Integration Health and Social Care Jennifer McGovern – Assistant Director, Integrated Commissioning

GM Heath & Social Care Reform

Early Years Transforming Justice Troubled Families Reducing demand today Reducing demand for generations Reducing demand today and tomorrow Turning off the dependency tap at source X Better outcomes, lower cost Health & Social Care Better outcomes, lower cost SAVINGS Re-investment of resources across partners Skills and Worklessness Aging Population 3 GM Public Service Reform programme

Promote independence for older people, delivering: 1.Better health and social care outcomes 2.Improved experience for services users and carers 3.Reduced health and social care costs Salford’s Integrated Care Programme 4

High demand and rising 34,541 people aged 65+, 28% projected increase 1: 14 have dementia and over-represented in acute beds Growth in limiting long-term illness Disability-free life expectancy 2,130 falls related A&E attendances Growth in people living alone: 12,542 in 2011 to 15,998 in 2030

Population Stratification

Salford’s Integrated Care Programme Multi Disciplinary Groups provide targeted support to older people who are most at risk and have a population focus on screening, primary prevention and signposting to community support 3 Local community assets enable older people to remain independent, with greater confidence to manage their own care 1 Centre of Contact acts as an central health and social care hub, supporting Multi Disciplinary Groups, helping people to navigate services and support mechanisms, and coordinating telecare monitoring 2 1 Promoting independence for older people Better health and social care outcomes Improved experience for services users and carers Reduced health and social care costs 3 2

2020 targets – what and why? Emergency admissions and readmissions 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn) Reduce readmissions from baseline Cash-ability will be effected by a variety of factors Permanent admissions to residential and nursing care 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn) Savings directly cashable but need to be offset by cost of alternative care (especially increased domiciliary care) Quality of Life, Managing own Condition, Satisfaction Maintain or improve position in upper quartile for global measures Use of a variety of individual reported outcome measures Flu vaccine uptake for Older People Increase flu uptake rate to 85% (from baseline of 77.2%) Proportion of Older People that are able to die at home Increase to 50% (from baseline of 41%)

Cost reductions (work-in-progress) 9 Forecast spend ~£100m+ on care for older people of which c. 50% (£48.3m) from SRFT Need to account for primary care/GP practice expenditure 65+ population projected to grow by 24% by 2030 Significant cost reductions already required by each partner Reduction in care home admissions Reduction in hospital admissions 19.7% reduction in emergency hospital admissions 2071 admissions avoided £8.63m value (part cashable)* 26% reduction in permanent care home admissions 84 admissions avoided £1.57m value (cashable) * Only a subset of this will be releasable due to the fixed and semi-fixed costs within the hospital.

Financial context and implications 10 Current spend: ~£100m on care for older people (£48.3m from SRFT) 65+ population projected to grow by 24% by 2030 Significant cost reductions required by all partners Status quo is unaffordable and unsustainable Economic risks and benefits not equitably shared by partners £ benefits need be set against – Cost of new delivery models – Growth in population and associated demand – Existing savings plans Integrated care is likely to create costs before it generates savings Integrated care solutions are more cost-effective than the status quo Three categories of £ benefit – Reduction in admissions (hospital, care homes) – Removal of duplication and fragmentation – Reducing future demand Not a quick fix but the most credible and sustainable solution Support and mitigate adverse consequence of cost reductions 4 New contractual and financial arrangements will be required (section 75 / Alliance Agreement / JV) Modelling assumptions to be refined and tested through pilot work 5

“Provider income reductions … should be based on an ability to reduce costs … the rate and pace of income reduction should … be equal to the realisable reduction in marginal and fixed costs” “All parties are required to demonstrate ‘best endeavours’ to deliver the agreed cost reductions … If resolution cannot be agreed by the Board or the resolution is not actioned … then standing contractual arrangements … will apply after 12 months notice of the deadline passing” “Some parties within the Partnership have separate contractual arrangements with third parties which are governed by separate commercial arrangements.” “Cost reduction, income loss and any reinvestment will need to be reconciled … cashable savings will be reinvested in care for this population. If savings exceed the predicted growth in demand, the Integrated Care Board will agree appropriate benefit sharing arrangements.” Some costs will remain fixed during the duration of the Programme and there is likely to be a time-lag between change and cost reduction. BUT not an excuse to maintain the status quo And some costs can be extracted at the same rate that demand is reduced Benefits and risks need to be shared, recognising that underlying demand may limit cashable savings Risk and benefit sharing 11

