulance Service (LAS).

Over 3000 patients have been supported by @home during the course of 15/16, with an average length of stay of 6 days. This has led to a material reduction in admissions at local hospitals and a reduction in length of stay for patients who are admitted as they are able to access enhanced out of hospital support.

Less than 10% of patients referred to @home are admitted or re-admitted to hospital, demonstrating the effectiveness of the service and its ability to provide acute care at home.


5.8 Agreement on local action plan to reduce delayed transfers of care (DTOC) Performance on DTOC in 2015/16 has been improving over the year but remains above the target we set for 2015/16 of 596 (per 100,000 population per quarter). Against a target of 5.2 DTOC per 100,000 population, our forecast outturn for 2015/16 is 7.6 per 100,000. Key to system wide planning is the need to continue the significant progress made on reducing levels of DTOCS. Lambeth have low levels of DTOCS compared to national performance. However, as part of 2016/17 Better Care Fund plans, we have committed to trying to reduce these figures yet further. This is consistent with our CCG operating plans, and the plans of the Lambeth, Southwark and Bromley System Resilience Group. In devising an action plan for further reducing DTOC in Lambeth we have based our work around the eight high impact interventions:

Early discharge planning

Systems that monitor patient flow

Multi-disciplinary and multiagency discharge teams, including voluntary and community sector

Home first/discharge to assess

Seven day services

Trusted assessors

Focus on choice

Enhancing health in care homes There is a robust governance and accountability structure in place through which DTOCs are analysed and managed. The diagram below depicts this structure.

From analysis of DTOCS in 2015/16, it is noted that a significant proportion of DTOCs stem from patient and family choice, particularly where patients and their families have not made, or been supported in making, decisions about care arrangements post hospital. To help reduce these delays, in 2016/17, a new Best Practice Discharge Protocol has been agreed and being rolled out across Guy’s and St Thomas’


and King’s College Hospitals. The protocol gives clearer advice to patients and their carers’ and families about what support the patient is likely to need post-discharge to aid forward planning. The protocol supports staff in understanding the need for an integrated and multidisciplinary approach to aid effective discharge. In designing the Best Practice Discharge Protocol we worked extensively with Healthwatch across Lambeth and Southwark to ensure patients and public influenced how to make discharge from hospital effective with a process that made sense to them. Our analysis has also indicated that the main area of overperformance for DTOC is with our mental health provider South London and Maudsley NHS FT (SLaM). Commissioners will be working closely with SLAM to understand and resolve DTOC issues and this is included in the DTOC section of the action plan – see below (for full action plan refer to Appendix V BCF Action Plan). In Lambeth we have a number of work streams underway to support continued reduction of DTOC which include:

Three discharge related CQUINS which include:- Cross system care coordination Clinical Utilisation Review Timeliness of discharge and staff training

The development and implementation of a best practice protocol for managing discharge from an NHS bed including a process for managing and resolving dispute and patient choice issues

Step-down to assess extra care flats

South East London Repatriation Project

Needs assessment of specialist neuro-rehabilitation bed capacity across the sector, development of a specification to create additional capacity which is currently out to providers for expression of interest

Simplified discharge group which has representation from GSTT, KCH Lambeth and Southwark councils and Lambeth and Southwark Healthwatch organisations

Review of continuing care assessment processes and paperwork

Input into reducing the number of mental health DTOCs include Voluntary sector provider (One Support) who proactively case manages and works with ward

staff to facilitate discharge – includes interventions around housing and benefit Development of local escalation processes for mental health delays

Commissioner input into resolving issues with complex placements The main focus for DTOC in 2016/17 will be working with our mental health provider to review, analyse and resolve mental health DTOC issues.


