The Better Care Fund

Bracknell Forest Better Care Fund Narrative Plan 2017-19

Version Sign Off Date Draft Submission

Sign off Service Heads

25/08/17

Review with Regional BCF manager

31/08/17

Sign off BCF Programme Board

06/09/17

HWBB sign off (delegated authority granted to DASS)

06/09/17

BCF Final

Submitted to NHSE

11/9/17

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Bracknell Forest BCF Narrative Plan 2017-19 Contents

• Bracknell Forest at a glance • Vision for Integration of Health and Social Care services • Strategic overview • Key strategies, plans and drivers • Key policy drivers and context • Strategic context- East Berks CCG and BCF • Leadership and Culture • BCF mapping - % of population in CCG area • Progress on health and social care integration • The Council’s Vision and Transformation Process • The Council’s Vision for Health and Social care services in

Bracknell Forest • Linking the Council’s Transformation process to the wider

context • Evidence base – understanding the local priorities /

Population profile / frailty cohort / JSNA • BCF schemes identified through the JSNA • Delivering the plan – QIPP projects supported by BCF • Additional local resources and infrastructure

• Bracknell Forest BCF – overview of agreed funding contributions – BCF and iBCF

• NEL admission context – targets and trajectory • Evidence base to inform further investment • DTOC – performance and Deep Dive / HICM • DTOC plan – summary of actions • Reablement • 65+ Permanent admissions • BCF Schemes – Infographics • 2017/18 BCF Schemes of work –summary • New iBCF schemes for 2017/18 • Programme Governance and Assurance • Assessment of risk / risk share • NHS Commissioned out of hospital services • Expenditure on social care from CCG minimum • National Conditions and KLOES • Appendix – High Impact Change Model • Key Documents and links.

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BRACKNELL FOREST AT A GLANCE

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12% over 65 yrs

Small Unitary Authority

Population: 118,000

25% under 18yrs 4% over 75 yrs

Life Expectancy: Men: 81.4 yrs

Women: 85 yrs

Town Centre Regeneration: 2500

new jobs

Frimley STP Footprint

Bracknell & Ascot CCG

Frimley Hospital

Berkshire Health

3 x Nursing homes

5 x domiciliary care providers contracted by the Council

6 x Residential care providers

High levels of employment

Thriving local economy

37% of the Council’s budget is spent on adult social care

Oldest social care customer is 103

Vision For Integration of Health and Care Services Our vision for 2017/18 confirms and intensifies a shift from reactive to proactive health and social care to enable more people to have healthier, safer and more independent lives in their own home and community for longer, receiving the right care in the right place at the right time. This plan sets out the next steps in the collaborative programme towards a shared goal of integration by 2020. Reinforcing our commitments within the Health and Wellbeing Strategy, (Promoting Healthy Lifestyles; Mental Health services; Preventing People becoming socially isolated and lonely; Workforce – having the right people with the right skills), we continue to focus on ensuring more people are able to self-care and, through earlier interventions and preventative services, people will have received treatment or care earlier in their condition or problem. For our adult population, people’s mental health as well as physical health will be supported, particularly those people with dementia, diabetes, people with co-morbidities and those identified as frail. For our children, the priorities will focus on prevention in the early years, particularly immunisation and tackling obesity. In a complex health and social care economy, we continue to develop a proactive approach to the provision of health and social care and support in the community delivered in partnership through GP practices, integrated health and social care multi-disciplinary teams, community based health and social care services working with local specialist services and the third sector, underpinned by consultation and collaboration with our residents. Delivery of good quality crisis and urgent care in the community will prevent unnecessary hospital admissions and provide additional health and social care and support capacity to facilitate discharge services and community based reablement and promote continued independent living. The BCF will continue to act as a catalyst and transformation partner to support the local delivery of the Five Year Forward View and support the “New Vision of Care” principles which are particularly pertinent to our aging population with increasing longevity and complexity of health and social care needs. We recognise the invaluable contribution and support of carers to the local health and social care system and the increasing demand for their services. We will continue to invest in the identification of carers and services to ensure that they are able to maintain their own health and wellbeing and will also consider how we can support carers better when they or the cared for person, faces a crisis or requires a stay in hospital. Connected information systems will ensure a smoother journey for the patient through health and social care systems, with technology and risk stratification used to ensure that patients/customers will be proactively supported and receive earlier interventions and/or more targeted treatment or care. The 2017-19 plan continues to build on the work started in 2015/16, developed during 2016/17 and is embedded across health and social care systems. 4

Bracknell Forest HWBB are committed partners within the Frimley STP – working closely with organisations within the STP and across all interfacing boundaries to deliver the agreed transformation programme; these being: • Prevention and Self-Care • Integrated Care Decision-making Hubs • New model of General Practice • Design a Support workforce • Transform the Care and Social Care

market • Reduce Clinical Variations • Implement a Shared Care Record

Strategic overview – linking BCF to the Frimley STP

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Key strategies plans and drivers- the links The key national strategies, plans and drivers that underpin the vision for integration of health and care services in Bracknell Forest are shown below:

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Key Policy Drivers and Context Links to key strategic national and local strategies and workstreams: Frimley STP: The Frimley Health and Care Partnership covers a population of 750,000 residents through nine councils (county, borough and district). It sets out how social care and health services delivered by councils and health authorities will become a more integrated system fit for the future. The overarching document setting out the 5 Priorities for the next 5 years and 7 Initiatives for the years 2016-18 can be found here: https://www.fhft.nhs.uk/media/2388/frimley-stp-oct-submission-for-publication.pdf Chief Officers from Bracknell Forest are members of key STP groups including Social Care Market (Initiative 5); Workforce (Initiative 4); Prevention and Self Care (Initiative 1) Integrated Care Decision Making Hubs (Initiative 2) and Shared Care (Initiative 7). Governance and reporting arrangements for the 7 STP Initiatives are shown below:

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Key Policy Drivers and Context (continued) Links to key strategic national and local strategies and workstreams: Urgent and Emergency Care 5 Year Forward View: The UEC Delivery Plan contains 7 pillars, which link directly to the Frimley STP workstreams; but also to workstreams within the Bracknell Forest and East Berkshire Better Care Fund Plans; including the Hospital to Home High Impact Change Model for Managing Delayed Transfers of Care (see later section). The formal links and relationships to key national and local strategies are shown below: Right Care

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Bracknell Forest BCF Initiatives

Support workforce- Care Home Quality

NHS unique identifier for ASC records

Interoperability (Shared Care)

iBCF –DTOC Hospital to Home

Intermediate Care redesign

Integrated Care Teams

Prevention and Self-Care

Key Policy Drivers and Context (continued) Links to key strategic national and local strategies and workstreams: Urgent and Emergency Care 5 Year Forward View: On 16 June 2017 the Frimley STP leadership submitted the Urgent and Emergency Care Delivery Plan. The Urgent & Emergency Care (UEC) Strategy for the STP describes how urgent and emergency care will be realised across the STP area. The main focus remains on self care, prevention and pro-active management of complexity but recognises the requirement to provide a more intuitive, timely access for urgent and emergency care. The UEC Delivery Plan envisages that Transformational investment will enable the system to accelerate redesign of local out of hospital services to ensure local residents receive the “Right care, at the right time, in the right place”. This will allow the continued delivery and improvement on performance targets such as A&E 4 hours, delayed transfers of care and ambulance response times against projected increases of overall activity in a ‘do nothing’ scenario. The Bracknell Forest BCF plans supports these principles at every level and, in particular support the Admission avoidance and Home from Hospital agenda with local responses through: Implementation of the High Impact Transfer of Care model including discharge to asses and trusted assessment; remodelling of the Intermediate Care service and development of the new “i-Hub” and “e-marketplace” providing a range of advice for all residents including self funders. Right Care

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Key Policy Drivers and Context (CCG Operational Plan 2017-19) CCG Operational Plan. The 3 East Berkshire CCGs Operational Plan for 2017-19 has been informed by NHS E Planning Guidance, the Frimley STP and key local transformation programmes including the New Vision of Care. The approach outlined in the plan, complements the themes highlighted in the STP plan and focusses on: • A greater emphasis on prevention and putting people in control of their own care planning • Ensuring CCG Operational plans explicitly align with STP / NVOC programmes • Exploiting opportunities for expanding the use of technology enabled care • Commissioning services to ensure care closest to home is offered wherever possible • Expanding and strengthening the role of primary and out of hospital care. • Evaluation of the impact of the BCF arrangements and consideration of greater pooling of resources with the 3 Local

authorities ensuring alignment with the STP plan for the Frimley footprint. Right Care

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Policy Drivers and Context - CCG Operational Plan 2017-19 and links to BCF plans / Local themes (continued)

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Strategy Local Theme CCG plan BCF Plan

Bracknell Forest Health and Wellbeing Strategy

Protecting vulnerable people

Safeguarding of vulnerable people, care homes, carers

Care Home Quality Project across East Berkshire BCFs; Carers’ service (Signal)

Increasing life expectancy by focussing on inequalities

Cancer, Cardiology, diabetes

Memorandum of understanding for Carers across East Berks BCFs;

Improving mental health and wellbeing

Mental health and prevention services

Mental Health asset based community model

Bracknell Forest Council Plan 2015-2019

Supporting people to live healthy and active lifestyles

Diabetes prevention programme; CAMHS; physical inactivity project; smoking cessation; weight reduction; cancer screening

BCF Prevention and Self-Care Programme including the “Year of Self-Care”; range of programmes including smoke cessation, exercise and activity; Integrated Respiratory Service (“AIRS”)

Increasing the number of young people participating in leisure and sport

Physical inactivity project Year of Self-Care – physical activity

Increased personal choices available to allow people to live at home

Personal health budgets, complex case management, assistive technology, social prescribing

Personal Health budgets as an East Berks collaborative; complex case management as part of Integrated Care team workstream; Assistive Tech identified as collaborative BCF opportunity across East Berks; Outcome based Domiciliary Care; Intermediate Care services in Bracknell Forest.

Policy Drivers and Context - CCG Operational Plan 2017-19 and links to BCF plans / Local themes (Continued)

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Strategy Local Theme CCG plan BCF Plan

Bracknell Forest Council Plan 2015-2019

More preventative activities Prevention section, falls prevention, diabetes prevention programme, care homes

Prevention and Self-Care; Year of Self-Care; Care Home Quality Programme

Increased integration of council and health service care pathways for long term conditions

Integrated Care Integrated Care teams – augmentation of team funded through BCF to include community matron and in-reach function to acute trusts and voluntary sector to address social isolation; Assessment and Rehabilitation Centre including the “RACC” Community Clinic at Brants Bridge; new Home based Intermediate Care Service.

Accessibility and availability of mental health services for young people and adults

Child and Adolescent Mental Health services

Business case in preparation for BCF funding for various East Berkshire initiatives focussing on mental health.

Bracknell Forest HWBB are committed partners within the East Berkshire footprint and work closely with the 3 CCGS and other East Berkshire BCFs to jointly develop and deliver strategies relevant to subsets of the East Berkshire populations. The STP, Urgent and Emergency Care Plan and East Berkshire operating plans set out frameworks for NEL admission targets and DTOC approach which are the common drivers for the three East Berkshire BCFs, but rely on whole system/collaborative implementation. By working together to move to operational implementation of these strategies, the BCFs can tailor activity to meet the needs of local populations in a “value added” approach. For example:

Strategic context - East Berkshire CCGs and BCFs

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Opportunity Activities Identification of Carers and promotion of the NHSE Memorandum of understanding

Concept launched through CCG patient panel workshop - supported by CCG Clinical lead –best practice approach supported by Surrey at Runnymede GP practice - planned series of autumn promotional event plan informed by carer, third sector and activity leads across East Berks. Through support from NHSE now widened to STP footprint

Improving Quality of care in Care Homes to reduce NEL admissions and reduce ALOS

Amalgamation of 3 East Berkshire care home CCG/LA programmes into one – BCF funding to support appointment of dedicated care home quality/integration resource – to implement best practice from Vanguards and from Frimley South facing STP partners + to implement the Enhanced Health in Care Homes framework.

DTOC plans – Frimley facing workshops with Frimley South facing with Bracknell Forest

Joint workshops with acute trust community health and CCG partners to develop Urgent Care plans as system wide approach to improve hospital flow and maximise care and reablement in the community and to implement the High Impact Changes Model for Managing Delayed Transfers of Care.

Recommissioning of stroke support services

Following redesign of clinical stroke pathway, collaboration to amalgamate fragmented commissiong of stroke Association services and invite tenders for a more outcome focussed specification with pooled resourcing across East Berkshire.

Alignment of BCF finances and reporting

The 3 East Berkshire BCF leads and finance teams have developed collaborative working relationships over the year – promoting best practice, shared understanding and laying the groundwork for effective support for the newly configured East Berkshire CCG subject to final agreement.

Leadership and culture As evidenced by the number of initiatives that cut across BCFs and HWB boundaries, (see previous slide) there is a strong track record of collaborative leadership across the East Berkshire footprint. This is also demonstrated through the creation this year of the joint A and E Delivery Board, combining Senior Leadership across Frimley North with Frimley South into one Delivery Board; the formation of the Urgent Care Operational Group (UCOG) which is multi- agency and which going forward, will act as a local delivery / operational group for the STP A and E Delivery Board, looking at Community Services and analysing metrics such as % of CHC assessments undertaken outside of the Acute setting etc. This is further exemplified through the holistic approach to DTOC and the consistent and collaborative approach to coding of NHS and ASC delays across the Frimley System, which has enabled a system wide plan to be adopted for future performance monitoring / improvement. The development of the Urgent and Emergency Care plans that link closely with BCF initiatives and winter planning requirements, reduces duplication of effort and maintains shared focus and common priorities.

