A vision for health and social care services in Suffolk … 1 of 129 BCF – template 1 – 28th November - FINAL A vision for health and social care services in Suffolk 2019/2020

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BCF – template 1 – 28th November - FINAL

A vision for health and social care

services in Suffolk 2019/2020

Better Care Fund Plan

Approved – December 2014

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Better Care Fund planning template – Part 1

1) PLAN DETAILS a) Summary of Plan

Local Authority Suffolk County Council

Clinical Commissioning Groups Ipswich and East Suffolk

Great Yarmouth and Waveney

West Suffolk

Boundary Differences

Great Yarmouth and Waveney Clinical Commissioning Group (CCG) is located in two Health and Wellbeing Board (HWB) areas – Suffolk and Norfolk. The information in this template refers to the Waveney element of the CCG geography only, although where possible, plans are aligned with Norfolk plans for Great Yarmouth.

Date agreed at Health and Well-Being Board:

27/11/2014

Date submitted: 28/11/2014

Minimum required value of BCF pooled budget: 2014/15

£2,718,000

2015/16 £50,042,000

Total agreed value of pooled budget: 2014/15

£2,718,000

2015/16 £50,042,000

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b) Authorisation and signoff

Signed on behalf of the Clinical Commissioning Group

Ipswich and East Suffolk

By Julian Herbert

Position Chief Officer

Date 27/11/2014



By Andy Evans

Position Chief Executive

Date 27/11/2014


West Suffolk

By Julian Herbert

Position Chief Officer

Date 27/11/2014

Signed on behalf of the Council

Suffolk County Council

By Anna McCreadie

Position Director of Adults and Community Services

Date 27/11/2014

Signed on behalf of the Health and Wellbeing Board

Suffolk Health and Wellbeing Board

By Chair of Health and Wellbeing Board Alan Murray

Date 27/11/2014

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c) Related documentation

Document or information title

Synopsis and links

A Joint Health and Wellbeing Strategy (JHWS) for Suffolk

Sets out a joint vision for health and wellbeing in Suffolk. The focus of this report is on four areas jointly agreed as priorities for the first three years of a 10 year health and wellbeing strategy, 2012-2022. The priorities are used to provide focus for plans across health, local authorities and other relevant organisations ensure sure we work together as efficiently and effectively as possible, spending public money in a better way. http://www.healthysuffolk.org.uk/assets/Useful-Documents/Health-and-Wellbeing-Strategy.pdf

Joint Strategic Needs Assessment (JSNA)

The Suffolk JSNA is a suite of resources to inform health and care commissioning. It is formed of a dynamic set of data presented in the Suffolk Observatory, alongside reports, profiles and health needs assessments produced to inform the JHWS and other commissioning plans and strategies. http://www.suffolkobservatory.info/JSNA.aspx

Ipswich and East CCG Operational Plan 2014/15 – 2015/16

The Operational Plan includes the key operational metrics needed to support the assurance of and measure performance against strategic plans including financial and QIPP plans. http://www.ipswichandeastsuffolkccg.nhs.uk/Portals/1/Content/Library/Governing%20Body%20papers/25%20March%202014/Agenda%20item%2008%20-%20IESCCG%2014-14%20Two%20Year%20Plan.pdf

West Suffolk CCG Operational Plan 2014/15 – 2015/16

The Operational Plan includes the key operational metrics needed to support the assurance of and measure performance against strategic plans including financial and QIPP plans. Operational Plan 2014/15 and 2015/16 | NHS West Suffolk Clinical Commissioning Group

Health and Care Review model

See Documents 1 and 2 in Suffolk Better Care Fund Template – Additional Related Documentation These reports show different aspects of our integrated system and have informed the Better Care Fund schemes in the Ipswich and East and West Suffolk areas.

Great Yarmouth and Waveney CCG 2 Year Operational Plan (incorporating a copy of Seven Day Services bid)

The Operational Plan for GY&W CCG. This document has a strong focus on the development of an Integrated Care System. It also contains a copy of the successful bid for 7 day services to the Transformational Improvement Programme http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/nhsgreatyarmouthandwaveneyccgoperationalplanpublicfacingversion_activelinks.pdf

http://www.healthysuffolk.org.uk/assets/Useful-Documents/Health-and-Wellbeing-Strategy.pdf

http://www.healthysuffolk.org.uk/assets/Useful-Documents/Health-and-Wellbeing-Strategy.pdf

http://www.suffolkobservatory.info/JSNA.aspx

http://www.ipswichandeastsuffolkccg.nhs.uk/Portals/1/Content/Library/Governing%20Body%20papers/25%20March%202014/Agenda%20item%2008%20-%20IESCCG%2014-14%20Two%20Year%20Plan.pdf




http://www.westsuffolkccg.nhs.uk/about-us/operational-plan-201415-and-201516

http://www.westsuffolkccg.nhs.uk/about-us/operational-plan-201415-and-201516

http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/nhsgreatyarmouthandwaveneyccgoperationalplanpublicfacingversion_activelinks.pdf



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Suffolk County Council Adult and Community Services service plan 2014/15

The ACS service plan sets out the priorities and action for ACS over the year 2014/15 http://www.suffolk.gov.uk/assets/suffolk.gov.uk/Your%20Council/Plans%20and%20Policies/Directorate%20Plans/2014-04-25%20%20Final%20Adult%20%20Community%20Services%20Directorate%20Plan%202014-15.pdf

Suffolk County Council Cabinet Paper 21 February 2012: Adult and Community Services: Supporting Lives Connecting Communities

Within Adult and Community Services (ACS) a new social work operating model has been developed to reflect the directorate’s Service Plan and priorities including the new way of working titled: Supporting Lives, Connecting Communities (SLCC). SLCC relies on a person centred approach to planning and designing care, collaborative working between all parties around the person, keeping people living independently at home, helping people to help themselves, putting people in touch with what’s happening in the community that can help them, getting people back to independence as quickly as possible after a crisis and providing ongoing support only for those who need it. http://committeeminutes.suffolkcc.gov.uk/LoadDocument.aspx?rID=0900271180640bea&qry=c_committee%7e%7eThe+Cabinet

Great Yarmouth and Waveney CCG Engagement Strategy

This Engagement Strategy reflects the vision and goals of HealthEast. It builds on extensive engagement completed during the development of NHS Great Yarmouth and Waveney’s Communications and Engagement Strategy, with focus on patient engagement and clinical commissioning, engagement from staff, partners, stakeholders, individuals and groups, as well as a baseline mapping exercise. http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/commsandengagementstrategy_july2013update.pdf

Tricordant Report: Joined up Services for Older People

The Tricordant pathway enables health and social care integration at both micro and macro-levels. Tricordant was jointly commissioned to map its person centred health and care pathway for older people in Suffolk. It included not just partnership between health and social care, with local authority housing, leisure and education services as well as the police, backed by the social capital in the voluntary and faith sectors. This work has informed the service model design, priorities and work programmes. The outcomes of this report were taken to the shadow Health and Wellbeing Board on the 1st December 2011 within the Suffolk Ageing Well – Transformation for Achievement Stage 2 Report”. Copies of the HWB report are available from Committee Services at Suffolk County Council ([email protected])

http://www.suffolk.gov.uk/assets/suffolk.gov.uk/Your%20Council/Plans%20and%20Policies/Directorate%20Plans/2014-04-25%20%20Final%20Adult%20%20Community%20Services%20Directorate%20Plan%202014-15.pdf




http://committeeminutes.suffolkcc.gov.uk/LoadDocument.aspx?rID=0900271180640bea&qry=c_committee%7e%7eThe+Cabinet

http://committeeminutes.suffolkcc.gov.uk/LoadDocument.aspx?rID=0900271180640bea&qry=c_committee%7e%7eThe+Cabinet

http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/commsandengagementstrategy_july2013update.pdf

http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/commsandengagementstrategy_july2013update.pdf

mailto:[email protected]

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Terms of Reference GYW Integrated Care System Programme Board

Sets out the remit and responsibilities of the Programme Board http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/agenda_governing_body_part1-30january2014.pdf Copies of the following documents are available on request from [email protected]

• GYW System Leadership Board Terms of Reference

• GYW Integrated Care System Operational Group Terms of Reference

• GYW Better Care Fund Plan on a Page

Integrating health and care systems to support healthy ageing: Public Health Suffolk December 2013

This paper summarises the findings from an evidence review of health system models that support healthy ageing. The review focuses on healthy ageing policies and on the integration of health and social care systems. Both local and international examples are presented. Discussed at the Health and Wellbeing Board on 12th December 2013. http://committeeminutes.suffolkcc.gov.uk/LoadDocument.aspx?rID=0900271180fc1023&qry=c_committee%7e%7eSuffolk+Health+and+Wellbeing+Board

Age UK Suffolk – Voice Project Reports

Older people are interviewed individually in their own homes, two or three times per year, on various subjects. These are agreed by a reference group, with members from Suffolk County Council ACS, NHS Suffolk, NHS Great Yarmouth and Waveney, Age UK Suffolk and representatives from older people themselves. Voice Project | Age UK Suffolk

Suffolk Family Carers Needs Assessment (Draft)

See Document 3 in Suffolk Better Care Fund Template – Additional Related Documentation Suffolk wide assessment of carers needs scheduled for completion in October 2014.

Report from Healthwatch on public engagement summer 2014

This report gives the public feedback on the Health and Care Review model, and the Better Care Fund schemes. http://www.healthwatchsuffolk.co.uk/sites/default/files/hasci_engagement_report_-_v9.pdf

http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/agenda_governing_body_part1-30january2014.pdf

http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/agenda_governing_body_part1-30january2014.pdf

mailto:[email protected]

http://committeeminutes.suffolkcc.gov.uk/LoadDocument.aspx?rID=0900271180fc1023&qry=c_committee%7e%7eSuffolk+Health+and+Wellbeing+Board



http://www.ageuk.org.uk/suffolk/about-age-uk-suffolk/voice-project

http://www.healthwatchsuffolk.co.uk/sites/default/files/hasci_engagement_report_-_v9.pdf

http://www.healthwatchsuffolk.co.uk/sites/default/files/hasci_engagement_report_-_v9.pdf

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2) VISION FOR HEALTH AND CARE SERVICES

a) The vision for health and social care services in Suffolk for 2019/20

The vision of Suffolk's Health and Wellbeing Board is that people in Suffolk live

healthier, happier lives. We also want to narrow the differences in healthy life

expectancy between those living in our most deprived communities and those who

are more affluent through achieving greater improvements in more disadvantaged

communities. The foreword to Suffolk's Joint Health and Wellbeing Strategy states

"Many things influence our health and wellbeing including the lifestyle we lead, the

environment we live in and the health and care services which support us". Our

vision recognises that to achieve improvements we all need to work together with a

common aim, principles and direction. Our vision has prevention at its heart and

seeks to address inequalities in Suffolk’s population

Suffolk’s existing health and care system, is not sustainable in the face of the

projected future level of need. Our population is older than the national average and

with this comes a higher than national average prevalence of long term conditions.

The demographic change anticipated in Suffolk between now and 2020 and looking

further forward 25 years is stark:

• The total population of Suffolk will grow by 3% by 2020 and 13% in 25 years

• The number of people aged 65 and over will increase by 14% by 2020 and by

almost 70% in 25 years

• The number of people aged 85 years and over in Suffolk is projected to

increase by 23% by 2020 and by 173% over 25 years (Source – ONS)

In Suffolk we spent £84m in 2013/14 on urgent care for our over 65 population. This

is likely to grow by at least £12m pa over five years due to the change in age

demographic alone. There are currently significant financial pressures within our

health and care system and these will worsen if we do not take action.

Our plans are designed to transform health and care services to meet these

challenges as follows:

• The whole system will be focused on preventing need, throughout people's

lives, whatever their age or health problems

• Health and care staff will be working in integrated teams delivering person-

centred coordinated care rooted in their locality and working closely with their

communities

• There will be a focus on people (with multiple long term conditions) rather than

single disease entities

• There is a growing recognition of the importance of frailty and dementia, and of

the need to support and educate informal carers

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• Hospitals will be strong and vibrant, delivering more planned care than

emergency care and providing expertise to teams in the community

• Voluntary and community sector organisations will be playing a bigger part in

supporting people with health and care needs

• More services will be jointly commissioned, taking advantage of pooled

funding arrangements to deliver transformed services.

Our vision will be delivered through two transformation programmes which

recognise the different populations and structures existing in the county. The Ipswich

and East Suffolk and West Suffolk CCGs (IEWS) are working with Suffolk County

Council to deliver integrated care through the Health and Care Review. Great

Yarmouth and Waveney CCG (GYW) is working with Suffolk County Council to

deliver change for the Waveney area of Suffolk and with Norfolk County Council for

the Great Yarmouth area through their Integrated Care System.

We will achieve this change through working in partnership across all parts of the

system, putting the patient and customer at the centre of our planning and through

being relentlessly focused on the changes we have signalled through this plan. Some

changes will be brought about through commissioning differently, some through

organisational service redesign and some through strong leadership translating this

vision into action on the ground.

b) What difference will this make to patient and service user outcomes?

People have told us what they think is wrong with our current system of health and

care provision. Over the summer of 2014 the CCGs and SCC spoke face to face

with over 500 members of the public across the county about our plans for

integrated care. Comments were gathered about problems now (and also the many

positive experiences) and views on the proposed changes.

People stated that they want to be independent for longer and that they

wanted services to work more closely together to achieve this with good

communications between professionals (particularly between mental health

services and primary care)

“There didn’t appear to be a joined up approach to her care and in the end they

both pretty much gave up with it all”.

“we just need to tell the problem once”.

‘Something that the she [a family member] loved is that her GP knew both her and

her husband by name and knew their health history”

“a single point of contact or one main co-ordinator would help a great deal by

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taking away a lot of the stress in trying to manage all the services.”

A lack of services over the weekend was also highlighted as a problem to

remaining independent.

“if the GPs worked seven day weeks, then both of us wouldn’t have had to go to

A&E… this would be the same for many people across Suffolk”.

People want services closer to home

“local centres seem to be a great idea”.

“would definitely use the local centre if available”.

“the best quality of care needs to be local”.

There was an acknowledgement that being better prepared for older age (including

mental as well as physical wellbeing) whilst likely to improve people’s outcomes, is

not happening widely enough and is heavily reliant on the family and friends

network the person already has. People want service providers to work to ensure

that those who do not have these networks are also better prepared for older age

as this is where most of the public feel there is a risk. A lack of information –

particularly on availability of Voluntary Care Service support was identified as a key

reason why people are not better prepared for ageing.

Our plans foresee that by 2020 most people in Suffolk will be living as

independently as possible and where people do fall into crisis or require ongoing

support the right help will be easily accessed and promptly provided. Taking a more

preventative approach will allow more people to reach old age as healthy as

possible and delay the onset of long-term conditions. A more proactive system will

also deliver better care to the increasing number of older people living with multiple

long term conditions.

The difference we will make to people in Suffolk is:

• They will find it easy to navigate around the health and care system to find the

right information, care or services that meet their needs.

• Their physical and mental health and care needs will be identified early – in many

cases before a crisis occurs.

• They will have access to a range of mostly local services throughout the week that

focus on supporting people to self-care and supporting primary prevention.

• They will have control and choice over their care, with greater access to personal

health and care budgets so that they can manage their own health and support

costs.

• They will have a named co-ordinator when they need help who will ensure that the

system works effectively, with a single care record.

• They will have access to planned care when they need it.

• They will have the help they need to recover from an episode of ill health including

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support to getting back to the things that they enjoy doing.

Our Health and Care Review and Integrated Care System plans are targeting

improvements that will lead to improved outcomes for service users and patients:

• Reduced emergency admissions to hospital: The focus of our Health and Care

Review and Integrated Care System on prevention and supporting people to live

independently will reduce the need for costly urgent and long term care. We are

targeting a reduction of 3.5% in total emergency admissions during the period Q4

2014/15 to Q3 2015/16, against a baseline of Q4 2013/14 to Q3 2014/15, which

equates to 2,241 admissions. The system recognises that this is the biggest driver

of cost that the Better Care Fund can affect and has quantified a benefit of £1.7m

as result of this reduction.

In GYW the existing Out of Hospital strategy is already leading to reduced

emergency activity. In IEWS the Integrated Neighbourhood Teams and wider

Integrated Neighbourhood Networks will provide a model of care which is more

holistic and preventative and less reliant on reactive emergency admissions.

• Improved patient and service user experience: We are committed to ensuring that

people have a positive experience of care. Suffolk patients and customers have

told us repeatedly that they want to experience a joined up system. The National

Voices patient centred coordinated care overarching definition is: “Integrated care

means person centred coordinated care [where…] I can plan my care with people

who work together to understand me and my carer(s),allow me control, and bring

together services to achieve the outcomes important to me”. We already listen to

patients and service users and measure their experience through a number of

mechanisms such as the Adult Social Care Survey and the GP Patient Survey. As

we further develop integrate care on the ground we are working with user led

organisations to develop effective co-production, so that our plans deliver what

works for people alongside a greater understanding of how we track and measure

patient experience. We will be using national resources such as the Making it Real

“Making progress towards personalised community based support” markers.

• Reduced rates of permanent admissions to residential care and nursing homes:

Suffolk has high rates of permanent admissions to residential care and nursing

homes for people aged 65 and over when compared with many other regions as

shown in the map below where Suffolk is outlined in red.

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Many of these admissions could be delayed or avoided through good support for

family carers. Evidence suggests that those who have no carer are more likely to

be admitted to care homes. Carer-related reasons for admission to nursing or

residential care are common, with carer stress the reason for admission in 38% of

cases and family breakdown (including loss of the carer) the reason in a further

8% of cases. Consequently, carer support services are fundamental to the new

system in enabling people to be supported in a sustainable way and to avoid

unnecessary admissions. Our plans take account of the impact that our ageing

population is likely to have on future admissions and aim to mitigate this future

pressure and target a reduction in the rate of admissions during the Better Care

Fund period.

• Improved reablement outcomes so that people do not have to return to hospital:

We will help people to recover from episodes of ill-health or following injury. This

will be achieved through Integrated Neighbourhood Teams and the Out of Hospital

Service supporting people more effectively once they are back home in the

community. People at risk of readmission will have a single co-ordinated plan that

is focused on helping them to return to and sustain their independence.

We have targeted an improvement of almost 7% by 2015/16 in the proportion of

people (65 and over) who remain at home 91 days after discharge from hospital.

This means that these people will avoid being readmitted to hospital possibly as a

costly emergency admission which will contribute to our overall planned reduction

in emergency admissions.

• Reductions in delayed transfers of care: Our aim is to ensure that we have an

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effective, integrated health and care system with acute, mental health and

community based care working together to ensure timely and appropriate transfer

from hospital.

We are targeting a reduction of 913 delayed days which will contribute to

commissioner savings as well as freeing up capacity within the hospital system.

• Dementia diagnosis We believe that every person with dementia, who wishes it,

deserves a timely diagnosis and to allow them to access post diagnostic support

with all the benefits that can bring for them, their families and carers. It is our

ambition to increase rates of dementia diagnosis from 54% (13/14) to 67% by

2015 and to further enhance care through greater integration and alignment. Our

planned models of care include:

o Dementia diagnosis services with seamless pathways between primary and

mental health services

o Development of a comprehensive post diagnostic service model for people

with dementia and their carers. This work is being undertaken jointly with


c) Change that will have been delivered in the pattern and configuration of services over the next five years, and how the Better Care Fund funded work will contribute to this

The changes to our system will be delivered through our two transformation

programmes

• The Health and Care Review in the Ipswich and East Suffolk and West Suffolk

CCG area

• The Integrated Care System in the Waveney area of the Great Yarmouth and

Waveney CCG.

The scope of these programmes is significantly wider than the schemes described within

this Better Care Fund plan.

The following diagram represents the change in focus of health and care provision in

Suffolk showing a shift of activity and resource from reactive to proactive and

preventative care.

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During the next five years people in Suffolk will experience a transformed health and care

system:

• From fragmented services to integrated locally based services

• From multiple, single focused assessments to one holistic assessment

• From multiple (sometimes conflicting) care plans to one co-ordinated care plan

Whilst the vision for integrated care is common across the whole Health and Wellbeing

Board area, the concrete changes that will deliver the vision are different in each area.

Ipswich East and West Suffolk CCGs area: Health and Care Review

Changes in service delivery that will bring about our vision for the future are:

• The creation of Integrated Neighbourhood Teams that bring together GPs,

community health and social care staff to work as one team. The teams will

proactively support the health and care of their local population, pulling in specialist

interventions and with access to reactive care as needed.

• Organisational processes will be integrated. People receiving health and care will

have one plan, and the people working with them will use the same procedures and

processes. Integrated Neighbourhood Teams will have local data and intelligence

that helps them to tailor resources to their local population needs.

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• The following diagram gives a high level picture of the proposed integrated system:

• Voluntary and community sector organisations will become key partners in care.

Working as Neighbourhood Networks with the support of a Local Area Co-ordinator

organisations within the network will be involved in delivering shared care and

support plans, particularly around issues of social isolation and lifestyle

• People will have the tools to manage their health, in particular where they have long

term conditions. This will include access to training, information and advice so that

they can understand the options and choices available to them, and trigger tools so

that they know what to do if their condition deteriorates.

• People at risk of deterioration and crisis will be identified and will receive a co-

ordinated response. This will be achieved through risk stratification and care co-

ordination, as well as the introduction of urgent care centres working along-side acute

hospitals.

• The diagram below shows the model for delivering urgent and emergency care.

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Great Yarmouth and Waveney CCG area - Integrated Care System (ICS)

By 2018/19 the citizens of Great Yarmouth and Waveney will receive their health and

social care, and some district/borough services, from a cohesive integrated care system

(ICS) acting as a single provider of services. The ICS will be user focused, delivering

high quality and safe services with an orientation to innovate and develop new methods

delivering better care based on the ideas and ambitions of professionals and the

feedback of users. Because it is operating in a coordinated way, eliminating inefficiency

and waste, and striving for more effective delivery methods it will be using resources

optimally and constituent member organisations will be in financial balance and able to

invest in further improvements The ICS is a radical, ambitious and transformational

approach towards integration, working across two county councils and two district

councils.

Changes in service delivery that will bring about our vision for the future are:

• Blurring of the boundaries between acute and community providers with shared

teams, in reach and out-reach services between the organisations.

• Larger, stronger, better resourced teams of GPs, nurses and other professionals

working from multi-disciplinary healthy living centres in close concert with non-

health partners such as benefits officers, community police staff and social care

professionals.

• A move away from traditional bed-based models within acute and community care,

to a model that supports people remaining safely at home, wherever possible.

This will be delivered through Out of Hospital Teams (one already up and running

with a team of health and social care workers, using shared facilities, increasingly

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sharing data and with streamlined management)

• An increase in preventative activity

• A Community hub will be developed in each of four areas across the CCG (two in

Suffolk) to support local communities and care closer to home across a range of

services including primary care, community health, social care, district/borough

councils and the 3rd sector.

• A change in the way in which we use capacity and provide community based care.

We will work with our acute provider to maximise reductions in length of stay and

reduce the need for inpatient care. Our proposed change in community bed

capacity involves commissioning care home bed days based close to local

communities, together with providing higher acuity community beds as necessary.

Closing capacity will prevent beds freed up by reduced emergency demand being

filled, and we also anticipate that our proposed scheme to have a strong GP

practice base at the ‘front door’ of JPUH will also reduce emergency demand

within JPUH.

• Pathway design around one stop services, and providing interventions in reduced

activity settings e.g. increased day case activity and moving some day case

activity to outpatient settings.

These changes will be experienced by everyone who accesses care and health services.

However they will be most felt by those with complex (often multiple) long term

conditions, the frail elderly and people with disabilities. Their experience will be of a

single system supporting them 7 days a week, regardless of the provider or which

organisation has commissioned the service.

All partners are signed up to the vision of integrated care. The Better Care Fund will be

an enabler for delivery of the change, and specific elements of the funding will be spent

on our Better Care Fund schemes as detailed in Template 2. Through pooling funding

and developing a joint plan at this level of detail the Better Care Fund deepens and

extends our understanding of how the mechanisms to deliver integrated care, particularly

the funding, might work. It is likely that without the Better Care Fund progress in these

areas would be limited and would shift at a slower pace.

The Better Care Fund will be used to part fund all of the schemes described in this plan.

IEWS Schemes

The service models which are being designed as part of the Health and Care Review

feature the following which have been captured as Better Care Fund schemes.

Scheme 1 - IEWS: Integrated Neighbourhood Teams

Multi agency, multi professional teams who proactively work to support people with

health and care needs and in particular those who are risk of hospital admission or

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deterioration in order to shift activity and resource from reactive to proactive and in so

doing reduce emergency admissions.

Scheme 2 - IEWS: Access to specialist services and support

Linking specialist services eg continence services and specialist dementia teams to

Integrated Neighbourhood Teams to support people with particular health and care

needs.

Scheme 3 (a) - IEWS: Admission prevention

Implementation of risk stratification and personalised care plans designed to get

upstream of a crisis in order to reduce the number of people who are admitted to hospital

during a crisis.

Scheme 3 (b) - IEWS : Admission prevention - crisis response.

Whilst our plans are targeting a shift in unplanned care to planned care, there will be

times when a crisis response is needed which will be achieved through partnership

working across the system.

Scheme 3 (c) - IEWS : Admission prevention - reablement and rehabilitation

Patients will have a single outcome focused reablement and rehabilitation plan which will

be coordinated by a named care coordinator in the Integrated Neighbourhood Team.

GYW Schemes

We believe that the development of an Integrated Care System across GY&W can help

tackle the issues faced by health and social care (highlighted above) and that our Better

Care Fund schemes listed below will provide a catalyst towards this.

Scheme 4 - GYW: Supporting independence by provision of community based support -

delivered closer to people’s homes, 7 days per week. This will help people

maintain/regain their independence

Scheme 5 - GYW: Integrated Community Health and Social Care Teams including Out of

Hospital Team and Palliative Care Service – to deliver timely joined up quality care and

support to people in the community

Scheme 6 - GYW: Urgent Care Programme - The delivery of integrated community care

services that reduce admissions and expedite faster appropriate discharge thereby

reducing delayed transfers of care

Scheme 7 - GYW: Support for People with Dementia and Mental Health problems -

People with dementia and their carers receive specialist support which will avoid/delay

admissions to hospital/residential care and provide assessment of on-going care needs.

