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Updated July 2014 Better Care Fund planning template – Part 1 Please note, there are two parts to the Better Care Fund planning template. Both parts must be completed as part of your Better Care Fund Submission. Part 2 is in Excel and contains metrics and finance. Both parts of the plans are to be submitted by 12 noon on 19th September 2014. Please send as attachments to [email protected] as well as to the relevant NHS England Area Team and Local government representative. To find your relevant Area Team and local government representative, and for additional support, guidance and contact details, please see the Better Care Fund pages on the NHS England or LGA websites.
Local Authority Doncaster Metropolitan Borough
Council
Clinical Commissioning Groups NHS Doncaster Clinical Commissioning
Group
Boundary Differences
Doncaster Health and Social Care
boundaries are coterminous. However the
GP registered population includes some
people who reside in another LA area. The
Doncaster Model will accommodate these
boundary differences
Date agreed at Health and Well-Being
Board: 17th September 2014
Date submitted: <date>
Minimum required value of Better Care
Fund pooled budget: 2014/15 £0
2015/16 £24,163,000
Total agreed value of pooled budget:
2014/15 £0
2015/16 £24,163,000
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a) Authorisation and signoff
Signed on behalf of Doncaster Clinical
Commissioning Group
By Chris Stainforth
Position Chief Operating Officer
Date 17th September 2014
Signed on behalf of Doncaster
Metropolitan Borough Council
By David Hamilton
Position
Director for Adults, Health and
Wellbeing
Date 17th September 2014
Signed on behalf of Doncaster Health
and Wellbeing Board
By Cllr Patricia Knight
Position Chair of Health and Wellbeing Board
Date 17th September 2014
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c) Related documentation Please include information/links to any related documents such as the full project plan for the scheme, and documents related to each national condition.
Document or information title Synopsis and links
Doncaster Health and Wellbeing Strategy
https://www.doncaster.gov.uk/Images/fin
al%20HWB%20StrategyrevisedFeb2013
%20final37-102059.pdf
The strategy sets out the priorities for
Doncaster‟s Health and Wellbeing Board and
addresses five areas of focus as well as
focussing in ensuring a „safety net‟ of
services for those that need them
NHS Doncaster CCG
Moving forward, getting better
Five year commissioning strategy:
2014/15 - 2018/19
http://www.doncasterccg.nhs.uk/wp-
content/uploads/2014/04/5-Year-
Commissioning-strategy.pdf
The NHS Doncaster CCG five year
commissioning strategy: 2014/15 – 2018/19
communicates the five year strategic vision
that was developed with local partners and
patients.
The strategy also demonstrates how the NHS
Doncaster CCG plans to achieve their vision
through outcome focussed delivery plans.
Operational Plan Document for 2014/15
– 2015/16
Doncaster & Bassetlaw Hospitals NHS
Foundation Trust (DBHFT)
https://www.gov.uk/government/uploads/
system/uploads/attachment_data/file/338
333/DONCASTER_Operational_Plan_14
-16_1_.pdf
The Doncaster & Bassetlaw Hospitals NHS
Foundation Trust Operational Plan is
intended to reflect the Trust‟s business plan
over the next two years. The document
reflects the strategic and operational plans
agreed by the Trust Board.
Annual Planning Review 2014/15,
Operational Plan
Rotherham Doncaster and South
Humber NHS Foundation Trust (RDaSH)
https://www.gov.uk/government/uploads/
system/uploads/attachment_data/file/338
932/RDASH_NHS_Foundation_Trust_Op
erational_Plan_2014-16_1_.pdf
The operational plan addresses the
immediate challenges and opportunities
facing Rotherham Doncaster and South
Humber NHS Foundation Trust (RDaSH) and
its services over the next two years.
Building the Road Towards Person-
Centred Commissioning
Doncaster Metropolitan Borough Council
Adults Commissioning Strategy
http://www.doncaster.gov.uk/db/chamber/
This strategy sets out a framework for the
allocation of social resources and provides a
guide to inform the expectations of those in
need of care and/or support. Within this
strategy, key themes have been identified
which will need to be progressed with
Page 4 of 136
.%5CReports%5Ci%206%20Adults%20C
oms%20Strat%20App%20A.pdf
partners and the population as a whole.
Joint Strategic Needs Assessment
(JSNA)
The JSNA provides an overarching
assessment of need across the Borough.
The most recent versions are available at
http://www.doncastertogether.org.uk/Don
caster_Data_Observatory/JSNA.asp
The 2012/13 assessment highlighted 12
„outlier‟ public health outcome indicators
which the Health and Wellbeing Board has
reviewed. The 2013/14 JSNA focussed on
Dementia.
The 12 indicators were perinatal mortality,
low birth weight, breastfeeding prevalence,
infant mortality, children in relative poverty,
excess weight in children, killed or seriously
injured on the roads, cancer screening,
suicide, liver disease mortality, respiratory
disease mortality and excess winter mortality.
Page 5 of 136
2) VISION FOR HEALTH AND CARE SERVICES
a) Drawing on your JSNA, JHWS and patient and service user feedback, please describe the vision for health and social care services for this community for 2019/20
Partnership Background
The Doncaster Health and Social Care community has a long history of working together
in partnership to achieve positive change for local people. The Better Care Fund (BCF)
is viewed as a further mechanism to support the on-going development of integrated
services that consider and respond to both the health and social care aspect of an
individual‟s needs.
This is a joint plan which has been developed by all health and social care organisations
in Doncaster. It has been produced by the Joint Adult Commissioning Forum (JACF) on
behalf of the Doncaster Health and Wellbeing Board (HWBB).
The membership of the Doncaster HWBB is made up of representatives from all key
agencies. In addition to Doncaster Health and Council Commissioning agencies, the
Board includes acute, mental health, voluntary and community service providers, the
local social housing provider, Healthwatch Doncaster, NHS England and South Yorkshire
Police colleagues.
Vision and Ambition
The BCF Plan has been developed over time and takes account of intelligence gained by
the Health and Wellbeing Partnership and engagement with Doncaster citizens.
The Doncaster HWBB met in shadow form from April 2011 and became formally
operational in April 2013. During this period the Board developed the first Health and
Wellbeing strategy (2014/15 – 2016/17). This was developed with partners and involved
a range of public consultation events including a Community, Voluntary and Faith sector
consultation event and telephone interviews with 400 Doncaster residents.
The Board agreed two domains of activity;
- Ensuring a „safety net‟ of services for those that need them when they need them
- Areas of focus
- Reducing the harmful impact of alcohol
- Reducing obesity
- Improving mental health
- Improving the quality of life for those with Dementia
- Families
- Increasing personal responsibility
The strategy also consulted on the vision for Doncaster and a number of supporting „I‟
statements.
Page 6 of 136
The HWBB vision for Doncaster is;
Doncaster people enjoy a good life, feel happy and healthy,
and agree Doncaster is a great place to live
The HWBB ambition is for Doncaster people to say;
- I‟m able to enjoy life
- I feel part of a community and want to give something back
- I know what I can do to keep myself healthy
- I know how to help myself and who else can help me
- I am supported to maintain my independence for as long as possible
- I understand my health so I can make good decisions
- I am in control of my care and support
- I get the treatment and care which are best for me and my life
- I am treated with dignity and respect
- I am happy with the quality of my care and support
- Those around me are supported well
- I want to die with dignity and respect.
The BCF now provides a mechanism to progress our local ambition further, faster. These
ambitions are at the centre of our planning.
Understanding Current Need
The vision and ambition for service change and transformation has been directed by
understanding the needs of the individuals living in the borough and by considering the
key issues influencing the health and wellbeing of the Doncaster population.
The total resident population of Doncaster is 303,000 (mid-2012 population estimate
ONS). The population registered with a NHS Doncaster CCG GP is 311,844. This
includes a wider geography than just the main conurbation around the town centre,
ranging from urban to rural; with a deprivation score of 19.8 making it more deprived than
the England average of 36.6.
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The map below demonstrates the range of deprivation levels across the borough;
Fig.1. Doncaster Deprivation Map
Within the patch there is;
- One Council (Doncaster Metropolitan Borough Council; DMBC)
- One Clinical Commissioning Group (NHS Doncaster Clinical Commissioning
Group)
- One Acute Hospital Foundation Trust (Doncaster & Bassetlaw Hospitals NHS
Foundation Trust; DBHFT)
- One Community & Mental Health Foundation Trust (Rotherham, Doncaster &
South Humber NHS Foundation Trust; RDASH).
The Doncaster Joint Strategic Needs Assessment (JSNA) and locally produced
benchmarking was used by the partnership to underpin the development of the BCF plan.
The JSNA and benchmarking data from HSCIC told us that;
- Health and Wellbeing is improving in Doncaster for both men and women
- However, health and wellbeing is not improving as fast as in the rest of the
country. Heart disease, strokes, cancer and alcohol are still the major killers
- In general, lifestyles including smoking, physical activity and nutrition are less
healthy than the rest of the country. This is true for children as well as adults
- There are more people who report living with three or more long term health
conditions in Doncaster than the national average – Doncaster ranks 202 of 211
CCGs and 142 of 152 upper tier Councils
http://ccgtools.england.nhs.uk/ltcdashboard/flash/atlas.html
- There are increasing numbers of older people in the borough, many live alone and
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require help and support to maintain their independence. The numbers of people
living with Dementia are increasing
- Where people live, as well as education, housing, work, crime and the
environment all contribute to health and wellbeing.
This is more clearly demonstrated in the spine chart below, which sets these issues in
the context of the Doncaster peer group and England rates, using the latest available
data.