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Leadership and Culture (Cont.) Clinical leadership is well documented in the STP, CCG Operating plans and development of the 5YFV and New Vision of Care; all of which are key to the success of the BCF. Locally, within Bracknell Forest this clinical leadership is continued through:

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BCF Activity Clinical Representation Health and Wellbeing Board

Dr William Tong (Vice Chair of the HWBB)

Urgent Care Operations Group

Dr Sohnia Tariq – GP Discharge Lead, Wexham

BCF Programme Board Dr Rohail Malik – GP Partner and Director at BA CCG and member of BCF Programme Board

BCF Steering Group Dr Rohail Malik – as above and also member of BCF Steering Group

Prevention and Self-Care Programme Board

Dr Martin Kittel – GP Director at BA CCG; Medical Partner and member of Programme Board and sponsor for Prevention and Self-Care projects

Care Home Quality Dr Megan John – East Berks GP member

BCF mapping - % of HWB within CCG footprint

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Bracknell Forest NHS Bracknell and Ascot CCG 94.6%

Bracknell Forest NHS North East Hants and Farnham CCG 1.1%

Bracknell Forest NHS Surrey Heath CCG 0.1%

Bracknell Forest NHS Windsor, Ascot and Maidenhead CCG 2.3%

Bracknell Forest NHS Wokingham CCG 1.9%

The Bracknell Forest BCF continues to recognise the importance of the Ascot population that live within Royal Borough of Windsor and Maidenhead but are supported by GPs from Bracknell CCG and are more likely to use the acute services in Frimley. The active engagement of Bracknell GPs and opportunities for joint working – for example through the Bracknell Forest Integrated Care team cluster covering Ascot - recognises that locality relationship, communication and services overlay.

Progress on health and social care integration in Bracknell Forest Bracknell Forest Council Bracknell and Ascot (BAA) CCG and Bracknell Forest Council (BFC) are broadly co-terminus and in population terms relatively small in scale. The population of Bracknell Forest Borough is approximately 118,000. They form part of the Frimley Sustainability and Transformation Partnership, which in June 2017 was announced as one of the 8 ‘accountable care systems’ (ACSs) which will bring together local NHS organisations, often in partnership with social care services and the voluntary sector. The ACS will build on the learning from and early results of NHS England’s new care model ‘vanguards’, which are slowing emergency hospitalisations growth by up to two thirds compared with other less integrated parts of the country. Integration – work achieved to date Bracknell Forest Council (BFC) is building on a 10 year history of strong foundations in integrated and jointly commissioned services, but there is no complacency regarding the challenges ahead. All of the approaches outlined in this plan are commensurate with the priorities identified through/within the Joint Strategic Needs Assessment, the new “Seamless Health”, Bracknell Forest Health and Wellbeing Strategy, the CCG 2-year commissioning plan and the Joint Commissioning strategies. Lead officers for the BCF programme are also lead officers for the implementation of the above strategies and ensure that all the work streams are coordinated. The BFC Better Care Plan builds on a history of successful integration between BFC and Bracknell and Ascot (BAA) CCG. Intermediate Care and Reablement Services have been jointly funded through a Section 75 Pooled Budget Agreement and run in a partnership between Local Government and the NHS for the past ten years. This integrated service is hosted by Bracknell Forest Council with Berkshire Healthcare NHS Foundation Trust, providing supplementary community nursing and therapy. Success within the wider service has been acknowledged with the 2013 Social Work Team of the Year Gold Award being won by the Hospital In- Reach Team.

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Progress on health and social care integration (Cont.) Bracknell Forest Council The team is fully integrated across health and social care and works closely with the three acute hospital trusts primarily used by people living in the area. Alongside the in-reach team, the service has a single point of access, including community nursing, and can respond to urgent cases within two hours, preventing hospital admissions. The service operates 7 days a week with the out of hours management provided by the Emergency Duty Service. Intermediate Care including reablement is provided in both the home and a residential setting and is supported by a commissioned Berkshire Integrated Community Equipment Service that provides equipment 7 days a week including out of hours. Other integrated teams within Bracknell Forest include the Community Mental Health Team (CMHT), the Community Mental Health Team for Older Adults (CMHT OA) and the Community Team for People with Learning Disabilities (CTPLD) and ASD. All the teams are joint funded between BAA CGG and BFC and have both social work and care management functions alongside health practitioners including nursing, therapists and psychology. More recently, a further integrated approach was taken around the development and implementation of the Integrated Care Teams for people with complex needs, part of the LTC QIPP workstream, with leads from Bracknell & Ascot Clinical Commissioning Group, Bracknell Forest Council and Berkshire Healthcare NHS Foundation Trust. The project board provided governance arrangements for a range of workstreams for implementation, with leads from each of the three organisations, including Information Sharing and Patient Triangulation, Governance, Operational Procedure / Process and Communications developed in real partnership. 18

Progress on health and social care integration (Cont.) Bracknell Forest Council (continued): One outcome of assessment from the Integrated Care Teams is a Crisis Escalation Plan - put in place to militate against each individual's lifestyle and condition risks to reduce the occurrence and severity of crisis and to reduce unnecessary admissions. These plans are shared with the acute providers, out-of-hours providers, GPs, Social Care and other relevant and agreed parties to make sure that anyone who is contacted is in a position to respond appropriately. This approach resulted in significant successes around reduction in activity, spend and an increase in patient satisfaction and quality of life. Following a successful year it is intended that the approach be continued and expanded through the Better Care Fund. Berkshire Healthcare NHS Foundation Trust – community health partner Of critical importance is our relationship with our community provider, Berkshire Healthcare NHS Foundation Trust (BHFT) in the delivery of integrated physical health, mental health and social care services. The success of our operating model rests with joint responsibility and accountability with jointly funded service managers and the co-location of health and social care staff. Collaborative working to find common ground in the objectives of both organisations, in order to deliver the best possible patient experience and outcomes has enabled us to maximise the effective delivery of a truly integrated services. Effective relationships underpin the success of our ‘Assessment and Rehabilitation Centre’ clinics, multi-disciplinary team working (Doctor, Nurse, Physio, OT), and our community in-reach matron at the acute hospital in Frimley Park who actively supports patient discharge. The community in-reach matron’s presence in BFC offices provides opportunity for open discussion to effect early discharge and prevent delayed transfers of care.

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The Council’s Vision and Transformation process Bracknell Forest Council: Our vision for health and care in Bracknell Forest is that “People are well informed and able to manage their own health and care to stay well, safe and connected to their families and friends, leading independent, happy lives in their communities”. Through a process of ongoing transformation within the Adult Social Care Health and Housing Department, (ASCH&H) the Council is ensuring that people and their carers, families and personal support networks will be properly equipped and supported to arrange and manage more of their care with less reliance on direct support from the Council. The ASCH&H transformation programme focusses on three major programmes of work: 1. Care practice transformation: Different and more efficient ways of working, tools and systems that help people assess, plan and directly manage their own care. Remove bureaucracy and excessive controls so staff are free to work more closely with customers, use their judgement and make decisions without unnecessary delays. 2. Community and market development and service redesign: Development of local assets such as Council buildings, community networks and voluntary organisations to create more locally provided care and support options that are more focused on promoting independent living, give people more choice, greater flexibility and offer better value for money. 3. Integrated partnership working (delivering the agreed priorities for the New Vision of Care and STP work programmes): This programme is being delivered jointly with local and neighbouring Health and Local Authority commissioning and provider partners across Berkshire. It is focused on joining up resources, functions and information across Health and Adult Social Care. See next page for the Adult Social Care Transformation Roadmap, including links to key Health partnerships.

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ADULT SOCIAL CARE TRANSFORMATION ROADMAP

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The Council’s Vision for Health and Care Services in Bracknell Forest As shown in the Transformation Programme Roadmap, the Council’s vision for health and care services is that across the system: • Care will be well co-ordinated and seamless; • More people will be directly able to manage their own care; • People will be well informed and will have more choice and control over their own care; • There will be increased investment in prevention, self managed services and support for carers; • There will be well supported health and care networks. • Financial savings targets will be achieved. The Council vision seamlessly blends to the overall vision of the Frimley Sustainability and Transformation Partnership (STP) which states that people will: • Be supported to remain as healthy, active, independent and happy as they can be • Receive better coordination of heath & social care system - a ‘no wrong door’ approach. • Know who to contact if they need help and be offered care and support in their home that is well organised, only having to tell their

story once; • Work in partnership with their care and support team to plan and manage their own care, leading to improved health, confidence and

wellbeing. • Find it easy to navigate the urgent and emergency care system and most of their care will be easily accessed close to where they live; • Have confidence that the treatment they are offered is evidence based and results in high quality outcomes wherever they live -

reduced variation through delivery of evidence based care and support; • Increase their skills and confidence to take responsibility for their own health and care in their communities; • Benefit from a greater use of technology that gives them easier access to information and services; • As taxpayers, be assured that care is provided in an efficient and integrated way.

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Linking the Council Transformation programme to the wider health and social care context, including BCF.

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Council Executive

Overview & Scrutiny Commission & Panels

Health & Wellbeing Board BRACKNELL COUNCIL TRANSFORMATION GOVERNANCE

STRATEG

IC M

ANDATE

LEAD

ERSH

I

P &

ASSU

RA

NC

E

DELI

VER

Y &

QUA

LITY

MAN

AGEM

ENT Challenge Directors

Customer Reference Panels

Gateway Reviews

Programme Delivery Groups

Project Delivery Groups

Member Performance Review Groups

Project Accountable Owners

Programme Accountable Owners

Project Managers

Programme Managers

ASCH&H Programme Delivery Office

Quality Management Reference Groups

Council Transformation PMO

ASCH & Housing Transformation Delivery Board

Council Management Team (CMT) Council Transformation Board

Council

Frimley Sustainability & Transformation Partnership Board Chairs, NEO’s, Lay Group H&W Alliance Board

STP Finance Group System wide leadership group

STP Programme Delivery Board A&E Delivery

Board

111 Board

O&C Chairs/ Health-watch

External Stake-

holders MH Reference

group

Nursing & Quality

EAST BERKSHIRE CCG CONFEDERATION

Windsor, Ascot & Maidenhead CCG

Bracknell & Ascot CCG

Slough CCG

CCG GOVERNANCE Bracknell & Ascot CCG Governing Body

CCG Programme Boards Better Care Fund

QIPP Programmes

CCG Board Management Office

Local Governance and Delivery

LWAB Comms SG Estates SG LDR Board Analytics SG

GP Trx SG Variation SG Prevention SG Social care market SG

ICDMH SG

Shared Care record SG

Support workforce SG

Bracknell Forest Council Better Care Fund Governance

Evidence Base - Understanding the local priorities Links to key local strategies: JSNA / Health and Wellbeing Strategy / Commissioning Strategies: Key strategies which inform the priorities for the Bracknell Forest Better Care Fund include the Joint Strategic Needs Assessment which outlines 5 key priorities; 2 of which directly link to funded programmes within the Bracknell Forest Better Care Fund (Falls Prevention and Self-Care) and 2 which link to wider Public Health programmes. (Smoking; Mental Health). The Bracknell Forest Joint Health and Wellbeing Strategy 2016-2020 identifies 4 key priorities: Health - Promoting Healthy Lifestyles; Mental Health services; Preventing People becoming socially isolated and lonely; Workforce – having the right people with the right skills. These priorities helped to shape and inform programmes within the Bracknell Forest Better Care Fund. See later section for detail. The Bracknell Forest Joint Commissioning Strategies build on the overall analysis provided by the Market Position Statement and provide clear analysis of national policy and legislation; linking these to local needs and priorities identified through consultation. The resultant Action Plans identify how the local needs will be realised within the period of the strategy. These plans are regularly reviewed through the work of the Council Partnership Boards. For the full list of Strategies see here.

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Evidence base - Population Profile – Summary of Local Needs Our vision for the BCF continues to build on the assessed local needs as advised by the recommendations of the Joint Strategic Needs Assessment (JSNA) produced by the Council, national and pathway-specific benchmarking tools and good practice examples such as the Atlas of Variation, Commissioning for Value packs, and the evolving Vanguards and Right Care CCG packs. Plans for the redesign of care pathways are then shaped by the needs of the population, local community profiles/dynamics including transport links, and what local people, patients and partners tell us about through our communication and engagement with them (eg One Borough meetings, Community Partnership, PPGs) The Bracknell Forest Health Profile 2017 profiles key statistics and population details as follows: The population profile (source: Housing, Health and Wellbeing In Bracknell Forest ) and Bracknell Forest JSNA The 2015 population was 119,00 within the Borough, with a projected total of 125,000 predicted by 2020. The Borough has a lower share of adults aged 20 -24 compared to the national picture with a higher than England average number of adults in the age range 30 -54. The population of older people 65-90+ is lower than the England average for 2015. The Bracknell Forest JSNA predicts that by 2021, the population in Bracknell Forest is estimated to increase by almost 12,000 people from the mid-2012 estimate. The older population is expected to increase at the greatest rate followed by the younger adult population and the child population aged 5 to 14. This will have an impact on the type and scale of future services. The average age of the population of is 37 years. This compares to an average age of 39 years for England. Overall, 20.8% of the population are aged under 16 and 14.0% are aged 65 and over. Winkfield and Cranbourne Ward has the highest proportion of residents aged 65 and over at 27.9%. The health of people in Bracknell Forest is generally better than the England average. Bracknell Forest is one of the 20% least deprived districts/unitary authorities in England, however about 11% (2,400) of children live in low income families. Life expectancy for both men and women is higher than the England average.