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3) CASE FOR CHANGE

Our plans are based on an assessment of need and opportunity derived from an analysis

of our population using risk stratification and segmentation.

Summary

• Life expectancy in Suffolk is good. In 2007-11 life expectancy at birth was 83.7

years for females and 79.9 years for males, however

• The population of Suffolk is generally older than that of the East of England and

England as a whole.

• The prevalence of most long term conditions is higher than average for England.

• Emergency admission rates are slightly lower than the national average, however,

as a consequence of the projected growth in older residents there is a high risk

that emergency admissions will increase if no change is made. There is also

variation in admission rates across CCG areas in Suffolk.

• The relative rurality of Suffolk is an important factor which has been taken into

account in the system redesign.

• The health and care system in Suffolk will experience increasing financial pressure

as a result of these challenges.

• Importantly people tell us that they want a better health and care system -

whilst people are generally happy with health and care services they state very

clearly that there are aspects of the care they receive that should be improved

(see section 2 b) on page 8). This is an important factor in our case for change

alongside the demographic and financial challenges in Suffolk.

Population segmentation by age

Suffolk is a rural county with a resident population of over 730,000. The chart below

depicts the distribution of the Suffolk population by broad age-band compared with

England population and shows the projected change in the population profile between

2012 and 2037.

Page 19 of 129


By 2037, Suffolk will have a further 94,900 people overall. There will be 103,900 more

over 65s and 37,400 more over 85s. About 31% of the population of Suffolk will be over

65 compared with 24.0% in England as a whole.

We have made an initial assessment of the cost impact of our older population focussing

on urgent care using 2013/14 as our baseline. The following analysis shows that 48% of

all emergency admissions were aged over 65 attracting 63% of spend. With a projected

increase of 14% in over 65s by 2019/20 it is apparent that this age group will continue to

consume an increasingly disproportionate level of care which drives significant cost

across the system.

Cost analysis of emergency admissions per age band to 2019/20

Population segmentation by relevant long term condition

As people get older they develop more long-term conditions e.g. dementia, osteoporosis,

Age band 2013/14A&E

attendances

% of

total

Emergency

admissions (@full tariff)

% of

total

Total spend

£m

Total

A&E/EA

spend per

capita £

Projected

increase in

population

by 2019/20

Projected

spend in

2019/20 £m

Increase

£m

0-18 Activity 41,459 24% 10,697 17%

Spend £m 4.0 21% 10.1 8% 14.1 84 1% 14.2 0.2

19-64 Activity 90,247 52% 22,237 35%

Spend £m 9.6 52% 36.0 29% 45.7 111 0% 45.7 0.1

65+ Activity 41,987 24% 30,361 48%

Spend £m 5.0 27% 79.3 63% 84.3 519 14% 95.8 11.5

Total Activity 173,693 100% 63,295 100%

Spend £m 18.6 100% 125.4 100% 144.0 195 3% 155.7 11.7

Page 20 of 129


diabetes and chronic obstructive pulmonary disease (COPD). Evidence suggests that

majority of over-65s have 2 or more long-term conditions and that majority of over-75s

have 3 or more long-term conditions. Overall, there are more people living with 2 or more

long-term conditions than those with only 1.

The most common long term conditions experienced by the Suffolk population include

high blood pressure (13.7%), depression (13.4%), asthma (6.5%), diabetes (5%) and

coronary heart disease (3.7%). By 2020 the number of people living with diabetes,

chronic obstructive pulmonary disease (COPD) and coronary heart disease is expected

to increase by 21,000.

The following chart shows disease prevalence by CCG as covered by QOF in 2010/11.

This shows a higher prevalence compared to the average for England for most long term

conditions in each CCG area with the Great Yarmouth and Waveney CCG higher in all

but one area.

It is recognised that QOF data tends to underestimate the true prevalence of long term

Prevalence of conditions covered in QOF

disease register 2010/11

Total

Suffolk

Coronary Heart Disease 14,660 3.8% 8,226 3.5% 5,149 4.2% 28,035

Stroke or Transient Ischaemic Attacks (TIA) 7,342 1.9% 4,185 1.8% 2,587 2.1% 14,114

Hypertension 53,211 13.9% 33,319 14.2% 20,063 16.4% 106,593

Chronic Obstructive Pulmonary Disease 5,705 1.5% 4,066 1.7% 2,837 2.3% 12,608

Hypothyroidism 12,854 3.4% 8,315 3.6% 5,538 4.5% 26,707

Cancer 6,572 1.7% 4,723 2.0% 2,487 2.0% 13,782

Mental Health 2,755 0.7% 1,710 0.7% 1,032 0.8% 5,497

Asthma 24,631 6.4% 15,693 6.7% 8,072 6.6% 48,396

Heart Failure 3,249 0.8% 2,027 0.9% 1,230 0.1% 6,506

Heart Failure due to LVD 1,684 0.4% 1,043 0.4% 675 0.6% 3,402

Palliative Care 595 0.2% 408 0.2% 332 0.3% 1,335

Dementia 2,220 0.6% 1,232 0.5% 903 0.7% 4,355

Atrial Fibrillation 6,481 1.7% 3,824 1.6% 2,292 1.9% 12,597

Cardiovascular Disease Primary Prevention 4,620 1.2% 3,079 1.3% 2,196 1.8% 9,895

Diabestes Melitus (17+) 15,868 5.1% 10,014 5.2% 6,242 6.2% 32,124

Epilepsy (18+) 2,418 0.8% 1,388 0.7% 868 0.9% 4,674

Depression (18+) 42,027 1.4% 25,975 13.8% 14,600 14.8% 82,602

Chronic Kidney Disease (18+) 14,290 4.7% 6,542 3.5% 5,811 5.9% 26,643

Obesity (16+) 35,230 11.2% 20,555 10.6% 13,155 12.9% 68,940

Learning disability (18+) 1,094 0.4% 792 0.4% 489 0.5% 2,375

Lower than the England average

Close to the England average

Higher than the England average

Ipswich and

East Suffolk

CCG

West Suffolk

CCG

Waveney area

of GYW CCG

Page 21 of 129


conditions as it relies on the disease registers being complete and only indicates the

number of people known to services. For instance, the number of people with learning

disabilities not known to health or social care services is estimated to be considerably

larger than that of those in contact with services. Based on national estimates, there

could be as many as 20-25,000 people in Suffolk with a diagnosed or undiagnosed

learning disability. The population of Suffolk (over 14 years) is projected to increase to

around 644,000 by 2021. This increase in population size, added to improved survival

rates for pre-term birth babies and changes to diagnostic practice could see increases in

both the proportion of the population and the total number for people diagnosed with a

learning disability. Future social care need and spend is therefore likely to be

significantly higher in this group.

Emergency Admissions

Non-elective admission rates are lower than the national average and lower than the

comparable ONS clusters. This means that reducing emergency admission rates will be

more challenging in Suffolk compared to CCG which have been underperforming. In

Suffolk, the average change in non-elective activity from 2009/10 to 2013/14 was an

increase of 1% which is in line with the national median increase of 0.7%. However, as a

consequence of the fact that Suffolk’s population is growing older at a higher rate than

the national average there is a significant risk that the non-elective admission rate is

likely to increase. This is consistent with the primary objective of this Better Care Fund

plan which is to reduce emergency admissions.

Rurality

The map below shows population density in Suffolk at the 2011 Census. The map shows

a concentration of population in the towns in the county but it is also clear that urban

areas form only a small part of the geographical area of Suffolk.

Page 22 of 129


People over 75 are more likely to experience isolation, ill health and mental illness

including depression than any other section of the population. As high users of

healthcare this has implications for access to Urgent Care services. The limited

availability of public transport outside of normal working hours and travel times to

community health services is therefore being taken into account in our design of

Integrated Neighbourhood Teams and Networks.

Risk stratification in practice

We have defined as high risk the top 2% of our adult population who are at risk of

emergency admission in the following year. In Suffolk, this equates to an estimated

11,700 adults. This cohort is being identified through our risk stratification tools.

These people at high risk will have a named care coordinator, who will help them to

develop a shared outcome focused plan which will assess risk and plan care. This lead

professional will be the most appropriate based on the needs of the customer.

In IEWS the RAIDR risk stratification tool will be used to identify patients at risk. These

patients will be included in a Proactive Case Management Register and will be the focus

of prevention opportunities (Every Contact Counts).

• Adults 18 + years old

o Vulnerable adults

o High risk patients

o End of Life Care

• 0-17 year olds

o Complex physical or mental conditions

Page 23 of 129


In GYW, we recognise that establishing sustainable year-round delivery requires demand

and capacity analysis to be ongoing and robust, which then informs the planning and

delivery of services based on evidence. The rigorous and ongoing analytical review of the

drivers of system pressures has now been agreed by all partners in the Great Yarmouth

and Waveney system. This should help us develop plans to mitigate these pressures

using a collaborative approach. The project is well underway and we are in a position to

agree a baseline for the current activity pressures across the acute, community, mental

health, out of hours and ambulance trusts. This data will be updated monthly and

benchmarked against the system capacity. This will enable the whole system to move

away from a reactive approach to managing operational problems, calculating the

amount and type of capacity that will be required in the future, and towards a proactive

system of year round operational resilience.

The following theory of change diagram represents both health and care integration

programmes. The Better Care Fund will impact generally across both programmes, but

more specifically to deliver certain outcomes.

To help people to be healthy and more independent for longer, whenever possible

Create a system that is rewarding to work in

Reduce costs of health and social care

Health and care system is co-ordinated and effective

Higher cost interventions are replaced with lower cost interventions (consideration of whole system costs)

People manage their own health and social care

Health and care staff work together in an integrated system

Organisational processes are integrated

People have the tools to manage their LTC

Information and advice is readily available to people

Voluntary and Community sector organisations are key partners in care

Key Primary objective Secondary objectives Overarching outcomes Immediate outcomes

Health and care integration – theory of change

Communities are easy and supportive places to live with a health or care need

People at risk of deterioration and crisis are identified and receive a co-ordinated response

Main interventions that support BCF metrics including reduced emergency admissions

Better Care Fund Schemes

Page 24 of 129


4) PLAN OF ACTION The key milestones for delivery of the Better Care Fund Plan are on the plan below:

Scheme

ReferenceKey tasks and milestones Leads RAG

w/c

4

w/c

11

w/c

18

w/c

25

w/c

1

w/c

8

w/c

15

w/c

22

w/c

29

w/c

6

w/c

13

w/c

20

w/c

27

w/c

3

w/c

10

w/c

17

w/c

24

w/c

1

w/c

8 D

ec

w/c

15 D

ec

w/c

22 D

ec

w/c

29 D

ec

w/c

5

w/c

12

w/c

19

w/c

26

w/c

2

w/c

9

w/c

16

w/c

2 M

ar

w/c

9 M

ar

w/c

16 M

ar

w/c

23 M

ar

w/c

30 M

ar

w/c

6 A

pr

w/c

13 A

pr

w/c

20 A

pr

w/c

27 A

pr

w/c

4 M

ay

w/c

11 M

ay

w/c

18 M

ay

w/c

25 M

ay

w/c

1 J

un

e

w/c

8 J

un

e

w/c

15 J

un

e

w/c

22 J

un

e

w/c

29 J

un

e

Ju

l-15

Au

g-1

5

Sep

-15

Oct-

15

1 - IEWS Integrated Neighbourhood Teams

Nic Roper

Gillian Montague

Dawn Barrick-Cook

G

2 - IEWSAccess to specialist services and

support

Nic Roper

Gillian Montague

Dawn Barrick-Cook

G

3(a) -

IEWS

Admission prevention - risk

stratification, personalised care plans, a

reponsive health and care system

Nic Roper

Gillian Montague

Dawn Barrick-Cook

G

3(b) -

IEWSAdmission prevention - crisis response Mark Lim G

3 (c)-

IEWS

Admission prevention - reablement and

rehabilitation

Gillian Clarke

Mark Cook

Dawn Barrick-Cook

G

4 - GYW

Supporting Independence by provision

of Community based support

interventions

Geoff Empson G

4- GYW

Supporting Independence by provision

of Community based support

interventions

(Integrated Home Care)

Geoff Empson G

5 - GYW

Integrated Community Health and Social

Care Teams including Out Of Hospital

team and Palliative Care

Jane Hackett and

Maggie ParsonsG

6 - GYWUrgent Care Programme

(Integrated Home Care and Reablement)Geoff Empson G

6 -GYW Urgent Care Programme Jane Hackett G

7 - GYW

Support for people with dementia and

older people with functional mental

health problems living in the community

Kim Arber G

Key

Milestone Planned

Milestone Achieved

Milestone Delayed

Core and specialist

integrated reablement

service in operation

Finalise service model

Set up delivery team

System model agreed for using reablement and rehabilitation services across health, social care and the

voluntary sector Delivery plan agreed, including workforce development plan

Community Services

reprocured

INTs and specialist

services working to new

structure

Capacity matched to

demand

Methodologies agreed for

INTs and specialist services

Shared guidance for integrated working

produced

Define structure of teams including skills mix and staff numbers

Comms, propoerty and workforce development plans all in place and operational

Great Yarmouth and Waveney Scheme Milestones Aug-14 Sep-14 Oct-14 Nov-14 Jun-15Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15

Transition to

new

integrated

home care

Transition to

new

integrated

home care

Procure integrated home care

Implement models

Finalise proposals, following NSFT

consultation, and produce report for

GYW Governing Body

Implement recommendations agreed at September GYW Governing Body

Finalise service model, procurement model and

relevant documentation

Finalise proposals and obtain relevant authorisation (from Norfolk County Counisl, Suffolk County Council

and Great Yarmouth and Waveney CCG) to proceed

Finalise model Recruit/commission

Review current services and agree future models of service provisionRecommission and implement agreed models of service

provision

Recruit/commissionFinalise models

Implement model

Finalise proposals and obtain relevant authorisation (from Norfolk County Counisl, Suffolk County Council

and Great Yarmouth and Waveney CCG) to proceed

Finalise service model, procurement model and

relevant documentationProcure integrated home care

Page 25 of 129


Key interdependencies:

• Contracts: Suffolk Community Healthcare, 111 and the Out of Hours contracts

terminate in 2015/16. The remodelling of the services currently provided by these

contracts is key to the delivery of our vision for integrated care. The health aspects

of the IEWS Better Care Fund schemes are likely to be largely delivered through

these contracts and their successors. As a consequence of the timing of the

contract renewals and the ongoing engagement process with patients and system

partners the service specifications are not yet at a stage where final costings are

known. As a result expenditure estimates included in Part 2 of the template are

based on the existing cost envelope and will be updated during the coming

months.

• Transformation programmes in Suffolk County Council are key

interdependencies for this plan. They are:

o Supporting Lives Connecting Communities – changing adult social care

so that it promotes independence and recovery, local solutions in

supportive communities, working in partnership, building on people’s

capacity and strengths and looking for tailored support to individuals

tailored to their situation.

o Making Every Intervention Count - Re-shaping Children and Young

People’s Services so they remain effective into the future and provide the

best possible outcomes for children and families within available resources.

o Local response - Suffolk’s public services are designed and delivered in a

way that reflects and responds to the varying needs, priorities and

opportunities within our communities and in different places.

• 7 day working pilot in Great Yarmouth and Waveney – one of the DH pilots to

deliver and test 7 day working.

• The CCGs have had considerable success in recent years in making significant

QIPP savings year on year, but ongoing savings are becoming increasingly harder

to achieve. This has led to three main conclusions and ongoing pieces of work, as

set out briefly below.

o The need to reshape the system so that we have modern, community

based, services to enable services closer to people’s homes. This will

entail some changes to facilities going forward, and may necessitate a

degree of public consultation.

o Linked to the point above, modelling of the impact on capacity, activity and

cost within the system as IEWS and Great Yarmouth and Waveney

proceed with their integrated care system implementation. This modelling is

being undertaken in conjunction with refreshing the CCG’s Five Year

Strategy.

o A realisation, that with the financial pressures on the health and social care

systems, that there is an imperative to review health and social care spend

together, in order to identify further efficiencies which can benefit the pooled

fund within the Better Care Fund.

Page 26 of 129


Resilience Plans

• Ipswich and East Suffolk CCG is able to evidence system-wide resilience by the delivery of several complex redesign programmes of work which will deliver sustainable system-wide integrated care. These programmes are aligned with the BCF schemes and include:

o Development of pathways for ambulatory care conditions, falls (multifactorial assessments and interventions) admission avoidance (including community IV therapy clinics), alcohol and substance misuse.

o Integrated Neighbourhood Teams are being developed across the area to increase collaborative working.

o A care home improvement programme. o Integrated winter planning schemes developed in partnership with social

care, primary care, community services, the acute hospital and voluntary sector.

o QIPP schemes and resilience schemes are interrelated and interdependent and are all designed to reduce unnecessary A&E attendances, acute hospital admissions, ambulance call-out and conveyance and to promote self-care.

• West Suffolk CCG has developed a local operational resilience plan for urgent

care in collaboration with the membership of our local System Resilience Group

and reflects the principles of good practice outlined in the national guidance. This

plan which was recently rated as ‘assured’ by the Area Team builds on the work

already underway in West Suffolk which aims to reduce urgent care demand on

the system through delivery of evidence based good operational practice, system

wide working and proactive case finding and care planning for people who are

most at risk of presenting to the urgent care system.

• GYW is a resilient system, as demonstrated by good A&E performance, reducing

non elective admissions and reasonable referral to treatment performance. We

have made sure that our plans around the Better Care Fund schemes are

complementary to other schemes funded non recurrently out of operational

resilience monies during 2014/15. These include ambulatory care pathways and

an urgent care centre co-located with A&E, both of which should help to further

reduce pressure on A&E attendances and non-elective admissions, and thus help

with developing a sound platform for the delivery of the Better Care Fund.

b) Please articulate the overarching governance arrangements for integrated care locally

Our programmes are under the oversight of the Suffolk Health and Wellbeing Board

supported by the two System Leaders Partnerships. The Health and Wellbeing Board will

oversee the integrated plans and also enable strategic influence and encourage and

support integrated working across our whole system.

Page 27 of 129


Ipswich & E Suffolk andW Suffolk SLP

Gt Yarmouth & Waveney SLP

Suffolk Commiss-

ionersGroup

Norfolk HWBSuffolk HWB

Norfolk Joint

Commi-ssioningGroups

Suffolk Joint Working

The Systems Leaders Partnerships hold oversight of the progress on the Health and

Care Review in the Ipswich and East and West Suffolk areas, and the Integrated Care

System programme in the Waveney area. They are able to unblock problem areas

escalated to them by SLP members or identified by the Health and Wellbeing Board.

They can also identify further areas where integration would benefit the system and

commission the work to take these forward.

The delivery structures below the SLPs are as follows:

Ipswich and East and West Suffolk

The Integrated Care Boards are monthly multi-agency meetings with senior

representation. Their remit is to:

IEWS SLP

Ipswich and East

Integrated Care

Board

West Suffolk Integrated

Care Board

Operational Delivery

Group

Operational Delivery

Group

Page 28 of 129


- Ensure clear local plans are in place to deliver the agreed Health and Care

Review service model (which incorporates the Better Care Fund schemes)

- To ensure adequate resources and leadership are in place to deliver the plans

with joint roles established as appropriate

- To identify local issues and concerns and ensure these are addressed

- To build local system working with all parties.

Members of the SLP take responsibility for clearing decisions through their own

organisational governance arrangements.

Joint working in the IEWS area is supported through:

- Regular joint meetings at all levels to progress projects and unblock barriers

- Co-location of staff in West Suffolk House

- Joint leads for programme work streams and Better Care Fund schemes

- Joint Health and Social Care Integration (HASCI) Resource Hub

- Workforce Planning and Development Forum

- Suffolk Informatics Partnership


The ICS Programme Board is a monthly multi-agency meeting with senior representation.

Their remit is to:

- work closely in partnership with all local organisations responsible for health,

county and district council services to ensure whole system engagement,

commitment and implementation of ICS principles through aligned activities,

sharing of budgets and pragmatic integrated projects.

- Manage the relationships between implementation groups to ensure effective

coherence to deliver desired outcomes in the real world rather than a whole

project approach delivering a product.

- Ensure projects and integration activities are built from the bottom up and support

the emergent ICS; they will be concerned with action and delivery as a priority.

- Explore how resources can be shared and work to achieving their use optimised at

an ICS level.

GYW SLP

ICS Programme

Board

ICS Operational

Delivery Group

Integration Committee

CCG Governing Body

Page 29 of 129


Members of the SLP take responsibility for clearing decisions through their own

organisational governance arrangements.

Joint working is supported in Waveney through:

- Regular joint meetings at all levels to progress projects and unblock barriers

- Collocation of front line staff

- Workforce Planning and Development Forum

- Suffolk Informatics Partnership

Suffolk’s health and care system is keen to use innovative estates management to facilitate fundamental change, help improve efficiency, move activity out of hospitals and exploit new technologies.

• We are taking every opportunity to co-locate our services with appropriate partner

organisations through our Single Public Sector Estate programme and seek to go

further and develop new ways for delivering integrated public services in our

communities.

• This programme aims to work with Public Sector Partners to efficiently use their

estate, to improve customer access and improve service benefits by sharing

buildings and services. The initial vision was to create a ‘one front door’ where

customers can visit one place to access services they need, while saving money

for organisations.

The project was launched in Suffolk in 2010 and has since opened new shared spaces in

Bury St Edmunds (West Suffolk House), Ipswich, (Endeavour House) and the current

project in Lowestoft (Riverside Road) in addition to significant sharing across the whole of

Suffolk.

Page 30 of 129


c) Management and oversight of the delivery of the Better Care Fund plan

The management and oversight of the delivery of the Better Care Fund Plan will be

through the governance arrangements described above.

The reporting and monitoring arrangements will be as follows:

Will receive Will produce

Health and Wellbeing

Board

Quarterly performance updates

Quarterly highlight BCF report

System Leaders

Partnership

Monthly programme updates

Quarterly BCF expenditure reports

Monthly/quarterly (dependent on

availability of metric measures)

performance updates

- Emergency admissions

- Residential care home

admissions

- DTOCs

- Effectiveness of reablement

- Patient and service user

satisfaction

- Dementia diagnosis rates

Quarterly Signed off

performance updates

and BCF report for the

HWB

Monthly requests for

remedial action where

plans are off track

Integrated Care

Boards/ICS

Programme Board

Requests from the SLP for remedial

action where plans are off track

Monthly project updates from

projects delivering BCF schemes

Quarterly BCF expenditure reports

Monthly / quarterly (dependent on

availability of metric measures)

performance updates

Monthly performance updates

- Emergency admissions

- Residential care home

admissions

- DTOCs

- Effectiveness of reablement

- Patient and service user

satisfaction

- Dementia diagnosis rates

Monthly performance

updates for the SLP

on progress with

delivering BCF plans

Reports outlining

remedial actions

where plans are off

track

Requests to delivery

projects for remedial

action where plans

are off track

Page 31 of 129


d) List of planned BCF schemes Please see Annex 1 for Detailed Scheme Description for each of these schemes.

Ref no. Scheme

1 IEWS - Integrated Neighbourhood Teams

2 IEWS - Access to specialist services and support

3 (a) IEWS - Admission prevention - risk stratification, personalised care plans, a

responsive health and care system

3 (b) IEWS - Admission prevention - crisis response

3 (c) IEWS - Admission prevention - reablement and rehabilitation

4 GYW - Supporting independence by provision of community based support

interventions

5 GYW - Integrated Community Health and Social Care Teams including Out

of Hospital teams and Palliative Care

6 GYW - Urgent Care Programme

7 GYW - Supporting people with dementia and older people with functional

mental health problems living in the community

Page 32 of 129


5) RISKS AND CONTINGENCY a) Risk log The following risk log has been jointly developed in accordance with acknowledged risk management good practice that identifies the risk, its likelihood and impact and offers a risk rating that has an associated mitigation plan.

There is a risk that: How likely is the risk to materialise? Please rate on a scale of 1-5 with 1 being very unlikely and 5 being very likely

Potential impact Please rate on a scale of 1-5 with 1 being a relatively small impact and 5 being a major impact And if there is some financial impact please specify in £000s, also specify who the impact of the risk falls on)

Overall risk factor (likelihood *potential impact)

Mitigating Actions

1. There is a system wide risk that resources available to us are unable to reduce forecast demand growth and manage the impact of reductions in central government resources for health and care.

4 5 Our target reduction in non-elective admissions will result in a cost saving of £1.7m. In the event that this saving is not realised the cost of this activity will be compensated by the CCGs.

20 High

We recognise that this is a risk that we need to manage together across the health and care system. All partners are involved, as the impact of this risk affects all our organisations. We have committed to managing this risk together as system leaders, dynamically and collaboratively. We will ensure effective joint working to implement the schemes, timely monitoring and evaluation of the impact when schemes are implemented and joint governance, risk sharing and financial monitoring/planning

Page 33 of 129





Mitigating Actions

Owner – System Leaders Partnerships Timeline – monthly programme and performance reports – see performance and monitoring arrangements on page 30 (please see governance section p 27 onwards)

2. This plan is not rigorously or coherently delivered due to an organisational inability to co-ordinate and manage change leading to inefficient service models.

3 3

9 Medium

Senior leadership directly involved, with strong programme governance arrangements and robust delivery plans, including a collaborative workforce development plan. CCG and County Council design leads are working closely together and with key partners (eg, VCS, providers, service users/patients). Plans are being tested against the best available evidence and jointly modelled to assess local impact. Plans implemented through a “learning through doing” approach that allows development to flex to build on what

Page 34 of 129





Mitigating Actions

works and stop what is not working. Owner – System Leaders Partnerships Integrated Care Boards/ICS Programme Board meet monthly and have direct responsibility for ensuring that there is a coherent change programme in place. Timeline – monthly programme and performance reports - see performance and monitoring arrangements on page 30

3. Operational pressures will restrict the ability of our workforce to deliver the required investment and associated projects that will make the vision of care outlined in our Better Care Fund submission a

4 5

20 High

A performance dashboard is being developed as part of the year one activity. This information will identify system stress and where schemes are not delivering. By using clear metrics success can be accelerated and unsuccessful interventions reviewed. As a result, timely intervention by the appropriate part of the local system’s governance will be undertaken.