Fig.2. Doncaster Outcomes
Understanding The Future Challenge
NHS England “The NHS belongs to the people; A call for Action” gave a clear message
on the impact of an aging population;
People are living longer and while this is good news an ageing population also presents a
number of serious challenges for the health and social care system;
- Nearly two-thirds of people admitted to hospital are over 65 years old
- There are more than 2 million unplanned admissions per year for people over 65,
accounting for nearly 70% of hospital emergency bed days
- When they are admitted to hospital, older people stay longer and are more likely to
be readmitted
- Both the proportion and absolute numbers of older people are expected to grow
markedly in the coming decades. The greatest growth is expected in the number
of people aged 85 or older – the most intensive users of health and social care
Indicator Doncaster Peer
GroupEngland
Lowest in
EnglandEngland Range
Highest in
England
Potential years of life lost (PYLL) from causes considered
amenable to healthcare DSR per 100,000 - P2705.20 2401.06 2060.80 1413.60
3214.70
Under 75 mortality rates from cardiovascular disease 84.70 76.20 65.47 39.03
121.79
Under 75 mortality rates from respiratory disease 38.00 36.77 27.44 13.41
65.90
Under 75 mortality rates from cancer 155.92 144.62 123.26 90.82
169.54
QOF Smoking prevalence 32.34 32.50 28.73 17.65
35.69
QOF Obesity prevalence 13.29 13.79 10.72 5.69
16.34
QOF COPD prevalence 2.62 2.55 1.74 0.77
3.55
QOF Asthma prevalence 6.67 6.48 6.00 3.73
7.61
QOF Diabetes prevalence 7.45 6.78 6.01 3.53
8.87
QOF CKD prevalence 6.07 5.04 4.25 1.60
8.53
Emergency admissions for acute specialties 124.09 114.87 96.90 59.20
140.51
Unplanned hospitalisation for chronic ambulatory care
sensitive conditions 894.20 1025.24 800.18 167.10
1483.80
Emergency admissions for acute conditions that should
not usually require hospital admission1792.50 1662.67 1226.27 277.20
2287.20
Better Care Fund
Page 9 of 136
- Studies suggest that older patients account for the majority of health expenditure.
One analysis found that health and care expenditure on people over 75 was 13-
times greater than on the rest of the adult population.
The partnership considered the expected age profile change in Doncaster when
developing the areas of focus for the BCF plan. The data was clear. It confirms that
there will be a stable 18-64 year population but an increasing ageing population to 2018.
This is clearly demonstrated in the following graphs;
Fig.3. Doncaster Predicted Population
The Doncaster population are also high users of hospital services, in particular
emergency services, as demonstrated above in table Fig.2. During 2013/14 there were a
total of 38,580 non elective admissions (source SUS including specialised); this includes
2,633 Chronic Ambulatory Care non elective admissions and 5,213 Acute Ambulatory
Care Sensitive Conditions non elective admissions. This latter cohort are considered to
“avoidable” Furthermore there were 152 more people dying in hospital in Doncaster
than the England average (source; End of Life Care Profile NHSE Atlas, 2010-12
average). Local data also shows that non elective admissions to hospital in Doncaster
are highest for those aged 0-4 and over 65 years, with over 65s accounting for 40% of all
non-elective admissions. Improvement to the level of the Acorn 10 for Doncaster would
result in;
Current Future
Fig.4. Impact of improvement for Doncaster Acorn
Page 10 of 136
Transformation Programme
The approach taken locally, to tackle the issues noted above, was to identify and agree a
Health and Social Care Transformation Programme (HSCTP) focussing on where an
integrated approach to service delivery would deliver most benefit.
The Transformational Programmes identified by the Board focus on three areas. These
are;
- Community and Universal Programme
The strategic intent of this programme is to release personal, community, state,
private and third sector assets to increase community self-help and increase the
effectiveness of coproduction to improve health and wellbeing.
It focuses on three areas, community capacity building using the Think Local, Act
Personal framework for HWBB, ensuring a consistent approach to the voluntary,
community and faith sectors and maximising the role of universal services.
- Short Term Programme
Interventions that preserve the independence of people. The aim being that
patients are supported to maintain independence in their own home as long as
possible. The service offer will focus on rehabilitation, independence and care as
close to home as possible.
- Long Term Programme
Responsive and tailored support for individuals when their needs become long
term. The aim being the long term care, support or treatment at home, in the
community and within institutional settings.
The three Transformational Programmes are supported by fourteen detailed schemes as
follows;
1. Community Capacity
2. Targeted Support
3. Falls
4. Admission Avoidance Schemes
5. Reablement Services
6. Discharge Schemes
7. Intermediate Care
8. End of Life
9. Equipment, Technology and Adaptations (ETA) Programme
10. Mental Health Including Crisis
11. Dementia Services
12. Supporting Carers Including Respite Services
Page 11 of 136
13. Personalised Support
14. Housing Options
The table below demonstrates how each of the fourteen schemes supports the three
Transformational Programmes and the key metrics that they will deliver against.
Better Care Fund Metrics
Programme Area Scheme Ref
No Scheme
Reduction in permanent residential admissions
Increased effectiveness
of reablement
Reduction in delayed
transfers of care
Reduction in non-elective (general &
acute)
Community and Universal
1 Community Capacity
2 Targeted Support
3 Falls Programme
Short Term
4 Admission Avoidance
Schemes
5 Reablement Services
6 Discharge Schemes
7 Intermediate Care
8 End of Life
Long Term
9
Equipment, Technology and
Adaptations (ETA) Programme
10 Mental Health including Crisis
11 Dementia Services
12 Supporting Carers including Respite
Services
13 Personalised Support
14 Housing Options
Fig.5. Doncaster Better Care Fund Matrix
Patient and User Feedback
Service user and public engagement events have also influenced and supported the
development of the Health and Wellbeing Strategy, local Commissioner Strategies and
the BCF plan. An example being the partnership work with the local Council for
Voluntary Services to find out views on priorities for the Health and Wellbeing Strategy.
More than 400 people were surveyed and a number of consultation events were held.
More recently, public and partnership events have been held to re-test the HWBB vision
and ambition.
Further engagement and communication events are planned and as such, a
communication and engagement plan is in development and will be implemented by the
JACF on behalf of the Doncaster HWBB.
Moving forward, the partnership feels strongly that patients and the public are involved
and influence local BCF transformational change.
It is a requirement that patients and the public are engaged in the delivery of the three
Transformational Programmes. A number of arrangements are already in place ranging
Page 12 of 136
from Healthwatch input into programme boards, utilising Partnership Alliance Meetings
(chaired by patients) and Voluntary Sector input.
In addition, Healthwatch Doncaster is a member of the Doncaster HWBB and the NHS
Doncaster CCG Governing Body.
b) What difference will this make to patient and service user outcomes?
System Impact
The Doncaster HWBB ambition is that services will look and feel very different in five
years time. Key deliverables include;
- Patients won‟t attend hospital for a lot of their care. Services will be provided
much closer to where they live
- Health and social care commissioners will be working collaboratively to ensure
that services are co-ordinated and integrated. An early focus will be to develop
intermediate care services, Dementia care and community services
- Service provision will be based on the health and social care needs of the patient
- Care will be provided in a holistic and integrated way across health and social care
services
- Commissioners and providers will receive real time feedback on user experience
of services
- Users will be an equal stakeholder in determining their care and support packages
- Services will have been commissioned that take advantage of new technologies
and these will be supporting patients to maintain and manage their medical
condition
- Service users and Doncaster people will help us to design a health and social care
system that is easy to navigate and understand
- Services will be available when required, not just during the week
- Care provision will be co-ordinated and service users will know who their lead
accountable professional is
- Services will be commissioned to support service users in their own home to
manage their condition and maintain independence
- Services will address the mental health as well as the physical needs of
individuals
The Doncaster HWBB ambition is that by promoting and supporting independence in the
community, patients and users will live independently and continue to have a good
quality of life for longer.
Also, as the focus is on maintaining independence and mobility and the development of
community based services to support this, non-elective admissions to hospital will reduce
and patients will be supported to maintain physical wellness.
Page 13 of 136
When individuals do need access to urgent care, those services will be responsive to the
needs of the patient and user and will be of a high quality. Urgent care services will also
promote independence and mobility and a primary aim will be to facilitate urgent care
treatment and a transition into an integrated intermediate care service that promotes
home based care.
Patient and Outcome Impact
The following scenarios demonstrate how the development of the three Transformational
Programmes will support commissioners and providers to work in an integrated way to
respond to the needs of individuals. The scenarios are based on what would happen to
“Mavis”, a character that typifies an older resident of Doncaster.
Mavis is 82 and lives in Conisbrough. She has a low income and lives alone in a Housing
Association house which she has lived in for 50 years. She is recently widowed. She misses her
husband, who was her carer and organised her medicines. Her family all now live away and the
friends she used to talk too have either died or moved into Care Homes. Mavis wants to stay in
the home that she has lived in for most of her adult life, where she has memories of her family
and some good neighbours, but she is lonely and often feels depressed.
Mavis has multiple long term conditions including Diabetes, Arthritis, COPD and early signs of
possible Dementia. However, she does have capacity and is managing well at the moment.
She does not receive homecare services but she has had some minor adaptations made to her
home such as grab rails, as she often wobbles on her feet. She can cook, but has to rely on her
neighbours to do her shopping. She misses shopping as much for the lunch she used to have at
the supermarket, as she does for the independence and choice it provided her every week.
Since her husband died, she makes frequent 999 calls, because she is not sure what else to do
when she is worried and unwell. She makes several A&E visits each month, each time staying at
least overnight for observation.
Page 14 of 136
Following a call to the local authority by her neighbour to say Mavis was struggling to put her bin out, Mavis agreed to and received a call from the Community Wellbeing Officer. The Wellbeing Officer visits Mavis and carries out a support planning assessment which looks at Mavis‟s assets and needs. As a result of this assessment they make a referral regarding her benefits and connect her with the local chair based exercise group, which helps keep her mobile and reduces her risk of falling. The Wellbeing Officer also talk to Mavis‟ neighbours to see if there is any support they might need as informal carers for Mavis. Mavis is also connected with the local Community Dementia café, who are able to support her as her condition progresses. This group is also connected into the Winter Warm scheme and when the weather changes, Mavis receive a winter warm pack and some help in keeping her house warm. Mavis now attends A&E less often and is in regular contact Care Coordinator from the Primary Care Community Team. The Care Coordinator is a member of the MDT who is best placed to holistically coordinate Mavis‟ support. This assists in keeping grip of and accountability for Mavis‟ package of care and is a big relief to Mavis who previously had to contact lots of different people.