Domain

Delayed transfers of care (DTOC) Q1 Q2 Q3 Q4

Review mental health services DTOC performance with provider highlighting

areas of concern and improvement

Continuous review of mental health services DTOC performance at all monthly

core contract meeting as standing item on agenda

Mental health services provider to escalate specific DTOC cases to Lambeth

CCG commissioning when inpatient discharge plan is unable to be

implementedTo implement reporting mechanism whereby mental health provider regularly

report on DTOC’s arising from internal delays between inpatient units

To undertake six monthly review of mental health One Support service to

evaluate its effectiveness in improving DTOC

Establish reporting of DTOC in UCWG

Establish regular review of DTOC and consequential actions in UCWG

Implementation and monitoring impact of Best Practice Discharge Protocol via

UCWG

Ongoing evaluate of discharge to assess for higher level needs pilot scheme in

Extra Care flats

Ongoing evaluation of interim discharge arrangements to Extra Care for those

with housing needs

Continue commissioner/provider joint work on streamlining continuing

healthcare assessment process

Review


6. An agreed approach to financial risk sharing and contingency

Name of Health and Wellbeing Board: Lambeth

Is there an amount held as contingency as part of local risk share to ensure value to the NHS? (Y/N)

Yes

Value of contingency held:

£849k

Value identified as at risk in your BCF plan: £849k – this is mitigated in full as outlined below.

How you have calculated the value of the risk associated with your BCF plan?

The risk has been calculated on the basis of the potential non delivery of the 2% reduction in emergency admissions.

Please outline the rationale for your decision in relation to contingency and risk

The main risk to the CCG is the failure to reduce non elective activity in the acute sector which means that the CCG may also incur additional costs in terms of financial over performance should these not be managed in year. The performance fund is based on the agreed 2% reduction in emergency admissions and totals £849k. In terms of the risk to the BCF from any potential loss of funding during 2016/17, it has been agreed that it would be damaging to the delivery of successful service integration if an approach of disinvesting from BCF schemes were taken to balance the fund. It has therefore been agreed locally the CCG will set aside a contingency that can be used in the event of short term under performance. It should be noted that whilst the CCG is currently delivering the reduction in emergency admissions we continue to set aside a risk reserve locally for 2016/17.

Please specify the data behind your rationale

The target reduction in emergency admission based on the target for 2015/16 which is being currently being delivered.

If a risk share is not in place, please outline how you will mitigate any cost pressures of under-delivery of any elements of your BCF plan

Not applicable.


7. National metrics

Metric 2015/16 2016/17

Non- elective admissions (NEA): Measured by the rate of non-elective admissions per 100,000 population

On target to achieve Against a target of 2% reduction in NEA, on target to achieve a 4% reduction.

Operating plan indicates a 2% reduction per annum, therefore NEA for 2016/17 already achieved. 2016/17 plan NEA activity will remain stable using 2015/16 as baseline.

Delayed transfers of care (DTOC): Measured by the number of DTOC per 100,000 population for people aged 18+

Did not achieve target Target 5.2 per 100,000 population Forecast outturn is 7.6 per 100,000. NB there has been an improvement in reducing DTOC across the year: April 2015 - 9.0 per 100,000-February 2016 - 7.6 per 100,000

2016/17 plan DTOC activity will be number of delayed days per quarter, forecast average 589.1. Refer to DTOC action plan for mitigation.

Reablement: Measured by the proportion of older people 65+ who are still at home 91 days after discharge from hospital into reablement/rehabilitation services

On target to achieve Against a target of 96% of older people still at home, forecast outturn of 94.3%.

2016/17 plan for reablement is set at a lower target of 90.1%. The lower target has been set because reablement service will be the first offer for individuals who have been assessed to receive a home care package. There are some risks associated with this approach but we are confident the provider GSTT Adult Community Services has an excellent track record and will be able to deliver.

Permanent admissions to residential care: Measured by long term support needs of older people aged 65+ met by permanent admission to residential or nursing care per 100,000 population

On target to achieve Against a target 653 per 100,000, forecast outturn is 648.8.

2016/17 plan for admissions to residential care is 622. Continuity of the 2015/16 forecast against an assumption of increased activity has been agreed because:

test of enhanced reablement offer (see above) will have impact on residential admissions

Additional extra care facilities coming on line during 2016/17

Testing discharge to assess models during 2016/17

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