Page 35 of 129





Mitigating Actions

reality.

This risk has been particularly raised during public engagement.

Owner – Integrated Care Boards/ICS Programme Board Timeline – monthly finance and performance reports – see performance and monitoring arrangements on page 30 Performance dashboard will be ready and operational by April 2015

4. Improvements in the quality of care and in preventative services will fail to translate into the required reductions in acute and nursing/care home activity by 2015/16, impacting on the overall funding available to support core

4 5

20 High

Action plans for our transformation programmes set out high impact changes. We will monitor delivery of our action plans against anticipated outcomes. This information will be embedded in the governance system and monitored regularly. This will enable the right part of the local system to take appropriate remedial action Owner – Integrated Care Boards/ICS Programme Board for system oversight, and commissioners and provider organisations for remedial action. Timeline – monthly performance reports – see performance and monitoring arrangements on

Page 36 of 129





Mitigating Actions

services and future schemes.

page 30

5. Social care services fail to be protected as a consequence of financial agreements reached in the development of the Better Care Fund plan, with a subsequent impact on the ability to reduce non-elective emergency admissions.

3 5 A minimum amount of £16.748m has been committed to protecting social care, A further £5.4m has been committed upon realisation of additional savings through joint working.

Moderate 15

. The Section 75 agreement will set out how funding the protection of social care will be paid across to Suffolk County Council. This will include schedules showing agreed savings plans, and how savings are allocated initially to SCC and then on a risk sharing basis. The plan will be reviewed through the Suffolk Commissioners Group as part of their overview of system health Owner – System Leaders Partnership for joint performance and Section 75 agreement. SCC and CCGs for savings plans (as schedules to the S75) Timeline –Section 75 agreement and savings schedules will be in place by the end of February 2015 performance and monitoring arrangements on page 30.

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Mitigating Actions

Section 75 agreement and savings schedules will be reviewed monthly.

6. The introduction of the Care Act will result in a significant increase in the cost of care provision from April 2016 onwards that is not fully quantifiable currently and will impact on the sustainability of current social care funding and plans.

4 5 20 High

Suffolk adult social care has undertaken an initial assessment of the effects of the Care Act and the additional costs associated with its introduction. The initial amount allocated for implementation is reflected in the Better Care Fund finance table. This will continue to need significant focus as our integrated plans develop. Owner – Adults and Community Services Transformation Board Timeline – the ACS Transformation Board will receive monthly programme reports Key milestones for the Care Act are April 2015 and April 2016. Ongoing monitoring will identify where financial pressure building because of Care Act requirements, and this will be escalated to the Systems Leaders Partnerships as part of the regular reporting and monitoring processes.

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Mitigating Actions

7. Having a Suffolk overview of performance fails to recognise changes in performance in constituent planning unit areas.

4 5 20 High

Performance dashboard will include overview of performance on constituent planning unit areas. Owner – Health and Wellbeing Board Timeline – quarterly review – see performance and monitoring arrangements on page 30.

8. Sharing data at a system level is not possible due to restrictions on NHS organisational use of local patient information.

5 4 20 High

Plans to implement the NHS number are well advanced; however, the statutory restrictions on data sharing reduce the ability to plan in an integrated way. It also undermines the local system’s ability to fully understand an individual’s journey through the system. Owner – Suffolk Informatics Group Timeline – dependent on national policy

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Mitigating Actions

changes

9. Public confidence is not maintained during the development and implementation of our plans.

4 5 20 High

We have clear communication, consultation and coproduction strategies and aligned messages so that people in Suffolk have a coherent story of change, know what we are doing and why. Where appropriate we will carry out formal consultation exercises. We have a strong ethos of co-production in our transformation programmes which will involve people in changes to the health and care system. The Health and Wellbeing Board takes an active role in overseeing the Suffolk wide shift to integrated working. We have representatives from service

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Mitigating Actions

user groups, including Healthwatch at all levels of our system governance. Owner – Health and Wellbeing Board Timeline – Initial Communication, Consultation and Co-production report published December 2014. Phase 2 strategy will be coproduced with user led organisations and refreshed by April 2015.

10. 7 day services are not effective due to affordability with some parts of the system not able to deliver 7 day services or there is a delay in implementation

4 4 16 High

Integrated Care governance arrangements and the Workforce Development and Planning Forum will be asked to develop mitigating actions to manage this risk. Owner – Integrated Care Boards/ICS Programme Board Timeline – ongoing – see Plan of Action

11. The anticipated impact of closer working with the Voluntary and

2

4 8 Medium

Early engagement through established joint forums such as the Working Together Forum and Suffolk Congress.

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Mitigating Actions

Community Sector is not realised.

Building on the Supporting Lives Connecting Communities approach which has delivered significant demand reduction in adult social care. Locality work with our early adopter sites between statutory and VCS partners to deliver change on the ground. VCS are key partners in the work we are doing to deliver early adopter sites and initiatives. Early adopter sites have specific VCS workstreams. Owner – Integrated Care Boards/ICS Programme Board Timeline – Engagement with the VCS – building on an event in October 2014, further events planned. Will be reported as part of the monthly programme reports. .

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Mitigating Actions

12. Contracting timescales slow down implementation of transformation plans : IEWS and WSCCG 111, OOH and community health services original contract expiry dates fall within 2015/16.

3 4

12 (moderate)

IEWS and WSCCG have agreed the process for extension / reprocurement of existing services during 2015/16. Robust transitional plans will be developed as appropriate to ensure that service transformation (ie the BCF schemes) can be implemented to agreed timescales. Owner –CCG Governing Bodies Timeline – Procurement to be complete by 31/3/2015. Escalation through to Suffolk Commissioners Group as part of regular reporting.

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Risks have been assessed using the following risk matrix, which takes into account likelihood and impact. Each is given each a score from 1 to 5. The overall risk score is the product of the two.

Almost certain (5)

5 10 15 20 25

Likely (4)

4 8 12 16 20

Moderate (3)

3 6 9 12 15

Unlikely (2)

2 4 6 8 10

Rare (1)

1 2 3 4 5

Insignificant (1)

Minor (2)

Moderate (3)

Major (4)

Extreme (5)

b) Contingency plan and risk sharing

Our integration plans are overseen by the HWB supported by the two System Leaders Partnerships. The delivery of the BCF will be managed through the IEWS Integrated Care Boards and the GYW ICS Programme Board as described in section 4b) of this Plan. These Boards are multi-agency with senior representation and meet on a monthly basis. The financial impacts of the agreed funding for the Better Care Fund are embedded in the CCG two year Operational Plans and Five Year Plans and in SCC’s financial plans. Financial balance for the CCGs and SCC are predicated on challenging QIPP targets and savings plans which are tightly monitored through the appropriate governance arrangements. For CCGs these targets include reductions to emergency admissions. The principal risks to the CCGs are those associated with failure to achieve the savings associated with the delivery of the Better Care Fund target outcomes and in particular the failure to reduce non elective activity in the acute sector. The CCGs are considering a variety of contracting methods with providers in the future which will assist in increasing wider ownership of the Better Care Fund plans and distribution of risk to the system., These reviews are in their early stages and will take time to develop, the current expectation is that these changes will start to be implemented from October 2015. From an acute provider perspective, it is unlikely that the BCF presents a risk to them as they tell us that they make a loss on non-elective activity. At two of our acute providers, activity above the 2008/09 threshold (or adjusted) is paid at 30% as per National Tariff arrangements. Acute providers will continue to be paid as per the contractual agreement on activity performance. In the event that the Better Care Fund is successful in reducing emergency admissions, there is a risk to that there will be some ‘stranded costs’,

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primarily fixed costs that the trusts may not be able to take out of the system immediately. However, our providers advise us that reductions will ease the considerable pressure on clinical resources and that they are planning to reduce capacity in line with reductions as they materialise. £1.7m has been identified as the Payment for Performance element of the Better Care Fund. This sum will be available to the Fund in the event emergency admissions are reduced by 3.5% from the baseline. In the event that the target for emergency admissions is not met, there will be a commitment to pay acute providers, in accordance with contractual arrangements, for the activity which has not been avoided. In IEWS, an amount equivalent to the planned benefit from reducing emergency admissions (£1.1m) is identified as a Contingency in the BCF pooled fund (see Expenditure Summary in Template 2). The GYW share of the Payment for Performance amount of £0.6m is embedded within their schemes – see Template 2. The nature of our agreement means that SCC have certainty over £16.7m allocated to protect social care. A further amount of £5.4m is conditional on additional savings achieved through joint working, both from the Better Care Fund schemes and through joint commissioning, procurement activity and reductions in non-elective activity. This provides a strong incentive for all parts of the system to work together to achieve savings albeit that there remains a risk to social care from the funding settlement as outlined in the risk log and in Section 7 below. The CCGs and SCC are committed to working collaboratively to identify opportunities for additional savings and have identified finance and staff resources to move this on at pace. A detailed risk sharing agreement will be agreed as part of the s.75 agreements (one for each of the CCGs) and a comprehensive risk register will be in place to manage or mitigate known and emerging risks associated with the development and implementation of the Better Care Fund Plan. High level principles for the s.75 have been agreed. Detailed drafting is to be finalised by end December with a view to approval at CCG Governing Body meetings and SCC Cabinet in January with final sign off by the HWB in March.

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6) ALIGNMENT a) Alignment with other initiatives related to care and support underway in Suffolk

Suffolk is ambitious in accelerating collaborative working. The Better Care Fund is a

catalyst but only a small part of our wider ambitions for integrated working across

Suffolk’s public sector along with VCS and private sector partners. Our approach to

transformation, based on a drive towards more efficient services through cost

reductions and demand management is threaded through all our transformation in

Suffolk, creating synergy and opportunities that complement our ambitions for

integrated health and care.

There is a strong foundation of joint working in Suffolk and there are a number of

work streams focussing on better integrated working across health and care. These

are also embedded in the Suffolk system governance that means relevant partners

can take appropriate action to ensure the work delivers the desired impacts. The

work is focussed at different levels from strategic to operational and locally based,

which reflects local partners’ commitment to work more efficiently together but not

impose top down action and focus on what is most appropriate to the specific

issue/need being addressed.

Leaders of NHS Great Yarmouth and Waveney Clinical Commissioning Group and

local government partners were presented with the top prize in the ‘improved

partnerships between health and local government’ category at a prestigious Health

Service Journal award ceremony in London on 19th November 2014.

The national award comes in recognition of the work being undertaken in developing

an integrated care system. This has seen NHS Great Yarmouth and Waveney CCG,

Suffolk, and Norfolk County Councils, Great Yarmouth Borough and Waveney

District Councils and local health providers work more closely together to improve

services for local people. The judges said “The strategic vision and commitment

required to achieve this project across a range of councils, providers and CCG is

truly outstanding.

The above endorses the commitment to work together and recognises the progress

that has already been made.

Other initiatives that align to and support integrated working in Suffolk are listed

below.

Through the DCLG community budget pilot in Haverhill and asset based

community development projects in some local market towns, partners have begun

to better understand local need and communities’ capacity to become more self-

sustaining.

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Our schemes emphasise the need to develop health and care services on a local

basis so that services deliver against local priorities, but also so that local assets and

opportunities are maximised to support people to stay and remain healthy and

independent. In particular the development of Integrated Neighbourhood Teams

(Scheme 1) and community based support interventions (Scheme 4) will benefit from

work already carried out to strengthen communities. Specific benefits will include the

use of buildings and the ability to develop strong relationships between the voluntary

and community sectors and the local health and care teams.

A Transformation Challenge Award (TCA) bid has been submitted by the public

sector in Suffolk under the steer of its Public Sector Leaders group. This has been

developed from the collaboration principles agreed by Suffolk’s Public Sector

Leaders in 2013, and commits to collaboration as a way of working but which

respects organisational sovereignty and is focussed at strategic or operational level

according to where the greatest impact is made. As a result, the bid seeks to build

capacity at strategic and operational levels through skills development and

infrastructure investment to improve collaborative working (for example, IT that

enables more effective information sharing and co-location). Economic growth and

wellbeing, health and social care will be the areas of focus for the bid. To avoid

duplication, the wellbeing focus will use the JHWS as a framework.

If Suffolk is successful with the TCA bid there will be a major boost to the health and

care integration programme. Depending on the size of any award and the decisions

made locally as to priorities for spend it is anticipated that funding will support

schemes to grow community based support, develop integrated locality working and

support for people with dementia living in the community. Benefits are likely to

include funding for community development, support for the costs of colocation and

general funding that helps us to make faster progress with our plans.

In implementing Suffolk’s Joint Health and Wellbeing Strategy (JHWS), the Health

and Wellbeing Board acknowledged that additional help would be valuable in

tackling its priority that “people in Suffolk have the opportunity to improve their

mental health and wellbeing”. As a result it successfully bid for Local Vision support.

Their support programme expanded from focus on mental health crisis to prevention

and recovery. Consequently, a joint commissioning strategy for mental health is

being developed (supported by a new partnership board reporting into the System

Leaders Partnership) in order to deliver the multi-agency strategy for mental health

promotion and early intervention. The strategy will be in line with the integration

programmes in Waveney and in IEWS. These outputs have been incorporated into

the Board’s JHWS delivery plan.

The connections and integration with mental health services is a key issue for our

schemes as it is widely agreed that the different elements of our services are

disjointed – leading to inefficiencies in the system and a poor service for people.

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The Local Vision support will provide a clear way forward which will help all our

schemes to deliver on their ambition to provide integrated care in a holistic and

person centred way.

The Health and Wellbeing Board is also in the process of consulting on a Suffolk

Health and Housing Charter since housing is acknowledged as underpinning its

JHWS’s strategic outcomes. The Charter (due for agreement at the November

Board) sets out a shared vision and commitments designed to improve the overall

health and wellbeing of Suffolk’s residents. As such, encouraging sustainable

supplies of age appropriate housing within Suffolk’s localities is likely to be part of

Suffolk’s TCA. In addition to the potential additional resource, this provides a shared

priority between the Board and wider public sector governance in Suffolk.

The development of the Housing Charter will ensure that local integrated teams can

work with district and borough councils to access appropriate housing support for

people they are working with. Whilst this will not provide immediate financial benefit

to our work, it is an important element of the prevention and early intervention

agenda and will support people to stay well and out of crisis, thus reducing demand

on emergency and other services.

Suffolk County Council, as well as Ipswich and West Suffolk Hospitals, each with the

support of the CCGs have bid to the NHS England Technology Fund to ensure that

their IT systems are compatible and can interface at a customer level. If success the

projects funded will support faster and more effective transfer of information, shared

care plans and risk stratification. If successful this initiative will be of financial benefit

to all our schemes through the introduction of technology that supports our vision for

integrated care.

b) Alignment with existing 2 year operating and 5 year strategic plans and local government planning documents

The Better Care Fund plan of action is embedded within the County Council’s medium

term financial plans that are updated on an annual basis as part of its annual budget

setting process. In 2014 a set of corporate transformation programmes were agreed in

order to deliver the radical changes required to meet the savings required from 2015-18.

These programmes include health and social care integration along with the

implementation of re-design delivery models for adult and children and young people’s

social care.

For IEWS, the BCF plan is viewed as an opportunity to drive forward delivery of

integrated services through the Health and Care Review. Integration, system-wide

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working and partnership are key themes underpinning the two CCG two year Operational

Plans and the Suffolk 5 year Strategic Plan. The detailed activity and financial impacts

will be incorporated in the refreshes of these plans post finalisation of this BCF plan.

The Better Care Fund plan is embedded within the Great Yarmouth and Waveney two

year Operational plan and five year strategic plan and will be used as a catalyst to

achieve Great Yarmouth and Waveney’s ambition to create an integrated care system

(virtual at first) encompassing the activities of all of the local organisations responsible for

health, social care and District Council services.

Examples of the relationship between the Better Care Fund and the 5 year strategy

include:

Out of Hospital Care: Impact on System:- reduced A&E attendances and emergency

admissions. Reduced residential nursing home admissions, reduced DTOCs. Major

contributors are scheme one, two and four. Supported by Urgent Care Centre pilot

(funded through Operational Resilience monies)

Shift from acute inpatient (elective and non-elective) to less intensive forms of

support (including social care): Impact on system:- Permits change acute capacity and

facilitates availability of capacity to support repatriation of activity from other acute

hospitals. Major contributors are schemes one, three and four. Supported by

development of in-reach/outreach resources shared between our providers

Combining budgets, streamlined management, co-location within an Integrated

Care System: Impact on system:- fewer handoffs for patients, increased purchasing and

financial efficiencies, reduced use of expensive facilities. Public consultation regarding

services and facilities to start late 2014.

c) Alignment with plans for primary co-commissioning

Ipswich and East and West Suffolk CCGs submitted expressions of interest to co-

commission primary care on 20th June 2014 and received a green rating from NHS

England as ‘ready to co-commission now’ with ‘delegated responsibility transferred with

clear accountability to Area Team’.

Progressing to the next stage requires clarity of governance and implementation

arrangements with NHS England, which will then inform a final decision by the CCGs’

member practices in line with their Constitution. The CCGs were clear in their

submissions that final agreement to proceed is inextricably linked with the outcome of the

PMS Review and the retention of viable, PMS contracts with current minimum levels of

premium funding which enable meaningful co-commissioning for our patients. The

submissions were approved in principle by the Suffolk Health and Wellbeing Board.

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Co-commissioning has the potential to enable delivery of the Health and Social Care

Review and emerging Primary Care Strategy, both of which have involved member

practices systematically in their development. All member practices were engaged in the

initial scoping of the urgent care redesign programme in December 2013 and received

the model for comment in July 2014. The GP members of the CCG Clinical Executives

have been involved at each key point in the model’s development and preparation of

individual service specifications for the out of hours, community service and 111

services. A core group of GPs from both CCGs have engaged in weekly meetings with

Suffolk County Council, Healthwatch and other partners in detailed review of evidence

and design options.

Primary care is integral to the current and new model of health and independence and

urgent care most specifically, the principle that people in Suffolk will be served by an

integrated model with an overall responsibility for urgent care across the population –

primary, community, mental health, social care, secondary care, the voluntary sector and

other organisations working as part of an integrated system with common objectives.

The CCGs’ primary care strategies will enable delivery of this model. The first draft of the

strategy will be completed by the end of September 2014. It will include a vision for

primary care, building on its current strengths in delivery of high quality services and

integrated working as demonstrated through Multi-Disciplinary Teams. The strategy and

its subsequent action plan will set out models of delivery at multiple scales and practical

action to respond to associated collaboration, workforce, property, IT challenges.

Great Yarmouth and Waveney CCG has submitted an expression of interest to the east

of England area team to become involved in their work developing co-commissioning

with CCGs. At present we are waiting further news regarding how the area team intend to

take this initiative forward but we anticipate that further details will emerge over the next

3-6 months. GYWCCG welcome the opportunities that co-commissioning will offer in

terms of developing an integrated healthcare system for all the patients in East Norfolk.

As soon as the direction of travel is clarified we will take prompt action to ensure timely

implementation

GP practices in Great Yarmouth and Waveney are all Members of NHS GY&W CCG and

member practices are closely involved in decision making. There is strong GP and

practice manager representation on the Clinical Executive Committee and on the CCG’s

Governing Body which ensures clinical input into all areas of our work. Alongside this

there are regular GYW Clinical Leads Forum, where a representative from every practice

attends, and our monthly PTL (Protected Time for Learning) sessions, plus our practice

manager meetings and a range of regular informal practice visits.

Each practice sends a GP to the clinical leads meetings and in addition there is a lead

practice manager from both of the main geographical areas at each meeting, i.e. Great

Yarmouth and Waveney. These groups guide strategic development, prioritisation, and

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practical implementation.

There are also ten retained GPs and two retained Nurses working in NHSGYWCCG who

provide a valuable resource to help with commissioning decision making, they inform this

process through the programme boards and specific work areas.

Meetings are held with all Clinical Leads across GYW to identify and agree our

commissioning priorities and intentions for 2014/15 and beyond. The clinical leads

groups have been involved in shaping and approving our overall strategic plans at both a

health system and Programme Board level.

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7) NATIONAL CONDITIONS a) Protecting social care services

i) Agreed local definition of protecting adult social care services

Our definition of protecting social care in Suffolk is that the criteria for adult social care

will remain at substantial and critical and that the provisions of the Care Act will be fully

implemented. This means that people in need of care and support will continue to receive

the appropriate services they need in an integrated and preventative health and social

care system. Our approach is founded on a whole system approach to health and care

services.

The Health and Wellbeing Board understands the vital importance of robust social care

provision in Suffolk as part of a whole system approach to health and social care.

We recognise that the way we allocate resources within adult social care may change

because of our shared transformation programmes, but what we are interested in is

delivering the better outcomes for individuals.

In Suffolk we know that the social care demands from our population are increasing year

on year in part because of the rising numbers of older people in our communities. At

present approximately 10% of Suffolk’s population is aged over 75 and this is set to rise

by 72% by 2031. Between 2012 and 2017 there is a predicted 15% increase in people

with high and very high care needs and the number of people with dementia will double

between 2013 and 2030. The cumulative effect of demographic changes will place

additional demands on adult social care, which translates into ongoing financial

pressures of around £5 million each year.

Meeting these challenges requires transformation of the health and social care system

and we recognise that the best way of protecting adult social services is to do this

together. This means developing integrated services together, commissioning jointly and

differently and working to ensure that different elements of the health and care system

interact in an effective, efficient way in the interests of the service user.

ii) How local schemes and spending plans will support the commitment to protect social care

Delivery of the Better Care Fund schemes and the national conditions will enable the

services and supports provided by social care to be delivered alongside health provision,

leading to efficiencies in delivery and outcomes, a better experience for customers, and

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eventually to transformed services.

The focus of our schemes on prevention and getting upstream of crisis and long term

care (the “shift left” approach) will reinforce the role that social care plays within an

integrated system. In the short term, an integrated approach to care in a crisis and to

reablement will stop people from needing to go to hospital and into more intensive longer

term care. In the longer term it will delay the onset of long term conditions and frailty that

lead to health and care needs.

Suffolk County Council and the CCGs have agreed how Better Care Fund spending will

support the commitment to protect social care.

iii) The total amount from the BCF that has been allocated for the protection of

adult social care services.

The amount of the Better Care Fund that has been allocated for the protection of social care services is a minimum of £16.748m. This is made up of:

- £1.8m for implementation of the Care Act responsibilities. - £14.948m – previously referred to as S256 -

In order to better protect social care our agreement is to rigorously identify additional savings, targeting a further £5.4m through joint working, both from the Better Care Fund schemes and through joint commissioning, procurement activity and reduction in emergency admissions and demand. The CCGs and Suffolk County Council have identified finance and staff resources to move this on at pace.

- In IEWS it has been agreed that £3.4m achieved through this process will be passed across to the County Council for the protection of social care.

- In Waveney £2m will be transferred to SCC at the beginning of 2015/16, with a

50/50 risk share agreement if savings are not achieved up the value of £2m. In both IEWS and Waveney savings over and above this amount in 15/16 will be split equitably between the County Council and the CCGs in accordance with a risk sharing agreement, to be developed.

iv) How the new duties resulting from care and support reform set out in the Care Act 2014 will be met

The requirement to provide universal information, advice and guidance to the citizens

of Suffolk in their geographical or common interest communities gives us the opportunity

to jointly commission the voluntary and community sector, who will work alongside the

integrated health and care system to deliver information, advice and guidance within their

locality or to their community of interest. This activity is already underway through our

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transformation programme, Supporting Lives Connecting Communities, which focuses on

the least intrusive interventions in order for people to maximise their independence.

We are also refining our Information and Digital Strategy to address the aspects relating

to self-funders and financial capping and new assessment and eligibility responsibilities.

We are piloting new data sharing protocols between Health and Social Care and county

wide Information Standards. Current arrangements with Independent Financial

Advisors will be expanded to be Care Act compliant.

The development of Neighbourhood Networks with Local Area co-ordination to support

the effectiveness of Integrated Neighbourhood Teams is underway and will be further

refined through co-production with User Lead Organisations in Suffolk (such as the

Suffolk Coalition of Disabled People) and evolving user and carer led monitoring and

evaluation processes. Supported self-assessment, robust risk stratification and shared

care planning are integral to these changes.

New policy and guidance and resource allocation systems are being developed for carers

assessments and personal budgets and will be used by the new Integrated

Neighbourhood Teams and partners in the Neighbourhood Networks if this function is

delegated. This will promote parity of access to assessments and support for carers

with their cared-for across Suffolk.

An Integrated Carers Commissioning Group has been established to oversee carers

developments when the Care Act comes in in April 15. This group has been endorsed

through governance of all three CCGs in Suffolk and through Suffolk County Council’s

Adult and Community Services and Children and Young People Directorates.

These changes are wholly in line with our integrated care transformation programmes in

both IEWS and in Waveney and are within the main programme. They will be overseen

by the relevant programme boards within these two systems. These programme boards

will be accountable for delivery against the plans.

iv) Level of resource that will be dedicated to carer-specific support

The total spend on carers by Suffolk County Council is £2,425,961:

- Provided to carers as a personal budget - £1,594,052

- Funding to commission services for carers - £831,909

The resources identified through the Better Care Fund totals £1.724m and is made up

of:

- Ipswich and East and West Suffolk CCGs carers breaks funding - £1,406m

- Waveney element of the Great Yarmouth and Waveney CCG carers breaks

funding - £0.318m

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The intention in Suffolk is to pool this funding (apart from that provided to carers as a

personal budget) in order to jointly commission carer support. An Integrated Carers

Commissioning Officers Group has been established to take a strategic view about

responding to the needs of carers. Carers needs in Suffolk have been identified though

our recent stakeholder engagement and within the recent Suffolk Family Carers Needs

Assessment. Engagement events have identified the need for training for carers, both in

safe moving and handling and “Carers with Confidence” type courses, as well as a

“mumsnet” type website to promote opportunity for sharing of information and support.