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Evidence base – Population Profile - Local Needs (cont.) Deprivation: Bracknell Forest in terms of deprivation is ranked 292 out of 326 local authorities, where a ranking of 1 is the most deprived (based on the 2010 Indices of Multiple Deprivation). This means Bracknell Forest as an area is in the least deprived quintile nationally. The overall Index of Multiple Deprivation (IMD) score combines information from the seven domains of Income Deprivation, Employment Deprivation, Health Deprivation and Disability, Education Skills and Training Deprivation, Barriers to Housing and Services, Living Environment Deprivation, and Crime. The overall IMD score (2015) in Bracknell Forest is 10.462. Within the area, Wildridings and Central Wards has the highest overall score at 19.215. The average for all English Wards is 18.937. Furthermore, an average of 0.8% of the population of Bracknell Forest claim out of work benefits, with the highest proportion of people residing in Old Bracknell Ward at 1.4%. This compares to 1.8% for England overall. The Barriers to Housing and Services domain of the Indices of Deprivation (2015) measures the physical and financial accessibility of housing and local services. The higher the score, the more deprived an area is in this regard. Bracknell Forest has a score of 24.201. Within the area, Winkfield and Cranbourne ward has the highest score at 34.992. The average for all English Wards is 22.544 Lifestyle: The Health Summary for Bracknell Forest shows that 63% of adults are physically active, which is significantly higher than the England average of 57%.

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Evidence base - Local Needs – identification of Frailty cohort

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The significant impact of frailty on health and social care services will be taken forward through the implementation of the new G.P GMS contract, and 5YFV Urgent and Emergency Care programme and will be integral to BCF investments, including development of the Integrated Care Decisions Making Hubs. A recognition that a patient has a degree of frailty can prompt a clinician to review the care offered to their patient, to make sure that it is tailored to their needs, and to be mindful of the risks of polypharmacy and inappropriate treatment. It can also help in the planning and delivery of services, particularly for older people.

Evidence base - Local Needs – identification of Frailty cohort using eFI – likely numbers of Bracknell Forest residents

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The significant impact of frailty on health and social care services will be taken forward through the implementation of the new G.P GMS contract, and 5YFV Urgent and Emergency Care programme and will be integral to BCF investments. Based on work undertaken through the New Vision of Care, the following evidence will inform future BCF priorities: Bracknell & Ascot Frailty Prevalence Report: September 2016 Actual Population 140,250, minus 1 practice not on EMIS 124,750. Population reviewed as part of this study: 124,750. Calculation and grading: Mildly Frail 0.11 - 0.20 (4 - 7 deficits) Moderately Frail 0.21 - 0.32 (8 - 11 deficits) Severely Frail =/>.33 (> 12 deficits) Number of individuals identified with Frailty: 22,709 - 18% (18.2%) of the overall population of which: 14% (14.16%; 17,662) Mildly Frail 3% (3.17%; 3,955) Moderately Frail 1% (.87%; 1092) Severely Frail The findings of this study are in line with National findings in terms of population prevalence; the prevalence of severe frailty is similar to the number of individuals on the CCGs End of Life Care Register Activity limitation (“Deficit” ) Anaemia and haematinic deficiency Arthritis Atrial fibrillation Cerebrovascular disease Chronic kidney disease Diabetes Dizziness Dyspnoea Falls Foot problems Fragility fracture Hearing impairment Heart failure Heart valve disease Housebound Hypertension Hypotension / Syncope Ischaemic heart disease Memory/cognitive problems Mobility/transfer problems Osteoporosis Parkinsonism & tremor Peptic ulcer Peripheral vascular disease (PVD) PolyPharmacy Requirement for care Respiratory disease Skin ulcer Sleep disturbance Social vulnerability Thyroid disease Urinary incontinence Urinary system disease Visual impairment Weight loss and anorexia

Evidence base- 2017/18 BCF schemes identified from the JSNA The Bracknell Forest JSNA identifies 5 local priorities; 2 of which are directly addressed through the Bracknell Forest Better Care Fund (Falls Prevention; and Self-Care); with the third and fourth (smoking and mental health) also identified as priorities through the various initiatives in the Frimley Sustainability and Transformation Partnership Plan.

Falls Prevention: Falls are the largest cause of emergency hospital admissions for older people, and significantly impact on long term outcomes, e.g. being a major precipitant of people moving from their own home to long-term nursing or residential care. The highest risk of falls is in those aged 65 and above. Although not all falls will lead to hospital admission or fractures, they can reduce confidence and mobility. Falls prevention therefore remains a priority as it is estimated that 4,354 Bracknell Forest residents aged 65 will have fallen in 2015. This is predicted to increase to 6,864 by 2030. See JSNA. The graphs below show the numbers of recorded falls incidents over the last few years as well as comparator with other authorities.

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Existing 2017/18 BCF Schemes– Falls Preventative support Identification of the population cohort at greatest risk of falling – using the Joint Strategic Needs Assessment. See link to JSNA. In addition, targeted prevention and Self-care campaigns, aimed at promoting healthy lifestyles, to prevent or delay the onset of ill health including falls, amongst older people. The Bracknell Forest BCF funds a Prevention and Self-Care workstream. This work includes developing and promoting advice and information on self-care, including falls awareness campaigns to the local population. The self-care work also includes the publication of the annual Helping you stay independent guide with a range of information about prevention, help and support regarding falls. The Bracknell Forest Falls Prevention Advisory Service is both a preventative and support service for anyone aged 65 or over who believes they may be at risk of falling or who is recovering from a fall. Individuals can access the falls clinic without seeing a doctor or social care practitioner to arrange an in-depth home assessment to identify fall risks and changes that might be made to make it safer. The service also offers well balanced classes, which are a programme of strength and balance classes that lasts for 12 weeks and helps to improve mobility.

Response and Treatment Forestcare Registered Response service. Funded through the Better Care Fund as a pilot in 2016, the service offers a CQC registered Responder service for community “helpline” alarm customers; providing personal care including assistance / triage in the event of a fall at any time of day or night. See link. In addition, the Tier 3 Rapid Assessment Community Clinic. Funded through the Better Care Fund and commissioned to Berkshire Healthcare Foundation Trust, the Bracknell RACC service operates at Brants Bridge for 2 sessions per week, 52 weeks per year. In addition, a further 5 day a week RACC service is provided at St Mark’s Day Hospital in Maidenhead. See link. The Community and Home Based Intermediate Care service. This service is operated through the Council and provides up to 6 weeks care and support. The annual costs are funded from the BCF budget, within the Intermediate Care Service. This includes the costs of 4 Intermediate Care beds at a newly opened care home in Bracknell. The Bracknell Forest Joint Commissioning Strategy for Intermediate Care 2015-2018 sets out the model for intermediate care in Bracknell Forest to avoid unnecessary hospital admission, reduce unnecessarily long hospital stays and help patients to improve and maintain independence and reduce readmissions to hospitals. 31

Ancillary / supporting services A range of BCF funded initiatives operate; these include the Red Cross Home From Hospital Service. Commissioned and funded through the Better Care Fund to the British Red Cross, providing a 7 day a week supported hospital discharge service for up to 30 individuals per month, for up to 6 weeks; Age UK Promoting Independence Co-ordinator. Funded through the BCF, the service provides a Promoting Independence Co-ordinator who works as part of the Integrated Care Teams. Visiting those individuals receiving multi disciplinary care planning, the PIC undertakes guided conversations with the individual to establish their personal goals (social / leisure / cultural etc) and arranges appropriate support for the individual to achieve these goals, thereby improving wellbeing and reducing isolation; Befriending service. Commissioned and funded by the Bracknell Forest Public Health team, the befriending service provides 1:1 befriending and visiting services to lonely and isolated individuals, including those who have lost confidence due to falls.

Summary of Falls Provision

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Evidence base - BCF schemes identified through the JSNA – Self Care

Self-Care Another of the priorities identified in the JSNA relates to Self-Care. The 2014 Bracknell Forest Better Care Fund submission formally established Prevention and Self-care as one of the nine core projects to be funded from the Better Care Fund. Quoting from the submission, the objectives of the Prevention & Self-Care Programme were that: • “People should be supported to take responsibility for their own health and wellbeing as much as possible – This includes things like eating healthily, reducing smoking or taking drugs, getting exercise. • Everybody should have equal access to treatment or services – “reducing health inequalities” - so there should be no differences in what treatment people can get based on factors such as where they live, how old they are, etc. • Organisations should work together to make the best use of all the resources they have – This includes staff and money, and working together to get more things done safely for more people and more quickly. This may mean that some organisations have to change the way they work to focus more on preventing ill health, as well as than treating it. • The support and services that people get should be of the best possible quality, and should keep them safe from harm that can be avoided.” In 2015 the Bracknell Forest Prevention and Self-Care workstream won the first National Self Care Week award, winning first prize for providing the most comprehensive programme of self-care nationally. Since 2016, the BCF funded Self-Care work has been developed under the banner of the Year of Self Care, which provides a range of support and advice programmes – see attached.

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Delivering the Plan: Example QIPP projects that will be supported by Bracknell BCF schemes

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Integrated Care End of life care Complex Case Management Mental Health, Joint & Continuing Care MH & LD spot purchases MH Alcohol activity in Acute setting Young People with Dementia Interoperability Connected Care

Medicines Management Biosimilar High Cost Drugs Continence Advisory Service Prescribing Optimise use of inhalers High Cost Drugs Brands to Generics Reducing over-ordering Scrip Switch Continence Advisory Service

Urgent & Emergency Care NEL AMBULATORY CARE Childhood Illnesses AIRs Service/Respiratory Reprovision of Walk in Centre

Planned Care Heart Failure Atrial Fibrillation Cardiac Rehab Heart Failure IV Furosemide Lounge Hypertension Diabetes Musculoskeletal Ophthalmology Cancer Gynaecology Neurology

Medicines Management

Integrated Care

Mental Health Joint &

continuing care

Urgent and emergency

Care

Inter operability

Planned Care

BCF

Bracknell Forest BCF: Overview of agreed funding contributions

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BCF National Metrics – Value of Schemes within the Bracknell Forest BCF that contribute to these metrics.

17/18 £ m Projected 18/19 £ m

Non Elective Admission avoidance 1.188 Allocations will be agreed by Steering Group

DTOC including iBCF 1.703 Allocations will be agreed by Steering Group

91 day Reablement (inc Intermediate Care) * Note this also includes projects to develop D2A; Step Up / Step Down etc so is also arguably part of DTOC.

4.833 Allocations will be agreed by Steering Group

Reduction in admission to Care Homes Included in above Allocations will be agreed by Steering Group

Carers support 228 Allocations will be agreed by Steering Group

Protecting Social Care 1.369 Allocations will be agreed by Steering Group

Disabled Facilities/ Social Care Capital 1.627 Allocations will be agreed by Steering Group

Care Act 344 Allocations will be agreed by Steering Group

Total BCF £11.292m * inc c/forward £10.2m

Funding contributions for the BCF have been agreed and confirmed by all parties. The value of schemes that contribute to the 4 BCF National Metrics are shown below.

Overview of funding contributions (iBCF)

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Bracknell Forest Council has a strong record of partnership working through the BCF Board and this joint working creates a platform within which the iBCF investment sits. The iBCF additional grant is being invested to build on the DTOC Deep Dive that the department undertook during June 2017, to look at the causes and factors associated with an increase in Bed Delays (DTOC) during 2016/17. (See slide 47) A range of initiatives identified in the iBCF are being developed during 2017 which will report into the BCF, to: • Improve DTOC performance; • Enhance and support capacity in the Domiciliary and Residential / Care Home sectors thereby improving DTOC “flow”; • Enhance the Intermediate Care service including initiatives to support earlier discharge, home to assess model and "Home First"

concepts. This will be further reviewed and prioritised to support the winter planning requirements across the local area as a joint approach;

• Stimulate and develop “community capacity” within the local area through development of Community connector roles. Further investment is planned for the next three years using the iBCF in conjunction with a number of other funding streams.

2017/18 2018/19 2019/20 Total over 3 years

Bracknell Forest iBCF allocation

929K 1,016K 508K 2.454K

Additional local resources and infrastructure

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Bracknell Forest has a long record of working closely with community leaders, volunteer groups and third sector organisations and local residents to promote the best interests of all at individual, family unit, and locality level. The iBCF is funding 3 Community Connectors who will work to develop the Council’s Asset Based Community Development strategies, to foster sustainable communities in the longer term. The Better Care Fund programmes are well connected with many of these existing groups through which they engage with many individuals and organisations – a few of which are shown below and overleaf.

BCF projects

Plan

Do

Review Learn

Share

Community Connectors Dementia Action Alliance Carers issues Strategy Group Prevention and Self Care Board Healthwatch

PPGs Patient Panel

Community Partnership Year of Self-Care

8

Job

Skills

Home

Hobbies

Savings & Belongings

Health & Wellbeing

Family Friends Carers

Transport

Housing &

Planning

Council Services & Buildings

Health Services & Buildings

Leisure Facilities

Open Spaces

Businesses Education Training Community

+ Voluntary Orgs +

Networks

Individuals & Personal Networks Communities & Neighbourhoods

Community Leadership

Community Development

INCREASING THE FOCUS ON EARLY INTERVENTION & PREVENTION

Strengths And Asset Based System Of Care

NEL admission context – targets and current trajectory

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Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19 Total 17/18 Total 18/192,519 2,570 2,512 2,580 2,465 2,510 2,456 2,522 10,181 9,954

No

HWB Non-Elective Admission Plan* Totals

Are you planning on any additional quarterly reductions?If yes, please complete HWB Quarterly Additional Reduction Figures

Please only record reductions where these are over and above existing or future CCG plans. HWBs are not required to attempt to align to changing CCG plans by recording reductions.