Following a call to 999 Mavis is taken to A&E. Instead of being admitted to hospital unnecessarily she is seen by one of the Integrated Transfer Team who are co-located at the hospital. They suggest that Mavis would benefit from a single outcome based assessment to look at her Health and Social Care needs, but that this would best be done at home. They refer her to the Integrated Reablement Team and the trusted assessor meets Mavis at home within a two hour period. In partnership with Mavis an asset based support plan is developed which focuses primarily on what Mavis can do for herself. The installation of Telecare equipment, and a falls assessment is an integral part of her assessment as this will further support Mavis to feel safe particularly during this initial period. Mavis receives 2 visits each day for 3 weeks from the Reablement Team, throughout this period the support workers enable Mavis to maximise her independence and confidence through an Occupational Therapy plan which includes activities of daily living. Mavis‟ progress is monitored through a reablement Case Manager led Multi-Disciplinary Team which responds to any fluctuation in need. As Mavis regains her independence the Case Manager will start to assist her to connect with her local community by facilitating a referral to the Wellbeing services.
‘Communiversal’ services
Community Support Short Term Support
Intermediate Care
All the staff at the lunch club that Mavis attends are „Dementia Friends‟ and are aware of the Care Coordinator and One Team Working arrangements in the locality .The lunch club notice that Mavis appears a little confused and agree with Mavis that it would be a good idea to contact her GP. As part of the Connected Communities Network they arrange for a volunteer befriender to assist her to make contact with her GP and the services available as part of the Primary Care Community Team. Mavis‟ Care Coordinator is connected to the Primary Care Liaison Nurse for Dementia and together with Mavis they agree a support plan, with the universal support planning tool. A culture of Continuous Review means that Mavis is connected into the right services at the right time throughout the progression of her dementia as well as managing her other health and social care needs. The universal support tool and single assessment approach allows her to discuss plans for the future and she has expressed she would like at the right time to move to the Dementia Friendly Extra Care Facility in the locality. Mavis also discusses with her care coordinator how she would like to manage the end stages of her life and together they create an Advanced Wishes and Living Will.
Long Term Services Dementia and Community Care
Page 15 of 136
Performance Impact
The three Transformational Programmes will deliver the range of benefits described
above. In order to understand whether the expected benefits are realised a number of
key metrics will be regularly reviewed through the HWBB governance structure (see
section 4b).
The key metrics that will indicate the success of the programmes and supporting
schemes are;
- Reduction in non-elective admissions to hospital by 3.5% between 2014/15 and
2015/16. This equates to 1314 fewer non-elective admissions to hospital for
Doncaster residents per year
- Reduction in permanent admissions of older people to nursing and residential
homes by 24
- Increasing the proportion of people still at home 91 days after discharge to 84%;
this equates to 48 more people still at home 91 days after discharge in comparison
with 2013/14
- Reduction in delayed transfers of care by 90 days during the period
- Increasing the number installations of assistive technology for people aged 65 and
over from on average 55 per month to 77 per month; this equates to approximately
an additional 260 people in receipt of assistive technology
- Patient /service user metric is still to be determined nationally
Underpinning these key metrics is a suite of further metrics which represents both broad
aims in support of each Transformational Programme, such as increasing the number of
people receiving reablement in their own home, and measures specific to each scheme.
Please see section 3 Case for Change and details under each scheme in Annex 1 for
further details regarding metrics.
Data to support the key metrics is already being collected; an overall BCF dashboard and
dashboards for each Transformational Programme are in development. These
dashboards will be presented to each of the Transformational Programme Area Working
Groups, and to the JACF on a regular basis. The screenshot below shows the dashboard
in development.
Page 16 of 136
Fig.6. Doncaster Health and Social Care Transformation Programme Performance Monitoring
Dashboard for the BCF Metrics
c) What changes will have been delivered in the pattern and configuration of services over the next five years, and how will Better Care Fund funded work contribute to this?
Expected pattern and configuration of services
The Kings Fund (2013) Transforming our healthcare system; Ten priorities for
commissioners states that;
The ageing population and increased prevalence of chronic diseases require a strong
reorientation away from the current emphasis on acute and episodic care towards
prevention, self-care, more consistent standards of primary care, and care that is well co-
ordinated and integrated.
Services in Doncaster are currently focussed on responding to patients and service users
when they have an urgent care need. Services have responded very well to this model
of care but with an aging population and an expected increase in service user need and
expectation, a different approach to care provision is required.
The vision for the future configuration of services in Doncaster focuses on a move from
treatment to prevention.
The current model of Primary Care service provision focuses heavily on the treatment of
illness and patient contact at the point of illness and crises. There will be a shift in focus
to prevention of illness and avoiding the deterioration of patients with long term
Page 17 of 136
conditions.
Community based services are currently provided in a transactional and task orientated
way. In the majority of cases they are delivered by either health or social care providers.
Individual specialists will also provide care to patients dependent upon specific identified
conditions. We aim to move away from this model of care to provide a holistic service
taking account of the health and social care need of the individual. We will support
service providers to develop relationships with service users so they can agree and
endorse their own care plans. We will also help develop local professionals to enhance
their skills in managing patients and users with complex needs. Specialist input will be
provided differently and will underpin the provision of universal services, providing
education and support to the professional overseeing and managing the care of the
individual.
Urgent hospital care currently focuses on providing urgent access to A&E services and
acute hospital based diagnostics and beds. There will continue to be a need for this
service but the HWBB will work with acute hospital colleagues to focus on understanding
the needs of patients to maximise independence, work across the health and social care
system to enhance discharge arrangements and transfer patients into intermediate care
services quickly to support rehabilitation and a transition to home.
Intermediate care services in Doncaster have developed over a number of years and are
uncoordinated and difficult for patients and professionals to navigate. It is currently a bed
based model with limited rehabilitation and reablement opportunities in the community.
There are limited step up opportunities for any group of patients to avoid unnecessary
hospital admissions. The ambition moving forward is that a clear and simplified service
offer will be commissioned. There will be a range of service offers available depending
upon patient need. These will range from low level service input to supporting patients at
the end of life to die in their own home if this is their preference. Services will offer a step
up and step down facility and the primary focus will be on maintaining and promoting
independence and living longer at home.
Underlying Themes
In developing the service model highlighted above, a number of themes for the
commissioning and provision of services has also been agreed. These will inform the
development of all service offers under the BCF programme.
The themes are;
- Develop services to reduce non-elective admissions and facilitate timely and
appropriate discharges
- An Accountable Lead Professional Approach will be developed and embedded
into services
- The primary aim is to maintain patients and service users in their home as long as
possible
- Universal services can cater for the needs of all patients and service users –
Page 18 of 136
including patients with Dementia
- Patients and users will be able to access services 7 days a week
- Services will be delivered in an integrated way taking account of health and social
care needs
- Commissioners will work with providers to ensure that the primary aim of all
partners is to maximise independence, maintain patients in their own home and
avoid unnecessary hospital admissions
- The partnership will support education and development programmes in the
public, private and third sector to ensure that services are provided to a high
quality and in line with these agreed principles.
Page 19 of 136
3) CASE FOR CHANGE Please set out a clear, analytically driven understanding of how care can be improved by integration in your area, explaining the risk stratification exercises you have undertaken as part of this.
Commissioners and providers in Doncaster have a strong track record of working in
partnership to deliver change. This provides a good foundation to move forward the
significant transformational change programme that is required to ensure services are
integrated, avoid unnecessary hospital admissions and provide a service offer that is fit
for the longer term.
The HWBB has established that focus should be placed on the three Transformational
Programmes underpinned by fourteen detailed schemes. The rationale for this approach,
which focuses on where an integrated approach to service delivery would deliver most
benefit, in described in Section 2 – Vision for Health and Care Services.
Each Transformational Programme area is interlinked and connected across the wider
system. This mirrors the profile of the Doncaster population, which has been determined
through local risk stratification;
Fig.7. Doncaster Population Profile
Typical Age
Typical Number of Chronic Diseases
Transformational Programme Focus
BCF Spend
76+ 2 or 3 Short & Long Term £74,000
56-85 1 or 2 Short & Long Term £671,000
36-70 1 Community & Universal
£10,600,000
6-65 1 Community & Universal and Prevention
£12,818,000
Source – Doncaster Risk Stratification System
1,515
13,635
45,450
242,400
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The local data has been further segmented by age and condition.
Fig.8. Number of acute emergency hospital admissions by age and sex in Doncaster 2013/14
The top 10 primary diagnosis codes made up 27.3% of all non-elective hospital
admissions in Doncaster in 2013/14. The most frequent reason coded for was pain in
throat and chest, followed by abdominal and pelvic pain and pneumonia.
The top 10 primary diagnosis codes for non-elective readmission to hospital in 2013/14 in
Doncaster made up 6.1% of all non-elective hospital admissions over the same period.
The most frequently coded reason for non-elective readmissions to hospital is abdominal
and pelvic pain, followed by pneumonia and pain in throat and chest.
The top 10 communities with the highest rate of non-elective admissions have been
identified and there is a strong relationship between admissions and deprivation.
Fig.9. The 5 primary diagnosis for the 10 areas with the highest proportion of emergency hospital
admissions in Doncaster
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The population has also been segmented using the costing tool published by monitor.
Fig.10. Estimated population breakdown by segments
If the cost model is applied to the current spend on each of these segments and the
impact of population growth is factored in then Doncaster will need to find an additional
£61,000,000 to meet the needs of the population (average cost per person increasing
from £1,721 to £1,881) unless either the population is distributed differently across the
segments or the average costs of each segment are reduced.
Fig.11. Projection of population size
Fig.12. Projection of spend
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The case for change and expected outcomes for each Transformational Programme are
as follows;
Community and Universal Case for Change
The community and universal programme links closely to the health improvement and
prevention work streams of the HWBB. Initial areas of focus are on reducing the harmful
effect of excess alcohol, reducing tobacco smoking prevalence and increasing physical
activity.