The principle of carer-led commissioning and evaluation of services is integral to the work

of the Integrated Carers Commissioners Officer Group. By working together we can

prioritise those schemes which work on a risk stratification approach to carer support,

targeting interventions with those carers most at risk of leaving education, employment or

training and those where the caring role is at risk of breaking down due to lack of

information, advice and support. The Integrated Carers Commissioning Officers Group

will also be responsible for building business cases for new carer’s services, for making

sure that services are equitable across Suffolk, and for ensuring that new Care Act duties

are implemented.

A number of pilot schemes have been running in Suffolk and our integration programmes

will facilitate roll out of the things that we know work well and will address shared

outcomes in critical areas, for example delayed transfers of care (supporting carers as

experts in discharge planning – West Suffolk and Ipswich Hospitals), and preventing

avoidable admissions to hospital and residential care caused by carer breakdown.

Our schemes will support carers in their role as a key partner in care. Integrated delivery

arrangements (such as Integrated Neighbourhood Teams and the Out of Hospital Team)

will support carers to access the help available through current services such as:

- Supporting Carers at hospital discharge – this is a service available at the

hospitals which provides information and support when people are discharged

from hospital

- Suffolk Family Carers GP workers – based in GP practices and delivering 1-2-1

support for carers.

- Respite on Prescription initiative which enables GPs to “prescribe” information,

breaks and bespoke support from voluntary and statutory sector partners.

- Strategic Partnership funding for Suffolk Family Carers – countywide and covers

generic carer support and information and advice, together with community

development, training and awareness raising. Suffolk Family Carers in addition

has a jointly funded Mental Health Team.

- Carers budgets – iCARE and Enhanced Carers Budgets offered to carers who

have received a carers assessment.

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vi) Extent to which Suffolk County Council’s budget been affected against what was

originally forecast with the original BCF plan

Provisional agreement was reached in May that in addition to the £16.748m for implementation of the Care Act and s256, an additional amount of £4m would be transferred unconditionally to Suffolk County Council for the protection of adult social care. This amount has risen to £5.4m as described in (iii) above. This amount is conditional on achievement of savings through joint commissioning and contracting. Plans are well developed, with savings opportunities being scoped and identified and staffing resources in the recruitment pipeline. The risks associated with the protection of social care are incorporated within the BCF risk log in Section 5 (particularly risks 1 and 5). Ownership for these risks is with the Systems Leaders Partnerships and they will receive regular monitoring reports to support them to manage the mitigations required as the Plan moves forward. The extent to which the County Council’s budget plan has been affected by the new agreement for the protection of social care: The BCF Section 75 agreement and savings plans sit alongside other County Council savings plans. If these savings are delivered in full there will be sufficient funding to meet the needs of eligible adult social care customers, based on current demand projections.

b) 7 day services to support discharge

In Suffolk, the three CCGs and social care are already committed through our System

Leadership Partnerships to providing person centred health and social care services

seven days a week. Delivering effective 7 day services are a core part of our system

wide plans for integrated services. Progress will be monitored through our Integrated

Care Boards in IEWS and the ICS Programme Board in Waveney.

All three CCGs in Suffolk have CQUIN initiatives with provider organisations that

incorporate the 10 clinical standards, and require 7 day services to support discharge

and admission prevention within agreed timeframes.

In IEWS areas there are already existing services operating and available 7 days a week

in Suffolk, but a more effective and integrated response is being developed through our

integration delivery plans by both the CCGs and Suffolk County Council. New service

models will ensure that health and care services work together to support discharge and

admission prevention both in-hours and out of hours with scalable health and social care

capacity to match demand. This will be tested in practice as we role our pilot sites for

integrated working across East and West Suffolk. This will mean:

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• Scoping out the demand and options for delivering 7 day services that support

discharge, in line with our integrated service model – Nov 2014 - March 2015

• Ensuring our commissioning activity is aligned to deliver the services and support

needed eg Out of Hours GP services, Care Line crisis support, step down and

rehab bed capacity – Nov 2014 - March 2015

• Ensuring assessment and delivery capacity is available 7 days a week so that

decisions can be made at the appropriate time, and people can flow through the

system in a timely and effective way. Managing crisis with the effect of reducing

emergency admissions, and securing timely, safe hospital discharge, thereby

reducing delayed transfers of care and associated costs. We will test this through

our early adopter pilots in IEWS which are aiming to be active from April 2015 and

then roll out once confident of the delivery model (target June 2015)

o Acute hospitals are working to a similar timeframe for sustainable

improvements in workforce, flow and communications. This includes

additional consultant, therapy and critical care outreach capacity.

o Community Health CQUIN will have put elements of 7 day working in place

by April 2015.

• Monitoring and performance review arrangements implemented – April 2015

Other activity that will take place within our transformation programme will support 7 day

services:

• Aligning core hours in Integrated Neighbourhood Teams for health and care

professionals

• Alignment between our out of hours provision, and between out of hours and in

hours.

• Reviewing workforce needs and building the flexibility to deliver 7 day services into

core contracts.

Gt Yarmouth and Waveney CCG and partners, including social care, have successfully

bid to be an early adopter for the Seven Day Services Transformational Improvement

Programme. This work is supported by a strategic ambition to include all public sector

partners in an integrated system, and will deliver initiatives such as 7 day working

through one part of the patient pathway at a time. Learning from Gt Yarmouth and

Waveney’s early adopter work is being shared across the County through the

governance and programme arrangements.

There is Great Yarmouth and Waveney system recognition that we cannot implement 7

day services across the board all at once, therefore we aim to seek agreement that we

concentrate our resources on the areas that can have the best benefits in terms of

addressing variation in urgent and emergency services.

The proposed 7 day service focus areas therefore are around admissions avoidance,

diagnostics and discharge which are all interdependent and need staff from all parts of

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the system to work together across organisational and professional boundaries for the

good of the person in order for the whole system to be successful in achieving the above

outcomes.

Work is well underway to deliver 7 day services in Waveney due to being part of the

Seven Day Services Transformational Improvement Programme. Future milestones for

the 7 day services programme in Waveney are:

• Improve communications regarding Out of Hospital Team and their services with

James Paget University Hospital (JPUH) – December 2014

• Enhance multidisciplinary team working in JPUH – April 2015

• Enhance clinical recording systems in JPUH in relation to access to a consultant

within seven hours – April 2015

• Develop Out of Hospital model across Waveney – April 2015

The risks associated with 7 day services are:

• Financial implications of delivering 7 day services, in terms of affordability.

• All providers need to provide 7 day services for the process to work as they are all

independent. Un-willingness or capacity to deliver from some providers including

private and 3rd sector could hinder progress.

• Workforce issues: Not only capacity to deliver across 7 days but potential changes

of contract for staff and consultants could require consultation / negotiation,

resulting in potential time lags in delivery.

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c) Data sharing

i) Suffolk plans for using the NHS Number as the primary identifier for correspondence across all health and care services

NHS partners in Suffolk and Suffolk County Council are committed to using the NHS

number as the primary identifier for correspondence. This is a key enabler for integrated

working. The NHS is already using the NHS number as the primary identifier for

correspondence across all health and social care services.

The NHS number is a key field in all social care records within the core social care

system in Suffolk, and is currently populated in around 55% of these records. A project

has been put in place that will achieve 100% coverage and allow for information sharing

at customer and population levels; this project is underway and aims to have the batch

processing update mechanism fully in place by December 2014 and will be run on a

regular basis (anticipated to be monthly). It is expected that the first run of this will

identify some data mismatches so achieving full coverage is likely to take some months

to achieve. In addition, a further system related to our Home First activity, being

implemented with planned go live in early 2015, includes a core requirement for NHS

number to be a primary identifier.

It is also planned that the NHS number will be a key enabler to sharing of data for

secondary use, particularly between commissioners across the CCGs and Local

Authority. However, this has only been made possible to pioneer sites through a Section

251 exemption and will not be possible in Suffolk until the national legal framework is in

place to enable sharing at this level.

Our service redesign plans will ensure that as a default health and care staff will be using

a shared care plan. This will use the NHS number as the common identifier.

ii) The Suffolk approach for adopting systems that are based upon Open APIs

(Application Programming Interface) and Open Standards (i.e. secure email

standards, interoperability standards (ITK))

Suffolk County Council and the three CCGs in Suffolk are committed to Open APIs and

Open Standards. We wish to ensure that that they are secure for information and data in

all cases.

We will ensure procurement, implementation and upgrade of systems factors in Open

APIs and Open Standards throughout the health and care system; this has been evident

in our most recent NHS England Technology Fund Application.

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iii) The Suffolk approach for ensuring that the appropriate IG Controls will be in place.

We are committed to ensuring all appropriate IG controls are in place. The Suffolk

Partnership Agreement, signed off by the Health and Wellbeing Board, is a general

protocol already in use across our system.

Other data sharing arrangements are in place between NHS organisations and with

Suffolk County Council in order to share customer data. Specific agreements are in place

to facilitate the Multi Agency Safeguarding Hub which was set up earlier in 2014.

SCC is compliant with the NHS Information Governance Toolkit and has undertaken

internal audits to improve ratings in this area. The County Council has a Caldicott

Guardian who advises on data exchanges, beaches, sharing of data keeping customer

data information safe. All ACS Staff have received Data Protection Training.

CCGs - Information Governance is taken seriously with robust arrangements in place to

ensure compliance with the Data Protection Act, Common law duty of confidentiality and

other relevant legislation. All Suffolk CCGs have attained as a minimum level 2 on the

information Governance Toolkit providing assurance to organisations who wish to share

data with CCGs. In addition the Suffolk CCGs also have Accredited Safe Haven (ASH)

status, which enables the CCGs to receive, monitor and analyse certain data flows to

support its role as a commissioner. The IG Toolkit is audited on an annual basis. All

CCG staff undergo annual mandatory training in respect of IG and IT security.

The CCGs work collaboratively with social care and are in the process of finalising

Information Sharing Protocols with Suffolk County Council. Data sharing agreements are

used to provide detail for more specific sharing arrangements and the controls that are in

place. These documents are signed by the CCG appropriately. SIRO and Caldicott

Guardian roles are I place within CCG’s. These roles actively monitor IG & IT security

controls & Patient confidential data flows.

Any introduction of significant new systems, services or products involves the use of ICO

recommended Privacy Impact Assessments. Thus allowing the CCGs to identify any

privacy concerns and reduce the risks of harm to individual’s personal information.

Where there is a duty to share or legal basis in place the CCGs will share information for

the direct patient care or if there is a significant risk of harm to an individual or individuals.

j) Joint assessment and accountable lead professional for high risk populations i) Proportion of the adult population identified as at high risk of hospital admission, and approach to risk stratification used to identify them

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Risk stratification - We have identified predicted top 2% of our adult population who are

at risk of emergency admission in the following year. This cohort is identified through our

risk stratification tools. The total number of adults in Suffolk that this gives us as high risk

is 11,700.

Risk stratification tools have also been used to identify the top 2% of high risk customers

for case management intervention and support. The list is reviewed monthly. People at

high risk will have a named care coordinator, who will help them to develop a shared

outcome focused plan which will assess risk and plan care. This lead professional will be

the most appropriate based on the needs of the customer. In IEWS the RAIDR tool,

which is based on the combined predictive model is in the process of being rolled out. It

takes into account a variety of factors, including primary care and hospital admissions

data and identifies a risk level for every patient. In Waveney GPs and other professionals

have signed up to the Eclipse tool which can identify patients at high risk of hospital

admission.

Multi-disciplinary team (MDT) meetings in GP surgeries are used to identify adults at

high risk of hospital admission or of needing long term care. MDTs are attended by GPs,

Community Health staff and social care staff. This practice provides the foundation for

the Integrated Neighbourhood Teams across Ipswich and East and West Suffolk CCG

areas – described in Scheme 1 and the Integrated Community Health and Social Care

Teams – described in Scheme 8. Currently these meetings take place on a monthly

basis, but it is intended that the identification of high risk patients will become more

frequent as integrated neighbourhood working develops and with the implementation of

the new risk stratification tool.

Will also be identifying the cohort of people who are not yet frequent users of services or

at risk of hospital admission but who are developing LTCs and therefore who potentially

could fall in the high risk group. Our new service models will define the support offer for

people in these groups in order to reduce or mitigate the risks and help people to sustain

independent living.

ii) Joint processes in place to assess risk, plan care and allocate a lead professional for this population

Suffolk County Council and NHS organisations in Suffolk are committed to ensuring that

there is joint assessment, an accountable lead professional and care co-ordination for

people at high risk of hospital admission.

The key tools for achieving this are:

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Multi-disciplinary teams - to undertake joint assessments with the lead case

management role being taken by the person that makes most sense for the individual

across the whole of the area. This will often be the lead social care professional

undertaking the lead on-going care management role but sometimes by others, for

example the Occupational Therapist who has had the most involvement or the nurse

case manager. Whoever it is will be working on behalf of the whole team, always linking

back to the team, and thus a seamless service can be provided without the individual

having to be referred multiple times and handed off at each point. All Better Care Fund

schemes will link into the delivery of this key tool.

Care coordination to provide the lead professional role, co-ordinated care and to ensure

that joint assessment is carried out. The case manager is determined based on which

professional has the most appropriate skill-set at the time, and in some cases will be the

persons GP. The Care Coordinator will be the patient’s main contact for issues around

their care plan. They will liaise with other health and care professionals to ensure that the

right clinical and professional inputs are in place for patients. This will include specialist

teams and resources, including mental health and learning disabilities teams. (Scheme 2

develops this link between locality resources and specialist resources).

Joint assessment that will be based around a core assessment covering a standardised

set of questions and fields. Specialist assessment will build on the core assessment to

provide a comprehensive assessment across health and social care. In some cases this

will be carried out in specialist teams, for example for those people with a mental illness

or people with dementia. In Children’s services the Common Assessment Framework

(CAF) and Single (Statutory) Assessment provides the framework for multiagency

assessment and planning and allocation of a lead professional to oversee the

implementation of the care plan. The Better Care Fund schemes 1,3(a) and 7 will work

to overcome the barriers in achieving joint assessment and shared care planning.

Shared care planning is being developed across health and social care so that people

have a single outcome focused plan that co-ordinates all their immediate physical and

mental health and care needs. The plan will be developed collaboratively with a patient

and their carer (if applicable) and be jointly owned by the patent, carer, and named

accountable GP and/or care coordinator. If the patient consents, the personalised care

plan will be shared with the multi-disciplinary team and other relevant providers. All Better

Care Fund schemes will link into the delivery of this tool.

Workforce development will define roles within new teams, build the culture to support

joint working and embed working practices so that joint working becomes the norm for

health and care staff.

Accountable professional role will be delivered through the Reducing Unplanned

Admissions Enhanced Service specification which requires all GPs to provide the

accountable professional role for people who are elderly, with complex needs or who are

needing end-of-life care, particularly those who are at risk of admission to hospital. This

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is particularly relevant for Better Care Fund schemes 1, 5 and 7.

iii) The proportion of individuals at high risk already have a joint care plan in place

Our understanding of how many individuals at high risk have a joint care plan is currently

under development. At this stage there are no firm figures at CCG level for the proportion

of individuals identified as being high risk who already have a joint care plan in place.

However, there are established multidisciplinary teams working within the CCG area

and individuals identified at high risk supported through these MDTs have a joint care

plan.

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8) ENGAGEMENT a) Patient, service user and public engagement

Our Plan is based on what people have told us is important to them over a number of

years. Suffolk Healthwatch has helped us engage with the public, patients and services

users over the summer. Evidence from this work has helped focus the schemes to

support people’s needs as effectively as possible. We know, from previous Suffolk

consultation events, the Voice Project and involvement forums that people are not

interested in structures – seamless service provision seems obvious to them. They are

more concerned about their own care and independence, and that any support should be

tailored to their needs, provide them with choices and control, be delivered with dignity

and respect and for their care to be planned with them, so that it will support their

aspirations of living well. This feedback forms the guiding principles for the design of our

schemes: integrated, timely and responsive and enabling independence as much as

possible. The final report of this work is listed in Section 1 c) Related Documents.

Across the area there is active patient, carers, service user and public engagement

where views are regularly sought to inform the development of integration and future

commissioning intentions. In developing our integrated health and social care plans we

have also been able to build on pre-existing partnership work and plans, which have had

active public, service user, patient and family carer involvement. In Waveney

Commissioning Programme Boards include representation from patients, family carers,

service users and the public.

In IEWS for the Health and Care Review, stakeholder events were held prior to the

Urgent Care work stream starting to inform the work programme, for example Town Talk

Village Voices where lead GPs and officers went to ten locations across East Suffolk,

such as Felixstowe’s Morrisons supermarket and Ipswich Crown Pools, asking for the

public’s opinion on the NHS 111 service and what would they would like the NHS to do

differently if they were taken suddenly ill. In addition, we are building on existing public

consultations, working alongside patient groups in GP Practices, and the Council’s

connecting communities work in localities, working with Healthwatch and Health Scrutiny

Committees.

Great Yarmouth & Waveney partners have listened to what patients and service users

have said and included their views in strategic and operational planning including the

overall approach to the Better Care Fund. The CCG also has a patient representative on

the Board and the Better Care Fund has been fully discussed and debated in this forum

with key focus on patient experience and outcomes. Patients and customers have said

clearly that they want to experience a joined up system.

In order to continue engagement with our patients and public about the design of our

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services going forward a programme of events such as public participation forum, our

Patient and Public Experience Group meeting and our Patient, Carer and Community

events have been put in place. Alongside this we will continue our dialogue with other

representative organisations such as the Older Peoples Network.

The Suffolk System Leaders Partnership agreed an Engagement and Communication

Plan in February 2014 to

• Ensure that engagement starts with co-production with people who use our

services.

• Include statutory and voluntary stakeholders, with service users as equal partners.

• Recognise the need for engagement with staff.

• Ensure engagement and communications are planned and co-ordinated.

• Build a long term engagement partnership across organisations in Suffolk.

The Engagement and Communications Plan enables the SLP to ensure that key

messages and questions are developed and that there is a timetable for engaging with

key partners not already involved with the Health and Care Review. Healthwatch and

other voluntary sector partners have agreed to lead on co-production and engagement

with service users and to bring insights and experience into the debate.

We have a track record of co-production, for example in developing our integrated plans

for dementia services, in integrated health and care service delivery for children in our

Suffolk Family Focus (troubled families) programme, in Lowestoft Rising (testing place

based models of service delivery) and in the development of the new operating model for

adult social care: Supporting Lives Connecting Communities and children’s services:

Making Every Intervention Count.

Two mental health workshops (April 2014) have been co-produced by service users and

commissioners focussing on early intervention and prevention, crisis response and

recovery. The workshops will support the development of the Suffolk Needs Assessment

for Mental Health, shape the 5 year Joint (CCG’s and County Council) Commissioning

Strategy for Mental Health and clarify how to continue to engage with service users and

mental health organisations alike.

Evidence from engagement and co-production activity has been used in the development

of the Better Care Fund schemes outlined in annex 1.

The following diagram shows the Suffolk Health and Wellbeing Board organisational

engagement map.

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This diagram shows the connections from the Suffolk Health and Wellbeing Board and

the two System Leaders Partnerships in Suffolk (which include a wide range of

commissioner and provider organisations).

b) Service provider engagement i) NHS Foundation Trusts and NHS Trusts

The main service providers in Suffolk listed in the following table which also shows in

which areas they operate.

Provider Waveney area IEWS area

Ipswich Hospital

West Suffolk Hospital

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James Paget Hospital

Norfolk and Suffolk

Foundation Trust (mental

health)

Health East

Suffolk Community

Healthcare

Primary Care providers

Care providers – both

home care and

residential care

Voluntary and

Community sector

organisations

District and Borough

Councils

All service providers have been involved in developing the two integrated services

programmes in Suffolk through the governance and delivery arrangements.

The Suffolk Better Care Fund Plan (the Plan) has been developed by working groups of

the Suffolk Health and Wellbeing Board. The accountability for the development work is

the two System Leaders Partnerships which include Chairs of the three Suffolk CCGs,

the Chief Officers of the CCGs, the Director of Public Health, the Director of Adult Social

Care and Director of Children’s Service, Chief Executive of the Norfolk and Suffolk

Foundation Trust, Chief Executives of Ipswich, West Suffolk and James Paget Hospitals,

the Chief Executive of Suffolk Community Healthcare, the Chief Executive of East Coast

Community Healthcare, Healthwatch, Community Action Suffolk/Suffolk Congress

representing the voluntary and community sector, the Cabinet Lead for Health and Adult

Care and District and Borough representatives.

The acute providers have now become regular invited members of the Health and

Wellbeing Board.

In the IEWS area:

- Two initial workshops to build the vision for integrated care were attended by provider

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organisations in November/December 2013. During these workshops they played a

critical role in shaping the vision going forward, and the work streams that are

developing the proposed changes.

- All providers have been core members of the Systems Leaders Partnership and the

programmes making up the Health and Care Review. They have also been involved

in workshops and other meetings to develop the integrated model for the area. At the

SLP meeting in May the acute providers and the mental health trust were invited to

present their future vision for their organisation.

- There has been extensive provider engagement in a number of work stream groups,

and forums where practical plans for integration have been developed, for instance

around urgent and integrated care. Their involvement has led to a greater

understanding of the risks and opportunities of developing safe and effective care..

In the Great Yarmouth and Waveney area:

- A Great Yarmouth and Waveney integrated care system event in December 2013,

attended by all public sector commissioners and providers from the area including

health and social care. At this event the development of an Integrated Care System

was fully debated including the opportunities presented by the Better Care Fund. Key

principles were agreed and issues discussed in greater detail to inform the plan

including seven day working, cohesive pathways, combining budgets and impacts on

the workforce.

- All three Waveney providers are core members of the Great Yarmouth and Waveney

System Leadership Partnership and the Integrated Care System Operational Delivery

Group. In addition there are a number of specific multi-agency groups that these

organisations are involved in, such as Programme Boards and Seven Day Services

where specific Better Care Fund schemes are discussed.

- All provider organisations were consulted on focussed areas for the schemes and

have continued to be actively involved in both the design and the implementation

phases to ensure alignment of operational planning.

- The James Paget Hospital is already aligned with the CCG in terms of forecast

reductions in emergency activity and acute capacity. This is due to increasing

integration of pathways, and the hospital playing an important role around

increasingly offering outreach services into the community and primary care.

All provider organisations have incorporated integration and the Better Care Fund in their

2 year operational plans and 5 year Strategic Plans.

ii) Primary care providers

Seeking member practices views – All Suffolk GP practices are members of one of the

three CCGs. We’re focused on member practices being closely involved in decision

making and have published our Practice Charter and Constitution documents, which are

our ‘rules for engagement’ laying out what practices can expect from the Governing

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Bodies, and the Governing Bodies from practices, and how practices interact as a unified

body.

We have strong GP and practice manager representation on our Clinical Executive

Committees and on the CCG Governing Bodies which ensures clinical input into all areas

of our work.

The CCGs variously have regular Clinical Leads Forums and Locality meetings with

representation from all practices, along with monthly PTL (Protected Time for Learning)

and Education and Training sessions, plus practice manager meetings and a range of

regular informal practice visits.

We have a number of retained GPs and retained Nurses working with the CCGs. This is

a tremendously valuable resource to help us with commissioning decision making, and

being clear on our commissioning intentions going forward.

CCG members are involved in quality priority setting in Plans – Each CCG met with

clinical leads to identify and agree commissioning priorities and intentions for 2014/15

and beyond. We recognise the need to engage with member practices to help them

understand the quality challenge in both primary and secondary care to develop an

appropriate response for our population and our area, and to translate that into real

action and real quality improvement.

Member practices involved in decision making processes - Our clinical leads

meetings are fully representative with GPs and practice managers in attendance. These

groups guide strategic development prioritisation, and practical implementation of

pathway redesign, and meeting the QIPP challenge via system transformation. Retained

GPs inform this process through the programme boards, and workstreams. The Clinical

Executive Committees are the delegated authority for decision making from Governing

Bodies. Thus clinical leadership is not only accountable at Governing Body level, but

involved at executive level in all spending decisions, monitoring delivery of the QIPP

challenge and priority setting for each commissioning year. The CCG Governing Bodies

include member practice representation at clinical and managerial level and lead

strategic planning for the CCGs, with extensive clinical involvement in decision making.

Member practices understand at a high level our local plan and priorities - Our

clinical leads have been involved in shaping and approving our overall strategic plans at

both a health system and Programme Board and workstream level. Specifically, the

Health and Independence and Urgent Care models (IEWS) and Urgent Care Strategy

and Frail Elderly Strategy (GYW) have been discussed in detail with clinical leads and

amended in the light of feedback prior to their presentation to the Clinical Executive

Committees.

Effective and transformational Integrated Care Network System Forum and Clinical

Workstreams (IEWS) and Programme Boards (GYW) have extensive clinical

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engagement from a wide range of providers and are actively influencing commissioning

intentions.

One example of CCGs supporting GP practices is in transforming the care for patients

over 75 years old by providing funding to practices to commission additional local

services that will improve the quality of care for older people and reduce avoidable

emergency admissions. This funding is an enabler to the CCGs’ integrated care

programmes in supporting people with complex needs. The CCGs are supporting primary

care to develop plans that underpin the principles of the plans relating to case finding,

comprehensive assessment and proactive case management with shared care planning.

The plans being developed by primary care aim to further develop the accountable GP

and case management approach to managing people with complex care needs with a

focus on prevention and admission reduction.

iii) Social care and providers from the voluntary and community sector

The Health and Wellbeing Board includes social care and voluntary and community

sector (VCS) representation. There is a voluntary sector subgroup that meets regularly in

between HWB meetings to ensure engagement of the wider sector in the work of the

Board.

The VCS are also represented on the two System Leaders Partnerships, and on the

programme boards designing and implementing integrated systems in Suffolk.