The table above shows the Non Elective Admission Plan totals for 2017 onwards. These figures are derived from the CCG Non Elective Admission plan figures included in the Unify 2 planning template, aggregated to quarterly level extracted on 10/07/17. In terms of current trajectory, Bracknell Forest performed well during 2016/17; finishing the year at 9,476 admissions against BCF target of 9,422; an adverse variance of just 0.6% or 54 Non elective admissions in excess. See slides overleaf showing performance against BCF plan on Non Elective admissions. This evidences the success of the range of Prevention and Self-Care initiatives aimed at encouraging the public to use alternatives to A and E that have been successfully developed in Bracknell Forest over the last 3 years, as well as the availability of the Urgent Care Centre, 111 and GP Out of Hours services as alternatives to A and E. See the following link for the full range of initiatives and projects within the Bracknell Forest Self-Care workstream. Indicative metrics for Month 1 and 2 in this Financial year (latest data) show NEAs at 753 and 832 respectively – suggesting performance will be close to the planned trajectory by the end of Month 3. However, in line with previous years, no further reductions in Non Elective Admissions additional to those in the CCG operating plan and shown in the table above, have been considered.

NEL admissions 16/17 outturn against BCF Plan.

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Month2014/15 Activity

Cumulative

2015/16 Activity

Cumulative

2016/17Activity

2016/17 Activity

Cumulative

2016/17 Plan

Variance

M01 711 788 788 780 +0.9%M02 1,473 776 1,563 1,561 +0.2%M03 2,255 798 2,362 2,341 +0.9%M04 3,038 855 3,217 3,124 +3.0%M05 3,742 790 4,007 3,907 +2.6%M06 4,471 844 4,851 4,690 +3.4%M07 5,175 788 5,640 5,487 +2.8%M08 5,930 801 6,441 6,285 +2.5%M09 6,726 770 7,211 7,082 +1.8%M10 7,488 788 7,999 7,862 +1.7%M11 8,290 658 8,657 8,642 +0.2%M12 9,156 819 9,476 9,422 +0.6%

Bracknell Forest Top Six Acute HRG Subchapters (LA NEAs using postcode)

Based on data supplied by the Commissioning Support Unit, the top six acute Healthcare Resource Group categories are shown opposite. A number of the priorities identified in the CCG Operational Plan align with these HRG categories, including Diabetes prevention; Physical inactivity project, smoking cessation, weight reduction and cancer screening. See slide “Policy Drivers and Context - CCG Operational Plan 2017-19 and links to BCF plans / Local themes” earlier in this submission.

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0

20

40

60

80

100

120

140

160

M01 M03 M05 M07 M09 M11 M01 M03 M05 M07 M09 M11 M01

Digestive SystemProcedures and Disorders

Paediatric Medicine

Respiratory SystemProcedures and Disorders

Cardiac Disorders

Nervous SystemProcedures and Disorders

Immunology, InfectiousDiseases, Poisoning, Shock,Special E

2015/16 2016/17 2017/18

Evidence base to inform further BCF investment in schemes to reduce avoidable hospital admissions - admissions to hospital with alcohol related conditions

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The table opposite (Public Health / Local Alcohol Profiles for England) shows the Admissions events to hospital with alcohol related conditions where the primary diagnosis is an alcohol-attributable code or a secondary diagnosis is an alcohol-attributable external cause code. This is known as the ‘narrow’ alcohol related admissions indicator. The table shows the % change indicator from year to year. Higher values show the highest % change, so for example, in 2015/16 there was a +39% change in the number of hospital admittance episodes with alcohol related conditions in Bracknell Forest, compared to the previous year.

Evidence base to inform further BCF investment in schemes to reduce avoidable hospital admissions

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The table opposite shows the increase in hospital admissions within Bracknell Forest where the primary diagnosis is an alcohol-attributable code or a secondary diagnosis is an alcohol-attributable external cause code. As a result of this data, further work was undertaken across North East Hampshire and Farnham CCG, Surrey Heath CCG and Bracknell and Ascot CCG to understand: i) more specific data on types of admission (eg: acute alcohol intoxication, was chronic dependency a feature) ii) the demographic data on admissions iii) spread of admissions over time of day / week As a result, a Business case is being prepared for consideration at the BCF Steering Group to commission an Alcohol Intervention Team (Alcohol Specialist Nurse Service) across the CCGs, in order to mitigate against the rise in Non elective admissions for this cohort of patients.

Delayed Transfers of Care - Expectations around DToC planning

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• The BCF Planning requirements and DToC indicative expectations were published on 3 July. • This set out that reductions in DToC should be shared equally between the NHS and local

government. The ambition is to free up c2500 beds in advance of winter. • For local government this means, at a national level;

• reducing from 5.6 people delayed in hospital per 100,000 adults due to social care (February 17 performance) to approximately 2.6.

• reducing from 8.5 people delayed in hospital per 100,000 adults due to the NHS (February 17 performance) to approximately 5.5.

• maintaining the current levels of people delayed in hospital per 100,000 adults jointly attributable (February 17 performance) at 1.2.

Application methodology for DTOC reductions

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Distributing the required reduction across local authorities: The methodology that has been applied to distribute the reduction to the respective national figures means that: For adult social care: Local authorities performing below the 2.6 per 100,000 adults national ambition on ASC delays to

maintain their current (February 2017) performance Local authorities performing between 2.6 and 7.7 to reduce their performance down to 2.6. This

requires the poorest performer in this group to reduce their rate by two thirds. Local authorities above the 7.7 threshold to achieve the level of reduction required of the poorest

performer in the group above i.e. reducing their rate by two thirds. This means the current poorest performer Cumbria must lower their rate from 23.3 to 7.9.

For jointly attributable: At a national level we have assumed performance is maintained at current levels, and have

therefore not modelled local ambitions.

Bracknell Forest – DTOC performance over 2016/17

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Performance over 2016/17 is shown in the table below. A number of factors contributed to the adverse performance after the first Quarter of 2016 – these are explained in more detail overleaf.

Converting the quarterly figures to the NHS England daily delayed bed days. Example: 1. Quarter 4 2016/17 “Actual” activity was 1,450. 2. Number of days in that quarter = 90 days. 3. 1,450 divided by 90 = 16.11 delays per day. This

comprises NHS, Social Care and “Both” delay category types. To understand the breakdown by category, see the DTOC Deep Dive analysis at Slide 47 but assuming that over 16/17 there were approximately 59% of daily delayed days attributable to the NHS; 29% for social care and 12% for “both” this would give:

4. 59% x 16.11 delay days = 9.50 NHS delay days; 5. 29% x 16.11 delay days = 4.67 social care delay days 6. 12% x 16.11 delay days = 1.933 “both” delay days 7. Expressed in terms of per 100,000 population this is: 8. 10.20 NHS delay days; 9. 5.01 social care delays and 10. 2.07 “Both” delays In order to achieve the NHS E trajectory, this requires Social care delays to reduce from around 5 to 2.6 by November 2017.

Year Forecast Pop Quarter Plan Activity Forecast Qtrly Rate FOT Var FOT2016/17 Q4 93,124 800 1,450 1,557 +81.3%

Year Quarter Pop Activity Plan Activity Actual Rate Actual Variance2014/15 Q1 90,202 905 1,0032014/15 Q2 90,202 593 6572014/15 Q3 90,202 935 1,0372014/15 Q4 91,176 784 8602015/16 Q1 91,176 540 1,030 1,130 +90.7%2015/16 Q2 91,176 520 1,057 1,159 +103.3%2015/16 Q3 91,176 500 944 1,035 +88.8%2015/16 Q4 92,213 480 809 877 +68.5%2016/17 Q1 92,213 980 906 983 -7.6%2016/17 Q2 92,213 900 1,434 1,555 +59.3%2016/17 Q3 92,213 850 1,459 1,582 +71.6%2016/17 Q4 93,124 800 1,450 1,557 +81.3%

Bracknell Forest – DTOC Deep Dive undertaken in June 2017

In June 2017, the Council undertook a “Deep Dive” into the causes of the DTOC delays that occurred during 2016/17. A summary of the Deep dive document is attached here and the main document is attached at the KLOEs at the end of this document. Analysis showed several “spikes” in DTOC as shown opposite. These correlated exactly with specific market events which were in summary: • Publication of the Council’s Invitation to Tender for the new

outcomes based Domiciliary Care Contract in January 2017, with tenders closing by March 2017. (existing contractors delayed taking on new packages of care during this process)

• Market supply / demand factors in the residential and nursing home market causing an in-balance of supply and excessive price increases. Since 2013/14 the Council has seen an overall reduction of 205 residential and nursing beds within the Borough, and a further reduction of nearly 400 beds in homes previously used outside the Borough. Closure of 2 local homes in June/ July and December caused particular problems and ongoing delays.

• Lack of availability to local Step up / Step Down beds to facilitate hospital discharge.

• Delays in agreeing Continuing Healthcare Assessments. • Inappropriate or incomplete referrals from the hospital to the

Council’s Bridgewell Intermediate care unit resulting in delays whilst re-assessment was undertaken by the Council’s own therapy teams.

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Bracknell Forest – DTOC Deep Dive – follow up actions undertaken since June 2017 – High Impact Change Model

48

Following on from the analysis of the delay causes, a draft High Impact Change Model for Managing Delayed Transfers of Care was produced by the Council. This follows the format of the STP Urgent and Emergency Care Local Delivery Plan (Hospital to Home) Pillar but is tailored to the specific priorities and operational issues associated with the local system around Bracknell Forest. A multi-agency workshop was held at Bracknell Forest on 31st July 2017 in order to test and validate the assessment and actions proposed within the Bracknell Forest HICM and to give critical analysis and feedback to the draft. This workshop was attended by around 25 senior managers and operational staff within Adult Social Care; Frimley Health NHS FT; Berkshire Healthcare NHS FT, Bracknell and Ascot and WAM CCGs, Bracknell Forest Public Health, Healthwatch Bracknell Forest and NHS England. The Action Plan summarising the comments from the workshop and wider High Impact Change Model for managing Delayed Transfers of Care is set out in the following slides.

The High Impact Change Model for Managing Delayed Transfers of Care

49

Bracknell Forest High Impact Change Model

From the UEC Delivery Plan (Hospital to Home) - “Home First!” To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing The following slides set out a summary of the current approach within Bracknell Forest and improvement plans reflecting the 8 pillars of the High Impact change model for Transfers of Care and the workshop undertaken on 31st July with key stakeholders. The summary actions reflect an integrated, whole system approach which is needed to deliver transformation so reflect initiatives also being developed across the STP.

50

Change 1

51

Not yet established Plans in place Established Mature Exemplary Early discharge planning in the Change to clinical Joint pre-admission GPs and District Nurses Early discharge planning community for elective admissions commissioning group discharge planning is in lead the discussions occurs for all planned is not yet in place (CCG) and change place in primary care about early discharge admissions by an to adult social care planning for elective integrated community (ASC) commissioners admissions health and social care are discussing how team community and primary care coordinate early discharge planning

Discharge planning does not start Plans are in place to Emergency admissions Emergency admissions Evidence shows X per in A&E develop discharge have a provisional have discharge dates set cent patients go home on planning in A&E for discharge date set in which whole hospital are date agreed on admission emergency admissions within 48 hours committed to delivering

Early discharge planning. In elective care, planning should begin before admission. In emergency/unscheduled care, robust systems need to be in place to develop plans for management and discharge, and to allow an expected date of discharge to be set within 48 hours.

1. Early Discharge Planning. Hospital based. The Frimley Park Hospital Patient Discharge Policy states that “A Predicted Date of Discharge (PDD) should be identified within 24-48 hours of admission and reviewed daily. This PDD should be communicated on all referrals to the multi-disciplinary team members and to the patient and/or family. Any issues resulting in an unnecessary delay in reaching this PDD must be recorded and documented on ADT, paediatric care plan and where necessary escalated to, either the Matron, Head of Department or the Discharge Team, to ensure any delay is minimised.” For details of the policy see https://www.whatdotheyknow.com/request/283948/response/691312/attach/5/Discharge%20Policy%202013.pdf

Integrated Care Teams- Supported Discharge Matron and Case Co-ordinator. The Bracknell Forest BCF funds a project (augmentation of the Integrated Care Teams) which provides the Supported Discharge Matron and Case Co-ordinator who support the Integrated Primary Care Teams and the Supported Discharge Service operated by Bracknell Forest Council. These roles facilitate the early supported discharge (Adult Social Care) of people from hospital and their identification and follow up for multi-disciplinary review in the Cluster meetings (ICTs – Health). The project continues to be an important part of the process of supported discharge and ongoing support of Bracknell Forest residents with long term conditions. This has been in operation for 3 years.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 1. Early Discharge planning To have robust systems in place for management and discharge that allow an expected date of discharge to be set within 48 hours of admission and ensure working and communicating with patients and family to optimise the persons early discharge, embracing both simple and complex levels of care and support need.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

1 – Early Discharge Planning

Established.

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

1. Early Discharge Planning- Integrated Care Teams Continued

To achieve the best care the integrated care plans are shared with other organisations that these individuals may come into contact with, for example, the GP out of hour’s service and the local acute hospitals, so they recognise when the individual contacts them that there is an integrated care plan in place. Locally, there are three groups, or clusters, of GP surgeries who are working to support caseloads in their areas. The groups are Bracknell North, Bracknell South and Ascot. Amongst other criteria, people who are referred to the teams are those where there is a risk of unscheduled hospital attendance and Individuals identified during admission / supported discharge from hospital or bed based Intermediate Care. Other: Separate to the above, within the Hospital, a provisional discharge date is set within 48 hours for all admissions but with the caveat that this is dependent on the presenting need of the individual, as there may be underlying conditions that have contributed to the admission. In addition, funded by the BCF and operating via a pooled budget, the Intermediate Care Service provides a multi-disciplinary reablement / rehabilitation service to support the individual in early transition from hospital for rehabilitation in the community or in an individual’s own home. The Council’s Hospital Based Social Care team work with the Intermediate Care Service to ensure appropriate referral into the service during the Multi Disciplinary Team meetings at the hospital prior to discharge. See Section 4 for more information.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 1. Early Discharge planning To have robust systems in place for management and discharge that allow an expected date of discharge to be set within 48 hours of admission and ensure working and communicating with patients and family to optimise the persons early discharge, embracing both simple and complex levels of care and support need.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

1 – Early Discharge Planning

Established.