On behalf of the partnership, the Community and Universal Transformation Programme
is led by the Assistant Director Public Health, Doncaster Metropolitan Borough Council.
The strategic intent of this programme is to release personal, community, state, private
and third sector assets to increase community self-help and increase the effectiveness of
coproduction to improve health and wellbeing and build stronger more inclusive
communities with the expected impact of increased strengths and assets of communities
with reduced demand on services. Stronger more mutually supportive communities, who
look after each other, should reduce social isolation and enable people to stay in their
own homes.
Fig.13. Community Capacity Building Logic Model
Source; Developing the power of strong, inclusive communities; draft HWB framework, December
2013
Evidence
The evidence shows that strong, inclusive communities impact both on overall physical
and mental health and well-being as well as specific health conditions, such as heart
attacks and social outcomes, such as community safety.
- Improving overall health and well-being – for example; people with adequate
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social relationships have a 50% greater likelihood of survival, social support and
activity may protect against Dementia and cognitive decline and committing one
act of kindness, once a week, over a six week period, boosts overall well-being
- Impact on specific conditions and social outcomes – compared with conventional
approaches increased social cohesion and social networks can reduce fatal heart
attacks by 25% in men, social participation is the most significant predictor of
difference between people with and without mental health problems and time
credit schemes for young people can reduce crime by 17%.
Return on Investment
Both building community and individual capacity, and development and the redesign of
universal and targeted services to be much more effectively co-productive require
investment. However this investment is likely to be more than offset by the savings
resulting from improvements in health and well-being, reducing demand for services and
enabling disabled and older people and people with long-term conditions to be more
independent. These savings are of different types;
- Cashable savings
- Non-cashable savings
- Levering in investment
Savings for different types of community development may be found.
- Whole community – where the community development is used to improve the
health and well-being of all local people in an area. For example, the Health
Empowerment Leverage Project estimates that investing in the 20% most
disadvantaged neighbourhoods in a typical Council area would produce a health
saving of £4,242,726 over three years - just over £1,410,000 a year. Some of the
most powerful influences on behaviour change are family and neighbours and a
collective sense of self-esteem helping people believe that it is possible to take
actions to improve their own health and well-being (IdeA Glass Half Full)
- Particular population groups – for example disabled or older people. Partnerships
for Older People‟s projects showed that; overnight hospital stays were reduced by
47% and use of A&E Departments by 29%; and phone calls to GPs fell by 28%
and appointments by 10%. Every £1 spent on POPP services generated £1.20 in
savings on emergency beds
- Specific community initiatives – for example peer support in mental health can
save bed days and reduce hospital re-admissions by 50% compared with
traditional care, a saving of £28,000 each year in Leeds. Befriending schemes
reduce social isolation, loneliness and depression among older people and hence
the need for treatment. Schemes cost £80 per person per year to run and produce
savings of £300 per person per annum.
Examples of savings from investing in more effective co-productive services are;
- Enabling people to take more control of their lives and health – for example, the
Expert Patient Programme, enables individuals to better manage their long term
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health conditions, producing a £6.09 saving for every £1 spent. This includes;
reducing GP consultations by 7%, outpatient visits by 10% and A&E attendances
by 16%
- People providing part of the service themselves – for example, Shared Lives,
where a person with learning disabilities becomes part of another family costs
£423 compared with between £995 and £1,600 per person in supported living. The
social return on investment of volunteering is £2 and £8 per £1 spent on
supporting volunteers
- Redesigning existing service models – moving away from providing direct services
to enabling communities to run their own services. Through a transfer of assets to
community providers Lambeth has so far delivered £2,400,000 in efficiency
savings and community facilities and also levered in £5,500,000 in investment into
the borough.
Programme Objectives and Desired Outcomes
- To contribute to improved health and wellbeing, reduce hospital admissions,
increase community capacity, increase volunteering, develop stronger social
networks and communities, affect behaviour change, develop more local services
and support
- To assess the impact of the Care Act 2014 and identify relevant work programmes
- To describe a vision for Community and Universal Services and develop a
roadmap to deliver change to develop a roadmap to improve health and wellbeing
and support the development of stronger more inclusive communities.
System success indicators
Expected success indicators include;
- Reduction in non-elective admissions
- Reduction in the number of falls
- Reduction in non-elective admissions due to „cold weather‟
- Increase in satisfaction levels and an increase in community based support
- Increase in reported levels of community support
- Increased access to peer support services
Short Term Case for Change
On behalf of the partnership, the Short Term Transformation Programme is led by the
Chief of Strategy and Delivery, NHS Doncaster CCG.
To support the short term transformation programme, the HWBB has sponsored a joint
Intermediate Care Needs Assessment programme.
The HWBB, the JACF and the Doncaster Health and Social Care community want to
understand the needs of frail and elderly patients upon their admission and discharge
from hospital based services to support the development of a future integrated service
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offer.
Local Commissioners and Providers have already identified a range of strategic
ambitions and work programmes relating to care out of hospital, care of the frail and co-
ordinated care. The ambition is that this needs assessment will be a catalyst for
systematic transformational change „to maximise independence and improve quality
utilising resources effectively to get best value for money whilst improving and simplifying
the system for patients and healthcare professionals‟.
The needs assessment is required to help support the development of a new service
offer of health and social intermediate care that will;
- Fit the local health and social care landscape
- Be sufficiently flexible to respond to the changing needs of the population (future
proof)
- Reflect and be responsive to key service/pathway configurations taking place in
parallel and at different paces
- Identify those people living with frailty who will form an important part of the 2%
GPs will be required to case manage as stated in their new contract
Currently, the main focus for the care of frail elderly patients is in hospitals and is reactive
to sudden changes in health. A shift to a more proactive method of frail elderly care
management that is based mainly in primary care is a key aspiration and intermediate
care, or “care closer to home,” has been quietly evolving.
Understanding the needs of frail and elderly patients in Doncaster will provide a valuable
data set that will be available to support the Doncaster health and social care partnership
in designing and delivering a service off that will respond to the needs of the Doncaster
population in the future.
Evidence
Ideas for change will be supported with strong evidence, gathered by professional, expert
advisors who have sought guidance and direct inputs from wider stakeholders in the
community. Research will be undertaken to support this element of the programme
including data and advice gathered from the Social Care Institute for Excellence.
http://www.scie.org.uk/topic/keyissues/integration
Initial research is also suggesting that a wider range of evidence can be used to support
the design of a future service offer including;
Title: Intermediate care for older people in the UK
Source: Clinical Medicine 2010 Vol 10 No 2: 119–23
Author(s): Henry J Woodford and James George
Title: Hospital discharge: a descriptive study of the patient journey for frail older
people with complex needs
Source: Journal of Integrated Care, 18(3), June 2010, pp.30-36
Author(s): MITCHELL Fraser, GILMOUR Mhairi, MCLAREN Gordon
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Title: Complex interventions to improve physical function and maintain
independent living in elderly people: a systematic review and meta-analysis
Source: The Lancet, Volume 371, Issue 9614, Pages 725 - 735, 1 March 2008
Author(s): Andrew D Beswick BSc, Karen Rees PhD, Prof Paul Dieppe FRCP, Salma
Ayis PhD, Rachael Gooberman-Hill PhD, Jeremy Horwood BSc, Prof Shah Ebrahim
FRCP
A primary aim in sponsoring change going forward will be to;
- Improve patient outcomes based on a care model of maximum independence and
reablement
- Provide a service offer that is integrated and considers both the health and social
care requirements of the individual.
In John Young‟s introduction to the 2013 National Audit of Intermediate Care (IC), he
states that “Intermediate care services have always been a platform to develop new ways
of working – particularly multi-agency , but the national audit revealed that Intermediate
Care as a whole is not yet delivering the type of service patients hope for.”
Process
A timely and rigorous review of intermediate care services is now underway which will
focus on the following;
- Analysis, comparison and overview of the current system of care for patients
- An assessment of the ability of the current delivery model to meet the required
service outcomes, including variation in care under the contract
- Identification of wider enablers and barriers to the modernisation of intermediate
care services
- The use of existing and new information to produce a population needs analysis to
inform the scope of the service/s
- Appraisal of a range of commissioning models for intermediate care services as
part of integrated care offer
- Evaluate processes and outcomes measures of the current system/provider using
clinical audit
- Determining whether the patient and carers‟ voice and views are currently
captured in the intermediate care service
- Identification of measurable project and service benefits.
Programme Objectives and Desired Outcomes
The short term transformation programme will initially focus on collecting information,
understanding need and recommending the future service offer. A number of key
deliverables will be produced throughout the programme. These will be considered by
the partnership and a future service model will be recommended. Expected deliverables
include;
- A report explaining the initial health needs identified, the current system
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constraints and challenges and what constitutes the case(s) for changing them,
including any gaps in information requiring resolution to validate any further
service models and recommendations of future dashboards to focus on targets
and improvement themes
- A Clinical Audit report explaining the statistical case(s) for changing the current
Intermediate Care (IC) system, including qualitative perceptions of care needs.
- A scenarios report that will feed into a final Strategic Outline Case
- An Evidence pack to inform the change agenda for Doncaster and recommend
next steps such as benchmarking and further testing/ analysis/ modelling of new
designs with Doncaster data
- Organise any exploratory conversations with providers of identified best practice
models of care and fact finding visits from NHS Doncaster CCG‟s JACF/IC
Working group
- A Strategic Outline Case to define the change agenda for Doncaster Intermediate
Care frail and elderly service offer and recommending next steps for possible
implementation, including a comprehensive performance management and quality
dashboard (based on outcomes). Detailed format to be agreed, but including;
- A description of Audit/ Needs Assessment
- A review of all outputs and the key themes identified
- Recommendations for future service offer
- To implement a key pause for consultation with stakeholders, patients and public
- Publish options for service models to be taken for further consultation with
stakeholders, the IC Working Group and patient and public.
