1. Health & Social Care Integration Potential, problems & positives and the role of IM&T Geoff Lake NEL Care Trust Plus

2. Part 1 - Context The Facts About NEL Organisational Journeys The Care Trust Approach

3. The Facts About NEL North East LincsEngland Unemployment rate6.6%5.5% Average weekly earnings (male)£453.50£500.00 Percentage of private households deemed unfit for habitation 11.2%4.8% Household burglary rate per 10,000 households aa 204128 Percentage of children in low income households aa 51%40% Number of pupils gaining 5 or more GCSE 53%60.4% National Comparisons

4. 49 th most deprived out of the 354 Local Authorities in England (2007) 24% of lower level super output areas (LSOAs) in North East Lincolnshire are amongst the most deprived 10% in England 49% of LSOAs in North East Lincolnshire are amongst the most deprived 30% in England Deprivation The Facts About NEL

5. Population – 158,400 (ONS estimates for 2007) Forecast to increase by 12.21% by 2031 (from 158,900 in 2006 to 178,000 in 2031) Greatest reduction – 15-19 age group (-11.76%) Greatest increase – 85+ age group (+126.47%) 95.53% ‘White British ’ The people The Facts About NEL

6. Male life expectancy 75.9 years (below national & regional average) Female life expectancy 80.8 years (below national & regional average) Biggest contributors to life expectancy gap: - circulatory diseases - cancers - external causes High teenage pregnancy rates Smoking prevalence 33% Third worst area in England for alcohol abuse Childhood obesity Health Impact The Facts About NEL

7. Organisational Journeys PCG to PCT: Continuity Clinical and managerial leadership High performer / Innovation Investment in partnership architecture View of ‘single’ economy best served by integration NHS

8. Organisational Journeys ‘Humberside’ demise ‘0’ stars Difficult transition, particularly operationally Intervention Loss of Chief Executive Recovery to 1 star and ‘monitoring’ form of intervention whilst building partnership North East Lincs Council

9. The Care Trust Plus Proposal Four Commissioning Groups led by front line staff and key stakeholders – the engine room for self directed, integrated care Creating a membership organisation with strong community links Building a healthy community through increased choice, increased control and moving from engagement to co-production Our contribution to wider economic and social regeneration an important element of our community leadership role Only at the start of a significant journey The design concept

10. Part 2 – Policy and design Personalisation Transformation & Intervention model Transforming Care plan NEL Whole system model Integrated Single Point of Access

11. Policy Drivers Putting People First Personalisation and linked themes

12. Low to moderate needs Citizenship Information Lifestyle Practical support Early intervention Enablement Community support for LTC Institutional avoidance Timely discharge General population Complex needs Substantial needs Involvement of older people Tackling ageism – positive images Equal access to mainstream services Making a positive contribution, including volunteering “ No door the wrong door” Single point of access, self assessment, peer ‘navigators’ Active ageing initiatives Public health messages, including diet and smoking Peer health mentoring Befriending and counselling Shopping, gardening etc Case finding and case management of those at risk Intermediate care services Enablement services – developed from home care Hospital in-reach and step down pathways Post discharge support, settling in and proactive phone contact Integrated or co-located teams and/or networks Generic workers Case finding and case management of complex cases / LTC end of life care – enabling people to die at home Management of unscheduled care Choice & Control:- people receiving self directed support, including direct payments and individual budgets Dignity: - Dignity challenge and ‘champions’ Carers: - carers receiving assessment, specific carers services, information, Expert Carers Programme Home and community Community safety initiatives, including distraction burglary Locality based community development Population ‘needs’ Example interventions Intervention Model Making the links for transformation ( Acknowledgement Nick Marcangelo CSIP CAT )

