Healthy Communities = Healthy Lives Adult Social Care and the Joint Agenda Mark Branton Assistant Director- Adult Social Care Commissioning Gloucestershire County Council 27th February 2014

Needs analysis – Older People The number of older people aged 65+ in the county has been growing by an average of 1,500 people per year over the last 10 years. Projections suggest that this will double to an increase of around 3,100 people annually on average between now and 2021. In particular, the number of people aged 75 and over, is projected to increase by an annual average of 1,700 between 2011 and 2021. The number of 85+ will see the fastest rate of growth during this period. The rising trend of older people aged 65+ living alone could also place extra pressure on care and infrastructure provision. Data from the Census suggests that there were 33,800 of older people aged 65+ living on their own in 2011. The number is projected to rise to 41,000 by 2021. Dementia is also an increasingly common condition. In Gloucestershire, there are estimated to be 8,610 people living with dementia. That number is expected to almost double over the next 20 years.

It’s not just age – it’s long term conditions

Ageing Population - It’s a positive! Strengths based Inclusive communities Time bank schemes - casserole club Addressing loneliness and isolation Commercial argument

Support focus Assessment of Needs Care Management Personal Budget Entitlement Promotion of Health & Wellbeing Hospital Admission avoidance Reablement / intermediate care Public Information Robust local community capacity Crisis support Carer Support Advice & support Range & Quality of provision Safeguarding Family & Info Network Peer Support Community Service Statutory Friends Support Provision Services

The pathway in old age Health and Death of a spouse Well Being First fall Increasing age

Changing the pathway Health and Well Being Increasing age

Changing the pathway Not possible for any one sector of public care – interrelation between health and local government and between the state and the individual. Target different interventions at key points along the pathway where they are likely to then may prove most successful. Create a context and an environment that supports independence and well being.

Our Shared Vision for the next 5 years To improve health and wellbeing, we believe that by all* working better together - in a more joined up way - and using the strengths of individuals, carers and local communities, we will transform the quality of care and support we provide to all local people. * The health and care community in Gloucestershire consists of the Clinical Commissioning Group and main NHS service providers in the county, the County Council and District Councils, and colleagues representing the public and those representing the voluntary sector.  

Our Ambitions People are provided with support to enable them to take more control of their own health and wellbeing. Those that are particularly vulnerable will benefit from additional support;   People are provided with more support in their homes and local communities where safe and appropriate to do so, thus moving away from the traditional focus on hospital-based care; When people need care that can only be provided in a hospital setting, it is delivered in a timely and effective way.

How are we going to work together to make all this happen? We have agreed a set of principles as the foundation of our collaborative working:   A person-centred approach, where organisational boundaries are less important than the outcome and experience for each individual; To build stronger, more sustainable communities and in turn improve the health and wellbeing of local people, we will draw upon, and stimulate the provision of, the diverse range of assets within each local community; We will adopt a “one system, one budget” approach. This means the money we have available can only be spent once to achieve the best possible outcomes for all local people, regardless of organisational boundaries. This will be implemented through:

How are we going to work together to make all this happen? (continued) Utilising a clinical programme approach, where we identify the budget for a specific condition and review the whole clinical and care pathway from prevention to end of life. The aims include achieving the best possible outcomes within available resources, whilst also reducing waste, harm and variation;   Exploring and testing the use of innovative forms of contracting, enabling individual providers to work together collaboratively to deliver elements of a care pathway or service, working to shared objectives; Maximising the opportunities to commission services jointly across health and care organisations.

How are we going to work together to make all this happen? (continued) We will design the most efficient and effective services possible:   Agreeing the best route people take through their care. Care pathways - will be a key mechanism for change and be developed based on evidence of best practice, maximising the use of available technology. The pathways must then be implemented to ensure people access the right care, in the right place, at the right time; services, where appropriate, will be available seven days a week; We will create a systematic approach to delivering transformational change, training a wide range of staff across our health and care community on an ongoing basis. When designing services, we believe a relentless focus on reducing the time patients spend waiting will deliver the most efficient care.