System success indicators
Expected success indicators include;
- Reduction in non-elective admissions
- Reduction in delayed transfers of care
- Reduction in admission to long term care
- Increase in user satisfaction levels
- Increase in the number of patients receiving rehabilitation and reablement in their
own home
Long Term Case for Change
On behalf of the partnership, the Long Term Transformation Programme is led by the
Head Of Commissioning and Contracts, Adults, Health and Wellbeing, Doncaster
Borough Council.
The Long Term Programme of the BCF in Doncaster is concerned with driving and
implementing radical change and modernisation of services and support for local people.
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Huge cultural change is required, alongside the structural changes that implementation of
the Care Act 2014 will bring, in how support is funded and delivered. This includes
shifting the long-term care arrangements away from the current default model of
residential care, towards a flexible range of different options and opportunities.
The changes required are fundamental. They will not be realised if this is treated as an
incremental or quality improvement model of change. This is not just about dignity and
respect, already current cornerstones of government policy and best practice guidance.
This is about a completely different, rights-based approach, beginning with an increased
focus on citizenship, personal identity and self-expression.
The Long Term Group will need a multifaceted approach to sharing, testing and
embedding this vision to ensure it becomes a reality.
At the centre of this shift in culture, the Care Act will overhaul the social care system in
England, reforming and streamlining much of the legislation on access to, administration
of, and responsibilities for care services. This complex and lengthy Act introduces the
following new duties and powers;
- From April 2016 a cap on care costs an individual will pay over their lifetime
(£72,000 for people who develop care needs after the state pension age and a
lower cap for people below the state pension age), together with extended means-
test support for people in residential care
- National eligibility criteria to ensure that everyone across England is eligible for the
same level of social care wherever they live
- Formal recognition of the rights of carers and support for those eligible
- A duty on Councils to consider the physical, mental and emotional wellbeing of
individuals in need of care
- New powers for the Chief Inspector of Social Care to hold poor-performing
providers to account
- A requirement for Council‟s to offer deferred payment schemes so that individuals
do not have to sell their homes to pay for residential care in their lifetime.
As we move to define the new Care Act landscape, the delineation will require new
partnerships across the wider public and private sector community. Significant to the
Health and Social Care partnership in Doncaster will be the relationship with Housing and
the evolving understanding that the shift from institutional solutions and a bed based
hospital culture can only be successful if communities have the appropriate housing
options to remain independent in the long term.
Good housing on its own however does not provide the total solution, there needs to be a
revolution in connectivity that will require a massive increase in the use of technology and
joined up Social Care/Health thinking. Communities themselves will also need to be
responsive to the demands of an aging frail population, creating internal solutions
through peer support to local dynamics. This approach will be essential as the Long Term
group tackles the emerging issues around Dementia and the challenges around
developing Dementia Friendly Communities.
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In delivering a new Social Care/Health environment the Long Term Group will need to be
mindful that traditional care and support in Care Home settings and via domiciliary care
will continue to be an “available” element of the strategic picture. With that understanding
it will be necessary to move away from the task based contract monitoring currently in
place and move to a more outcome based strategic intelligence approach across the
wider partnership. This will allow an “honest” discussion with providers on how to improve
the quality of service provision at the early stages of “service failure” without recourse to
a punitive sanction approach.
The most fundamental challenge for the Long Term Group will be for Commissioner‟s
and provider‟s to develop a real partnership with individuals and communities to develop
new proactive and flexible services that meet outcomes and deliver choice and control. In
understanding that approach the Social Care/Health Market will also need to begin to
fundamentally change from a prescribed model of delivery to a flexible outcomes based
approach that puts the client/patient as an asset at the centre.
The broad scope for the Long Term Programme will include;
- Delivering alternatives to institutional care
- Delivering support and options for carers
- Delivering the Care Act delineation
- Delivering continuous improvement for Dementia Care
- Delivering a partnership delivery of Housing Options
- Delivering technological solutions to support independent living
- Delivering a co-produced approach wherever possible.
System success indicators
Expected success indicators include;
- Reduction in non-elective admissions
- Reduction in Mental Health and Dementia crises
- Increase in satisfaction levels and an increase in community based support
- Increase in the number of patients receiving rehabilitation and reablement in their
own home
- Improved supported housing option in place
- Increased use of Telehealth and Telecare services
- More people utilising personal health budgets
- Doncaster will be Dementia friendly.
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4) PLAN OF ACTION a) Please map out the key milestones associated with the delivery of the Better Care Fund plan and any key interdependencies
Community and Universal Key Programme Milestones
Fig.14. Community and Universal Transformation Programme Milestones
Three schemes have been identified that contribute to this theme. They include
- Community Capacity
- Targeted Support
- Falls programme
Seven existing initiatives already funded via the transfer of health monies to Social Care
were identified, agreed to be relevant, aligned to the schemes and included in the BCF
plan.
Community Capacity Building
- Community Day services offer
- Community connectors
- Community Funding Prospectus
- Community based patient centred care
Targeted Support
- Sexual Violence Advocacy
Co-production of Community & universal services strategy
Jan 2015 20152015
March 2015 2015
July 2015 2015
Community and Universal offer action plan complete
Interim Evaluation
/performance of Key
services complete
External evaluation of Community Innovation fund
Sept 2014 2014
Sep 2015
Launch of outcomes based Community Innovation Prospectus
Stocktake of current community and universal offer of services complete
New initiative implementation
Dec 2015
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- Domestic violence
- Winter Warmth
Falls Programme
- Falls
These existing schemes will be reviewed as part of the stocktake of community and
universal offer of services during Sep 2014 - Jan 2015
Three additional areas were identified from the Care Act duties as relevant to this
programme;
- Information and Advice (Community Capacity)
- Advocacy (Community Capacity)
- Veterans Health (Targeted Support)
Through the identification and stocktake already underway a number of other
programmes that will contribute to the Community and Universal Service programme
have been identified and these will be considered as part of the co-production approach
to developing a new community and universal offer. These include;
- Local Primary Care co-commissioning by NHS Doncaster CCG with NHS England
South Yorkshire and Bassetlaw area team.
- Wellbeing officers, Community Networks, Community Connectors
- Connecting multiple funding streams to maximise potential in delivering key
shared outcomes
- Library and other sport and culture offers
- Peer Support/Mutual Aid Services
- Adult, Community and Family Learning
- Community Resilience
- Wellbeing College developments to support recovery
- Community engagement and volunteering streams of work under the Stronger
Doncaster Theme Group
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Short Term Key Milestones
The programme will be delivered in an 8 month timeframe. At this point, the partnership
will consider and consult on the future service offer.
Key milestones include;
Fig.15. Short Term Transformation Programme Milestones
- Manage a series of engagements with key stakeholders and key stakeholder
groups
- Undertake a detailed desk top analysis to give clarity on existing system, capacity,
admissions/discharge arrangements, Telecare
- Compare data to service specifications
- Benchmark data, identify gaps/duplication, identify health conditions and
determinant factors for future profiling
- Conduct a statistically-valid and significant clinical audit of need around discharge/
admissions with a full multi-disciplinary team
- Undertake a comprehensive evidence review of academic and national practical
approaches being taken elsewhere to address the health priorities and system
challenges identified in intermediate care for frail and elderly
- Evaluate Key findings against correlate against National evidence based practice
gathered from the literature review and determine avenues of opportunities to
explore.
Diagnostic report and
evidence pack
Month 3 Month 5 Month 7
Clinical audit report
Clinical Audit undertaken and
stakeholder engagement
Findings and recommendations
Project initiation
Month 1 Month 8
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Long Term Key Milestones
Six schemes form the Long term programme of transformation. They include;
- Equipment, Technology and Adaptations (ETA) Programme
- Personalised Support
- Dementia Services
- Mental Health including Crisis
- Housing Options
- Supporting Carers including Respite Services.
The Long Term Transformational Programme will be delivered over a 2 year period with the following key scheme milestones
Fig.16. Long Term Transformation Programme Milestones
Equipment, Technology and Adaptations (ETA) Programme
In 2014/15 the ETA offer in Doncaster will;
- Be developed and delivered by a partnership of Doncaster Adults Commissioning and NHS Doncaster CCG, with a range of assistive technology and equipment providers
- Overseen by robust governance arrangements put in place through the Doncaster Assistive Equipment and Technology Strategy Group
- Include a review of the current contract arrangements and specification for Telecare and Telehealth provision
- Include a review of Disabled facilities grant and the process for adaptations
Jan 2015 20152015
March 2015 2015
July 2015
Review of mental health services complete
Doncaster wider review of therapy services complete
Sept 2014 2014
Sep 2015 Dec/March
2015
Review of Disabled facilities grant & the process for adaptations complete
Review of Telecare and Telehealth and the Home emergency response service complete
Dementia friendly communities programme year 1 complete
Revised offer for carers complete
55+ connected housing offer plan complete
55+ housing review report complete
Social work Rescript complete
New processes and systems for direct payment sin place
Direct payment support service in place
Housing Options plan delivery start
LT Programme high level plan complete
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- Include a full Doncaster wide review of therapy and equipment services
- Include a full review of Home emergency alarm response services.
The services within this scheme have been clustered to recognise key the interdependencies between adaptations, equipment therapy, technology and response services.
Mental Health including Crisis In 2014/15 the Mental Health offer in Doncaster will;
- Review and redesign the crisis care pathway to ensure that it is as responsive as
possible to people who are experiencing a mental health crisis and then co-
ordinating that response which meets individual need
- Include the Crisis House (community bed) provision and how this can be more
responsive to people who need advice and support before they reach the pinnacle
of their crisis and provide prevention and management support
- Include specialist care pathways including Perinatal Mental Health, Eating
Disorder and Personality Disorder services
- Include a review of primary care mental health services to develop more, cohesive
support services to be in place to prevent mental illness and emotional distress
- Identify include access to housing and benefits advice, family support and
employment/social activities. The review will therefore work closely with the
BCF/Universal Service developments.