13. Enablers Process Change Measurable Outcomes Strategic Objectives Establish platform for changeTransformation Exploit the Transformation Year 1 Year 2 Community & provider option “shaping” Integrated Organisation Integrated Information Accessibility Integrated frontline delivery Personalisation ( choice & control ) Planning Stakeholder Engagement Leadership Numbers using self-directed support Positive experience measures SAQ/RAS/IB learning Personal Health Budget learning Development of Support Planning Options Corporate commitment Transformation Grant Integrated Care Record Approach & development & deployment Integrated Information sharing Requirements NEL CAF definition Reduced duplication of info gathering Set in context of AIMS Intermediate Tier & Complex case Managemen re-design Coordination experienced Practitioner efficiencies through improved information sharing Navigation skills Support accessible Peer support options available ( via AIMS ) High Quality Provider Market User Led Organisation development Influencing shape of market Equity of information available for self-funders Streetfront Presence Integrated Information available from AIMs & other defined outlets Information strategy definition Information and update process development Seamless patient transits Workforce development & OD initiatives Integrated care system re-design Efficient/value for money Integrated measures Transforming Care

14. NEL Whole System Model Specialist providers GP Tier 1 Home Low level interventions Early Intervention Prevention Participate Long Term Care CCM Intermediate Tier Community nursing A3 ‘Social Capital’ Volunteers Information Refer Brokerage Care Navigators Home care providers Information 5% Tier 2 Home or short intervention Rapid response Safeguarding Reablement Tier 3 Home Complex interventions Needs driven Intensive case management Prevention Tier 4 Long Term care 3 rd Sector ULOs Self

15. Single Point of Access Model Public first contact via Shop front 9 am – 5pm 10 am – 4 pm w/e Public first contact via telephone – 629100 8am – 6pm 10 am – 4 pm w/e Professional contact via telephone – xxxxxx 24/7 Advice Officers Admin Answering ( A3 daytime / Provider OOH ) Assessment/triage ( telephone ) Acute Discharge Community Nursing GP & Other Agencies Self/Family/Carer A3 Rapid Response ( hands on ) Duty Officers OOH Safeguarding Provider – Intermediate Tier

16. Part 3 - Integrated Delivery & IM&T

17. Integrated Delivery Strategic approach to adopt a single System/record for Primary Care and Adult Social Care

18. Require a “Do Once and Share” approach to demographics and assessment as individuals move through the care system Requires processes that; -Ensure person centred (self) assessment -Ensure proportionate assessment -Effectively identify those who would benefit from more in-depth assessment Requires trust in information And Requires a means to share an evolving record – the Shared Care Record in NEL Common Assessment Framework Integrated Delivery

19. Examples of learning models: To enable effective tracking of Continuing Care IMCA/DOLS determinations To enable effective alerting re risks to person/staff To support coordination by providing an view of who is involved and how to contact them Potential ( with other initiatives ) to alert complex case managers of unscheduled admissions To enable the delivery and maintenance of Integrated care plans and Person Held Records To be the focus for collaboration on preventative strategies Ambition for a broader approach to shared information Integrated Delivery

20. Two key elements: To enable management of a de-coupled Self Directed Support process where control points are vital. Assessment, planning/provision may be external to CTP To support the management of the allocation of individual care budgets and future integrated care budgets through Personal Health Budget development Supporting Personalisation in a shared record Integrated Delivery

21. Three Performance elements: Delivering statutory Performance indicators Supporting the emergence of health specific and integrated team management performance indicators To support the recording of overall benefits realisation information to demonstrate delivery of the strategic Quality and Efficiency premiums Supporting Management in a shared record Integrated Delivery

22. Part 4 – Challenges Making sure the programme delivers the Quality and Efficiency premiums Establishing a shared record concept with the flexibility to learn and shape with our staff Governance ( access/sharing/consents/audit ). Meeting Care Record Guarantees in an integrated approach Performance – statutory and integrated team measures Systems transition Developing information links with partners outside of the single system

23. Part 5 – Growth of internet use Web based Brokerage Tools: – “same as me” knowledge base for self-directed support planning Web based Provider registers: – Personal Assistant/volunteer networks Web based data from remote assessment tools: – Telehealth and home activity monitors