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Action plan /Deliverables

Early Discharge Planning Lead Completion Date

Safer Bundle - Establish Baseline of implementation to date Produce a plan to get to 100% Full implementation across all wards of the SAFER Bundle

Acute trust

Align with UEC Delivery Plan timeline – Q3 2017

Explore feasibility of linking Hospital based social care team to I.T. systems used by Discharge team to ensure real time patient data access.

BFC End Q3

Explore developing the IRIS team to include Bracknell Forest staff presence to avoid admitting patients who can be treated in the community.

BFC End Q3

1 Early Discharge Planning – Action Plan

Change 2

55

Systems to monitor patient flow. Robust patient flow models for health and social care, including electronic patient flow systems, enable teams to identify and manage problems (for example, if capacity is not available to meet demand), and to plan services around the individual.

Not yet established Plans in place Established Mature Exemplary No relationship between demand and Analysis of demand Policy agreed and plan in Capacity usually matches Capacity always matches capacity in care pathways underway to calculate place to match capacity demand along the care demand along the whole capacity needed for each to care pathway demand pathway care pathway care pathway

Capacity available not related to current Analysis of demand Analysis completed and Capacity usually matches Capacity always matches demand variations underway to practice change rolled demand 24/7 to match demand 24/7 reflecting identify current variations out across trust and in real variation real variations community

Bottlenecks occur regularly in the trust Analysis of causes of Analysis completed Bottlenecks rarely occur There are no bottlenecks and in the community bottlenecks underway and and practice changes and are quickly tackled caused by process or practice changes being being put in place and when they do supply failure designed evaluated

There is no ability to increase capacity Analysis of admissions Staff understand the need Capacity is usually Capacity is always when admissions increase – tipping variation ongoing with to increase capacity when automatically increased automatically increased point reached quickly capacity increase plans admissions increase when admissions increase when admissions increase being developed

Staff do not understand the relationship Staff training in place to Staff understand the need Senior clinical decision Senior clinical decision between poor patient flow and senior ensure understanding to increase senior clinical making support is usually making support clinical decision making and support of the need to increase support when necessary available and increased available and increased senior clinical capacity when necessary automatically when necessary to carry out assessment and reviews 24/7

Systems to Monitor Patient Flow. 1. In December 2016 the Council created a new role -

Hospital Discharge and Intermediate Care Co-ordinator; to assist with gathering and reporting real time information to enable the department to track people through the system; identify delays and expedite discharge. This will build on the Alamac Reporting system in place already but provide the ability to track individual patients as they move through the system, including periods when they move from reportable delay back to medically unfit and vice versa.

2. The Co-ordinator is now able to produce detailed analytical evidence to track each individual patient, showing the cause of delay, type of delay, total number of days and periods when the individual returned from being medically fit for discharge back to medically unfit. Analysis of this evidence is being used to inform the shape of the new re-commissioned Council Intermediate Care Team, including understanding weekend patient admission / discharge processes. This evidence will also inform the DTOC narrative as part of the ongoing BCF Planning.

3. Daily Telephone calls take place across the Frimley system, which the Discharge Co-ordinator (see 1 above) and Operational leadership within Bracknell Forest participate. These discuss individual delay cases and highlight delays / issues to action.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 2.Systems to monitor patient flow To have a robust patient flow model, supported by an electronic patient flow system that enables teams to identify and manage delays.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

2. Systems to monitor patient flow

Plans in Place moving towards Established.

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Action plan /Deliverables

Systems to Monitor Patient Flow Lead Completion Date

Timely access to appropriate shared data, for example through Connected Care CCG Q3 2017

Ensure there is an agreed process in order to ensure intelligent, timely decision making by all teams to minimise barriers and delays.

CCG Q3 2017

Full ongoing review of “Stranded patients”. Daily reviews focused on the MFFD list, weekly reviews of delayed and long stay patients

CCG

Q3 2017

Proactive review of patients out of area and weekly repatriation planning meetings for those with ongoing health or care needs

CCG

Q3 2017

2 Hospital to Home – Systems to monitor patient flow – Action Plan

57

Change 3

58

Multi-disciplinary/multi-agency discharge teams, including the voluntary and community sector. Coordinated discharge planning based on joint assessment processes and protocols, and on shared and agreed responsibilities, promotes effective discharge and good outcomes for patients.

Not yet established Plans in place Established Mature Exemplary Separate discharge planning processes Discussion ongoing to Joint NHS and ASC Joint teams trust each Integrated teams using in place create integrated health discharge team in place other’s assessments and single assessment and and ASC discharge teams discharge plans discharge process

No daily multidisciplinary team meeting Discussion to introduce Daily MDT attended by Integrated teams cover Integrated service in place MDTs on all wards with ASC, voluntary sector all MDTs including supports MDTs using trust and community and community health community health joint assessment and health and ASC provision to pull patients discharge processes out

Continuing Health Care assessments Discussion between CCG Discharge to assess CHC and complex Fully integrated discharge carried out in hospital and taking and trust to establish arrangements in place assessments done to assess arrangements “too” long discharge to assess with care sector and outside hospital in in place for all complex arrangements community health people’s homes/extra discharges providers care or reablement beds

Multi Disciplinary Teams. The Council’s Hospital based Social Care team is part of the broader Intermediate Care service. The Hospital Social Work team work with the Hospitals’ NHS Discharge Team and to improve communication, the teams are co-located in the same office within the hospital at Frimley Park. There is a Monday PM meeting which the Social Work team attend, attended also by the NHS Bed Managers / Managers of the Discharge Teams plus Hants and Surrey Social Care and the Senior Sisters from each ward. Each ward patient is discussed, together with an explanation of proposed next steps for each patient. There is also a daily telephone call discussing each patient in delay. (See section 2 earlier) The Intermediate care team works in partnership with health and social care, forming multidisciplinary integrated teams; including support staff, therapists, social workers, mental health, medical practitioners and nurses and the falls service. In line with the Care Act 2014, support provided by the Hospital Social Workers includes assisting people who are self-funding their support and assisting their families with discharge planning and intervention. Conference calls also take place re delays and actions being taken to progress individual cases, each day.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 3. Multi-disciplinary discharge teams To carry out co-ordinated discharge planning based on ‘Home First’ principles ensuring joint assessment and shared responsibilities that are effective in minimising length of stay in acute and community services and optimise outcomes for patients.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

3 – Multi Disciplinary discharge teams.

“Established” moving towards “Mature”.

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Multi Disciplinary Teams (Continued) Working with the hospital, referrals into the Council’s Intermediate Care service firstly come into the multi-disciplinary triage service and the multi-disciplinary team will determine the onward care decision. This new model requires incoming referrals from health partners to concentrate on levels of function and medical interventions rather than a recommendation by the acute sector on what service needs to be delivered. The MDT Triage service will ensure that onward care is delivered in the most appropriate setting in the most appropriate way and minimises time spent in the acute setting. This may include accessing services beyond the confines of the intermediate care service across the health and social care economy, for example a sensory needs referral.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 3. Multi-disciplinary discharge teams To carry out co-ordinated discharge planning based on ‘Home First’ principles ensuring joint assessment and shared responsibilities that are effective in minimising length of stay in acute and community services and optimise outcomes for patients.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

3 – Multi Disciplinary discharge teams.

“Established” moving towards “Mature”.

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Action plan /Deliverables

Multi-disciplinary Discharge Teams Lead Completion Date

Ensuring appropriate teams are brought together and have an agreed structure and jointly work to operationalise the agreed admission avoidance and discharge model

All teams Q4 17/18

To monitor and review the model in order to continuously improve All teams Ongoing

Develop appropriate step up and step down pathways through intermediate care service to ensure that individuals are supported to remain in the community and receive care close to home. Integration between the community and acute nursing, therapy and social care teams to further strengthen the trust assessment role and facilitate safe and speedy discharge

BFC team Q4 17/18

Focus on Simple Discharges Hospital Discharge Team

Ongoing

3 Hospital to Home – Multi Disciplinary Discharge Teams – Action Plan

61

Change 4

62

Home first/discharge to access. Providing short-term care and reablement in people’s homes or using ‘step-down’ beds to bridge the gap between hospital and home means that people no longer need wait unnecessarily for assessments in hospital. In turn, this reduces delayed discharges and improves patient flow.

Not yet established Plans in place Established Mature Exemplary People are still assessed for care on an Nursing capacity in People usually return People return home with All patients return home acute hospital ward community being home with reablement reablement support from for assessment and created to do complex support for assessment integrated team reablement after being assessments in the declared fit for discharge community

People enter residential /nursing care Systems analysing which People usually only enter Most people return home People always return too early in their care career people can go home a care/nursing home for assessment before home whenever possible instead of into care – when their needs cannot making a decision about supported by integrated plans for self funder be met through care at future care health and social care advice home support

People wait in hospital to be assessed Work being done to Care homes assess Care homes usually Care homes accept by care home staff identify homes less people usually within 48 assess people in hospital previous residents responsive to assess hours within 24 hours trusting trust /ASC people quickly staff assessment and always carry out new assessments within 24 hours

Home First- Discharge to Assess. The Adult Community Team works on the basis that assessing someone in a crisis or within a hospital setting does not enable the person and the practitioner to explore the most effective way to meet long term needs. To improve the health and wellbeing outcomes for people, the Team’s philosophy is to meet immediate needs and when in a more settled environment, then have a more detailed discussion with the person about how to meet their long term needs. This philosophy encompasses “Discharge to Assess” and is carried through the hospital social work, intermediate care and long term services. There has already been investment in Intermediate Care Services which enabled the team to take on additional rehabilitation and “right sizing” of packages work – however it is not expected that everyone who is discharged from the hospital will access this service e.g. people who need an increase in their long term support. The Council is also investing in Mobile working, creating more opportunity for workers to base themselves in the hospital. We have already established a base for one of the practitioners when working at Frimley Park in the IRIS room – this enables the practitioner to develop formal and informal communications with the discharge team supporting timely intervention and discharge. Continuing Health Care check list will be completed in the community where appropriate with a view that the hospital is not the most appropriate setting to assess the onward health needs.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 4. Home First- Discharge to Assess To provide short-term care and reablement in people’s homes or where necessary using ‘step-down’ beds. Ensuring that people do not wait for assessments in acute and community facilities, and also ensure timely assessment in home based services to optimise system flow.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

4 – Discharge to Assess

Plans in Place, moving towards “Established”

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Home First- Discharge to Assess (Continued). The Discharge to Assess pathway has been introduced for East Berkshire CCGs and Local Authorities (Bracknell, Slough and Windsor) to enable patients who are identified as needing a CHC assessment to be discharged into the community in order for the assessment to be carried out. Depending on the patient’s needs, referrals can be made to any of the step-down beds in Windsar Care Centre (Slough), Upton Hospital (Slough), St Marks Hospital (Maidenhead), Bridgewell (Bracknell) or if appropriate to the patient’s home with intermediate care. Funding for the 28 day period whilst the assessment is carried out is picked up through our block contracts. D2A is being piloted for a cohort of patients with the Bracknell Forest Hospital Based Social Care Team. Initial evidence suggests this is achieving success – for example using the concept of “Earned Autonomy” the Social Worker at FPH was able to use his own professional judgement to increase the Care Package for a 64 year old lady, up to three times and day from two times, without needing to resort to prior approval from Panel. This enabled her to be discharged from hospital within 2 days, saving several extra days of unnecessary hospitalisation.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 4. Home First- Discharge to Assess (continued) To provide short-term care and reablement in people’s homes or where necessary using ‘step-down’ beds. Ensuring that people do not wait for assessments in acute and community facilities, and also ensure timely assessment in home based services to optimise system flow.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

4 – Discharge to Assess

Plans in Place, moving towards “Established”

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Action plan /Deliverables

Discharge to Assess Lead Completion Date

Investigate anomalies in process between Surrey / Hants and Berkshire CHC Assessment at Frimley Park Hospital, with a view to streamlining checklist and Decision Support Tool process for Berkshire CHC, in line with Surrey and Hants model.

CCG/BFC Q4 2017

Foster new relationships and delegated autonomy to hospital social work teams to enable them to facilitate D2A at home

Bracknell Forest Council

As above

Develop and embed Bracknell Forest Council model of earned autonomy to enable Discharge to Assess for all appropriate discharges to be mobilised in each locality. Inclusion of complex discharge Pathway

BFC Q4 2017

Strengthened joint commissioning arrangements of more flexible health and social care packages. BFC / CCG Q4 2017

4 Discharge to Assess – Action Plan

65

Change 5

66

Seven-day service. Successful, joint 24/7 working improves the flow of people through the system and across the interface between health and social care, and means that services are more responsive to people’s needs.