Dementia Services
In 2014/15 the Dementia offer in Doncaster will;
Roll out Dementia Friends and Dementia Champions training;
- Produce and rollout the Dementia “pledge” and “commitment” programme
- Commissioning a hub and spoke model of Dementia volunteering
- Launching, promoting and raising awareness of the carers‟ resilience toolkit
- Commissioning the design and deliver a series of innovative and interactive workshops with users and carers and the community
- Implement Consultation and engagement with users, carers and the community.
Supporting Carers including Respite Services
In 2014/15 the revised Carers offer in Doncaster will;
- Enhance the early identification of Carers
- Increase Carers awareness to their entitlement to a Carers assessment in their
own right
- Ensure access to advocacy support where appropriate
- Improve the choice, flexibility and timeliness of breaks for Carers
- Respond to the emotional support needs of Carers
- Help more Carers to maximise their income as appropriate.
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Personalised Support
In 2014/15 Personalised Support in Doncaster will;
- Deliver a wholesale Shift in organisational culture in respect of long term
community based provision, from a deficit model to an outcomes and asset
focussed ethos
- New approach, systems and process for delivering personalised social care „social
work rescript‟
- refreshed market position statement and e-market place - expands the local
market to provide choice for Direct Payment recipients as well as suitable support
services for Direct Payment management- Improve Direct Payment uptake
through expanding support for a range of access options
- New systems and process for increasing uptake of direct payments-including
review of policies and practices that are undermining the take up of direct
payments and move towards personalisation
- Deliver a new direct payment support service - Increasing the availability of
independent assistance with support planning and money management
- Take a planned approach to improving personal budget uptake by mental health
service users.
Housing Options
In 2014/15 the Housing Options in Doncaster will;
- Deliver an academic led review current housing provision, needs assessment and
a 55+ connected care housing offer
- The outcome of the Housing Needs Assessment is expected to identify the need
for a variety of housing and housing related support across Doncaster including
short term reablement accommodation, supported living schemes and expanding
options for delivering housing adaptations.
b) Please articulate the overarching governance arrangements for integrated care locally
Commissioner and provider partnership and joint working has made significant progress
in Doncaster in recent years. The Doncaster HWBB has promoted the development of
partnership groups, joint working, integrated commissioning and shared investment of
resources. Providers are integral to the development of Doncaster‟s strategic priorities
and have significant involvement through HWBB governance arrangements in the
development of this plan and the priority schemes for future integrated working and the
ambition and vision for the overall programme.
Strong Chief Executive understanding of the BCF across all agencies and agreement on
the three Transformational Programmes has been key to developing the Doncaster BCF
Plan.
With one Council, one CCG, one acute provider and one community services and mental
health provider, Doncaster has all the ingredients to deliver a simple but effective plan
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successfully.
In 2013 Doncaster Council and its partners also launched a corporate charter which
forged the way for a new concept of „Team Doncaster‟. To meet Doncaster‟s priorities
there is a real need for change in the nature and relationship between public services
and local citizens; to develop a true partnership with businesses and voluntary
organisations where people in Doncaster are more effectively empowered to make a real
difference to the place where they live. This is the ethos of the „Team Doncaster
approach‟.
Previous to the development of the Doncaster BCF already had a Social Care and Health
Development Board which jointly utilised the transfer of monies from Health to Social
Care, via section 256 of the Health Care Act. Governed by a JACF and multi-stakeholder
working groups, this approach has resulted in robust and innovative joint commissioner
and provider planning and decision-making and has realised some significant
improvements in key service areas in Doncaster. This approach to the Supporting and
Maintaining Independence programme was held up as an exemplar of innovative practice
by the LGA Peer review for Doncaster Adult services in January 2014.
Building on the foundations of the JACF arrangements, a Chief Executive tier partnership
board (The Strategic Health and Social Care Partnership Board SHSCPB) has been
established to manage the implementation of strategic area health and social care area
plans and will oversee the BCF, reporting to the Doncaster HWBB. This Board will
incorporate into its functions oversight of both the BCF and our joint responsibilities under
the Care Act.
The specific function, roles and responsibilities of the joint governance structure (see
appendix 1) is set out below.
Fig.17. Health & Social Care Transformation Programme Governance 2014/15
Underpinning the governance structure that is in place is a set of working principles
agreed by each partner in the SHSCPB. The principles are as follows;
Principle 1 - The allocation of the BCF monies will take place within the wider framework
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of the adult social and health care transformation and modernisation processes. This
principle recognises that the focus is on system wide integration, getting a single view of
the use of resource and that this has greater value in both cash and service delivery
terms than of using monies in isolation
Principle 2 - Patient and user involvement and working towards a co-production
approach, will be an integral part of developing and delivering the new offer for services,
recognising that increasing community capacity, social capital and self-reliance requires
and investment in and engagement with local people
Principle 3 - The use of monies should be focussed towards a new offer recognising
that sustaining current systems is not possible within the resource settlement across
Health and Social Care. This principle recognises that priority for funding allocation
should be on developing capacity within the system and targeted interventions to
manage care and health demands within new resource limits. Supporting existing
business pressures will be a valid use of monies if new ways of working and
sustainability are an integral part of the case for change
Principle 4 - The development of an integrated intelligence system will be supported by
a culture of performance and evaluation, ensuring that the services and system we
develop is based on the best available evidence and that continuous improvement is
embedded as a principle and value throughout the workforce
Principle 5 - With the emphasis on maintaining the safety of patients, service users and
carers, and avoidance of discrimination, there is a commitment to joint responsibility
for development and change. This principle recognises that any changes and new
ways of working impact across both Health and Social Care systems
Principle 6 - The Social Care and Health Community will work together to ensure and
establish a system of transparency, participation and collaboration. Openness will
strengthen our decision making and promote efficiency and effectiveness in programme
and service development
Principle 7 - In accordance with local compact agreements the voluntary sector will
have an opportunity to influence the Social Care and Health Development Programme.
This principle recognises that to achieve a transformation in services which reduces
dependency on statutory services and increases independence, third sector agencies
have a significant role to play
c) Please provide details of the management and oversight of the delivery of the Better care Fund plan, including management of any remedial actions should plans go off track
The three Transformational Programmes are being led on behalf of the partnership by
senior commissioners from both health and social care.
In addition to the current governance and planning structure a dedicated programme
team will ensure robust and effective programme and project management of both the
BCF and the implementation of the Care Act.
This programme management approach ensures multiagency system wide planning,
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whole system performance monitoring and operational implementation that manage
interdependencies across the health and social care system.
A robust system of highlight and exception reporting will ensure that plans are closely
monitored and risk is managed and resolved via the governance and organisational
structures.
Fig.18. BCF Programme Team - Management and Reporting Structure
d) List of planned Better Care Fund schemes Please list below the individual projects or changes which you are planning as part of the Better Care Fund. Please complete the Detailed Scheme Description template (Annex 1) for each of these schemes.
Fourteen detailed schemes support the delivery of the three Transformational
Programmes as follows;
Ref no. Scheme Programme Area
1 Community Capacity Community and Universal
2 Targeted Support Community and Universal
3 Falls Community and Universal
4 Admission Avoidance Schemes Short Term
5 Reablement Services Short Term
6 Discharge Schemes Short Term
7 Intermediate Care Short Term
8 End of Life Short Term
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9 Equipment, Technology and Adaptations (ETA)
Programme
Long Term
10 Mental Health including Crisis Long Term
11 Dementia Services Long Term
12 Supporting Carers including Respite Services Long Term
13 Personalised Support Long Term
14 Housing Options Long Term
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5) RISKS AND CONTINGENCY a) Risk log Please provide details of the most important risks and your plans to mitigate them. This should include risks associated with the impact on NHS service providers and any financial risks for both the NHS and local government.
The Doncaster Social Care and Health Partnership board have agreed this risk register based on the specific schemes being
implemented within the plan and in relation to wider strategic and organisational plans and challenges. It has been developed in
partnership with all stakeholders; in particular our Health and Social Care Forum (Voluntary/Third Sector members) have identified
additional risks, which are now incorporated in the risk register below.
Scheme leads will adopt a risk management approach as indicated in our local Risk Management Process Guide; it outlines roles and
responsibilities, steps in the process, tools and techniques. The BCF risk register will form part of the SCHPB assurance process and
therefore will be monitored and updated on a quarterly basis. Exceptions outside of the process will be escalated via the BCF
Coordination group using the programme management arrangements already in place for joint planning and commissioning activity.
There is a risk that; How likely is the risk to materialise? Please rate on a scale of 1-5 with 1 being very unlikely and 5 being very likely
Potential impact Please rate on a scale of 1-5 with 1 being a relatively small impact and 5 being a major impact And if there is some financial impact please specify in £000s, also specify who the impact of the risk falls on)
Overall risk factor (likelihood *potential impact)
Mitigating Actions
Patients and users
Lack of meaningful engagement with Stakeholders, users and carers.
2 4 8 The JACF have made significant progress since the first cut of the plan in formalising stakeholder engagement in the BCF, therefore the risk has been reduced. Formal links now agreed with Stronger Partnership programme Healthwatch Doncaster CVS New Horizons
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Doncaster Voluntary Sector Health and Social Care Forum.
Public resistance to proposed
changes and the time
required for cultural change
may take longer than the
current plan timescale allows.
3 3 9 The BCF plan and governance structure has public engagement
and co-production as a central principle of operation to ensure
that changes are developed with the local population,
stakeholders and providers.
A communication plan has been developed to raise public
awareness of the benefits of integration and specific changes
detailed in the schemes will involve the public though co-produced
or consultation.
There is a risk that fears over
a reduction in quality and
quantity of care will limit
public engagement with new
service offers.
3 3 9 Services developed through the BCF pooled budget will include a
clear co-produced quality statement as part of scheme
developments briefs through to service specification. The BCF
performance and intelligence team will ensure that quality is
monitored equally as part of performance reporting arrangements.
There is no intention to reduce the quality of any of the services,
in fact quality. Experience and safety should be improved.
Planning, development and impact on providers
Commissioners and
providers fail to connect
wider organisational planning
and BCF ambitions, resulting
in a disconnect between
programme and mainstream
planning.