Commissioner(s) P P P P P P As-is (traditional contracting) DIFFICULTIES FOR INTEGRATED CARE Changes difficult to enact; multiple parallel negotiations between commissioners and providers Focus on individual institutions rather than the continuum of care Payment systems are different in different sectors; no mutual incentives to work together Limited mechanisms to move resources between services / providers Providers primarily rewarded for treating service users not improving outcomes Short term contracts provide limited incentives to invest in longer term outcomes

As-is (do nothing option) Informal network - profit/risk sharing Accountable Care Organisation Integrated Care Hubs Prime contactor and subcontracting model Single Integrated Care Organisation Joint Venture with Joint Management Board of providers Alliance Agreement 13 Prime Contractor  The commissioner(s) hold one contract with one provider which has full accountability for the care model  The prime contractor subcontracts some provision to other provider organisations  The Prime Contractor determines any risk and benefit sharing arrangements with subcontractors Joint Venture  Collaborative approach between providers, promoting joint ownership of outcomes and accountability, and shared risk Alliance Agreement  Variant to the traditional Joint Venture  Collaborative approach with all organisations (commissioners and providers) sharing contractual responsibility and risk  The emphasis and focus is on the joint ownership and responsibility for agreed outcomes Contracting models

Lead Commissioner P P P P P P Alliance Agreement 14 BENEFITS Full range of services within a single management arrangement – more effective, efficient and coordinated care Collaborative environment without the need for new organisational forms Aligns interests of commissioners and providers, removing organisational and professional ‘silos’ that contribute to fragmented and sub-optimal care Collective ownership of opportunities and responsibilities; any ‘gain’ or ‘pain’ is linked to performance overall Supports a focus on outcomes and incentivises better management of population demand CCG, City Council, SRFT, GMW Health, social care & wellbeing for 65+ (may excl. specialist & elective surgical services) Some services subcontracted or directly contracted by commissioners General Practice or other parties could be incorporated Phased introduction from 2014/15

SCOPE OF THE AGREEMENT Population / client focus Proposed strategic partners Service content Aims and improvement measures Decision-making principles Management arrangements Payment options Commercial terms Pace of change Alliance Agreement 1Management arrangements  How should services within the Alliance be managed and governed? 2Payment options  What payment mechanisms should be considered?  How should income be distributed between providers? 3Commercial terms  What duration should be considered for the contract?  How should financial risks and benefits be distributed between parties? 4Pace of change  Do you support the proposed commencement of the Alliance Agreement in 2014/15?  What elements should be implemented from the outset and which should be introduced on a phased basis (and over what time period)?

£3.8 billion national funding to deliver closer integration between health and social care (est. £20m for Salford) “Single pooled budget for health and social care … based on a plan agreed between NHS and local authorities” – Transform health and social care – Deal with demographic pressures in adult social care – Support significant expansion of care in community settings Funding subject to national conditions and an element will be performance-related (est. £5m for Salford) Each locality to submit an investment plan by 4 th April 2014, setting out plans for 2014/15 and 2015/16 Better Care Fund (1)

Proposed that the BCF forms part of the Alliance ‘pool’, so that BCF investment supports PSR and integrated care plans Aligned to priorities in the Joint H&WB Strategy BCF (and pooled budget) to fund: – costs associated with the new integrated care model – capacity in community services and to ‘protect’ social care – implementation and change management costs – cost pressures and savings targets Plan was developed in partnership with SRFT and GMW Plan needs to be approved by the CCG and Council and endorsed by the Health & Wellbeing Board Better Care Fund (2)

Plan Assurance – High Ambition, Low Risk High Ambition? Fully integrated partnership of Health and Social Care Commissioners and Providers Scale and scope of service integration Alliance provides strong financial, governance and contractual framework Is it easy? Is it worthwhile Low risk - Careful, stepped progression Better Care Fund (3)

In principle decision to the further integration of commissioning across Salford CCG, Salford City Council and, if possible, others Absolute commitment to the further integration of adult health and social care for the benefit of the population Strong role for providers in the delivery of integrated care, building on the track record of partnership working Ambition to progress Salford’s Integrated Care Programme at greater scale Future direction of travel

Significant progress is being made through the Integrated Care Programme – a Salford focus, but part of a wider GM programme The new model will be rolled-out, city-wide, from April 2015, with a focus on enabling older people to retain their independence A key element is the use and expansion of local community assets It will be underpinned by an Alliance Agreement and a pooled budget, incorporating the Better Care Fund (AA = £98m, BCF = £20m) This work is being done in partnership with the Health & Wellbeing Board, which will have responsibility for endorsing the BCF plan The direction of travel is for further integration of both commissioning and provision Conclusions