Not yet established Plans in place Established Mature Exemplary Discharge and social care teams assess Plan to move to seven day Health and social care Health and social care Seamless provision of and organise care during office hours working being drawn up teams working to new teams providing seven care regardless of time five days a week seven day working day working of day or week patterns

OOHs emergency teams provide non New contracts and rotas New contracts agreed New staffing rotas and New staffing rotas and office hours and weekend support for health and social care and in place contracts in place across contracts in place and staff being drawn up and all disciplines working seamlessly negotiated

Care services only assess and start Negotiations with care Staff ask and expect care Most care providers All care providers assess new care Monday to Friday providers to assess and providers to assess at assess and restart care at and restart care 24/7 restart care at weekends weekends weekends

Diagnostics, pharmacy and patient Hospital departments Hospital departments Whole system Whole system transport only available Monday to have plans in place to open 24/7 whenever commitment usually commitment enabling Friday open in the evenings and possible enabling care to restart care always to restart at weekends within 24 hours, seven within 24 hours, seven days a week days a week

5. Seven Day Services. The Bracknell Forest Intermediate Care service has been re-designed, to offer a more integrated service providing a 7 day service to offer community based support as well as to facilitate hospital discharge processes at the weekend too. In terms of re-admission avoidance, the new service will offer Physiotherapy, Occupational Therapy and re-ablement support which will be provided within a 2 hours window from referral over an extended period each day during the week (08:00 – 20:00), and between 10:00 – 16:00 at weekends. The service will be available for a period of up to 5 days and will need to be supported by the individuals GP. As an additional layer of support, at the weekends the Bracknell Forest Emergency Duty Service operates. This provides social care / therapist support to individuals where an immediate response is required which cannot wait until the next working day. This may include provision of OT equipment or other Assistive Technology support to enable the individual to stay at home and prevent hospital admission. Other points: Consultant working in the Emergency Department 7 days a week- acute physician and medical and surgical consultant; Consultant ward rounds at Frimley taking part 7 days a week; Physios and OTs available in Emergency Department 7 days a week. Bracknell Forest Emergency Duty Service provides out of hours discharges and prevents admissions.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 5. 7 day services To establish and maintain access to affordable and sustainable 7 day services to minimise avoidable delays in a patients journey.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

5 – Seven Day Services

Plans in Place, moving towards “Established”

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Action plan /Deliverables

Seven Day Services Lead Completion Date

Implement new 7 day a week Intermediate Care Service. BFC Q4 2017 / inline with STP plan.

Establish opportunities for workforce to flex working patterns to provide cover for extended hours and weekend working.

STP /UEC initiative

In line with STP plan

Undertake an audit of 7 day provision across the System. Establish what is required and how it can be provided (within financial envelope) to address patterns of need.

STP / UEC initiative

Q4 2017/18

Operationalise 7 day model for agreed services As above As above

Engagement with patients, carers and representation groups to educate the safety element of 7 day discharge and the interim support available to bridge care at home until care packages can start.

BFC / Hospital Teams / Comms

Q4 2017

5 Seven Day Services – Action Plan

68

Change 6

69

Trusted assessors. Using trusted assessors to carry out a holistic assessment of need avoids duplication and speeds up response times so that people can be discharged in a safe and timely way.

Not yet established Plans in place Established Mature Exemplary Assessments done separately by health Plan for training of health Assessments done by Discharge and social Integrated assessment and social care and social care staff different organisations care teams assessing teams committing joint accepted and resources on behalf of health and pooled resources committed social care

Multiple assessments requested from One assessment form/ One assessment Single assessment in Resources from pooled different professionals system being discussed format agreed between place budget accessed by organisations /professions single assessment without separate organisational sign off

Care providers insist on assessing for Care providers discussing Care providers share Some care providers Single assessment for the service or home joint approach of responsibility of assess on each other’s care accepted and done assessing on each other’s assessment behalf and commit to care by all care providers in behalf provision system

6 . Trusted Assessor The LA have members of staff who are already Trusted Assessors in respect of Social Care/ Therapy interventions; further plans are in place to develop Trusted Assessor status for the Intermediate Care Service. Competency based training is being developed by the lead O.T. within the Local Authority to provide Generic workers able to provide Health and Therapy work with individuals. The LA are also developing the related concept of “earned autonomy” for weekend staff working in the Intermediate Care service and also being piloted in the Social Care Hospital Team (see earlier section), whereby decisions and financial authority will be granted to staff up to an agreed sum, when sourcing and enabling individuals to access the service either in the community or from hospital at the weekends. This aims to avoid delay and blockages whilst waiting for authorisations.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 6. Trusted Assessor Development of an agreed trusted assessment process for one person or team to perform trusted assessment on behalf of multiple teams A recognised cohort of trusted assessors with a mandated remit to undertake on behalf of whole system

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

6. Trusted Assessor

Plans in Place

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Action plan /Deliverables

Trusted Assessor Lead Completion Date

Development of a clinically led trusted assessment process on behalf of multiple partners across health, social care and the independent sector

CCG Q4 2017

A recognised trusted assessment process with standard documentation and a mandated remit to undertake on behalf of whole system. Accelerated access to trusted assessment co-ordinators to resolve concerns on behalf of the in-taking care provider.

CCG/BFC Q4 2017

Develop a common suite of documentation, including assessment template and communication protocol to in-taking care providers (e.g. email, teleconference, or face to face for complex patients).

CCG/BFC Q4 2017

Implement an appropriate crisis response to wrap around the trusted assessment process in the event that the care package breaks down within the first 48 hours.

CCG/BFC Q4 2017

6 Trusted Assessor – Action Plan

71

Change 7

72

Focus on choice. Early engagement with patients, families and carers is vital. A robust protocol, underpinned by a fair and transparent escalation process, is essential so that people can consider their options, the voluntary sector can be a real help to patients in considering their choices and reaching decisions about their future care.

Not yet established Plans in place Established Mature Exemplary No advice or information available at Draft pre-admission leaflet Admission advice and Patients and relatives Patients and relatives admission and information being information leaflets in aware that they need to planning for discharge prepared place and being used decide about discharge from point of admission quickly

No choice protocol in place Choice protocol being New choice protocol Choice protocol used All staff understand written or updated to implemented and proactively to challenge choice and can discuss reduce seven days understood by staff people discharge proactively

No voluntary sector provision in place to Health and social care Voluntary sector provision Voluntary sector provision Voluntary sector fully support self-funders commissioners co- in place in the trust integrated in discharge integrated as part of designing contracts with proving advice and teams to support people health and social care voluntary sectors information home from hospital team both in the trust and the community

7 . Focus on Choice The hospital operates a Patient Discharge Policy which has been in place since 2013. See attached. The policy acknowledges that “The preparation for discharge should start prior to admission for elective cases and soon after admission for emergencies.” Risks associated with discharge will be promptly identified by discussions with the patient, next-of-kin, carers and other health or social workers involved in the patient’s care, whether in hospital or in the community prior to admission. If during this process it is identified that there may be concerns regarding the patient’s ability to return to their previous accommodation, then the patient is referred to the Council’s Adult Social Care team and all other relevant multi-disciplinary team members including Ward Matron and the Discharge Team. In terms of patient choice, the policy states that: The patient can expect to be Involved actively in all discussions regarding their acute and ongoing care; Consulted and referred by the NHS to Social Services for assessment if additional community care needs are anticipated; Promptly assessed by Social Services (after referral) for his/her care needs and those of the carer. Patient’s choice is paramount in all decisions about discharge; Able to maximise independence. Given written information when pertinent, including the “Leaving Hospital” leaflet.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 7. Focus on Choice. Discharge Planning - Information and advice available. Matching hospital to home services with patient preferences, support needs and wishes.

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

7 Focus on Choice

Established for Frimley Park Hospital; elsewhere “Plans in place”

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Action plan /Deliverables

Focus on Choice Lead Completion Date

Operationalise a Multi-Agency Choice on discharge policy – set up Task and Finish Group CCG/ BFC / Acute Trust

Q4 2017

Develop staff training around choice in practice CCG/ BFC/ Acute Trust

Q4 2017

A local authority led approach to the education and support of self-funders to ensure wherever possible vulnerable individuals do not make life changing decisions in an acute hospital setting.

CCG / BFC Q4 2017

7 Focus on Choice - Action Plan

74

Change 8

75

Enhancing health in care homes. Offering people joined-up, coordinated health and care services, for example by aligning community nurse teams and GP practices with care homes, can help reduce unnecessary admissions to hospital as well as improve hospital discharge.

Not yet established Plans in place Established Mature Exemplary Care homes unsupported by local CCG and ASC Community and primary Care homes manage the Care homes integrated community and primary care commissioners working care support provided to increased acuity in the into the whole health and with care providers to care homes on request care home social care community identify need and primary care support

High numbers of referrals to A&E from Specific high referring Dedicated intensive No unnecessary No variation in the flow of care homes especially in evenings and care homes identified and support to high referring admissions from care people from care homes at weekends plans in place to address homes in place homes at weekends into hospital during the week

Evidence of poor health indicators Analysis of poor care Quality and safeguarding Community health and Care home CQC ratings in Care Quality Commission (CQC) identifies homes where plans in place to support social care teams working reflect high quality care inspections extra support and training care homes proactively to improve needed quality in care homes

8. Enhancing Health in Care Homes. Since 2014, Bracknell Forest have worked with the CCG to develop a Care Home Quality Programme, which reports to the Better Care Fund on a monthly basis. In the period November 2014 to December 2016, this focussed on 2 main areas: Qualitative benefits: Avoidance of unnecessary admission and stays in hospital; Improved quality of life arising from Overall improvement in underlying health; The earlier identification of a person's medical issues Quantitative benefits: Savings realised from reduction in NEL; Reduction in pressure on ambulance services; Quality of life for residents improved, measured through the EQ-5D Patient Survey A range of workstreams and monthly workshops were developed, attended by all or most of the Care Homes each time. These included a Medication Optimisation Review workstream including polypharmacy issues and problems, co-hosted by a BHFT Community Pharmacist, culminating in a planned care managers workshop in April 2016. Other workshops included training for care workers on Hydration and Nutrition which commenced with a Managers Workshop in February 2016 followed by 4 separate workshops in March 2016. This focused on Hydration and addressing poor appetite. Since May 2017, the 3 East Berkshire CCGs have collaborated to appoint an East Berkshire wide Care Home Quality Lead, who will take this programme of work forward across the 3 Boroughs.

Overall aims: To simplify processes and pathways throughout a persons journey in order to deliver a seamless transfer of care. Establish an inclusive route that gives equality of access for Bracknell Forest residents using acute or community based services across the Health and Wellbeing area. 8. Enhancing Health in Care Homes A framework to address shortfalls in current service delivery within the local area

Self-Assessment Description of local system (Bracknell Forest) High Impact Change

Change number Assessment

8 Enhancing Health in Care Homes

Established

Hospital to Home - ‘Home First!’. To improve the transfer of patients to the right place, with the right care and support without avoidable delays. People stay for a shorter time in hospital once their necessary medical care is complete. Initial support needs are met and assessments are completed in a settled environment, ensuring people feel safe to live the life they want with support to manage their risks, build independence, health and wellbeing. Lead Director : Other leads:

Action plan /Deliverables

Enhancing Health in Care Homes Lead Completion Date

Produce a mapping of current provision and outcomes against the framework for Enhanced Health in Care Home (Sept 2017).

East Berks Care Home Quality Group

Q4 2017/18

Develop a framework to address consistent shortfalls in current service delivery East Berkshire Care Homes quality Group

Q4 2017/18

More streamlined access to clinician via access to NHS 111 for Care Homes out of hours East Berkshire Care Homes quality Group

Q4 2017/18

8 Enhancing Health in Care Homes - Action Plan

77

2017/18 DTOC plans 21 July submission to NHSE

78

Extract from DTOC Template submitted to NHS E on 21st July: We have completed the Metrics plans on the basis of splitting both the current and target figures for delays between Social Care and NHS. We, as a system, prefer expressing all the delays as jointly attributable, and working as a system to reduce total delays, and were somewhat disappointed to be given the message that such an approach would open us to criticism. Delays expected to fall from October 2017 onwards due to new contracts being in place. However, the required reduction in delays is considered extremely challenging in such a short timescale, when based on such small

numbers.”

79

Delayed Transfers of Care 17-18 plans

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 NHS attributed delayed days 0 0 0 235 235 235 199 187 193.3 193.3 174.6 193.3

NHS Bracknell and Ascot CCG 235 235 235 199 187 193.3 193.3 174.6 193.3

Social Care attributed delayed days 90 90 90 75 71.7 74.1 74.1 66.9 74.1 Per day 2.90 2.90 2.90 2.41 2.39 2.39 2.39 2.39 2.39 Per 100K 3.11 3.11 3.11 2.59 2.56 2.56 2.56 2.56 2.56 Jointly attributed delayed days 93 93 93 78 73.9 76.4 76.4 69 76.4

Total Delayed Days 0 0 0 418 418 418 352 332.6 343.7 343.7 310.5 343.7

Population Projection (SNPP 2014) 93,124 93,124 93,124 93,124 93,124 93,124 93,124 93,124 93,124 94,045 94,045 94,045

DTOC(delayed days) from hospital per 100,000 pop.18+ 0 0 0 448.9 448.9 448.9 378 357.2 369.1 365.5 330.1 365.5

DTOC Baseline and Target- copy of submission to NHS England from 21st July

DTOC Plan – summary of actions to date

80

Maintaining patient flow through the local acute trusts and supporting early safe discharge is a high priority for Bracknell Forest. Since December 2016, the BCF has funded a Hospital Discharge Co-ordinator who monitors in real time, patient progress across each of the acute and community hospitals and escalates concerns and delays to Senior operational management. The Council employs 2 full time social workers who are based at Frimley Park hospital and are located in the Hospital Discharge Nursing team office. There are dedicated social workers in-reaching to Royal Berkshire; St Marks and Upton. The Bracknell Forest Community Mental Health Team for Older Adults also employ a social worker who in reaches to the hospitals. The results of the Deep Dive informed the development of a workshop and remedial actions, with senior management attendance from across the system and ongoing programmes of work funded through the iBCF as well as development of the High Impact Change Model (see earlier slides). Local Performance against national historical parameters (ASCOFF) is monitored and maintained through weekly discharge team meetings with ward managers, discharge nurses and social workers.

