1. 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

2. 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 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 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.

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

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

5. 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

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

7. Changing the pathway
Health
and
Well
Being
Increasing age

8. 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.

10. 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.  

11. 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.

13. 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:

14. 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.

15. 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.

16. 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

17. Integrated Care in Canterbury New Zealand

18. 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

19. 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

20. 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

21. Nature of the change programme

22. Original Outline Model

23. 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

24. 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

25. 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

26. Hub and Spoke

27. 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.

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

29. Whole System Culture Change
Cultural Expectations of Society
Individuals
Organisations
Communities

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

31. And culture change isn’t linear

32. 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

33. In context - we can do better!
Citizenship
Institution
Care