3 4 12 The SHSCPB have committed to a joint working agenda and will
produce a joint market position statement for 2015 and a take
corporate approach to market development.
All commissioner and provider plans will be monitored for
alignment with the Health and Wellbeing Strategy.
Development of plans to
deliver some of the national
conditions will take longer
2 3 6 The governance and planning structure is now in place and the
HWBB and the JACF are committed to the process. A dedicated
Programme team will support the coordination delivery of the
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than the plan timetable
allows.
planning and delivery timetable.
Single commissioner and
provider agency priorities and
funding pressures affect the
ability to agree on a joint plan
and priority spend.
2 3 6 Outcome of Commissioner and provider discussions and key
provider plans demonstrate a clear commitment to joint planning
as well sharing ambition and vision for Doncaster services in the
future.
The impact on NHS providers
is not fully known until further
stages of planning are
complete.
2 3 6 Dialogue with NHS providers has taken place and headline BCF
vision and schemes agreed. Shared commitment to on-going
impact and risk management has been agreed via the HWBB.
Limited knowledge on the
impact of the scheme on the
wider interdependent
agencies.
3 3 9 Phase 2 plan development and consultation processes are now
agreed and will identify major risks and plans to mitigate risks.
Strong joint leadership is
difficult to maintain.
3 3 9 A strategic JACF has been agreed and will meet every 3 months
to agree and mandate the scope and intent of the programme
priorities.
Schemes do not realise
expected outcomes and
benefits and performance
related funding is affected
limiting the ability to fund
changes in the system.
3 3 9 Benefits realisation planning has been undertaken at each
scheme level. This initial plan will be refined and monitored as the
schemes are implemented. Each scheme will hold its own risk
register and exceptions will be escalated.
Sheffield University will include benefits realisation as an early
capacity building skills need.
A proportion of BCF pooled budget will be identified as
transformation monies to support transitional scheme plans
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Increasing financial deficit of
the Council in particular
Social care funding may
result in reduction of
available resources to
support the shift to
community based care.
3 4 12 The SHSCPB provides a platform for joint planning and shared
management of risk.
The Council has an agreed budget for 2014/15 to 2016/17.
Shift of resources without
sufficient transitional planning
may destabilise provision
across the system.
3 3 9 Impact assessment will form part of the transitional arrangements
for programme development
Insufficient non recurrent
monies available for enabling
transformation.
2 2 4 A significant BCF transformation fund has been made available
within the BCF plan.
Policy and protocol
Limitations on existing data
systems, processes and
information sharing protocols
may impact on the extent of
performance reporting and
planning activity.
3 3 9 The HWBB and JACF commitment to joint performance reporting
and facilitating access to provider data sets has been agreed as
critical. A joint performance group has been embedded into the
BCF governance structure.
Wider organisational policies
and protocols limit the
ambitions of using technology
and intelligence to modernise
workforce and service
delivery practice.
3 5 15 Chief executive commitment to the BCF joint plan will enable
ambitious work to progress at speed outside of singular agreed
protocols.
The BCF has amalgamated the approach to technology and
workforce
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Workforce issues including
recruitment and skills
development delay speed at
which change can take place.
3 4 12 BCF has a dedicated workstream to tackle workforce issues and
industrial relations issues which will report directly to the SCHPB.
Organisational protocols for
joint commissioning and
procurement delay speed at
which integration can take
place.
3 4 12 Doncaster Council and NHS Doncaster CCG have already
established joint posts and contracts around several priorities
areas and plans to improve joint commissioning (including a joint
contracts team) are underway.
Partners and providers
Capacity of the market to
respond to significant
changes in model of service
delivery.
2 3 6 There is a commissioning focus on developing a strong market
position statement which is continuously refreshed to respond to
system changes.
Lack of understanding of
existing third sector and
community provision may
result in unnecessary
duplication of services being
developed.
2 3 6 Third sector members will sit on the theme working groups,
participating in decision making, ensuring extension market
research is undertaken before any investment is made.
Existing good practice is
overlooked in the drive for
innovation.
2 3 6 Evidence based and needs led assessment approach to project
planning and development will ensure that existing service
provision is mapped and reviewed as part of the planning
process.
Partners unable to engage in
the change process due to
2 2 4 The BCF transformation fund will support transition to new ways
of working across the BCF partnership. A Programme Office has
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lack of transformation
infrastructure and funding
support.
been established and an overarching approach to capacity
building has been approved.
The engagement of primary
care providers as key
stakeholders in developing
preventative services is
inhibited by current
contractual arrangements
and obligations.
3 4 12 NHS Doncaster CCG has Expressed an Interest in co-
commissioning primary car with NHS England. A locality structure
for the CCG exists and a Clinical Advisory group has been
established.
The non-elective admissions data highlights 10 communities with
high rates of admissions. Further work to be done to link the
relevant practice level risk stratification outputs.
A more formal programme of work is to be agreed to address
earlier diagnosis, cyclical A&E attendance, lifestyle, behavioural
and wider determinants. The first stage is a review of the local
inequalities picture by public health.
b) Contingency plan and risk sharing Please outline the locally agreed plans in the event that the target for reduction in emergency admissions is not met, including what risk sharing arrangements are in place i) between commissioners across health and social care and ii) between providers and commissioners
A locally agreed target has been set to reduce non-elective admissions by 3.5%. This has been agreed by the Strategic Health and
Social Care Partnership Board (SHSCPB).
Following the publication of revised BCF guidance in July 2014, the SHSCPB met to consider the impact of the changes and propose a
continued approach to driving forward change in partnership.
The following agreements were reached;
- The HWBB have agreed three Transformational Programmes – we remain focussed on these as we believe this is where the
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biggest impact will be demonstrated if services are integrated
- Continue to focus on reducing non-elective admissions in 15/16 by enhancing unplanned care and community based services.
It was agreed that a financial and service agreement will be developed and agreed to support the partnership and the wider health and
social care system until the Transformational Programme agenda starts to positively impact.
The agreement will include risk sharing arrangements across all partners and it will be agreed by the SHSCPB on behalf of the
Doncaster HWBB.
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6) ALIGNMENT a) Please describe how these plans align with other initiatives related to care and support underway in your area
The HWBB have focussed on three areas of system transformation where the biggest
impact will be achieved by commissioning and delivering services in an integrated way.
The successful implementation of the Transformational Programme is critical to achieving
the ambitions of the HWBB and improving services for Doncaster patients and users. It
is however, a subset of a wider system re-engineering programme across the
partnership.
The focus of the wider change programme;
- The redesign and implementation of local community nursing services in line with
the Department of Health (2012) Compassion in Practice; Nursing, Midwifery and
care Staff. Our Vision and Strategy
- Review and redesign of crises, inpatient and primary care mental health services
- Redesign and re-procurement of three unplanned care pathways in Doncaster in
line with Transforming Urgent and Emergency Care Services in England, urgent
and emergency care review. End of Phase 1 Report
- The development of locally focussed hospital avoidance primary care services
- System resilience system management.
The alignment for each of the developments identified is to ensure the health and social
care system works effectively to;
- Manage patients as close to home as possible
- Support early identification of a deteriorating patient
- Provide timely access dependent upon need
- Holistic care
- Reduce non-elective admissions.
b) Please describe how your Better Care Fund plan of action aligns with existing 2 year operating and 5 year strategic plans, as well as local government planning documents
Health and Wellbeing Strategy
Since establishment, the HWBB ambition has been to develop services in an integrated
way. This ambition is clearly identified in the Health and Wellbeing Strategy.
The mission of the HWBB is to;
Ensure everyone works together to improve
Health and Wellbeing for and with Doncaster People
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To achieve this, the HWBB will ensure there is a „safety net‟ of health and social care
services and interventions that promote integration and joined up commissioning across
the NHS, the Council and Public Health and support joint commissioning and pooled
budget arrangements.
NHS Doncaster CCG 5 year strategic plan
The vision of the NHS Doncaster CCG was created and agreed as the organisation
began to develop. It has been tested a number of times and still stands strong today.
The vision of the NHS Doncaster CCG is to;
Work with others to invest in quality healthcare for Doncaster patients
The NHS Doncaster CCG 5 year strategy identifies the system changes that will be made
and the outcomes that will be improved for Doncaster patients. The commitment to
partnership working and integration is clearly stated and supported. The strategy
highlights;
- We will work with co-commissioners to ensure opportunities for service integration
and efficiencies are realised
- NHS Doncaster CCG welcomes the opportunity to work with provider
organisations to support the development of a health and social care community
approach to workforce development
- We will engage with partners to ensure our Commissioning Plans are
complimentary across the HWBB footprint
- NHS Doncaster CCG will continue to work collaboratively with other CCG's and
co-commissioners to ensure that services delivered across a wider geography are
commissioned and delivered cohesively and consistently.
NHS Doncaster CCG 2 year operational plan
The NHS Doncaster CCG 2 year operational plan demonstrated a commitment to deliver
against statutory responsibilities and ambitious targets for improvement.
This commitment remains the same, although the revised national target, to reduce the
number of non-elective admissions by 3.5%, has provided the catalyst to push further
faster locally.
Building the Road to Independence A Draft Strategy for Modernising Adult
Social Care and Support in Doncaster
Doncaster Council‟s strategy for Modernising Adult Social Care along with its
Commissioning Strategy was conceived out of the need to support more people to
remain independent in their own homes. Its delivery includes many of the elements within
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the BCF plan and is committed to reducing admissions into institutional care.
c) Please describe how your Better Care Fund plans align with your plans for primary co-commissioning
For those areas which have not applied for primary co-commissioning status, please confirm that you have discussed the plan with primary care leads.
NHS Doncaster CCG has applied for primary care co-commissioning status and is
supportive of adopting this approach in the near future.
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7) NATIONAL CONDITIONS Please give a brief description of how the plan meets each of the national conditions for the Better Care Fund, noting that risk-sharing and provider impact will be covered in the following sections. a) Protecting social care services i) Please outline your agreed local definition of protecting adult social care services (not
spending)
In Doncaster we have recognised the significant interdependencies between Care Act
and BCF planning and delivery and have therefore ensured that the governance
arrangements for both are as integrated as possible and closely aligned as a minimum.