Better Care Fund Investment in Joint Working Announced at Spending Round 2013 £200m for Local Authorities (LAs) in 2014/15 (Section 256 of the NHS Act 2006) £3.8bn pooled budget in 2015/16 (Section 75 of the NHS Act 2006) for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities £1bn of £3.8bn ‘payment by performance’ in 2015/16 Signed off by Health and Wellbeing Boards (HWBs) Plans must deliver on national conditions: Delayed transfers of care Emergency admissions Effectiveness of reablement Admissions to residential and nursing care Patient and service-user experience Local metric Pay for Performance based on: Protecting social care services; 7-day services to support discharge; Data sharing and the use of the NHS number; Joint assessments and accountable lead professional

Integrated Care in Canterbury New Zealand

People’s preferences should they need care % Stay in my own home with care and support from friends and family 62 Stay in my own home but with care and support from trained care workers 56 Move to a smaller home of my own 35 Move to sheltered housing with a warden 27 Move in with my son or daughter 14 Move to a private residential home 11 Move to a local council residential home 7 Move to a residential home provided by a charitable organisation 3 Wanless Review 2006

Service Centred System Standardised Services ‘Fix Me’ How can we work together? How can we be protected? How do we control costs? How do we manage complaints?........ The more we do, the more we risk creating dependency Identify Needs Measure activity Design Services Assess eligibility Commission Services cost Standardise Services time

Person Centred System “I will only ask for what I need, when I need it” Voluntary Sector ‘Help Me Help Myself’ The more we do the less we need to do Friends Family cost Neighbours Community time Specialist Statutory Services GP and primary care Community care

Nature of the change programme

Original Outline Model

Promoting Well being through Community resources available to all Strategic Model Population (OP) Primary Prevention Promoting Well being through Community resources available to all Demand for Support Initial Contact Resolution Referrals Referral Screening Integrated ICT’s Rapid Response Core Business Resolution High Intensity Service EXIT Ongoing Needs Solutions

ASC Change – shaped by TLAP National Use of Resources ADASS framework domain Performance areas for self assessment PREVENTION Information and Advice, Health, well-being and social inclusion, Targeted Prevention, Equipment and Assistive Technology RECOVERY Reablement, Crisis response, Hospital discharge, Intermediate Care LONG-TERM SUPPORT Personalisation, Shifting the balance of care and support, In-house provision, Day Opportunities, Employment, Housing and support, Continuing Care and End of Life Care BUSINESS PROCESSES Outcome focus, Streamlining business processes, Workforce planning, Leadership and staff development, Equalities Impact: PARTNERSHIP Whole systems approach, Joined-up service delivery, Market Facilitation, Procurement, Transitions, Safeguarding CONTRIBUTIONS Fairer Contributions, Community Engagement, Co-production, Building Community Capacity, Local Accounts

Strengthening Integrated Community Team model Rapid Response High Intensity Core Business Case Management/Reablement Prevention, Wellbeing and Self care 24 hour access through SPCA for professionals Max 48 hours Step up/Step down depending on needs Safeguarding Approximately 10 days depending on patients needs Safeguarding Integrated Community Team partnership working between all professions including GP’s Safeguarding

Hub and Spoke

Outcomes Based Commissioning The concept: Rather than paying dom care providers to deliver tasks in blocks of time, we pay for the outcomes they help SUs to achieve. This achieves savings by incentivising providers to only deliver the services that are needed, and to encourage the SU to be as independent as possible. By increasing the frequency of the review period it is possible to more closely match the reduction in the SU’s needs with a corresponding reduction in the level of care support. The areas shaded in pink represent the waste associated with traditional care plan models where a person gets better Savings identified are based solely on Dom Care.

The issue of culture change The way you work now was once new… honestly!

Whole System Culture Change Cultural Expectations of Society Individuals Organisations Communities

Who do you think should pay for social care? - BAS

And culture change isn’t linear

Why are we doing this? Services that can dynamically respond as people’s lives change Focus on supporting people to achieve outcomes important to them Better /reduced use of resources Joining Up Your Care

In context - we can do better! Citizenship Institution Care