The key organisations involved are:

- Healthwatch

- Community Action Suffolk (which is the umbrella body for the VCS in Suffolk)

Other involvement includes:

- Suffolk Coalition of Disabled People are a core member of the Health and Care

Review Engagement Group and have been supporting the development of focus

groups to explore the implications of the changes proposed, particularly with hard to

reach communities.

- A large number of organisations have been involved in developing the community

facing aspects of the Health and Care Review:

o Hospices

o Support services for people with personal budgets

o Community development groups

o Groups working with people with drug and alcohol problems.

The wider VCS have been involved through established forums like the Working

Together Forum. In May an event was held by Ipswich and East Suffolk CCG with

Community Action Suffolk which involved around 100 VCS organisations with an

opportunity to feed into the Health and Care Review and therefore the design of the

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Better Care Fund plan.

Social care providers have been engaged through Market shaping events and provider

forums run by Suffolk County Council which have involved our private sector partners in

redesigning the home care market for a more integrated system.

c) Implications for acute providers

NHS commissioners will be working closely with partners towards the savings quantified

in Everybody Counts, namely reductions in emergency non-elective activity

and efficiency savings in planned care.

The three acute hospitals in Suffolk are committed to playing a full part in the

development of an integrated system and are key participants in the design and

implementation work. In order to plan services effectively we must develop clarity around

which services we will need in the future and which will no longer be provided, either in a

particular setting or none at all.

An integral part of our financial plans is to achieve a reduction in hospital activity. What

must be delivered, in collaboration with our partners, is a radical transformation of the

way services are provided which will enable public funds to be used more cost

effectively, across all sectors.

In IEWS we are working with our acute providers to support their sustainability.

Both Ipswich and West Suffolk Hospitals are reporting underlying financial deficit

positions and are rated as high risk according to TDA and Monitor risk ratings. We are

targeting reductions in emergency non-elective activity through our Health and Care

Review and local QIPP Plans. The BCF is expected to accelerate the progress of these

plans. Reductions in non-elective activity will provide the opportunity for the acute trusts

to reduce costs or release capacity to accommodate other commissioned activity. The

Marginal Rate paid for non-elective activity above threshold levels creates a cost

pressure for trusts which will be avoided by reducing this activity. Both hospitals agree

that a reduction in non-elective admissions will ease the considerable pressure on the

Trusts’ clinical resources but note that there is a risk in planning for delivery of changes

which do not occur.

Both hospitals are engaged in the system-wide Health and Care Review which is

developing the Urgent Care and Health and Independence service models. The elements

of these services which fall within the scope of these BCF plans (Schemes 1-3) are

targeting reductions in emergency admissions of 979 (Ipswich Hospital) and 640 (West

Suffolk Hospital) in 2015/16. It is our intention that when agreed, the output of the

detailed modelling will be incorporated in the refresh of the 2015/16 CCG and provider

plans.

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Ipswich Hospital has stated in its 5 year Plan: “Our commissioners are clear in their

desire to deliver integrated care and the importance of an Integrated Care Model. The

vision of integrated care is one wholly supported by the Board of IHT. It requires

organisations to work effectively across boundaries recognising the value and

contribution of all sectors of the health and social care community.”

West Suffolk Hospital stated in its 5 year Plan that it “is working in collaboration with

partners to deliver transformational programmes and maintain our excellent record for

delivering high levels of quality and operational performance. WSFT believes it will

remain clinically viable and deliver high quality services for the life of the plan, however at

this point we are unable to make a declaration of financial sustainability, although this

position is likely to improve over the five years if emergency activity is reduced in line with

national requirements.”

In addition, we are developing a number of schemes which will benefit providers such as:

• Rapid Assessment Interface and Discharge (RAID) psychiatric liaison service: a

high profile mental health team at the hospital front door providing a range of

mental health specialities within one multidisciplinary team. This is comprised of

mental health liaison practitioners specialising in general psychiatry, deliberate

self-harm, substance misuse and old age psychiatry. This means patients can be

assessed, treated, signposted or referred appropriately. By working closely with

hospital clinicians and managers, the professionals ensure that the mental and

physical health needs of people are considered and treated together.

• Clinical Forums: A Commissioning for Quality and Innovation (CQUIN) scheme

has been developed to support clinically led transformation of selected specialties

to meet the QIPP challenge. This is the vehicle for achieving high quality with

significant saving required for financial sustainability. The role of clinical forums is

to combine experts and patients to transform the care we deliver in distinct areas

across the system for true integration of primary, community, secondary and even

tertiary care.

• In Ipswich and West Suffolk Hospitals the psychiatric liaison service is being

embedded and further expanded to include services for young people aged 13 to

18 to address long term conditions. There will be a full evaluation in quarter two of

2014/15 which will inform the commissioning model going forward into 2015/16

and beyond.

• During 2014/15 post diagnostic service model will be developed for people with

dementia and their carers for procurement in 2015/16 in order to remodel

pathways of care for people with dementia to eliminate gaps in service and

support people and their carers to live well with dementia in their own homes for

as long as possible. This work is being undertaken jointly by West Suffolk CCG

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and Suffolk County Council.

• The 2014 mental health needs assessment will include a specific focus on

perinatal mental health. Ahead of its publication: we are working with Norfolk and

Suffolk NHS Foundation Trust to ensure that the services offered by the Suffolk

Wellbeing Service are accessible and available to pregnant women and new

mothers. We will support Norfolk and Suffolk NHS Foundation Trust to develop

more effective relationships with the Ipswich Hospital Midwifery Service so that

there is a better understanding of what the Wellbeing service offers and to

establish clear referral pathways. These pathways will help contribute to the 15

per cent treatment rate for IAPT during 2014/15. We are also participating in the

Strategic Clinical Network Pilot to develop the Integrated Delivery Commissioning

Toolkit for perinatal and post natal mental health care.

• A mental health practitioner has been commissioned to work alongside a Police

Emergency Response vehicle to support people with mental health care needs in

crisis.

In Great Yarmouth and Waveney the key implications are:

• An innovative scheme being considered with practices in the Gorleston area which

would collocate on the James Paget University Hospital (JPUH) site, providing

integrated front line care to patients from the whole area attending as

emergencies, diverting demand from traditional A&E services and reducing

cost. There will also be provision of services by East Coast Community

Healthcare (ECCH) within JPUH and provision of services by JPUH staff outside

the confines of the hospital buildings to move forward towards a fully integrated

provision model.

• Commissioners are working with providers in acute and community health to foster

a strategic alliance between JPUH and ECCH. It is intended that JPUH will retain

its provision of a full service District General Hospital, but drawing on the

opportunities for a networked approach with the Norwich and Norfolk University

Hospital wherever appropriate, in order to ensure highest standards of clinical

safety, but also ensure sustainability of services. It remains very clear that the

relative isolation of some Waveney residents means we need strong local

services.

• We will need to manage capacity effectively within the system to maintain a

balanced financial position over the next five years. Capacity will be supported by

an innovative out of hospital team, supported as necessary by additional care

home capacity locally. Emergency admissions have reduced compared to

2012/13 and the intention is to build on the evidence that the increasingly

integrated working between health and social care is starting to manage down

Page 73 of 129


demand.

We are also working through the consequences of non-achievement of the targeted

savings and associated contingency plans.

Page 74 of 129


ANNEX 1 – Detailed Schemes Description Scheme ref no.

Scheme 1 - IEWS

Scheme name

Integrated Neighbourhood Teams

What is the strategic objective of this scheme?

We will create multi agency multi professional teams which will pro-actively work to

support people with health and care needs and in particular those who are at risk of

hospital admission or deterioration in order to turn unplanned care into planned care.

Overview of the scheme

• Community health staff, social care staff, mental health staff, practice based staff

and GPs, co-located where possible.

• A core team of key multi-disciplinary staff and a wider team of other professionals, with strong links to staff within specialist services.

• Strong local focus with interface with the local voluntary and community sector,

district council, police partners and others.

• Shared holistic assessment and a single plan to co-ordinate care and support with

individuals holding their own plan and playing a key part in designing it.

• Self-care and prevention advice underpinning all service delivery and developed

within NICE guidelines, including the development of a Green/Amber/Red trigger

tool that supports people to identify what their own self care plan is and when to

contact services

• Build on existing work in Suffolk, but with accelerated progress through

commissioning, joint workforce development and the development of joint

operational policies and infrastructure.

• Aligned core in hours/out of hours.

• Appropriate 7 day coverage and clinical standards.

• Improved standards and responsiveness of services across community based,

specialist and mental health services.

• Shared workforce development plan that supports person centred culture and

practice within the Integrated Neighbourhood Team through shared planning

systems.

• The Integrated Neighbourhood Team will be working with all ages. However

particular focus within the team will be on the frail elderly, those with a Long Term

Condition and those at risk of higher future health and care needs, including on

hospital discharge

• The Integrated Neighbourhood Teams will work closely with the local voluntary

and community sector (Neighbourhood Network) to support people’s care.

The delivery chain

Page 75 of 129


The delivery of Integrated Neighbourhood Teams will be through partnership working

across Ipswich and East Suffolk CCG, West Suffolk CCG, Suffolk County Council’s

Adults and Community Services (ACS), Suffolk Community Healthcare, Norfolk and

Suffolk Foundation Trust and others.

Commissioning activity (eg the re-commissioning of community health, 111 and the Out

of Hours Services is aligned to deliver the new model.

ACS transformation programmes are delivering a transformed social care workforce.

All commissioners are working with community health providers to deliver change within

contract, prior to the termination of existing contracts.

In order to test out the transformation on the ground a number of early adopter sites (including the Sudbury Alliance) have been agreed. Establishing a locality alliance will give an opportunity to understand how the service model will operate in practice in a number of sites. It will give a test of concept, and the ability to develop the model further. It will provide a blueprint for further role out of the model, whilst building confidence in the new ways of working. The early adopter sites will include involvement from the local community health team, local GPs, the social care team, the acute hospital trust, the local voluntary and community sector, the District Council and others.

The evidence base

Integrated Teams - Evaluating integrated and community-based care – the Nuffield

Trust review of national integrated care pilots and virtual wards1 showed reductions in

planned admissions and in outpatient attendances for some interventions that involved

case management using multidisciplinary teams and those using virtual wards, but no

evidence of a general reduction in emergency admissions.

King’s Fund analysis of the evidence2 suggests that joint commissioning between health

and social care that results in a multi-component approach is likely to achieve better

results than those that rely on a single or limited set of strategies.

The Torbay integrated care model has reduced the use of hospital beds by a third from

750 in 1998/1999 to 502 in 2009/2010. Emergency bed day use for people aged 75 and

over fell by 24% between 2003 and 2008 and by 32% for people aged 85 and over.3 4

The Institute of Public Care at Oxford Brookes University reports that joint health and

social care investment in dental care, podiatry services, incontinence, dehydration

1 Evaluating integrated and community-based care – a review of national integrated care pilots and virtual wards http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/evaluation_summary_final.pdf 2 Goodwin et al, 2012, Integrated care for patients and populations: Improving outcomes by working together – The King’s Fund: http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together 3 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-study-kingsfund13.pdf 4 Thistlethwaite, P. (2011) "Integrating health and social care in Torbay: improving care for Mr Smith" The King's Fund, London: http://www.kingsfund.org.uk/sites/files/kf/field/field_document/PARR-combined-predictive-model-final-report-dec06.pdf

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-study-kingsfund13.pdf


Page 76 of 129


monitoring (liquid intake), falls prevention and stroke recovery services has a positive

impact on admissions to residential care.5

Structured Discharge Planning by multi-disciplinary teams - A Cochrane database

systematic review of hospital discharge planning provides robust evidence that a

discharge plan tailored to the individual patient probably brings about reductions in

hospital length of stay and readmission rates for older people admitted to hospital with a

medical condition. The impact of discharge planning on mortality, health outcomes and

cost remains uncertain. The review assessed randomised controlled trials (RCTs) that

compared an individualised discharge plan with routine discharge care that was not

tailored to the individual patient. Participants were hospital inpatients.6

A Cochrane systematic review of randomised controlled trials recruiting stroke patients in

hospital assessed the difference between those receiving conventional care with those

with early discharge with rehabilitation at home (early supported discharge).7 Results

showed that early supportive discharge significantly reduced the length of hospital stay

equivalent to approximately seven days. Early Supported Discharge can reduce long-

term mortality and institutionalisation rates for up to 50% of patients, as well as lower

overall costs.

7-day Service - Where hospitals, primary and community care providers and social

services have reduced services at weekends it becomes more difficult to transfer or

discharge patients at a rate that is consistent with weekdays. A recent report from the

National Audit Office found that 0.83 million acute bed days were lost due to delayed

discharges in 2012/13. A lack of availability of specialist community and primary care

services, resulting in more patients on an end of life care pathway dying in hospital.8

Optimal lengths of stay can only be achieved if all health and social care services are

provided seven days a week. More than one trust referred to patient audits which found

that a third or more of patients in hospital at weekends could actually be cared for outside

hospital; but this is hard to achieve when there is only a limited service from primary and

social care at weekends.9

There is a growing body of evidence that case mix-adjusted mortality rates are higher for

patients admitted electively or as emergencies to hospital ‘out-of-hours’, with most

research focussing on weekends. The size of the weekend effect lies between 0.2% and

1% absolute increase in crude mortality over all admissions. Factors contributing to

5 CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive services: a structured approach to service transformation and delivering better outcomes for older people

6 Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013, Issue 1. 7 Fearon P, Langhorne P Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev. 2012 Sep 12;9:CD000443. 8 National Audit Office (2013) Emergency admissions to hospital: managing the demand. 9 Healthcare Financial Management Association (2013). Costing seven day services. The financial implications of seven day services for acute emergency and urgent services and supporting diagnostics. NHS Services, Seven Days a Week Forum. http://www.england.nhs.uk/wp-content/uploads/2013/12/costing-7-day.pdf

http://www.scie-socialcareonline.org.uk/searchp.asp?query=author=%22CARE%20SERVICES%20IMPROVEMENT%20PARTNERSHIP.%20Care%20Services%20Efficiency%20Delivery%20Programme%22

http://www.ncbi.nlm.nih.gov/pubmed?term=Fearon%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22972045

http://www.ncbi.nlm.nih.gov/pubmed?term=Langhorne%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22972045

http://www.ncbi.nlm.nih.gov/pubmed/22972045

Page 77 of 129


increased mortality may include inadequate numbers of skilled staff, healthcare error and

adverse events, lack of organisation and structure for care delivery, and reduced access

to specific interventions. [Freemantle 2012, Mohammed 2012, Cram 2004, Cavallazzi

2010, Aylin 2010, Kruse 2011, Buckley 2012, MaGaughey 2007, James 2010, Worni

2012, De Cordova 2012, Deshmukh 2012, Kane 2007, Cho 2008, Needleman 2002,

Pronovost 2002, Wallace 2012, Kim 2010, Aiken 2002, Penoyer 2010].10 11

In a major study, retrospective statistical analysis of routinely collected acute hospital

admissions in England, involving all patient discharges from all acute hospitals in

England over a year (April 2008-March 2009), showed that weekend admission appears

to be an independent risk factor for dying in hospital and this risk is more pronounced in

the elective setting.12

Further evidence of this “weekend effect” was reported in an analysis of NHS inpatient

data from 2009/10 by Freemantle et al. The analysis concluded that being admitted at the

weekend is associated with an increased risk of mortality within 30 days of admission

compared to weekdays. This ranged from an 11% increase on Saturday to a 16%

increase on Sunday when compared to patients admitted on a Wednesday.13

Studies have shown an association between seven day physiotherapy services and a

reduction in overall length of stay for patients.14 15

The report by the Centre for Mental Health cites a wide body of evidence suggesting a

reduction in length of stay of 2-5 days per patient is achievable. An evaluation of the

RAID (Rapid Assessment, Interface and Discharge) service in Birmingham identified

reduction of 14,500 hospital bed-days (equivalent to £3.55m) in the first full year of

implementation.16

Suissa et al showed that patients hospitalised for COPD or pneumonia are at increased

risk of death when staying over on a Friday or a weekend. The additional 40-56 deaths

per 100,000 patients staying in hospital on those days are most likely due to reduced

access to healthcare at that time.17

10 Academy of Medical Royal Colleges (2012). Seven day consultant present care. Academy of Medical Royal Colleges.

http://www.aomrc.org.uk/doc_view/9532-seven-day-consultant-present-care 11 NHS Improvement. (2012) Equality for all: Delivering safe care – seven days a week. http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx 12 Mohammed et al (2012). Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency

setting: a retrospective database study of national health service hospitals in England. BMC Health Services Research 2012, 12:87.

http://www.biomedcentral.com/1472-6963/12/87 13 Freemantle, N. Et al (2012) Weekend hospitalization and additional risk of death: An analysis of inpatient data. J R Soc Med 105(2):74-84, http://jrs.sagepub.com/content/105/2/74.full 14 Cardiff and Vale University Health Board (2009). Extended day and seven-day physiotherapy service in acute medicine. 15 Rapoport J and Judd-Van Eerd M (1989) Impact of Physical Therapy Weekend Coverage on Length of Stay in an Acute Care Community Hospital. Journal of the American Physical Therapy Association. 69: 32-37. 16 NHS Services, Seven Days a Week Forum (2013). Evidence base and clinical standards for the care and onward transfer of acute inpatients. http://www.england.nhs.uk/wp-content/uploads/2013/12/evidence-base.pdf 17 Suissa S, Dell'Aniello S, Suissa D, Ernst P (2014). Friday and weekend hospital stays: effects on mortality. Eur Respir J. pii: erj00077-2014.

http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx

Page 78 of 129


Study from Scotland showed that patients admitted as emergencies to medicine on

public holidays had significantly higher mortality at 7 and 30 days compared with patients

admitted on other days of the week.18

Another Scottish study also showed that despite a general reduction in mortality over the

last 11 years, there is still a significant excess mortality associated with weekend

emergency admissions.19

Investment requirements

£12,570,000

Impact of scheme

This scheme will impact on:

• Reduction in non-elective emergency admission

• Reduction in delayed transfers of care

In conjunction with schemes 2, 3(a), 3(b) and 3(c) this scheme will generate a total

saving of £1,094,620

Feedback loop

The schemes will be overseen by current Integrated Care partnership arrangements: the

System Forum in West Suffolk and the Integrated Care Board in Ipswich and East

Suffolk. As part of maintaining the success of the early adopter site a suite of local

metrics will be developed. These will include consideration of the Better Care Fund

metrics, patient and user satisfaction, the costs of delivery and the impacts against the

Suffolk Theory of Change described above.

What are the key success factors for implementation of this scheme?

Higher cost interventions are replaced with lower cost interventions

a) Reduced emergency admissions

b) Effectiveness of reablement


a) Numbers of people identified through local risk stratification

b) Numbers of people with a named care co-ordinator and care plan

c) Patient satisfaction

18 Smith S, Allan A, Greenlaw N, Finlay S, Isles C (2014). Emergency medical admissions, deaths at weekends and the public holiday effect. Emerg Med J.;31(1):30-4. doi: 10.1136/emermed-2012-201881. 19 Handel AE, Patel SV, Skingsley A, Bramley K, Sobieski R, Ramagopalan SV (2012). Weekend admissions as an independent

predictor of mortality: an analysis of Scottish hospital admissions. BMJ Open. 6;2(6). pii: e001789. doi: 10.1136/bmjopen-2012-

001789.

Page 79 of 129


Scheme ref no.

Scheme 2 - IEWS

Scheme name

Access to specialist services and supports


This scheme links specialist services (for example continence services and specialist

dementia teams) to our Integrated Neighbourhood Teams to support people with

particular health and care needs.


• Clear revised service specifications for specialist services, jointly commissioned

where appropriate.

• Clear pathways in and out of specialist services (for example the post diagnostic

dementia pathway).

• Working practices that support the Integrated Neighbourhood Teams and the

Neighbourhood Networks (local voluntary, community and other services) to pull

the expertise for use with their customers and to enhance skills across the system.

• Inclusion of services addressing both mental and physical health.

• Consistency of access to specialist services, including by Neighbourhood

Networks.

• Patient pathways are those where specialist input is needed, eg those with

complex co-morbidities and where the Integrated Neighbourhood Team does not

have the appropriate clinical or other skill to provide effective care.

• Established strong links into the Integrated Neighbourhood Teams

The delivery chain

The delivery of specialist services will be through partnership working across Ipswich and

East Suffolk CCG, West Suffolk CCG, Suffolk County Council’s Adults and Community

Services, Suffolk Community Healthcare, Norfolk and Suffolk Foundation Trust and

others.

Commissioning activity (eg the recommissioning of community health, 111 and the Out of

Hours Services) is aligned to deliver the new model.



contract, prior to the contracts for services changing.

The evidence base

Page 80 of 129


Specialist Services for Continence Care - Urinary incontinence significantly increases

the risk of hospitalisation and admission to nursing homes.20 An intervention involving

behavioural and lifestyle counselling provided by specialised nurses led to reduced

incontinent events and incontinence pad use.21 This may mean that the costs of

professional time are offset by reductions in pad costs.22

Specialist Services for Dementia Care - In a systematic review of randomised

controlled trails, four out of six good quality studies found that case management of

dementia patients was associated with delayed or reduced institutionalisation, although in

one study this was only significant in one of three countries studied. However, none of

the good quality studies found evidence for savings in healthcare expenditure or reduced

hospitalisation rate/emergency visits. NHS investment in early assessment services for

people with dementia can produce significant savings for social care, particularly in

relation to residential care (National Dementia Strategy – Impact Assessment – economic

case for early assessment and memory services).23


£1,445,000

Impact of scheme




In conjunction with schemes 1, 3(a), 3(b) and 3(c) this scheme will generate a total

saving of £1,094,620

Feedback loop


System Forum in West Suffolk and the Integrated Care Board in Ipswich and East

Suffolk. As part of the early adopter site a suite of local metrics will be developed. These

will include consideration of the Better Care Fund metrics, the costs of delivery and the

impacts against the Suffolk Theory of Change described above.

20 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing 26(5):367-374. 21 Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ. 14;166(10):1267–1273 22 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A guide for commissioners written by continence care professionals. http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf 23 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf

Page 81 of 129




a) Reduced emergency admissions

b) Effectiveness of reablement


a) Specialist services have supported the Integrated Neighbourhood Teams to

deliver personalised, outcome focused care

b) Organisational processes are integrated – across multiple providers

Page 82 of 129


Scheme ref no.

Scheme 3(a) - IEWS

Scheme name

Admission prevention


Our approach to admission prevention is designed to get upstream of crisis in order to

reduce the number of people who are admitted to hospital during a crisis.


• Risk stratification as well as local knowledge to identify and support those at risk of

admission.

• An enhanced reactive responsive within the local health and care system which

will provide community based services to support people at risk of crisis, including

step up and step down beds and rapid access to diagnostics and treatment for

minor injuries. Staff trained to work with the urgent care centres to prevent

admission and support people to return to their own homes.

• Personalised health and care plans, and holistic assessment (including for family

carers) which support people to get information, advice and support in a timely

way, which more generally will reduce unplanned admissions to hospital.

• Ensure that Emergency Care Plans are developed to prevent future crisis due to

carer breakdown.

The delivery chain

The delivery of admission prevention will be through partnership working across Ipswich

and East Suffolk CCG, West Suffolk CCG, Suffolk County Council’s Adults and

Community Services, Suffolk Community Healthcare, Norfolk and Suffolk Foundation

Trust and others.

Commissioning activity (eg the re-commissioning of community health, 111 and the Out

of Hours Services) is aligned to deliver the new model.




The evidence base

Risk stratification or predictive modelling - Statistical models can be used to identify

Page 83 of 129


or predict individuals who are at high risk of future hospital admissions in order to target

care to prevent emergency admissions. The evaluation of predictive modelling options24

suggests including GP data in predictive modelling is particularly important, and including

all patients in an area rather than just those with prior hospital use was found to improve

case-finding. It also suggests25 using an ‘impactability model’ to identify high risk patients

who are most likely to benefit from preventive care.

Intensive Case Management - A Kings Fund Paper in 201026 on the research evidence

around avoiding hospital admissions recommended that commissioners and providers

should consider implementing intensive and/or assertive case management for people

with mental health illnesses. This is most effective when focused on patients with

frequent hospital use and assertive case management by multidisciplinary teams may

reduce mental health admissions.

A Cochrane review of ‘Intensive case management for severe mental illness’ (2011)27

found that Intensive case management is of value at least to people with severe mental

illnesses who are in the sub-group of those with high level hospitalisation (about 4 days a

month in past 2 years) and the intervention should be performed close to the original

model.

Falls Prevention - There have been a series of Cochrane reviews relating to falls

prevention.28 29 The most recent - a Cochrane review of 159 randomised controlled trials

of falls prevention interventions revealed that group and home-based exercise

programmes and home safety interventions significantly reduce rate of falls and risk of

falling, multifactorial assessment and intervention programmes significantly reduce the

rate of falls but not the risk of falling, and Tai Chi significantly reduces the risk of falling

but not the rate of falls.

The Cochrane reviews provide additional evidence on the following interventions:

a) Exercise for preventing falls

• Group and home-based exercise programmes, and home safety interventions

reduce rate of falls and risk of falling.

• Tai Chi reduces risk of falling.

b) Exercise for improving balance and physical functioning in older people

• Progressive Resistance Strength Training is an effective intervention for

improving physical functioning in older people, including improving strength

24 Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013).

Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR

Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf 25 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund 26 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010. 27 Intensive case management for severe mental illness (Review). Dieterich M, Irving CB, Park B, Marshall M. Wiley 2010. 28 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in

older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI:

10.1002/14651858.CD007146.pub3 29 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review) 2010 The Cochrane

Collaboration.