There are also email updates from the Discharge nurses and telephone calls with the hospital and social care team to identify patients “fit for discharge” and use of Alamac data set. The early supported discharge function of the Integrated Care Team also operate at Frimley Park, with a community matron leading a team to support discharge for patients with complex case management, using the appropriate frailty identifier. (See earlier section) The Bracknell Forest High Impact Change Model for Managing Delayed Transfers of Care builds on the Hospital to Home pillar from the Urgent and Emergency Care Delivery Plan, but focusses specifically on Bracknell Forest and includes: • Pilot Discharge to Assess model in the local community • Improved information flows and streaming at A&E • Develop investment in early reach/advice and guidance

particularly for self funders during their acute stay • Development of Step up / Step Down beds in the local

community • Increasing deployment of Trusted assessment model.

BCF / iBCF funded DTOC initiatives - examples

81

Summary of Bracknell Forest DTOC Action Plan

82

Issue Project / Pilot / Initiative Funded through Comments

Delays sourcing Care Package Discharge to Assess / New Domiciliary Care contract

BCF / Adult Social Care

A number of initiatives are being developed, including “earned autonomy” so that practitioners do not have to take cases to panel for funding agreement prior to discharge.

CHC assessment delays UEC Delivery Plan – Home from Hospital pillar

System transformation

The UEC Delivery Plan mandates that 85% of CHC assessment will be undertaken out of hospital. Anomalies in assessment between Hants, Surrey Heath and Bracknell identified – potential to improve process for Bracknell being explored.

Delays whilst approving care packages Discharge to Assess pilot BCF Intermediate Care service

The new Intermediate care service will include modelling for D2A which is being piloted at present.

Workforce – Need for Trusted Assessors

UEC Delivery Plan – Home from Hospital pillar

This is an STP priority

Identified as a development priority across the STP. Next phase is to identify pilot (e.g. disparity between CHC assessment process in East Berkshire compared to Surrey and Hampshire.)

Step up / Step Down and Nursing Bed availability

Commissioning beds in the locality

Better Care Fund –iBCF initiative

Short term and medium term solutions are being developed to enable Step up / step down capacity in the local market; facilitating hospital discharge

Delays whilst setting up Intensive Care Packages

Rightsizing Care Packages through Intermediate Care Service

Better Care Fund. Provides short term support for people who are either newly referred for social care support, or whose needs change, to inform assessment ; support reablement ; reduce or remove the need for on going support from traditional home care.

Traditional time and task focussed Dom. Care; increasing dependency

New outcomes based Domiciliary Care Contract

Council ASC funding; iBCF, BCF

Additional funding through BCF and iBCF to ensure provider capacity is maintained and workforce issues addressed.

Reablement – proportion of people > 65 at home 91 days after discharge

The dip in performance in 2015/16 has been investigated and is the result of a system recording inconsistency rather than an actual drop in reablement performance. The Council has conferred with NHS Digital (formerly the Health and Social Care Information Centre) to clarify the procedure for counting when an individual leaves hospital but returns to hospital for a separate, unrelated condition, during the 91 day time window. As a result of clarification from NHS Digital and corroboration with other authorities in the South East, the agreed methodolgy has been re-established for 16/17, in line with other South East Councils and advice received from NHS Digital. This has resulted in the performance on this metric returning to previous levels – in fact placing the Council for 16/17 at 24th in the National ranking (150th in the ranking in 2015/16).

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80.8 82.7

58.2

90.8

0102030405060708090

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Reablement – proportion of people > 65 at home 91 days after discharge – metric for 2017 -18

Based on the analysis described on the previous slide, the BCF Metric for reablement for 2017/18 has been set at the same level as for 16/17 (81.3%) which while challenging, is considered to be achievable given the initiatives to re-commission the Intermediate Care service and the range of schemes being developed in response to the DTOC and Hospital to Home workstreams. Performance at this level would place the Council in the top quartile in the Country.

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15/16 Actual 16/17 Plan 17/18 Plan 18/19 Plan

Annual % 58.2% 81.3% 81.3% 81.3%

Numerator 39 65 65 65

Denominator 67 80 80 80

Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services

65+ Permanent Admissions to Residential or Nursing Care - comparison of Q1 17-18 data with last year

The table and chart above show that 65+ Permanent Admissions for 2017-18 in April, May and June are significantly lower than the same period last year (Q1 2016-17), giving an overall indicator value of 61.5 per 100,000 of population compared to 159.6 last year.

Measure April May June 65+ permanent admissions indicator (per 100,000 population) (2017-18) 12.3 36.9 12.3 65+ permanent admissions indicator (per 100,000 population) (2016-17) 49.1 61.4 49.1 No of people admitted (2017-18) 2 6 2 No of people admitted (2016-17) 8 10 8

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65+ Permanent Admissions to Res/Nursing by Local Authority and Sequel to Assessment - 2017-18 versus 2016-17

65+ permanent admissions indicator (per 100,000population) (2017-18)

65+ permanent admissions indicator (per 100,000population) (2016-17)

65+ Permanent Admissions to Residential or Nursing Care

Performance against the 65+ Permanent admissions to residential or nursing care metric improved during the first quarter of 2017/18 compared against the same period for 2016/17. See previous slide. However, because the numbers of individuals are statistically small (for example 8 people admitted in April 2016 compared with 2 people in April 2017), it is considered prudent to maintain the trajectory already set in the previous plan. This will then be reviewed by the Steering Group later in the year, following an analysis of the impact of the new Outcomes based Domiciliary Care Contract which commences in August 2017 focussing on regaining skills and independence for the individual; as well as the effectiveness of the new Intermediate Care service with regard to the reablement function within the service.

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15/16 Actual 16/17 Plan 17/18 Plan 18/19 Plan

Annual rate 718.8 596.0 598.7 599.1

Numerator 117 101 104 107

Denominator 16,278 16,941 17,371 17,860

Long-term support needs of older people (age 65 and over) met by admission to residential and nursing care homes, per 100,000 population

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2017/18 Better Care Fund Schemes

The Infographic opposite shows the year end review of the 2016/17 Bracknell Forest BCF schemes. For 2017/18, the Care Home Quality workstream is being developed across East Berkshire (see earlier slide on “collaboration – East Berkshire”).

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2017/18 Better Care Fund Schemes

2017/18 – BCF Schemes of work - summary (See the 2016 BCF Submission for a detailed description of these existing schemes funded for 2017/18 through the BCF)

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BCF Scheme Description BCF National Metrics that the scheme contributes to

Extension of Integrated Multi-Disciplinary Care Teams.

Augmentation provides the Supported Discharge Matron and Case Co-ordinator, to facilitate the early supported discharge of people from hospital and their identification for follow up in the multi-disciplinary review in the Cluster meetings. Funding also includes Age UK Berkshire Promoting Independence Co-ordinator to address social isolation issues

• Non – elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

Community Based Intermediate Care

To re-commission the ICS to provide admission avoidance and early support discharge pathways. Multi disciplinary team comprising health and social care practitioners – providing single point of referral for acute, community and primary care.

• Non – elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

Prevention and Self-Care

To co-ordinate effective integration and co-ordination for the wide range of preventative and self-care programmes across Bracknell Forest.

• Non – elective admissions

Rapid Access Community Clinic (Falls Tier 3)

To ensure that people with Long Term Conditions and or frailty and high risk of falling can access the most appropriate care in a timely manner when referred by GP; community practitioners or ambulance service.

• Non – elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

2017/18 – BCF Schemes of work - summary (See the 2016 BCF Submission for a detailed description of these existing schemes funded for 2017/18 through the BCF)

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BCF Scheme Description BCF National Metrics that the scheme contributes to

Care Home Quality Project

An East Berkshire initiative building on work undertaken through Bracknell Forest and Royal Borough of Windsor BCFs, to develop learning from best practice and provide an STP wide approach, including Red Bag initiative Dashboard/performance monitoring Staff and registered manager training and development Meds management and prescribing support – a uniform approach to support NICE guidelines Trusted assessor model to facilitate discharge (trialled at Windsar Car Home in Slough)

• Non – elective admissions • DTOC

Carers’ Support Funding from the BCF will be used to support outcomes for carers in a variety of ways. Outcomes include: • Maintaining carers health and wellbeing • Reducing social isolation and maintaining social and family relationships • Carers knowing that the person they care for will get the support that they need, when the carer is unable to provide that care because of an emergency. • Carers working and studying if they wish • Carers maintaining other roles and have the life that they choose. • Carers maintaining their caring role (should they wish to) and supporting the person they care for in the best way possible. Please refer to the Bracknell Forest Joint Commissioning Strategy for Supporting People in an unpaid Caring Role 2015-20 for further information

• Non – elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

2017/18 – BCF Schemes of work - summary (See the 2016 BCF Submission for a detailed description of these existing schemes funded for 2017/18 through the BCF)

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BCF Scheme Description BCF National Metrics that the scheme contributes to

Protecting Social Care Services

Uplifted by an inflationary factor of 1.79% for 2017/18, a sum of £1.369m is recommended for approval by the HWB in 2017/18 for protecting social care services. This funding is to offset increases in demand arising from higher levels of need and other demographic pressures as well as the increased costs of support for residential and nursing home provision due to the local market supply / demand factors.

• Non – elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

Increased capacity in Domiciliary Care Market

Additional capacity to the domiciliary care market in Bracknell Forest was provided through the BCF last year, (£225,000) to enhance the hourly market rate paid to the Care Providers to reflect the local labour market within Bracknell Forest. This has been agreed to be continued for 2017/18. Additional funding ensures compliance with the recommendations in the UK Home Care Association for South East Home Care Providers (£16.70 per hour)

• Non – elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

NHS Commissioned out of hospital services

Business cases for BCF investment in appropriate commissioned out of hospital services will be considered and agreed by the BCF Steering Group and Programme Board during the year.

• Non – elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

2017/18 – BCF Schemes of work - summary (See the 2016 BCF Submission for a detailed description of these existing schemes funded for 2017/18 through the BCF)

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BCF Scheme Description BCF National Metrics that the scheme contributes to

Adult Integrated Respiratory Service

The AIRS service is an integrated service delivered by a multi-disciplinary team across the acute and community services, comprising medical, nursing, physiotherapy and administrative staff. The service is delivered both in a hospital and home based context for patients with a range of respiratory conditions, 6 days a week.

• Non – elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

Care Act and Independent Mental Health Advocacy

Including funding for Carers, (recognising that there are benefits to a joint and integrated approach to responsibility for identifying and supporting carers in line with the Government’s mandate to NHS England for 2017-18 which states that “carers should be routinely be identified and given access to information and advice about the support available*”); National Minimum eligibility threshold, advocacy, safeguarding and other workstreams in accordance with Department of Health revenue funding and grant allocation guidance. * https://www.gov.uk/government/publications/adult-personal-social-services-revenue-funding-2017-to-2018

• Non-elective admissions • Effectiveness of reablement

Better Care Fund Programme Support

To enable agreed transformational programme work to be funded.

• Non elective admissions • Admissions to residential and care

homes • Effectiveness of reablement • DTOC

Disabled Facilities Grants

The Director of Adult Social Care, Health and Housing is Chair of the BCF Programme Board. The Council’s Housing representatives have been involved in developing and agreeing the plan, in order to ensure a joined-up approach to improving outcomes across health, social care and housing. DFG expenditure is monitored at the monthly BCF Steering Group.

• Admissions to residential and care homes

• Effectiveness of reablement

2017/18 – BCF Schemes of work - summary (See the 2016 BCF Submission for a detailed description of these existing schemes funded for 2017/18 through the BCF)

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BCF Scheme Description BCF National Metrics that the scheme contributes to

Community Equipment

The BCF contributes to the Berkshire wide Community Equipment service which enables Social Care Practitioners and O.Ts to prescribe and arrange for equipment such as bed raisers, shower boards, slings etc to be installed at very short notice into individual’s homes, to enable hospital discharge, re-ablement and admission avoidance. The service can also provide minor adaptations as an alternative to the Disabled Facilities Grants.

• Non – elective admissions • Effectiveness of reablement • DTOC

2017/18 – BCF Schemes of work - former National Conditions

(See the 2016 BCF Submission for a detailed description of these existing schemes funded for 2017/18 through the BCF)

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BCF Scheme Description Former BCF National Conditions of these schemes

NHS Number as a unique identifier

A BCF funded scheme to expand the Council’s Adult social care software system to enable the use of an individual’s NHS number as a unique identifier.

• Improving data sharing between health and social care

Shared Care Record (Interoperability)

A BCF funded scheme across East Berkshire to ensure health and social care professionals have access to accurate and timely information regarding patients by being able to access electronic records from Community health provider, GP, Council, Hospital.

• Improving data sharing between health and social care

• Ensuring a joint approach to assessment and care planning

New iBCF Schemes for 2017/18

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iBCF Scheme Description BCF / iBCF Metrics of these schemes

Community Connectors x 3

To support people in their journey to gain independence and help prevent episodes of ill health and social isolation by connecting people to resources in their community and helping them to identify and build their own support networks amongst family, friends, people in their communities, and groups or organisations. This will be in line with the implementation of the “Conversation Approach”, which focuses on developing people’s assets and connections. Community Connectors will work together with the network to link people into their local communities to help them remain socially connected, better understand their needs, solve problems, develop their confidence, their life skills, and their resilience so they can live as independently as possible with a reduced likelihood of needing social care and support in future.

• iBCF type: Meeting Adult Social Care Needs – reducing or delaying need for care and support

Grass Roots innovation funding

Building on the point above, one off grants of up to £1,000 to small groups within the local community for projects that support older and vulnerable people to live independently in their local community and to strengthen community assets and networks.