Page 84 of 129


and the performance of some simple and complex activities. However, some

caution is needed with transferring these exercises for use with clinical

populations because adverse events are not adequately reported.30

• There is some evidence that some types of exercise (gait, balance, co-

ordination and functional tasks; strengthening exercise; 3D exercise and

multiple exercise types) are moderately effective, immediately post

intervention, in improving clinical balance outcomes in older people.

c) Medications and medical devices

• Gradual withdrawal of psychotropic medication reduced the rate of, but not risk

of falling. A prescribing modification programme for primary care physicians

significantly reduced risk of falling.31

• The effectiveness of the provision of hip protectors in reducing the incidence of

hip fracture in older people is still not clearly established. Poor acceptance and

adherence by older people offered hip protectors have been key factors

contributing to the continuing uncertainty.32

A Department of Health economic evaluation of fracture prevention services has

modelled that each hip fracture avoided will save on average over £12,000 for the NHS

and £3,879 for social care over two years, and an avoided fracture of the humerus, spine

or forearm will avoid over £5,000 for the NHS and over £200 for social care. Over a five

year period, the NHS and local authority social care save over £290,000, against an

additional £234,181 revenue costs, which nationally equates to a saving of £8.5 million

over five years. The model anticipates 797 fractures of the hip, humerus, spine or

forearm from a population of 320,000.33

Interventions for preventing falls in older people living in the community found potential

cost-savings when delivering falls prevention interventions to subgroups of people at high

risk of falling. The Otago Exercise Programme, involving people aged over 80, resulted in

fewer hospital admissions and therefore cost-savings.34 Salkeld et al found cost-savings

when delivering a home safety programme to participants with a previous fall35 and Rizzo

et al found cost-savings when delivering a multifactorial intervention of people with four or

more of eight risk factors.36

30 The Cochrane Library. Falls Prevention and Balance in Older People. Available at: 2011.http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html. 31 Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem Drugs

Aging. 2012 Jan 1;29(1):15-30. 32 Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews 2010, Issue 10. 33 Department of Health (2009) Fracture Prevention Services: an economic evaluation. http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fractures.pdf 34 Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697-701. 35 Salkeld G, et al, 2000:The cost effectiveness of a home hazard reduction program to reduce falls among older persons. Aust N Z

J Public Health. 2000 Jun;24(3):265-71. 36 Rizzo JA et al 1996: The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly

persons. Med Care. 1996 Sep;34(9):954-69.

http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html

http://www.ncbi.nlm.nih.gov/pubmed?term=Hill%20KD%5BAuthor%5D&cauthor=true&cauthor_uid=22191720

http://www.ncbi.nlm.nih.gov/pubmed?term=Wee%20R%5BAuthor%5D&cauthor=true&cauthor_uid=22191720



http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fractures.pdf


http://www.ncbi.nlm.nih.gov/pubmed?term=Salkeld%20G%5BAuthor%5D&cauthor=true&cauthor_uid=10937402



http://www.ncbi.nlm.nih.gov/pubmed?term=Rizzo%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=8792783


Page 85 of 129


Education and Self-Management For People with Asthma and COPD - Patient self-

management seems to be beneficial for patients with COPD and asthma.37 38 39 The

Cochrane reviews concluded that education with self-management reduced unplanned

hospital admissions in adults with asthma, and in chronic obstructive pulmonary disease

COPD patients but not in children with asthma. There is weak evidence for the role of

education in reducing unplanned hospital admissions in heart failure patients.40

Joint Health and Social Care Investment in Primary Prevention - The Institute of

Public Care at Oxford Brookes University reports that joint health and social care

investment in dental care, podiatry services, incontinence, dehydration monitoring (liquid

intake), falls prevention and stroke recovery services has a positive impact on

admissions to residential care.41


£4,833,000 (note that this investment requirement is for schemes 3(a) and 3(b))

Impact of scheme




In conjunction with schemes 1, 2, 3(b) and 3(c) this scheme will generate a total saving of

£1,094,620

Feedback loop


System Forum in West Suffolk and the Integrated Care Network in Ipswich and East




37 Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010 http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf 38 Effing T, Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD002990. 39 Tapp S, Lasserson T, Rowe B (2007). ‘Education interventions for adults who attend the emergency room for acute asthma

(Cochrane Review)’. Cochrane Database of Systematic

Reviews, issue 3, article CD003000. DOI: 10.1002/14651858.CD003000.pub2. 40 Kirsty J. Boyd; Living with advanced heart failure: a prospective, community based study of patients and their carers The

European Journal of Heart Failure 6 (2004) 585– 591. 41 CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive services: a structured approach to service transformation and delivering better outcomes for older people.

http://www.ncbi.nlm.nih.gov/pubmed?term=Effing%20T%5BAuthor%5D&cauthor=true&cauthor_uid=17943778



Page 86 of 129




a) People at risk of crisis are identified and receive a co-ordinated response

b) Reduction in emergency admissions


a) People have the tools to manage their Long Term Conditions

b) Information and advice is readily available to people

Page 87 of 129


Scheme ref no.

Scheme 3(b) - IEWS

Scheme name

Admission prevention – Crisis response


Whilst our transformation plans are working to shift unplanned care into planned care we

recognise that there are times when a crisis response is needed, including when people

have a mental health crisis.


• Our default response is to treat people at home, or as close to home as is possible

• People get the right response in a timely way wherever they access the system

including those with a mental health crisis, which returns them to a stable situation

and enables them to retain their home life for longer, whether they contact through

111, out of hours arrangements, through their GP receptionist or through social

care contact arrangements.

• This enables a timely and skilled response to avoid unnecessary ambulance

conveyances to hospital.

• We work closely with the Police Emergency Response service to support people

with a mental health need in times of crisis.

• There is effective transfer back into the non-urgent systems where appropriate,

including from the acute trusts so that scarce A&E resources are protected from

dealing with primary care problems. This is effected through urgent care centres

locally at acute trusts with speciality input for example 136 suites, psychiatric

liaison, diagnosis and minor injuries.

• Support following a crisis is available for patients and their family carers through

our Integrated Neighbourhood Teams working with their local Neighbourhood

Network and with specialist services, including mental health services.

The delivery chain

The delivery of services in a crisis will be through partnership working across Ipswich and

East Suffolk CCG, West Suffolk CCG, Suffolk County Council’s Adults and Community

Services, Suffolk Community Healthcare, Norfolk and Suffolk Foundation Trust and

others.


Hours Services) is aligned to deliver the new model.


The evidence base

Page 88 of 129


Integrated Crisis and Rapid Response Service - There is a lack of robust evidence to

evaluate the effectiveness of crisis response services. However some case studies

provide positive results.42 There are recommendations from The ‘Silver Book’43 – a

guidance document for care for frail older people during the first 24 hours of an urgent

care episode.

The national evaluation of the Department of Health Partnerships for Older People

Projects pilots (POPPs) found economic benefits from targeted intensive interventions to

prevent crisis (e.g. falls services) or at a time of crisis (e.g. rapid response hospital

admissions avoidance services) or post-crisis reablement services. For every £1 spent

on such services to support older people, hospitals were found to save £1.20 in spending

on emergency beds.44

Information from ‘A vision for social care’ 45 the Care Services Efficiency Delivery

Programme suggests that an integrated crisis or rapid response service, that responds to

people who have a crisis within a four hour period could save an average of £2 million

per PCT and £0.5 million per local authority by reducing ambulance call-outs,

unnecessary admissions to hospital and unplanned entry to long term nursing or

residential care.46

Crisis Resolution and Home Treatment (CRHT) services have been shown to decrease

unplanned hospital admissions and length of stay. 47 48

The National Audit Office suggests that the NHS could save £12-50 million annually by

increasing the number of patients taking part in CRHT programmes.49 Integration of

CRHT or other community teams with inpatient staff can lead to reductions in bed use,

and this approach in Norfolk has led to annual savings of approximately £1 million.50


42 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010. 43 Quality care for older people with urgent and emergency care needs http://www.bgs.org.uk/campaigns/silverb/silver_book_complete.pdf 44 Karen Windle et al, 2009: National Evaluation of Partnerships for Older People Projects: Final Report Dept of Health 45 A Vision for Adult Social Care – 2010. Dept of Health: http://www.cpa.org.uk/cpa_documents/vision_for_social_care2010.pdf 46 Humphries, 2011 Social care funding and the NHS An impending crisis? The King’s Fund: http://www.kingsfund.org.uk/sites/files/kf/Social-care-funding-and-the-NHS-crisis-Kings-Fund-March-2011.pdf 47 National Audit Offi ce (2007a). Helping People Through Mental Health Crisis: The role of Crisis Resolution and Home

Treatment services. London: The Stationery Office. www.nao.org.uk/publications/0708/helping_people_through_mental.aspx 48 Chiles JA, Lambert MJ, Hatch AL (1999). ‘The impact of psychological interventions on medical cost offset: A meta-analytic review’. Clinical Psychology: Science and Practice, vol 6, no 2, pp 204–20. 49 Howard C, Dupont S, Haselden B, Lynch J, Wills P (2010). ‘The effectiveness of a group cognitive-behavioural breathlessness intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease’. Psychology, Health and Medicine, vol 15, no 4, pp 371–85. 50 Department of Health (2009) partnerships for Older people projects final report. London. Department of Health.

http://www.bgs.org.uk/campaigns/silverb/silver_book_complete.pdf

http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/PartnershipsforOlderPeopleProjects/index.htm

http://www.cpa.org.uk/cpa_documents/vision_for_social_care2010.pdf

http://www.kingsfund.org.uk/sites/files/kf/Social-care-funding-and-the-NHS-crisis-Kings-Fund-March-2011.pdf

http://www.nao.org.uk/publications/0708/helping_people_through_mental.aspx

Page 89 of 129


£4,833,000 (note that this investment requirement is for schemes 3(a) and 3(b))

Impact of scheme




In conjunction with schemes 1, 2, 3(a) and 3(c) this scheme will generate a total saving of

£1,094,620

Feedback loop








a) People at risk of crisis are identified and receive a co-ordinated response

b) Reduction in emergency admissions


a) People have the tools to manage their Long Term Conditions

b) Information and advice is readily available to people

Page 90 of 129


Scheme ref no.

Scheme 3(c) - IEWS

Scheme name

Admission prevention – Integrated Reablement & Rehabilitation (IRR) Model


Reablement and rehabilitation is not a particular service, it is a journey that everyone

should have access to and be supported through in order to maximise their effective

recovery and independence outcomes. Reablement and rehabilitation services then

become one way that people can achieve certain short term outcomes that will prepare

them for longer term well-being and independence.

Integrating the reablement and rehabilitation services and offers across organisational,

and statutory and voluntary boundaries will allow the reablement journey to commence

earlier and to continue beyond the traditional cut-off points. This will deliver a more

personalised service and lead to sustainable outcomes,

The integrated reablement and rehabilitation pathway is a core element of our integrated

design. The right resource will be used at the right time in a person’s journey and without

delay or duplication, and will be targeted at specific outcomes to maximise their

reablement opportunity and reduction in demand for longer term services.


• A greater focus on prevention and self-management and timely intervention to

avoid admissions and maximise longer term independence and well-being.

• A single outcome focused reablement and rehabilitation plan.

• Delivery of a rapid response so that reablement and rehabilitation outcomes can

be maximised

• Family carers supported to play an active part in the reablement and rehabilitation

plan

• A greater use of assistive technology to support the achievement of greater

independence

• Market development to ensure that all services are delivered using an enablement

ethos and approach, for example the Home Care Market.

• Continuous stretch for providers to improve reablement rates, including from

mental health and inpatient units.

• Review of step up and step down bed provision as part of the retendering of NHS

community services in 2015.

• Community Equipment Store re-commissioning in 2015 to underpin new

integrated service model with timely access to equipment, that aligns to the

personalisation and prevention agenda by making equipment solutions available

as part of the approach to reducing or preventing increases in dependency in Long

Term Conditions.

Page 91 of 129


• Links with Neighbourhood Networks (voluntary, community and other services) so

that people can get back to doing the things that they enjoy.

The delivery chain

The delivery of the integrated reablement and rehabilitation model will be through

partnership working across Ipswich and East Suffolk CCG, West Suffolk CCG, Suffolk

County Council’s Adults and Community Services, Suffolk Community Healthcare,

Norfolk and Suffolk Foundation Trust and others within the voluntary sector.


Hours Services, the Support to Live at Home Service) is aligned to deliver the new

model.




The evidence base

Reablement Services - The evidence base for reablement services is limited by a lack

of robust studies. However, there is evidence that reablement can reduce on-going

homecare costs to social care.51 The results showed a reduced use of home care

services over time associated with median cost savings per person of approximately AU

$12,500 over nearly 5 years when compared with individuals who had received a

conventional home care service.

Glendinning et al (2010) showed that there is a 60% reduction in social care costs for

those receiving reablement.52

Physical Rehabilitation for Long-Term Care Residents - A Cochrane review of 67

trials, involving 6300 participants showed that physical rehabilitation for long-term care

residents may be effective, reducing disability with few adverse events, but effects

appear quite small and may not be applicable to all residents. There is insufficient

evidence to reach conclusions about improvement sustainability, cost-effectiveness, or

which interventions are most appropriate.53

Assistive Technology – Tele Health - Tele health is effective in reducing hospital

admissions in people with chronic heart failure (meta-analysis of 11 randomised

51 Lewin GF et al 2013 - Evidence for the long term cost effectiveness of home care reablement programs. Clin Interv Aging. 2013;8:1273-81. 52 Glendinning et al (2010) Home Care Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal

study) SPRU/PSSRU report http://socialwelfare.bl.uk/subject-areas/services-activity/social-work-care-

services/spru/135160Reablement10.pdf 53 Crocker T Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013 Feb 28;2:CD004294.

http://www.ncbi.nlm.nih.gov/pubmed?term=Lewin%20GF%5BAuthor%5D&cauthor=true&cauthor_uid=24124354


http://www.ncbi.nlm.nih.gov/pubmed?term=Crocker%20T%5BAuthor%5D&cauthor=true&cauthor_uid=23450551


Page 92 of 129


controlled trials showed a significant 21% reduction in hospital admissions in this group

of patients.54

In addition, the results of a meta-analysis study support the use of telephone-delivered

CBT as a tool for improving health in people with chronic illness.55

Assistive Technology – Tele Care - Tele care and Falls prevention: There is some

evidence from a longitudinal prospective cohort study that a light path plus tele-

assistance reduced falls and significantly reduced post-fall hospitalisation.56

Tele care and Dementia Care: The British psychological Society (2007) recommends that

dementia care plans should include environmental modifications to aid independent

functioning.57

Two case studies are highlighted below that show the effectiveness of tele care. This is

low quality evidence and must be interpreted with caution. Evidence from evaluation of

tele care provision in Essex and impact for social care found that for every £1 spent on

tele care, £3.82 was saved in traditional care.58 Tele care in North Yorkshire project

evaluation estimates one year savings in care packages of £1 million.59


£14,291,000

Impact of scheme




• Increased effectiveness of reablement

In conjunction with schemes 1, 2, 3(a), 3(b) this scheme will generate a total saving of

£1,094,620 + an additional anticipated saving of £46,610

54 Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF (2010). 'Structured telephone support or telemonitoring programmes for patients with chronic heart failure (Cochrane Review)'. Cochrane Database of Systematic Reviews, issue 8, article CD007228. 55 Muller I, Telephone-delivered cognitive behavioural therapy: a systematic review and meta-analysis. J Telemed Telecare. 2011;17(4):177-84. 56 E.A. Tchalla, et al The effect of fall prevention and management technologies Gerontechnology 2012; 11(2):347 57The British Psychological Society (2007) Dementia – available at: http://www.nice.org.uk/nicemedia/pdf/CG42Dementiafinal.pdf 58 Evaluating telecare and telehealth interventionsWSDAN briefing paper: http://www.kingsfund.org.uk/sites/files/kf/Evaluating-telecare-telehealth-interventions-Feb2011.pdf 59 Department of Health (2009) ‘Use of resources in adult social care A guide for local authorities’

http://www.thinklocalactpersonal.org.uk/_library/Resources/Personalisation/Personalisation_advice/298683_Uses_of_Resources.p

df

http://www.ncbi.nlm.nih.gov/pubmed?term=Muller%20I%5BAuthor%5D&cauthor=true&cauthor_uid=21357672


http://www.kingsfund.org.uk/sites/files/kf/Evaluating-telecare-telehealth-interventions-Feb2011.pdf


Page 93 of 129


Feedback loop








a) Effectiveness of reablement

b) Fewer people being admitted to permanent residential/nursing care

c) Reduced emergency admissions

d) Reduced use of social care support packages

e) Service user identified increase in independence and well-being


a) Numbers of people identified through local risk stratification

b) Numbers of people with a named care co-ordinator and plan

c) Numbers of people achieving personalised reablement / rehabilitation

outcomes

Page 94 of 129


Scheme ref no.

Scheme 4 - GYW

Scheme name

Supporting independence by provision of community based support interventions


To deliver community based support interventions, closer to people’s homes, 7 days per

week that maintains / regains independence, including the use of Personal Health

Budgets to help prevent people’s needs escalating


Fast track End of Life CHC / CHC Domiciliary Care - An increasing number of people

are receiving end of life care through NHS Continuing Healthcare funding; many of whom

are receiving this care in their own homes.

The delivery chain

Commissioners – NHS GYW CCG, SCC, NCC

Providers – ECCH, JPUH, NRS, NCC, Voluntary Sector, Social Care, Housing, private

care agencies, Charitable Organisations

The evidence base

Community based support interventions, Self-care & self-management - Patient

self-management seems to be beneficial for patients with COPD and asthma.60 61 62 The

Cochrane reviews concluded that education with self-management reduced unplanned

hospital admissions in adults with asthma, and in chronic obstructive pulmonary disease

COPD patients but not in children with asthma. There is evidence for the role of

education in reducing unplanned hospital admissions in heart failure patients.63

There is some evidence that demonstrates that investment in learning for older people

can reduce the costs of medical and social care and improve the quality of life for older

people, their families and communities, NIACE, 2010.64

60 Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010 http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf 61 Effing T, Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD002990. 62 Tapp S, Lasserson T, Rowe B (2007). ‘Education interventions for adults who attend the emergency room for acute asthma

(Cochrane Review)’. Cochrane Database of Systematic

Reviews, issue 3, article CD003000. DOI: 10.1002/14651858.CD003000.pub2. 63 Kirsty J. Boyd; Living with advanced heart failure: a prospective, community based study of patients and their carers The

European Journal of Heart Failure 6 (2004) 585– 591. 64 NIACE: Lifelong Learning: Contributing to wellbeing and prosperity http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf

http://www.ncbi.nlm.nih.gov/pubmed?term=Effing%20T%5BAuthor%5D&cauthor=true&cauthor_uid=17943778


http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf

http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf

Page 95 of 129


Reablement Services - The evidence base for reablement services is limited by a lack

of robust studies. However, there is evidence that reablement can reduce on-going

homecare costs to social care.65 The results showed a reduced use of home care

services over time associated with median cost savings per person of approximately AU

$12,500 over nearly 5 years when compared with individuals who had received a

conventional home care service.

Glendinning et al (2010) showed that there is a 60% reduction in social care costs for

those receiving reablement.66

Physical Rehabilitation - A Cochrane review of 67 trials, involving 6300 participants

showed that physical rehabilitation for long-term care residents may be effective,

reducing disability with few adverse events, but effects appear quite small and may not

be applicable to all residents. There is insufficient evidence to reach conclusions about

improvement sustainability, cost-effectiveness, or which interventions are most

appropriate.67

Risk Stratification - Statistical models can be used to identify or predict individuals who

are at high risk of future hospital admissions in order to target care to prevent emergency

admissions. The evaluation of predictive modelling options68 suggests including GP data

in predictive modelling is particularly important, and including all patients in an area

rather than just those with prior hospital use was found to improve case-finding. It also

suggests69 using an ‘impactability model’ to identify high risk patients who are most likely

to benefit from preventive care.

Carer Support Services - A systematic review and meta-analysis of cognitive re-framing

for carers of people with dementia showed beneficial effects over usual care for carer

mental health.70

A report assessing the effectiveness and cost-effectiveness of support and services to

informal carers of older people by the audit commission in 200471 showed that Day care,

Home/help care and Institutional respite care (but not in all cases) may lead to delayed

65 Lewin GF et al 2013 - Evidence for the long term cost effectiveness of home care reablement programs. Clin Interv Aging. 2013;8:1273-81. 66 Glendinning et al (2010) Home Care Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal

study) SPRU/PSSRU report http://socialwelfare.bl.uk/subject-areas/services-activity/social-work-care-

services/spru/135160Reablement10.pdf 67 Crocker T Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013 Feb 28;2:CD004294. 68 Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013).

Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR

Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf 69 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund 70 Vernooij-Dansen, M., Draskovic, I., McCleery, J., & Downs, M. (2011). Cognitive reframing for carers of people with dementia. The Cochrane Collaboration(11). 71 The effectiveness and cost-effectiveness of support and services to informal carers of older people http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/LitReview02final.pdf

http://www.ncbi.nlm.nih.gov/pubmed?term=Lewin%20GF%5BAuthor%5D&cauthor=true&cauthor_uid=24124354


http://www.ncbi.nlm.nih.gov/pubmed?term=Crocker%20T%5BAuthor%5D&cauthor=true&cauthor_uid=23450551


http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/LitReview02final.pdf

http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/LitReview02final.pdf

Page 96 of 129


admissions to institutional care (and may be cost-effective).

Respite Care - A report for the Princess Royal Trust for Carers and Crossroads Care

(2011)72 states that investing in respite care results in savings resulting from reduced

costs to health and social care: spending more on breaks, training, information, advice

and emotional support for carers reduces overall spending on care by more than £1bn

per annum, as a result of reductions in unwanted (re)admissions, delayed discharges

and residential care stays.

A focused review of the UK literature by the Audit commission looked at the effectiveness

and cost effectiveness of respite care of older adults (60+ or 65+) and included cost

effectiveness studies from the US literature.73 Day care, home help/care, institutional

respite care and social work/counselling were found to be effective and/or cost-effective

for carers in terms of one or more of the outcomes in improving carer welfare and

delaying admission to institutional care.

Assistive Technology – Tele Health - Tele health is effective in reducing hospital

admissions in people with chronic heart failure (meta-analysis of 11 randomised

controlled trials showed a significant 21% reduction in hospital admissions in this group

of patients.74

In addition, the results of a meta-analysis study support the use of telephone-delivered

CBT as a tool for improving health in people with chronic illness.75

Assistive Technology – Tele Care - Tele care and Falls prevention: There is some

evidence from a longitudinal prospective cohort study that a light path plus tele-

assistance reduced falls and significantly reduced post-fall hospitalisation.76

Tele care and Dementia Care: The British psychological Society (2007) recommends that

dementia care plans should include environmental modifications to aid independent

functioning.77

Two case studies are highlighted below that show the effectiveness of tele care. This is

low quality evidence and must be interpreted with caution. Evidence from evaluation of

72 The Princess Royal Trust for Carersand Crossroads Care. (2011). Supporting Carers: The case for change. 73 Pickard, L. (2004). The effectiveness and cost-effectiveness of support and services to informal carers of older people. A review of the literature prepared for the audit commission. Audit Commission. 74 Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF (2010). 'Structured telephone support or telemonitoring programmes for patients with chronic heart failure (Cochrane Review)'. Cochrane Database of Systematic Reviews, issue 8, article CD007228. 75 Muller I, Telephone-delivered cognitive behavioural therapy: a systematic review and meta-analysis. J Telemed Telecare. 2011;17(4):177-84. 76 E.A. Tchalla, et al The effect of fall prevention and management technologies Gerontechnology 2012; 11(2):347 77The British Psychological Society (2007) Dementia. http://www.nice.org.uk/nicemedia/pdf/CG42Dementiafinal.pdf

http://www.ncbi.nlm.nih.gov/pubmed?term=Muller%20I%5BAuthor%5D&cauthor=true&cauthor_uid=21357672


Page 97 of 129


tele care provision in Essex and impact for social care found that for every £1 spent on

tele care, £3.82 was saved in traditional care.78 Tele care in North Yorkshire project

evaluation estimates one year savings in care packages of £1 million.79

Supported and Sheltered Housing - There is some evidence from a variety of case

studies that local authorities are able to reduce their spend on residential care and

increase the level of support for people to live in their own homes by facilitating

supported housing; 80 for people with learning disabilities; and for older people

(sometimes referred to as extra-care housing, very-sheltered housing or assisted living).

The results from the case studies provide growing evidence that even people with

medium–high care needs can be supported in their own homes with the right staffing,

technology, aids and adaptations. This is recognised in the Government’s national

housing strategy for an ageing society, Lifetime Homes, Lifetime Neighbourhoods, and in

More Choice, Greater Voice.81

Research into the financial benefits of the Supporting People programme found that for

most groups, packages of housing-related support services avoid costs elsewhere and

as well as promoting independence produce a net financial benefit. The cost to savings

ratio for older people’s housing support was particularly favourable: £327.9m to

£1,398.3m.82

Home Improvement Interventions - There is a range of evidence demonstrating the

resultant cost benefits of home repairs, adaptations and hospital discharge housing

related help in the Fit for Living Network. This showed that for every £1 spent on

handyperson services (which provide fast, low cost help with adaptations and repairs),

£1.70 was saved, the majority to social services, health and the police; hospital discharge

schemes offering housing help to speed up patient release save local government social

care budgets at least £120 a day.

An analysis by Care and Repair Cymru of the outcomes of their Rapid Response

Adaptations programmes identified that every £1 spent generated £7.50 cost savings to

the NHS. These savings were associated with speeded up hospital discharge, prevention

of people going into hospital and prevention of accidents and falls in the home providing

an adaptation in a timely fashion can reduce social care costs by up to £4,000 a year.

78 Evaluating telecare and telehealth interventionsWSDAN briefing paper: http://www.kingsfund.org.uk/sites/files/kf/Evaluating-telecare-telehealth-interventions-Feb2011.pdf 79 Department of Health (2009) ‘Use of resources in adult social care A guide for local authorities’ http://www.thinklocalactpersonal.org.uk/_library/Resources/Personalisation/Personalisation_advice/298683_Uses_of_Resources.pdf 80 The Business Case for Extra Care Housing in Adult Social Care: An Evaluation of Extra Care Housing schemes in East Sussex http://www.housinglin.org.uk/Topics/type/resource/?cid=8988&msg=0 81 Lifetime Homes, Lifetime Neighbourhoods, and in More Choice, Greater Voice – A publication by communities and local government - 2008: http://www.cpa.org.uk/cpa/lifetimehomes.pdf 82 Communities and Local Government (July 2009) ‘Research into the financial benefits of the supporting people programme’

http://tiny.cc/k5czx



http://www.housinglin.org.uk/Topics/type/resource/?cid=8988&msg=0

http://www.cpa.org.uk/cpa/lifetimehomes.pdf

http://tiny.cc/k5czx

Page 98 of 129


The cost effectiveness of Home adaptations – a report by The University of Bristol based

on a review of case studies revealed: 83

• Adaptations to the home can reduce the need for Homecare daily visits. In the

cases reviewed – between £1,200 and £29,000 saved per year

• Savings in home care costs by home adaptations mainly found in younger

disabled people. In older people adaptations are found through prevention of

accidents or deferring admission to residential care and improved quality of life

• Home adaptations can reduce the need for residential care in disabled people

• Findings on the impact of adaptations include 70% increased feelings of safety

and an increase of 6.2 points on the SF 36 scores for mental health

• Home adaptations that improve the environment for visually impaired people leads

to savings through prevention of falls.

• The provision of adaptations and equipment can save money by speeding hospital

discharge and preventing hospital admission

• Audit commission stresses effectiveness and value of investment in equipment

and adaptation to prevent unnecessary and wasteful health costs

• Adaptations give support to carers and avoid health care costs for strain and injury


£4,010,000

Impact of scheme




• Increased effectiveness of reablement

In conjunction with schemes 5, 6 and 7 this scheme will generate a total saving of

£556,010 + an additional anticipated saving of £25,330

Fast track End of Life CHC / CHC Domiciliary Care - At present this care is delivered

by a range of private care agencies, with varying levels of quality and costs. The nature

of the commissioning of these services from a significant number of providers is that it is

very difficult to incorporate and manage quality monitoring of the services delivered to our

patients. The providers do not have the infrastructure in place to enable the monitoring

that we would require and doing so would likely significantly increase the cost. The cost

variation between providers and packages is also questionable and this indicates that a

83 The cost effectiveness of Home adaptations: Report - Better Outcomes, lower costs – University of Bristol Office for Disability Issues (Heywood and Turner, 2007) http://odi.dwp.gov.uk/docs/res/il/better-outcomes-report.pdf

http://odi.dwp.gov.uk/docs/res/il/better-outcomes-report.pdf

Page 99 of 129


provider model is needed to be able to address the quality requirements and finance

control.

Therefore a new model is being developed; this being the commissioning of NHS CHC

fast track domiciliary care from a single provider within Great Yarmouth & Waveney. The

ambition for this model is:

• A block contract would be issued to the preferred single provider (following the

appropriate procurement process).

• The block contract will include comprehensive quality requirements, information

requirements and delivery requirements.

• A single provider would have the infrastructure in place to ensure robust quality

monitoring and reporting within the contract with the CCG

• The preferred provider will have a level of guaranteed activity and as such could

allow improved recruitment/employment for the care giving workforce

• This approach will enable financial stability and in year cost control for the CCG

• Depending on the preferred provider, if this is an organisation within which there is

an established clinical infrastructure (or links to organisations with and established

clinical infrastructure) then the service provided to the patients will be enhanced; in

particular they will have an improved access to services such as occupational

therapy e.g. to meet equipment needs, Hospice at Home services, District Nursing

services, amongst others.

Feedback loop

This will be undertaken through the contract monitoring process.

Measures and metrics will be developed but will include measures of patient and family

experience/satisfaction, patient safety, workforce training and development,

recruitment/workforce metrics. Other evaluation of outcomes will include cost/value for

money to ensure that the budget is allowing the CCG to fund the best quality and

accessible service for our patients in receipt of NHS fast track CHC funding.


A project management approach is being developed for this programme development. In

2013/14 the CCG spent £718,454 on domiciliary fast track care with an anticipated year

on year increase in line with improving awareness of the benefits of dying within the

place of choice, which invariably is a person’s own home. Key factors will include the

ability of the provider to be able to be responsive to a person’s end of life care needs and

be able to implement the care packages within a rapid timeframe.

Page 100 of 129


Scheme ref no.

Scheme 5 - GYW

Scheme name

Integrated Community Health and Social Care Teams including Out of Hospital Team &

Palliative Care


Continue to develop integrated community out of hospital team and an integrated

palliative care service, delivering timely, joined up quality care.

Integrated Community Health and Social Care Team - Out of Hospital Team

Lowestoft - To Provide care at home whenever it is safe, sensible and affordable to do

so. The care will be organised around the patient, focusing on individual need and

empowering independence.

Thus enabling GYW CCG to achieve its strategic objectives of:

- Care closer to home

- Integrated service provision

- Reduction in emergency admissions to acute beds

The Out of Hospital Team (OHT) is an inter disciplinary team of health and social care

professionals for whom the objective of its service is to provide care at home whenever it

is safe, sensible and affordable to do so. The care the team provides is organised

around the patient, focusing on individual need and empowering independence. The

team offers intensive, short term care, reducing as the patient regains health and

independence. Care is holistic, co-ordinated, and responsive and goal focused, using a

case management approach.

The OHT is made up of key health and social care professionals supported by workers

able to perform many types of basic nursing, therapeutic and personal care tasks. The

shared values and aims underpinning care delivered by the entire OHT include:

• Patient centred care; staff will involve patients and their family and, or carers in the

care planning approach

• Staff will be sensitive to the needs of family and carers

• Care will be provided in patients’ usual places of residence but only if it is safe and

sensible to do so

• The OHT will be easily accessible to patients and their families and, or carers

• The OHT will focus on proactive delivery of care and if a patient is in crises will

react rapidly to keep that patient safe in their usual place of residence.


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Model of Care and Support

The OHT operates 24 hours a day, seven days a week. For all urgent referrals initial

assessment by the OHT is undertaken within two hours of receipt of the referral. Initial

assessment of all other referrals takes place within 1 working day. The response time is

determined by the triage process. Through Multi-Disciplinary Team Meetings and regular

patient review, care packages are kept relevant to the patients’ needs and personal aims.

Following assessment and on the same day as the assessment, the OHT organises

appropriate care provision for the patient in their place of usual residence or, if

necessary, in a bed with care.

The OHT ensures that, with immediate effect, provision is put in place to keep the patient

safe at home until the full care package can be implemented. The full care package is

always implemented within 12 hours of the initial assessment being made.

The OHT is made up of key health and social care professionals supported by workers

able to perform many types of basic nursing, therapeutic and personal care tasks.

The Senior Professionals

The range of Senior Health and Social care professionals comprising the Lowestoft OHT

include as a minimum:

• Independent Nurse Prescribers

• Community Nurses

• Physiotherapists

• Occupational Therapists

• Mental Health Workers; Dementia Intensive Support Workers and Complexity in Later

Life Workers

• Social Workers

• Social Care Assessors

The responsibilities of these Senior Health and Social Care professionals include as a

minimum:

• To undertake combined health and social care assessments of patients referred into

the service, to determine their suitability for care at home

• To agree with the patient an individual management plan to optimise recovery,

independence and wellbeing at home

• To ensure patients and their family and, or carers are fully included in the care

planning process

• To prescribe appropriate medication when necessary and support patients and their

family and, or carers to safely manage and comply with their medication regimes

• To oversee implementation of patients’ management plans by appropriate Assistant

Practitioners and care workers within the Lowestoft OHT

• To undertake regular review of patients’ needs to ensure the care package remains

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relevant and patients are progressing towards their optimum levels of independence

and health

• To work closely with community and acute providers to facilitate timely and safe

discharges to patients’ usual places of residence, if necessary it is expected that

assessors will visit patients in hospital to review their discharge requirements

The Support Staff

Within the Lowestoft OHT are included as a minimum, the following Support Staff:

• Assistant Practitioners

• Reablement Practitioners

• Generic Workers

• Home Care Workers

• Community Phlebotomists

The responsibilities of these staff are to actively support patients in achieving their

individualised care plans and personal goals. Practitioners must be trained in a wide

range of therapy and nursing competencies to enable in one visit, for example, a

dressing to be changed, an exercise programme to be completed and activities of daily

living to be developed.

Care Workers will also be trained in a range of health and social care competencies

enabling them to carry out multiple tasks when visiting a patient, for example, taking

bloods, assessing for a repose cushion and helping with activities of daily living.

Support staff also carry out welfare checks on patients.

Beds with Care

If, during the combined assessment process, it is determined that a patient is not

appropriate to remain at home and they require a short admission to a bed with care, this

admission is managed by the OHT. All admissions to beds with care, for Lowestoft

patients, will be through the OHT following assessment by them.

Where a patient is admitted to a bed with care the OHT monitors progress of that patient

and agrees an expected date of discharge with the Care Home. The Lowestoft OHT

provides in-reach therapy support to the Care Home. This support includes but will not be

limited to:

• Specialist therapy advice

• Advice on transfer and mobilisation of patients

• Programmes for rehabilitation and reablement

• Advice about equipment

The OHT attends MDTs at the Care Home and ensures all care plans are in place to

support discharge back to patients’ place of usual residence.

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Triage

The Lowestoft OHT operates a combined triage team made up of both health and social

care professionals including but not limited to:

• Day Co-ordinators (Health)

• Duty Workers (Social)

• Allocation Co-ordinators

• Administrators

The responsibilities of the triage team include as a minimum:

• Receiving referrals

• Contacting various others for further information

• Triaging referrals

• Allocating assessments

• Imparting necessary information to the assessor

• Daily contact with acute and community bed providers to ascertain details of patients

who will require supported discharge

• Daily contact with acute and community bed providers for updates on patients’

expected dates of discharge and any changes to patients circumstances and, or care

needs

General

All members of the Lowestoft OHT are responsible for:

• Assessing for and delivering equipment to patients in their places of usual residence

• Providing support, instruction, advice and sign posting to family and, or carers

• Ensuring patients and their family and, or carers are fully included in the care planning

process

• Attending MDTs as necessary

Where & When It Will Be Delivered

The Lowestoft OHT is located at Kirkley Rise and operates 24 hours a day, 7 days a

week.

Patient Cohorts being Targeted

Referrals to the Lowestoft OHT will be accepted for patients registered with a Lowestoft

GP. Referrals can be made by any health or social care worker. Patients referred to the

service must be 18 years of age and over.

Referrals are only accepted for housebound patients or those who are only able to leave

their place of usual residence with substantial support; irrespective of whether the

patient, when medically fit, is normally ambulant. Referrals for ambulant, self-caring

patients with capacity will not be accepted by the Lowestoft OHT.

Urgent referrals are made by phone. Non-urgent referrals can be made by fax.

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Referrals are made to the Lowestoft OHT through East Coast Community Health’s Single

Point of Access. Some referrals are expected to come through Suffolk County Council’s

Single Point of Access. These referrals are immediately and automatically directed to the

Lowestoft Out of Hospital integrated Triage Team.

Referrals must be for Lowestoft patients for whom it is considered input from the OHT will

be of benefit.

Referrals could, for example, include:

• Patients experiencing an acute exacerbation of their Long Term Condition

• Patients experiencing acute symptoms due to chest infection or urinary tract infection

• Patients whose mobilisation has suddenly reduced or is rapidly deteriorating

• Patients for whom the current care package is no longer robust enough and urgent

review and amendment is required to prevent a breakdown of carer support

• Patients requiring a supported hospital discharge to their usual place of residence

• Patients presenting at Accident and Emergency who do not require an emergency

admission but do require additional short term support to enable them to return home

• Patients who require a short term placement in a bed with care

• Palliative and End of Life patients requiring short term input for example following a

fall or an infection

Projected volume of activity: 2 referrals daily for crises intervention resulting in a daily

reduction of emergency admissions to the acute provider of 2.

This figure to increase to 3 after the first 8 months of service delivery.

Integrated EOL / Palliative Care - The aim of the integrated palliative and end of life

care service will be to provide high quality and consistent palliative care in the patient’s

preferred place of care

via: assessment of patient/carer needs, provision of 24/7, 7/7 palliative care advice and

information and sign posting to other services, co-ordination of a range of flexible

health and or social care packages to support further patients to die in the home care

setting, offer a timely and co-ordinated response to crises and ensure effective

information sharing with partner organisations, patients and carers.

The planned objectives of the service redesign are to:

• Increase the number of patients able if preferred to die in their home care setting

• Provide palliative care as defined in the national EOL Quality Standard (2012).

• Improve co-ordination and consistency of care packages thereby reducing care

package breakdown in the last weeks/days of life.

• Support informed choices through the proactive provision of information about local

services and support for patients/carers.

• Improve continuity and consistency via effective information sharing with partner

organisations.

• Audit care needs to promote improvement of service provided (e.g. the type of care

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required, the number of hours of care provided, the number of patients seen, the

number of patients who achieve their preferred place of care/death, and the number

of potential admissions to acute care and care package breakdowns avoided in the

last weeks/days of life).

• Carry out regular patient/carer surveys to ensure a responsive and high quality

service is being provided e.g. via “VOICES” or “I Want Great Care”.

The delivery chain


Lowestoft - The Commissioners are NHS Great Yarmouth and Waveney CCG and

Suffolk County Council (Adult Social Care)

The Providers are East Coast Community Health and Suffolk County Council (Adult

Social Care)

Integrated EOL / Palliative Care

• Local Health and Social Care commissioners: NHS GYW, Norfolk County Council,


• Local providers: East Coast Community Health, James Paget University Hospital,

Great Yarmouth and Waveney Continuing Health Care Palliative Care Fast Track

Service, Marie Curie Nursing Service, Big C Charity, St Elizabeth’s Hospice, All

Hallows Independent Community Hospital, Cruse and Crossroads Care

• Service user group: Together Against Cancer

• Other stakeholders (which link to the project through a Programme Board): Macmillan

Cancer Support, East Coast Hospice, Norfolk & Suffolk Palliative Care Academy,

Transforming Community Cancer Care pilot sites, EOE Strategic Clinical Network for

Cancer.

The evidence base

Integrated community health and social care teams - Evaluating integrated and

community-based care – the Nuffield Trust review of national integrated care pilots and

virtual wards84 showed reductions in planned admissions and in outpatient attendances

for some interventions that involved case management using multidisciplinary teams and

those using virtual wards, but no evidence of a general reduction in emergency

admissions.

King’s Fund analysis of the evidence85 suggests that joint commissioning between health

and social care that results in a multi-component approach is likely to achieve better

results than those that rely on a single or limited set of strategies.

84 Evaluating integrated and community-based care – a review of national integrated care pilots and virtual wards http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/evaluation_summary_final.pdf 85 Goodwin et al, 2012, Integrated care for patients and populations: Improving outcomes by working together – The King’s Fund: http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together

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The Torbay integrated care model has reduced the use of hospital beds by a third from

750 in 1998/1999 to 502 in 2009/2010. Emergency bed day use for people aged 75 and

over fell by 24% between 2003 and 2008 and by 32% for people aged 85 and over.86 87

The Institute of Public Care at Oxford Brookes University reports that joint health and

social care investment in dental care, podiatry services, incontinence, dehydration

monitoring (liquid intake), falls prevention and stroke recovery services has a positive

impact on admissions to residential care.88

Structured Discharge Planning by multi-disciplinary teams - A Cochrane database

systematic review of hospital discharge planning provides robust evidence that a

discharge plan tailored to the individual patient probably brings about reductions in

hospital length of stay and readmission rates for older people admitted to hospital with a

medical condition. The impact of discharge planning on mortality, health outcomes and

cost remains uncertain. The review assessed randomised controlled trials (RCTs) that

compared an individualised discharge plan with routine discharge care that was not

tailored to the individual patient. Participants were hospital inpatients.89

A Cochrane systematic review of randomised controlled trials recruiting stroke patients in

hospital assessed the difference between those receiving conventional care with those

with early discharge with rehabilitation at home (early supported discharge).90 Results

showed that early supportive discharge significantly reduced the length of hospital stay

equivalent to approximately seven days. Early Supported Discharge can reduce long-

term mortality and institutionalisation rates for up to 50% of patients, as well as lower

overall costs.

Specialist team for Continence Care - Urinary incontinence significantly increases the

risk of hospitalisation and admission to nursing homes.91 An intervention involving

behavioural and lifestyle counselling provided by specialised nurses led to reduced

incontinent events and incontinence pad use.92 This may mean that the costs of

professional time are offset by reductions in pad costs.93

86 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-study-kingsfund13.pdf 87 Thistlethwaite, P. (2011) "Integrating health and social care in Torbay: improving care for Mr Smith" The King's Fund, London: http://www.kingsfund.org.uk/sites/files/kf/field/field_document/PARR-combined-predictive-model-final-report-dec06.pdf 88 CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive services: a structured approach to service transformation and delivering better outcomes for older people

89 Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013, Issue 1. 90 Fearon P, Langhorne P Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev. 2012 Sep 12;9:CD000443. 91 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing 26(5):367-374. 92 Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ. 14;166(10):1267–1273




http://www.ncbi.nlm.nih.gov/pubmed?term=Fearon%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22972045

http://www.ncbi.nlm.nih.gov/pubmed?term=Langhorne%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22972045


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Local evidence

• Public health mapping: In July 2013 Public Health Norfolk published the following

findings re the palliative care needs of the population of Great Yarmouth and

Waveney:

• The number of expected deaths per annum in Great Yarmouth and Waveney is

approximately 2,000 patients per annum (Marie Curie EOL Atlas 2010/11), so

over 2 years the commissioners (the CCG, and Norfolk and Suffolk County

councils) would expect that approximately 80% of these 4,000 patients and their

carers would need support from health and social care services.

• Some of the wards in Great Yarmouth and Waveney are amongst the most

deprived in England with 27% of the population of Great Yarmouth living in the

most deprived postcode areas in the country. This leads to a significant incidence

of life limiting illnesses associated with lifestyle issues e.g. cancer, chronic

respiratory disease and heart disease. Dementia as a co-morbidity is also an

issue in relation to an increasing need for palliative and end of life care services

to 2025. This work also shows that 54% of local patients die in hospital, despite

their preference being for receiving care in their home care setting (62% EOE

wide).

• The development of services in or closer to home will in particular support the

needs of the elderly population who are more likely to experience rural isolation

and difficulty in accessing services.

• Palliative Care Skills Audit (Norfolk & Suffolk Palliative Care Academy and UEA

2013): The Academy carried out a skills audit with the UEA in 2013 which showed

that 63% of staff asked were providing palliative care but had not received any

training in the last 3 years to do so.

• Marie Curie Delivering Choice Programme: The Marie Curie Delivering Choice

Programme showed a significant variation in the quality of end of life care and also

showed a need to improve the education and training for generalist staff providing

palliative and end of life care (Marie Curie Delivering Choice Phase 3 report 2011).

• How We Manage Death and Dying in Norfolk (Norfolk County Council and Norfolk

and Waveney Cancer Network 2005): Showed a significant variation in the quality of

local palliative care services.


£1,505,000

Impact of scheme

93 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A guide for commissioners written by continence care professionals. http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf

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£556,010


Lowestoft

Benefits to Lowestoft Patients

The benefits to Lowestoft patients from this approach to care will be many. As a minimum

the benefits to patients are expected to include:

• Improved patient experience; the patient will be seen by the right professional at the

right time and will have a key worker they, or their relatives/carers, can contact for

advice

• Improved dignity and reduced exposure to communal acquired infections

• Patients will retain their independence for longer and will be able to remain in their

place of usual residence for longer

• Patients will recover faster and more fully in their place of usual residence;

• Patients and their families/cares will be involved in decision making around care

choices

Benefits to the Lowestoft Health and Social Care System

The benefits to the local system, from this type of care approach, will be many. As a

minimum the benefits to the system are expected to include:

• Reduced numbers of emergency admissions to acute and community beds

• Reduced length of stay in acute and community beds

• Reduced reliance on long term placements in residential and nursing homes

• Elimination of overlaps across service provision within the Lowestoft system

Projected volume of activity: 2 referrals daily for crises intervention resulting in a daily

reduction of emergency admissions to the acute provider of 2.

This figure to increase to 3 after the first 8 months of service delivery.

Integrated EOL / Palliative Care - This new integrated service will deliver an adapted

form of the Macmillan Cancer Support patient/carer outcomes (2013) for people

affected by life limiting illnesses in Great Yarmouth and Waveney by aiming for

people in GYWCCG who have reached the end of their life to be able to state:

• I was diagnosed early

• I understand and am involved, so I make good decisions

• I get the treatment and care which are best for my illness and my life

• Those around me are well supported to care for me at home if this is where I want

to be and it is safe to do so.

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• I am treated with dignity and respect

• I know what I can do to help myself and who else can help me

• I can enjoy life

• I feel part of a community and feel inspired to give something back

• I want to die well and to be offered choice about my place of care/death

Feedback loop


Lowestoft - KPIs:

A set of KPIs has been developed to reassure the commissioner that the Lowestoft OHT

is providing care timely and that the workforce capacity and skill mix within the team is

therefore appropriate:

- Service User Experience - % of patients issued with a service user

- Service User Experience – Provision of an action plan to address issues raised via

the service user questionnaires returned

- % of patients urgently referred that are assessed within 2 hours

- % of patients referred non-urgently that are assess within one working day

- % of patients urgently referred receiving provision of Care within 1 hour of

assessment.

- % of patients receiving care package within 12 hours of assessment

(Implementation of Provision of Care to Keep Patient Safe until Full care package

is implemented)

- % of patients receiving care package within 12 hours of assessment where the

referral was non-urgent

- % of Beds with Care MDT meetings where Out of Hospital team member attends

- Participation in clinical audit in partnership with NHS Great Yarmouth & Waveney

CCG

Monthly Minimum Data Set (MDS):

Data is recorded on SystemOne by the Out of Hours Team resulting in a monthly

minimum data set:

- Date and time of referral

- Referral source

- Registered GP

- Reason for referral

- For all urgent referrals; wait time for initial assessment

- For all other referrals; wait time for initial assessment

- For all urgent referrals; wait time for care package commencement

- For all other referrals; wait time for care package

The data from the MDS enables the commissioner to identify trends in for example,

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referral numbers, reasons for referral, use of the service by different parts of the system.

In order to measure the impact on emergency admissions, data from the acute provider

is analysed to:

- Compare emergency admission rates from the Lowestoft area for current and

previous months / years

- Compare emergency admission rates from the Lowestoft area to the rest of Great

Yarmouth and Waveney

Finally, clinical audit of patients under the care of the OHT but who have also presented

as an emergency admission is undertaken to understand what triggered the admission

and whether the OHT could have behaved differently in the patients pathway of care.

Integrated EOL / Palliative Care - Outcomes will be measured through the monitoring

of:

• %of patients/carers reporting a positive experience of their care

• % of patients with a recorded preferred place of care/death

• % of patients achieving this preference

• A reduction in the number of inappropriate admissions in the last year of life due to

care package breakdown

• % of palliative patients with a key worker in both community and acute care

settings

• Minimum standards for timeliness of response to care package breakdown and

information sharing with generalist providers

• Provision of NICE compliant specialist palliative care services

• Evidence of the competence and confidence of generalist staff to provide safe and

effective palliative care.



Lowestoft - The following are identified as key success factors for implementation of the

Lowestoft OHT and action is in place to ensure these factors are robustly built into the

implementation and delivery of the scheme

Workforce Development:

- Generic workers with an extensive competency base to ensure an holistic

approach to care – there is a generic worker programme lead by our community

provider

- Skill mix within the OHT

- Moving to 7 day and 24/7 contracts of employment - underway

- Cultural shift to integrated working – there is ongoing organisational development

work within both East Coast Community Health and Suffolk County Council Adult

Social Care

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Access to the OHT:

- Easy to access service – single point of access in place

- Ability of service to respond quickly and appropriately – skill mix and capacity is

planned

- System knows how and when to access the service and understands what the

service can offer – the CCG and the providers have invested significant time in

introducing the scheme to the system

- That the service is available 24/7

Sharing Information:

- Co-location of the staff which make up the OHT – based at Kikley Mill, Lowestoft

- MDTs with general practice in the Lowestoft area – these take place

- Handovers between shifts and across the team – these take place

- Shared IT - adult social care within the OHT will have access to SystemOne

Integrated EOL / Palliative Care - The number of expected deaths per annum in GYW

is approximately 2,000 patients per annum (Marie Curie EOL Atlas 2010/11), so over

2 years we would aim to meet 80% of these 4,000 patients and their carers under the

new model of care.

Successful delivery of this model of care will also improve performance vs. the nationally

defined proxy measures associated with the QIPP challenge:

• The % of patients with an advance care plan

• The % of patients able to die in the care setting of their choice

• Improved patient/carer experience of care

• Reduction of the number of inappropriate admissions to acute care settings in the

last year of life.

Scheme ref no.

Scheme 6 - GYW

Scheme name

Urgent Care Programme


Admission Prevention Service - To deliver integrated community care services that

reduce admissions and expedite faster appropriate discharge and reduce delayed

transfers of care

Thus enabling GYW CCG to achieve its strategic objectives of:

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- Care closer to home

- Reduction in emergency admissions to acute beds

The Admission Prevention Services will encompass Admission Prevention and Falls, and

will provide a community-based service to Service Users to enable them to live

independently and prevent admission to hospital.

The purpose of the service is to :

• Prevent admissions into hospital.

• Facilitate early discharge from acute and community hospitals enabling a prompt

supported recovery at home.

• Reduce admission to residential care.

• Reduce need for long term care package.

• Carry out aspects of a multifactorial falls assessment for people at high risk of falls

and injury

Admission Prevention will support Service Users at home and promote independence,

and will work with Norfolk and Suffolk Social Services to reduce avoidable admissions

into hospital beds (acute or community), and to facilitate early discharges, enabling

Service Users to make a prompt recovery at home.


-

Model of care and support

The Service

Admission Prevention Services will provide a “one-stop shop” approach to service

provision, encompassing, but not limited to:

• A multidisciplinary team who will provide rapid assessment/planning and

reablement;

• Same day social care assessment;

• Same day equipment provision;

• Carer support; and

• Facilitating early discharge.