• iBCF type: Meeting Adult Social Care Needs – reducing or delaying need for care and support

New iBCF Schemes for 2017/18

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iBCF Scheme Description BCF / iBCF Metrics of these schemes

Support to residential market

Following closure of a number of homes during 2016, prices significantly increased in the local care home market. This funding supports the Council to continue to find placements in the local area in the short term, whilst a new block contract for up to 20 beds in finalised with a new provider in the local area, thereby bringing available capacity and price stability back to the market.

• iBCF type: Stabilising the care provider market; reducing pressure on the NHS; Meeting Adult Social Care Needs

Support to Domiciliary care market

The Council’s new Domiciliary Care framework is to be implemented from August 2017 with 5 providers, moving away from Time and Task model to Outcomes based. The funding will support the transition from the previous providers, either through Brokered care or Direct payments; enabling additional care packages to be sourced on a temporary basis during the transition, ensuring DTOC related delays are minimised.

• iBCF type: Meeting Adult Social Care Needs – reducing or delaying need for care and support

Support to new intermediate care service implementation

The new Bracknell Forest Intermediate Care Service commencing in December 2017, will include for the first time, mental health practitioners. This will enable the ICS to support a larger cohort of individuals, as at present, 30-40% of hospital delays can be attributable to a primary diagnosis of dementia or related cognitive impairment. Funding will be used to support the implementation of this enhancement, for example in providing cover locum staff whilst the recruitment process for new ICS therapists is completed.

• iBCF type: Reducing pressure on the NHS including DTOC; Stabilising the care provider market; meeting ASC needs generally.

New iBCF Schemes for 2017/18

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iBCF Scheme Description BCF / iBCF Metrics of these schemes

Funding to develop Step up / Step Down facility

A key component in reducing DTOC delays hinges on the ability to source Step up / Step Down Nursing beds to enable hospital discharge or to prevent hospital admission. Options being explored include the current Bracknell Bridgewell unit, which could be re-modelled for this use. iBCF will be used to develop these facilities either at Bridgewell or in the vicinity.

• iBCF type: Reducing pressure on the NHS including DTOC; Meeting Adult Social Care Needs

Programme Governance and Assurance processes The Health and Wellbeing Board has oversight on the alignment of the BCF plan with HWB strategy, changes to BCF policy, progress with the delivery of the BCF Plan and exceptional items In the case of plans going off track the HWB will hold stakeholder organisations to account; Receive the action plans proposed by the BCFPB; Consider and recommend on the proposed actions; Assess the impact of the actions proposed. The Better Care Fund Programme Board has oversight on the alignment of strategies to supporting the BCF; BCF pooled budgets ; the performance of the BCF against specific metrics and budgets; the release of risk contingencies against priorities; Risks and issues. In the case of plans going off track the Better Care Fund Board will: Consider why the strategies (underpinning the HWB strategy) are not meeting expectation and propose changes; assess new risks and issues / material matters arising from the plans going off track; Seek assurance from the action plans proposed by the BCF Steering Group to stop and correct the adverse performance. The BCF Steering Group focuses on the delivery of service strategies supporting the JHWS; measuring outturns against national metrics; the performance of specific projects; reviewing the market for new initiatives / new ways of working; commissioning and assessing project / service development feasibility studies; effecting the BCF communications strategy; Programme management; Programme and project risk identification and assessment; Reporting to the BCF Programme Board. In the case of plans going off track the BCF Steering Group will receive/request information about the performance of specific projects and developments forming part of the BCF Programme from Leads Groups; agree action plans with Leads Groups to remedy any performance / budgetary variances. 98

Assessment of Risk/Risk Management (1) There are organisational, financial and reputational risks for all organisations within the health and social care system if they are unable to manage system pressures. The Council has a number of strategic risks detailed in the BCF Risk Register, which can be impacted by the effectiveness of schemes put in place to manage these system pressures. This may include the challenge of shaping the health and social care market. The BCF Programme Manager maintains a Risk Register and will monitor and escalate risks to the BCF Programme Board and HWB for consideration and action. Risks include: • Funds allocated to “Out of Hospital transformation” services not delivering or maintaining the anticipated reduction in Non Elective

admissions. (This will be managed and mitigated through the work of the BCF Steering Group which meets monthly and monitors performance against the key national metrics and will highlight any risks and proposed mitigation with the Council and CCG Chief Finance Officer through the work of the BCF Finance Leads group which also meets monthly).

• The on going trajectory of increased activity locally and nationally which may prevent evidencing improved outcomes. • The risk of maintaining status quo in services, and not transforming them for real integration by 2020. • BCF schemes fail to deliver the national conditions and funded schemes lead to an increase in the number of admissions to residential

and care homes or other Local Authority commissioned services. • Workforce development in professional health and social care skills, health care assistant and transformation management is recognised

by the STP partners as a key vulnerability and is putting steps in place to address it but the lead/lag times for impact may not be sufficient to meet transformational timetables

• Data and analytical capacity is recognised as a potential pressure point in the delivery of the complex programmes across the BCF, CCG and STP footprints. Credibility of business cases and ongoing monitoring of impact in a complex world of multiple initiatives will be impaired without sufficient capability to support new and on going initiatives.

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Assessment of Risk/Risk Management (2) Individual projects carry their own risk assessment and registers and consideration is given to the robustness of the mitigating actions before investment decisions are made and on an on going basis. A Monthly report is produced to the BCF Steering Group and also the Programme Board, which highlights each project, together with a summary Red Amber Green RAG rating of risk for each scheme in terms of a) Overall Programme Management issues for the month in question and b) Specific operational risks within the scheme that might have occurred for the month in question. There is also a Risk Register which is produced which details all of the schemes and the likely risks and mitigations within each scheme. The Monthly report also monitors progress of each of the schemes against the 4 national metrics: • Non elective admissions • Admissions to residential and care homes • Effectiveness of reablement • Delayed Transfers of Care and is based on monthly performance data received by the Commissioning Support Unit on Bracknell Forest’s performance against each of these metrics. Therefore the Board and Steering Group receive timely and relevant information and can identify and address any concerns or underperforming schemes, in accordance with the Terms of Reference shown in the previous slides. The Steering Group also provides the forum to capture and share learning both regionally and nationally, and to highlight good practice in other areas of the country or system. Voluntary Sector Through the work of the Transformation Programme, the Council is working to stimulate and develop links with third sector providers as strategic partners to ensure a vibrant, active responsive and relevant sector. Many third sector organisations are involved in different project areas, but fragmentation of funding sources, contracts and SLAs has mitigated against a cohesive approach historically. However the BCF focus to priority services and population cohorts has created a dynamic for change in our : • Approach to working with local communities to develop an asset based system of care • Sustainable contracts with regular review and development objectives and performance monitoring (eg stroke, Signal4Carers) • Promotion of collaboration between providers – e.g. new Outcomes based Domiciliary Care contract • Promotion of assistive technologies that support the needs of many third sector service users 10

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Risk Share Bracknell Forest has performed better than the national average and the East Berkshire average in NEA activity. (See graph earlier in the narrative) However, the BCF Steering Group have recommended that the equivalent sum to last year (£459,000) be retained as a contingency in the event of any additional activity which results from BCF schemes not having the expected impact in reducing demand. The Steering Group meets on a monthly basis, with the BCF pooled budget being a standing agenda item. Therefore the decision on when to release this contingency funding will be reviewed each month and will be dependent on performance of the overall fund during the year. Regular monitoring of spend will be through governance arrangements with quarterly reports to the HWB on spend. Further investment in NHS commissioned out of hospital / transformation services will be developed in year, should additional funds become available. Please refer to the Planning Template for more financial detail.

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Key Documents and Links Documents policies and journals accessed through the hyperlinks are set out below: Slide 7 – “Key policies and drivers” • Frimley Sustainability and Transformation Plan - https://www.fhft.nhs.uk/media/2388/frimley-stp-oct-submission-for-

publication.pdf Slide 17 – “Progress on Health and Social Care Integration in Bracknell Forest”. • Population details – Joint Strategic Needs Assessment webpage http://jsna.bracknell-forest.gov.uk/bracknell-forest-

profile/demography/population • NHS Moves to End fractured care system NHS Website at https://www.england.nhs.uk/2017/06/nhs-moves-to-end-fractured-

care-system/ • Social Work team of the year award - http://www.communitycare.co.uk/2013/11/29/social-worker-year-awards-2013-winners/ Slide 25 – “Evidence Base – understanding the local priorities” • Bracknell Forest Joint Strategic Needs Assessment - http://jsna.bracknell-forest.gov.uk/ • Bracknell Forest Joint Health and Wellbeing Strategy - https://files.bracknell-forest.gov.uk/sites/bracknell/documents/seamless-

health-2016-2020.pdf?VbHtb6FT0hPqbPRCL2RPD9jMojnYt52q • Bracknell Forest Market Position Statement - https://files.bracknell-forest.gov.uk/sites/bracknell/bracknell-forest-council-

market-position-statement.pdf?ILNAblG786sC_gPvjCwxTqR49zwMs6tt • Bracknell Forest Health and Social Care Strategies and Policies - https://www.bracknell-forest.gov.uk/council-and-

democracy/strategies-plans-and-policies/strategy-and-policy-documents/health-and-social-care-strategies-and-policies Slide 26 – “Evidence base – population profile – summary of local needs” • Housing, Health and Wellbeing in Bracknell Forest -

http://reports.esd.org.uk/reports/2345?pat=LA&pa=E06000036:AdministrativeWard • Bracknell Forest JSNA – Bracknell Forest Profile - http://jsna.bracknell-forest.gov.uk/bracknell-forest-profile

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Key Documents and Links (Continued) Documents policies and journals accessed through the hyperlinks are set out below: Slide 27 – “Evidence base – population profile – summary of local needs – continued” • Bracknell Forest Health profile 2017 - http://fingertipsreports.phe.org.uk/health-profiles/2017/e06000036.pdf Slide 28 – “Evidence base – local needs – identification of frailty cohort” • BMA article – “Focus on identification and management of patients with frailty” -

https://www.bma.org.uk/advice/employment/contracts/general-practice-funding/focus-on-identification-and-management-of-patients-with-frailty

Slide 30 – “Evidence base – 2017/18 schemes identified through the JSNA” • Bracknell Forest JSNA – current key issues - http://jsna.bracknell-forest.gov.uk/jsna-summary • Frimley Sustainability and Transformation Partnership Plan - https://www.fhft.nhs.uk/about-us/a-better-future-for-health-and-

care/our-local-sustainability-and-transformation-partnership-stp/ • Bracknell Forest JSNA - Falls and Mobility - http://jsna.bracknell-forest.gov.uk/ageing-well/living-well/falls-and-mobility-0 Slide 31 – “Existing 2017/18 BCF Schemes – Falls” • Bracknell Forest JSNA – Falls and Mobility - http://jsna.bracknell-forest.gov.uk/ageing-well/living-well/falls-and-mobility-0- • Bracknell Forest – “Helping you stay independent guide 2017/18” - https://files.bracknell-

forest.gov.uk/sites/bracknell/documents/helping-you-stay-independent-guide.pdf?ob_ADgMyOGaCiTKxrdPDh2r2AvSd4_DC • Falls Prevention Advisory Service - https://www.fallsfree4life.co.uk/ • Forestcare Responder service - https://www.bracknell-forest.gov.uk/health-and-social-care/forestcare/responder-service • Berkshire Healthcare NHS FT – Rapid Assessment Community Clinic - http://ihub.bracknell-

forest.gov.uk/kb5/bracknell/asch/service.page?id=rnmKXJk6IUo • Bracknell Forest Joint Commissioning Strategy for Intermediate Care 2015-2018 - https://files.bracknell-

forest.gov.uk/sites/bracknell/documents/joint-commissioning-strategy-for-intermediate-care-2015-to-2018.pdf?ATseP5O.yH1LqYBHwyS2eIoZGIIIfQK1

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Key Documents and Links (continued) Documents policies and journals accessed through the hyperlinks are set out below: Slide 33 – “Evidence base – BCF Schemes identified through the JSNA – Self Care” • National Self-Care week award - http://www.bracknellandascotccg.nhs.uk/self-care-week-wins-big/ • Self Care Forum – Self Care Week award winners - http://www.selfcareforum.org/2016/11/18/self-care-week-award-winners/ • Bracknell Forest “Year of Self-Care” – What is Year of Self-Care? http://yosc.bracknell-forest.gov.uk/self-care • Bracknell Forest Public Health Portal – range of services and information - http://health.bracknell-forest.gov.uk/ Slide 36 – “Overview of funding contributions– iBCF” • Gov.uk website – “The allocations of the additional funding for adult social care” -

https://www.gov.uk/government/publications/the-allocations-of-the-additional-funding-for-adult-social-care Slide 39 – “NEL admission contexts – targets and current trajectory” • Self Care week projects and campaigns - http://www.bracknellandascotccg.nhs.uk/health-campaigns/self-care-week-2016/ Slide 90 – “2017/18 BCF Schemes of work – summary” • Bracknell Forest Joint Commissioning Strategy for Supporting People in an Unpaid Caring Role 2015-2020 - https://files.bracknell-

forest.gov.uk/sites/bracknell/documents/Joint%20Commissioning%20Strategy%20for%20People%20in%20an%20Unpaid%20Caring%20Role.pdf?e5Xc2TC63sUaxE6cw.aY87yTU0oq3CLO

Slide 92 – “2017/18 BCF schemes of work – summary” • Gov.uk – “Adult Personal Social services – revenue funding 2017 to 2018” - https://www.gov.uk/government/publications/adult-

personal-social-services-revenue-funding-2017-to-2018

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