• Home Hazard/environmental intervention to reduce the risk of falls;

• Strength and balance training;

• Coping strategies and confidence building;

• Improving Service Users’, and their Carers’, confidence in their functional ability

and reduction in the fear of falling;

• Reducing the risk of Service Users being left for long periods incapacitated and

unattended following a fall (a “long lie”) (by, for example, encouraging the Service

User to utilise pendant alarm systems, or by teaching them techniques to get up

off the floor);

• Encouraging participation of older people in falls prevention programmes within

the community and through the exercise referral programme; and

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• Using a multi-agency, collaborative approach to falls management.

Care Planning/Co-ordination/Management

The Provider will plan, co-ordinate and manage care to:

• Develop, manage and review documented individually structured management

plans;

• Ensure access to a comprehensive range of services;

• Ensure the co-ordination of care across all agencies involved with the Service

User;

• Ensure that there is continuity of care and that Service Users are followed

throughout their contact with the treatment system;

• Maximise Service User retention within the treatment system and minimise the risk

of Service Users losing contact with the treatment and care services;

• Encourage Service Users who have dropped out of the treatment system to re-

engage and offer appropriate referral and sign-posting to services;

• Avoid duplication of assessment and interventions; and

• Apply best efforts to prevent Service Users “falling between services”.

Review of Care Plan

The Provider will review the individually structured management plan regularly and will

also review the Individually Structured Management Plans at the request of a healthcare

practitioner, the Service User or their Carer. The date of the next review meeting will be

set and recorded at each meeting. In any review of the individually structured

management plan, the Provider will consider:

• The relevance of the individually structured management plan;

• The effectiveness of the individually structured management plans/outcomes;

• Any unmet needs;

• Service User satisfaction with care;

• Treatment/Rehabilitation/Intensive support – Modality/Frequency of support/Team

Support;

• Activities of daily living / Social Care Support;

• Medication – how monitored/reviewed;

• Relapse prevention plans; and

• Risk assessment procedures and crisis/urgent response

The service is available across Great Yarmouth and Waveney 8am – 8pm, 7 days a

week. The service is delivered by 2 teams; one for the Great Yarmouth area and one for

the Waveney area. Both teams are co-located with other community staffing colleagues

and with colleagues from social care.

Staffing:

The service is led by qualified Occupational Therapists and Physiotherapists and

supported by generic Rehabilitation Support Workers.

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The Patient Cohort being targeted:

Persons referred to the service must:

• Be medically stable - an acute medical problem must have been assessed by a

GP or Community Matron in the previous 24 hours and a treatment plan

established.

• Give informed consent.

• Be an adult permanently residing and registered with a General Practitioner in the

Great Yarmouth and Waveney area.

• Have a need for a multidisciplinary team for crisis intervention, which can be met

within the community setting.

The Day Co-ordinator will contact you within an hour and request the relevant information

as highlighted within the referral guide.

On receiving a referral a member of the service will contact or visit the Service User

within 2 hours and carry out an assessment. They will liaise with the Service User and

relevant others to set up an action plan

Referrals will be accepted from any Health or Social Care Professional.

The service is not suitable for

• End of life care → consider Hospice at Home 01493 809977

• People unwell requiring hospitalisation for medical intervention

Eligibility Criteria for Facilitating Early Discharge

• Person must be medically fit for discharge.

• Person must be motivated and consent to the referral. The Service User must

have realistic aims about returning home and would benefit from active

intervention in one or more of the above areas.

If Service User is waiting for a long term care package a date must be identified, that is

no longer than 7–10 days wait.

The delivery chain

Commissioners – NHS Great Yarmouth and Waveney

Providers – East Coast Community Health

The evidence base

Urgent Care Programme - The Keogh report on the Urgent and Emergency Care

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Review sets out proposals for the future of urgent and emergency care services in

England.94 95 There are five key elements, all of which must be taken forward to ensure

success. The report suggests that we must –

• Provide better support for people to self- care.

• Help people with urgent care needs to get the right advice in the right place, first

time.

• Provide highly responsive urgent care services outside of hospital so people no

longer choose to queue in A&E.

• Ensure that those people with more serious or life threatening emergency care

needs receive treatment in centres with the right facilities and expertise in order to

maximise chances of survival and a good recovery.

• Connect all urgent and emergency care services together so the overall system

becomes more than just the sum of its parts.

The evidence base for change identified a number of areas for improvement within the

current system of urgent and emergency care in England.96 97 In summary:

• More people are using the urgent and emergency care system to access

healthcare, leading to mounting costs and increased pressure on resources.

• Overall fragmentation of the system means that many patients may not be able to

access the most appropriate urgent or emergency care service to suit their needs,

leading to unnecessary attendances and resource use.

• Poor access to social care being responsible for both emergency admissions and

poorly managed discharge resulting in re-admission or delayed transfers of care.

Accident and Emergency departments have seen a significant number of patients that

could be managed in other settings, adding to those with life-threatening conditions.98

One interpretation of this is that the new services are meeting a previously unmet need.

Alternatively, it could be that the increased provision has led to supply induced demand

and therefore increased uptake, or demand caused by a failure to intervene earlier in the

urgent and emergency care pathway or system.

Rising costs across urgent and emergency care services can be associated with

94 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care

services in England - Urgent and Emergency Care Review, End of Phase 1 Report (2013).

http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf 95 NHS England (2013). Transforming urgent and emergency care services in England - Update on the Urgent and Emergency Care

Review (2014).

http://www.nhs.uk/NHSEngland/keogh-review/Documents/uecreviewupdate.FV.pdf 96 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care

services in England - Urgent and Emergency Care Review, End of Phase 1 Report, Appendix I – Revised Evidence Base from the

Urgent and Emergency Care Review.

http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV.pdf 97 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care

services in England - Urgent and Emergency Care Review End of Phase 1 Report, Appendix 3 – Summary of Engagement

Responses.

http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%203.Engage.Results.FV.pdf 98 Coleman, P et al (2011) Why do patients with minor or moderate conditions that could be managed in other settings attend the emergency department?; Emergency Medicine Journal; 29: 487-491

Page 116 of 129


fragmentation of the current system of urgent and emergency care. This fragmentation

leads to confusion among patients about how and where to access the care they need,99

and many people are unable to navigate to the level of care appropriate to their condition,

leading to multiple calls or attendances and unnecessary use of A&E or ambulance

services.100 It is estimated that around three-quarters of A&E attendances relate to

serious or life-threatening conditions and about one quarter could have been treated

elsewhere.101 102 103 However there is variation between different A&E departments, with

deprived urban areas having the highest proportion of patients who did not require

hospital treatment.

Evidence suggests that patients’ experience of GP services, particularly when related to

ease of access, affects uptake and interaction with primary care. This affects the way in

which patients choose to access health care because patients that are not satisfied with

their GP practice are more likely either to resort to using urgent and emergency care

services for primary care needs; or only seek help when they become acutely ill,

increasing the risk of emergency admission.104

Urgent care services are highly fragmented and difficult to navigate causing many

patients to experience difficulty choosing the service most appropriate to their needs.105 106 Variations in opening hours, clinical expertise, access to diagnostics and

nomenclature can lead to confusion and referrals to a number of urgent care services

within the same episode of care. This increases cost, delay and clinical risk and leads to

poor patient experience.107

The evidence base for improving urgent and emergency care in England indicates that

there is variation in access to primary care services across England leading to many

patients accessing urgent and emergency care services for conditions that could be

treated in primary care.108

99 NHS Alliance (2012) A practical way forward for clinical commissioners; NHS Alliance on behalf of NHS Clinical Commissioners and sponsored by NHSCB (Now NHS England) 100 Bickerton, J. et al (2012) Streaming primary urgent care: a prospective approach; Primary Health Care Research & Development; 13(2): 142-152. 101 Cooperative Pharmacy (2011) Reducing needless A&E visits could save NHS millions 102 NHS Networks (2011) New Choose Well Campaign 103 Self Care Forum (2012) Over 2 million unnecessary A&E visits “wasted”; http://www.selfcareforum.org/2012/10/30/over-2-million-unnecessary-ae-visits-wasted/ 104 The King’s Fund (2012) Data briefing: improving GP services in England: exploring the association between quality of care and experience of patients 105 The King’s Fund (2011) Managing urgent activity – urgent care 106 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal 107 Primary Care Foundation (2011) Breaking the mould without breaking the system. Primary Care Foundation 108 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal

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There is a clear need to adopt a whole-system approach to commissioning more

accessible, integrated and consistent urgent and emergency care services to meet

patients unscheduled care needs.109

Falls Prevention - There have been a series of Cochrane reviews relating to falls

prevention.110 111 The most recent - a Cochrane review of 159 randomised controlled

trials of falls prevention interventions revealed that group and home-based exercise

programmes and home safety interventions significantly reduce rate of falls and risk of

falling, multifactorial assessment and intervention programmes significantly reduce the

rate of falls but not the risk of falling, and Tai Chi significantly reduces the risk of falling

but not the rate of falls.

The Cochrane reviews provide additional evidence on the following interventions:

a) Exercise for preventing falls

• Group and home-based exercise programmes, and home safety interventions

reduce rate of falls and risk of falling.

• Tai Chi reduces risk of falling.

b) Exercise for improving balance and physical functioning in older people

• Progressive Resistance Strength Training is an effective intervention for

improving physical functioning in older people, including improving strength

and the performance of some simple and complex activities. However, some

caution is needed with transferring these exercises for use with clinical

populations because adverse events are not adequately reported.112

• There is some evidence that some types of exercise (gait, balance, co-

ordination and functional tasks; strengthening exercise; 3D exercise and

multiple exercise types) are moderately effective, immediately post

intervention, in improving clinical balance outcomes in older people.

c) Medications and medical devices

• Gradual withdrawal of psychotropic medication reduced the rate of, but not risk

of falling. A prescribing modification programme for primary care physicians

significantly reduced risk of falling.113

109 NHS England (2013). Transforming urgent and emergency care services in England. http://www.nhs.uk/NHSEngland/keogh-review/Pages/urgent-and-emergency-care-review.aspx 110 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls

in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI:

10.1002/14651858.CD007146.pub3 111 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review) 2010 The Cochrane

Collaboration. 112 The Cochrane Library. Falls Prevention and Balance in Older People. Available at: 2011.http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html. 113 Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem

Drugs Aging. 2012 Jan 1;29(1):15-30.

http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html

http://www.ncbi.nlm.nih.gov/pubmed?term=Hill%20KD%5BAuthor%5D&cauthor=true&cauthor_uid=22191720

http://www.ncbi.nlm.nih.gov/pubmed?term=Wee%20R%5BAuthor%5D&cauthor=true&cauthor_uid=22191720


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• The effectiveness of the provision of hip protectors in reducing the incidence of

hip fracture in older people is still not clearly established. Poor acceptance and

adherence by older people offered hip protectors have been key factors

contributing to the continuing uncertainty.114

A Department of Health economic evaluation of fracture prevention services has

modelled that each hip fracture avoided will save on average over £12,000 for the NHS

and £3,879 for social care over two years, and an avoided fracture of the humerus, spine

or forearm will avoid over £5,000 for the NHS and over £200 for social care. Over a five

year period, the NHS and local authority social care save over £290,000, against an

additional £234,181 revenue costs, which nationally equates to a saving of £8.5 million

over five years. The model anticipates 797 fractures of the hip, humerus, spine or

forearm from a population of 320,000.115

Interventions for preventing falls in older people living in the community found potential

cost-savings when delivering falls prevention interventions to subgroups of people at high

risk of falling. The Otago Exercise Programme, involving people aged over 80, resulted in

fewer hospital admissions and therefore cost-savings.116 Salkeld et al found cost-savings

when delivering a home safety programme to participants with a previous fall117 and

Rizzo et al found cost-savings when delivering a multifactorial intervention of people with

four or more of eight risk factors.118

Desktop Research

The commissioners (both health and social) have thoroughly explored models in other

parts of the UK, which demonstrate successful working resulting in reduced emergency

admissions. Lessons learnt and best practice has been built into the Admission

Prevention Services model.

The commissioners (both health and social) have thoroughly explored models in other

parts of the UK, which demonstrate successful working resulting in reduced falls and falls

related admissions. Lessons learnt and best practice has been built into the Admission

Prevention Services model.

The CCG has undertaken extensive clinical audits, led by local GPs, of existing key

114 Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews 2010, Issue 10. 115 Department of Health (2009) Fracture Prevention Services: an economic evaluation. http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fractures.pdf 116 Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697-701 117 Salkeld G, et al, 2000:The cost effectiveness of a home hazard reduction program to reduce falls among older persons. Aust N Z

J Public Health. 2000 Jun;24(3):265-71. 118 Rizzo JA et al 1996: The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly

persons. Med Care. 1996 Sep;34(9):954-69.



http://www.ncbi.nlm.nih.gov/pubmed?term=Salkeld%20G%5BAuthor%5D&cauthor=true&cauthor_uid=10937402



http://www.ncbi.nlm.nih.gov/pubmed?term=Rizzo%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=8792783


Page 119 of 129


community services (community hospital beds, Community Matron Services and District

Nursing Services) to fully understand what works well, where challenges and barriers to

better care lay and to better understand the therapeutic and personal care inputs

required to empower patients to remain at home and be safe from risk of falling. This

detail informed the skill mix and competency base the admission prevention team.


£1,569,000

Impact of scheme





£556,010

The Admission Prevention Services will:

• Reduce length of stay in hospital;

• Reduce the risk of falls amongst Service Users;

• Reduce the number of fracture neck of femur, especially in female Service Users;

• Increase or maintain Service User’s independence in place of usual resident; and

• Service Users will be involved in decision making

Feedback loop

KPI:

LOC-011: % of referrals assessed within standard (APS). STANDARD: Assessed ≤ 7

working days from referral.

In order to measure the impact on emergency admissions, data from the acute provider

is analysed to:

- Compare emergency admission rates for current and previous months / years

Clinical audit of patients under the care of the admission prevention team but who have

also presented as an emergency admission is undertaken to understand what triggered

the admission and whether the admission prevention team could have behaved

differently in the patients pathway of care.


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The following are identified as key success factors for implementation of the Lowestoft

OHT and action is in place to ensure these factors are robustly built into the

implementation and delivery of the scheme

Workforce Development:

- Generic workers with an extensive competency base to ensure an holistic

approach to care – there is a generic worker programme lead by our community

provider

- Moving to 7 contracts of employment - underway

Access to the OHT:

- Easy to access service – single point of access in place

- Ability of service to respond quickly and appropriately – skill mix and capacity is

planned

- System knows how and when to access the service and understands what the

service can offer – the CCG and the providers have invested significant time in

introducing the scheme to the system

Sharing Information:

- Attendance at MDTs with general practices across great Yarmouth and Waveney

– these take place

- Handovers between shifts and across the team – these take place

- Joined up working with colleagues in social care and mental health – the APS

teams are co-located with colleagues from social care

Use of evidence based care for falls prevention

Scheme ref no.

Scheme 7 - GYW

Scheme name

Support for people with dementia and older people with functional mental health

problems living in the community


To deliver specialist support to people with dementia and their cares to avoid / delay

admissions to hospital / care and provide assessment of on-going care needs.


Dementia and complexity in later life community (DCLL) - A Community Mental

Page 121 of 129


Health Team for people with dementia and complexity in later life, offering specialist

assessment, diagnosis, treatment and care specifically to older adults with mental health

problems in their own homes and the community. They may provide a whole range of

community-based services themselves, or be complemented by one or more teams

providing specific functions. For example memory assessment.

The services provide a community focused resource for the residents of Great Yarmouth

& Waveney.

These are full multidisciplinary teams comprising nursing, medical, occupational

therapy/technical instructor & psychology staffing.

Interventions offered:

▪ Assessment and diagnosis of mental health problems including dementia

▪ Initiation and stabilisation of dementia treatment in accord with the shared care

protocol with primary care.

▪ Monitoring of mental health difficulties and agreed treatment plans

▪ Therapeutic interventions including; individual, family and group work

▪ Specialist psychology input

▪ Consultation to external agencies around mental health issues and the

management of challenging behaviour

▪ Diagnosis and treatment of other mental health issues other than dementia in the

CLL pathway

Referral and access to services is via Access and Assessment Team (AAT).

Service is provided 9am to 5pm, Monday to Friday.

Dementia Intensive Support Team - Dementia Intensive Support Teams (DIST) will

provide services in the community and in-reach into to acute hospitals to aid safe and

early discharge.

Service provided daily (7 days per week) 08:00 to 21:00

Service User Group covered

Adults with age related needs (usually, but not exclusively people over the age of 65

years) suffering from acute, severe and enduring mental health problems including

anxiety, depression, confusion (clusters 4 to 17) and adults of any age with dementia and

related behavioural problems (clusters 18 to 21).

Service users seen by the DCLL service will have complex age-related needs such as

physical frailty, multi-system pathology, and very poor mobility.

Geographical area covered

Service is provided across Great Yarmouth and Waveney CCG.

Page 122 of 129


The delivery chain

Commissioners – NHS GYW CCG

Providers – Norfolk and Suffolk NHS Foundation Trust, Norfolk County Council and


Services can be accessed in the following settings:

Patients home; GP surgeries; Local Hospitals; Community Venues

The evidence base

Dementia Care - In a systematic review of RCTs, four out of six good quality studies

found that case management of dementia patients was associated with delayed or

reduced institutionalisation, although in one study this was only significant in one of three

countries studied. However, none of the good quality studies found evidence for savings

in healthcare expenditure or reduced hospitalisation rate/emergency visits. NHS

investment in early assessment services for people with dementia can produce

significant savings for social care, particularly in relation to residential care (National

Dementia Strategy – Impact Assessment – economic case for early assessment and

memory services).119

Intensive Case Management for Mental Health patients - A Kings Fund Paper in

2010120 on the research evidence around avoiding hospital admissions recommended

that commissioners and providers should consider implementing intensive and/or

assertive case management for people with mental health illnesses. This is most

effective when focused on patients with frequent hospital use and assertive case

management by multidisciplinary teams may reduce mental health admissions.

A Cochrane review of ‘Intensive case management for severe mental illness’ (2011)121

found that ICM is of value at least to people with severe mental illnesses who are in the

sub-group of those with high level hospitalisation (about 4 days a month in past 2 years)

and the intervention should be performed close to the original model.

Integrating Mental Health into Chronic Disease Management - There is a growing

evidence base that suggests that more integrated ways of working with collaboration

between mental health and other professionals offers the best chance of improving

outcomes for both mental health and physical conditions. There is also evidence that the

costs of including psychological or mental health initiatives within disease management

or rehabilitation programmes can be more than outweighed by the savings arising from

improved physical health and decreased service use.122

119 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf 120 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010. 121 Intensive case management for severe mental illness (Review). Dieterich M, Irving CB, Park B, Marshall M. Wiley 2010. 122 The Kings Fund and Centre for Mental Health : Long-term conditions and mental health, Naylor et al 2012

Page 123 of 129


Integrated Care Pathways for Mental Health - An Evidence briefing (2011)123 produced

by the Centre for Reviews and Disseminations found that there is some evidence

suggesting that ICPs can reduce mental health hospital costs, most studies were not

conducted in the UK NHS.

Mental health promotion through early intervention in psychosis is thought to be cost-

saving for the NHS.124 This involves a multidisciplinary team with emphasis on an

assertive approach to maintaining contact with the patient and encouraging a return to

normal vocational pursuits. UK evidence shows it can reduce relapse and readmission to

hospital and improve quality of life.

Early intervention in psychosis (modelled on a target group of people aged 15-35 years)

is thought to save the NHS over £5 for every £1 spent within one year.

Crisis Resolution and Home Treatment for Mental Health patients (CRHT) - Crisis

Resolution and Home Treatment (CRHT) services for mental health patients have been

shown to decrease unplanned hospital admissions and length of stay. 125 126

The National Audit Office suggests that the NHS could save £12-50 million annually by

increasing the number of patients taking part in CRHT programmes.127 Integration of

CRHT or other community teams with inpatient staff can lead to reductions in bed use,

and this approach in Norfolk has led to annual savings of approximately £1 million.128

The clinical interventions are based upon NICE Guidelines.

The National Dementia Strategy (NDS) was supported by a full economic impact

assessment and it contains 17 objectives. Those objectives that are relevant to mental

health services have formed the basis of the service proposal’s objectives.

In the area covered by NHS Norfolk and Waveney there are over 15,000 people with

dementia but less than half of them are in receipt of a diagnosis. In other words more

than half of the people with dementia locally have no diagnosis and therefore no access

to treatment that can prolong their quality of life and independence, delay expensive

institutionalisation, and help prevent expensive episodes of unplanned care.

123 Evidence briefing on integrated care pathways in mental health settings. National Institute for health research. Sept 2011. 124 Knapp M, McDaid D, Parsonage M (eds) (2011). Mental Health Promotion and Mental Illness Prevention: The economic case. London: Department of Health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf 125 National Audit Offi ce (2007a). Helping People Through Mental Health Crisis: The role of Crisis Resolution and Home Treatment services. London: The Stationery Office. Available at: www.nao.org.uk/publications/0708/helping_people_through_mental.aspx 126 Chiles JA, Lambert MJ, Hatch AL (1999). ‘The impact of psychological interventions on medical cost offset: A meta-analytic review’. Clinical Psychology: Science and Practice, vol 6, no 2, pp 204–20 127 Howard C, Dupont S, Haselden B, Lynch J, Wills P (2010). ‘The effectiveness of a group cognitive-behavioural breathlessness intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease’. Psychology, Health and Medicine, vol 15, no 4, pp 371–85. 128 Department of Health (2009) partnerships for Older people projects final report. London. Department of Health.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf

http://www.nao.org.uk/publications/0708/helping_people_through_mental.aspx

Page 124 of 129



£665,000

Impact of scheme





£556,010

The key objectives will be met as a result of:

• Maintenance of functioning, independence and quality of life of people with dementia

for as long as possible

• Prevention of inappropriate admissions to acute and mental health care hospitals

• Prevention of or delaying admission to care homes, where appropriate.

• Early identification of people who might have dementia

• Early assessment and diagnosis.

• Early treatment and access to care.

• Support, information and advice for people with dementia and their carers

• Routine advanced care planning

• Appropriate review of patients and their carers

• Timely and appropriate support for carers

• Enhanced support for patients and their carers who are in crisis, at risk of admission

or who are already admitted to an acute hospital.

• To work with partners and wider services to ensure clear pathways and access to

wider support services, with the aim of improving patient outcomes and care.

• To work with AAT ensuring effective pathways from AAT to DCLL are done so in a

timely manner

• To discharge back to primary care as appropriate

Feedback loop

CQUIN goals

• Friends and Family Test

• Communication with GP

• DIST

Page 125 of 129


We have started to analysis the DIST data submitted by NSFT for the period April 2013 –

June 2014


With the recent public consultation on Dementia and Complexity in Later Life there

maybe changes to how the DIST and the older people’s services function. The final

decision on the recommendations and proposals will not be made until end of September

2014.

There are social workers within this service who are employed by Norfolk County Council

and Suffolk Council, so there is an element of integration and co-location. However, there

needs to be a move towards becoming part of the Out of Hospital Teams to ensure that a

more holistic and system wide approach is in place to support these complex

patients/service users.

Page 126 of 129


Annex 2 – Ipswich Hospital NHS Trust Commentary (note text in boxes amended but unable to show highlighted as inserted as a pdf)

Page 127 of 129


Annex 2 - West Suffolk NHS Foundation Trust Commentary

Name of Health & Wellbeing Board

Suffolk

Name of Provider organisation West Suffolk NHS Foundation Trust

Name of Provider CEO Dr Stephen Dunn

Signature (electronic or typed)

For HWB to populate:

Total number of non-elective FFCEs in general & acute

2013/14 Outturn 19,944

2014/15 Plan 17,630

2015/16 Plan 16,386

14/15 Change compared to 13/14 outturn

2,313(-11.6%)

15/16 Change compared to planned 14/15 outturn

1,244(-7.1%)

How many non-elective admissions is the BCF planned to prevent in 14-15?

0


640

For Provider to populate:

Question Response

1.

Do you agree with the data above relating to the impact of the BCF in terms of a reduction in non-elective (general and acute) admissions in 15/16 compared to planned 14/15 outturn?

The Trust supports the planned reductions of non-elective admissions targeted through the BCF, integrated in a wider programme of pathway change aimed to keep people out of hospital.

2.

If you answered 'no' to Q.2 above, please explain why you do not agree with the projected impact?

n/a

3.

Can you confirm that you have considered the resultant implications on services provided by your organisation?

Yes – our current plan is predicated on a more conservative reduction in non-elective demand however we are supportive of the planned reductions, are exploring further how we can contribute to their achievement, and will reduce our capacity in line with the reductions as they materialise.

Page 128 of 129


Annex 2 - James Paget University Hospital Foundation Trust Commentary

Name of Health & Wellbeing Board

Suffolk

Name of Provider organisation James Paget University Hospital Foundation Trust

Name of Provider CEO Christine Allen

Signature (electronic or typed)

For HWB to populate:

Total number of non-elective FFCEs in general & acute

2013/14 Outturn 9306

2014/15 Plan 9329

2015/16 Plan 9006

14/15 Change compared to 13/14 outturn

+23/ +0.2%

15/16 Change compared to planned 14/15 outturn

-323/ -3.5%


81


380

For Provider to populate:

Question Response

1.

Do you agree with the data above relating to the impact of the BCF in terms of a reduction in non-elective (general and acute) admissions in 15/16 compared to planned 14/15 outturn?

The Trust supports the planned reductions of non-elective admissions targeted through the BCF, integrated in a wider programme of pathway change aimed to keep people out of hospital. The 3.5% reduction should result from the BCF schemes. These have been designed to have an impact across the whole system. We are also anticipating additional system benefits through internal transformational change within JPUH.

2.

If you answered 'no' to Q.2 above, please explain why you do not agree with the projected impact?

n/a

3.

Can you confirm that you have considered the resultant implications on services

Yes – however further analysis will be completed across the system to quantify the impact as schemes are further developed.

Page 129 of 129


provided by your organisation? Our plan is predicated on a more prudent reduction in non-elective demand. This may enable planned reductions in capacity as whole scale system change starts to take effect, aided by the BCF schemes.