A single joint governance structure is in development to promote planning and practice
that is aligned across policy directives to ensure efficiencies and savings are maximised.
This joint structure will ensure that both operational and strategic planning is well
coordinated via a single reporting mechanism to articulate ambition and change.
The Care Act introduces new regulations and statutory guidance that will establish a new
framework for eligibility. The emphasis will also be on joint assessments to ensure that
both the health and social care needs of individuals are recognised and that frequent
reviewing will manage changing need.
The BCF allocation for protection social care services will be targeted at the following;
- Maintain care and support for those patients and service users who have high
and complex levels of need
- Enabling the local authority to shift emphasis away from traditional services to a
new offer that can meet the demographic changes in populations and provide
more self-determination and control over tailored support
- Develop more innovative, co-produced, person centred services that will enable
and encourage the effective use of personal budgets and direct payments
- An increase in community based preventative services including wellbeing, social
prescribing and services which harness the resources of communities and
individuals.
ii) Please explain how local schemes and spending plans will support the commitment to protect social care
The BCF spending plan includes significant resource across social care to support new
ways of working and a modernisation of care and support. All of the Better Care Fund
plan is designed to support and protect Social Care through new ways of working that
protect those with highest need and maximise resources across the system The specific
initiatives that will be funded from BCF allocation will include;
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Care Management
BCF funds will fund a re-engineering programme of how care management is delivered
including service configuration, staffing allocation, skills and competencies and area
structures. For 2014/16 a £340,000 investment has been allocated to enable a
significant increase in the number of individual social care reviews undertaken for
existing service users. These reviews will be the start of a flexible and dynamic approach
to assessment and review, including new quality of life measurement tool developed by
Sheffield Hallam University, that will support a shift away from traditional „package for
life‟ arrangements to independence and personalised support planning.
There will also be a particular focus on prisons and veterans to ensure equity and
efficacy of support and care to these vulnerable groups.
Community based services
A new community services offer will be developed which will include well-being services,
social prescribing as well as significant investment in new types of services organised by
the third sector to promote independence and alternatives to traditional care services.
This will supported by a significant increase in personal budgets and direct payments to
enable personalised and tailored support for both users and carers.
There will be a new and alternative offer for day opportunities across all client groups
replacing traditional day centre approaches. The alternative day opportunities offer is
being co-produced with existing and future users of services on an outcome based
commissioning prospectus approach to ensure that the new offer is innovative and
responds to the identified and expressed need of service users. An investment envelope
of £250,000 has been identified for the prospectus in 2014/15.
Housing Options
A new range of holistic housing/accommodation offers that support the wider health and
wellbeing current and future needs of older people aged 55+ in Doncaster will be
developed. This will a connected care model that supports keeping people at home,
reduces impact on acute and long term residential services and supports intermediate
care, enablement, community living support networks and supported housing provision.
Carers
The Care Act extends entitlement to carers to receive support on the same footing as
their cared for, formalising this entitlement that has locally been extended to Carers
through practice. The new offer will Enhance the early identification of Carers, Increase
Carers awareness to their entitlement to a Carers assessment in their own right. Ensure
access to advocacy support where appropriate, Improve the choice, flexibility and
timeliness of breaks for Carers and maximise their income as appropriate.
Further Investment has also been identified to respond to the requirements around social
care in prisons, and continuity of care for transitional arrangements.
A full description of these and additional schemes to protect social care are can be found
on the annex documents.
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Information and advice
Easy and timely access to Information and advice is a key principle of both health and
social care are a key duty of the Care Act. The new offer for information and advice will
seek to provide both multi-channel access for local people and a single point of access
for health and social care information advice and support.
iii) Please indicate the total amount from the Better Care Fund that has been allocated for the protection of adult social care services. (And please confirm that at least your local proportion of the £135m has been identified from the additional £1.9bn funding from the NHS in 2015/16 for the implementation of the new Care Act duties.)
The BCF Plan identifies the resources committed across the partnership to support
delivery.
It has been agreed that non recurrent resources will support the transformation
programme and recurrent funding will support the delivery of the future integrated service
offer.
It has also been agreed that a financial and service model will be developed across the
partnership to support system stability until the transformation programme can positively
impact on wider system delivery.
The BCF financial plan in Doncaster has been agreed and is documented in the following
table.
Fig.19. Doncaster BCF Financial Picture
The partnership has also agreed that resources from the £135,000,000 to support the
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implementation of the new Care Act duties in 2015/16 will be available from the
£1,000,000,000 NHS funding. The consultation on the funding formula for the
implementation of the Care Act 2105/16 published 31st July 2014 suggested that
£887,000 would be required in Doncaster and this figure has been used for planning
purposes.
iv) Please explain how the new duties resulting from care and support reform set out in the Care Act 2014 will be met
The Council is leading the implementation of the Care Act and commissioning partners
are involved in this process.
A Care Act Programme Group is in place and a programme management approach is
being adopted to support delivery. In addition, the national Care Bill Implementation
Stocktake has been completed locally. This has identified gaps, risks and where specific
focus should be placed.
This means that a portfolio of modernisation work is at an advanced stage of
implementation, which puts the Council in an advantageous position for Care Act
compliance on key policy agendas including prevention, personalisation and information
and advice.
- A systematic programme management approach is being taken to ensure that the
introduction of the new duties is timely and effective and risks are managed
- The programme will consider the opportunities presented by digital solutions for
customer self-assessment, and potential outsourcing of some assessment
functions, to more affordably manage the increased assessment and review
workload.
v) Please specify the level of resource that will be dedicated to carer-specific support
The partnership has agreed that a minimum of £818,000 will be available to support carer
support in Doncaster.
The figure of £818,000 has been identified as part of the national requirement that
£130,000,000 is identified for care support. The figure is based on the national capitation
formula.
vi) Please explain to what extent has the local authority‟s budget been affected against
what was originally forecast with the original Better Care Fund plan?
The Better Care Fund plan remains consistent with that originally planned and there has
been no impact on Doncaster Council‟s budget as a result of this submission.
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i) 7 day services to support discharge Please describe your agreed local plans for implementing seven day services in health and social care to support patients being discharged and to prevent unnecessary admissions at weekends
In Doncaster some services have already taken steps towards supporting 7 day working
and this has initially focussed on enhancing discharge arrangements. Commissioners
have worked with providers to ensure discharges can take place from the local acute
trust 7 days a week. The local jointly commissioned integrated community equipment
service will respond to requests to avoid unnecessary admissions and support discharge
7 days a week and current intermediate care step down facilities will also accept patients
7 days a week.
7 day working has been identified as an underlying theme (see section 2c). The HWBB is
adopting a system wide approach to rolling out 7 day working across Health and Social
Care Teams. All service transformation schemes will embed 7 day working as a key
service delivery requirement.
j) Data sharing i) Please set out the plans you have in place for using the NHS Number as the primary identifier for correspondence across all health and care services
In Doncaster there is an overarching strategy for information sharing. This includes
guidance on how to build underpinning topical information sharing agreements.
There is also an overarching strategic partnership data sharing agreement in place. The
agreement covers all members of the local strategic partnership including all NHS
partners, the Council and other statutory bodies such as Fire and Police.
Where possible the NHS Number is used to match services users/patients across health
and social care services. The Social Care Case Management System is partially
populated with NHS Numbers and plans are in place to ensure this data set becomes
robust. The NHS number is already routinely used within health services in Doncaster.
There is a commitment across the Health and Social Care system in Doncaster that once
NHS numbers are fully populated, data will be appropriately shared across services for
the purposes of service user/patient care, in line with IG requirements. It is also
expected that aggregate data, built from anonymised patient level pathway data, will be
used for planning purposes in the medium term.
In addition, NHS Doncaster CCG has been accredited by the Health & Social Care
Information Centre as an Accredited Safe Haven (ASH), and an assessed pre-requisite
of this accreditation was achievement of Level 2 in the NHS Information Governance
Toolkit (IGT). The use of the NHS Number in all healthcare settings is a requirement of
Level 2 in the Information Governance Toolkit. Information Sharing Agreements are in
place between NHS Doncaster CCG and relevant organisations with which we share
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data.
ii) Please explain your approach for adopting systems that are based upon Open APIs (Application Programming Interface) and Open Standards (i.e. secure email standards, interoperability standards (ITK))
Commissioners and providers in Doncaster including the Council are committed to
adopting systems that are based upon Open APIs and Open Standards.
The Council and local Mental Health/Community services ICT Departments are working
together to put local secure arrangements in place to allow access to systems from each
other‟s networks without the need for complicated additional security arrangements.
The specification of the new Adult Social Care Case Management System currently
being implemented allows sharing of information between third party systems, subject to
the availability of APIs and a detailed specification of data sharing requirements.
Furthermore, a Doncaster wide Information Management and Technology Forum,
chaired by NHS Doncaster CCG senior colleagues, is exploring a range of data sharing
opportunities through joined-up solutions across the Acute Trust, the Mental Health and
Community Trust, the CCG and the Council. Consideration is being given to a shared
Public Sector Network Solution and the Medical Inter-operability Gateway.
iii) Please explain your approach for ensuring that the appropriate IG Controls will be in place. These will need to cover NHS Standard Contract requirements, IG Toolkit requirements, professional clinical practice and in particular requirements set out in Caldicott 2
The partnership in Doncaster has an established Information Governance Framework in
place which covers both NHS and Local Government requirements. It facilitates the
sharing of data across Health and Social Care partners and has supported the
development of a Joint Performance reporting system to the HWBB that will report on
BCF activity.
There is a self-assessment undertaken annually against the requirements of the
Information Governance Toolkit overseen by the Health and Social Care information
Centre.
k) Joint assessment and accountable lead professional for high risk populations i) Please specify what proportion of the adult population are identified as at high risk of hospital admission, and what approach to risk stratification was used to identify them
Primary care providers in Doncaster currently identify 2% of registered patients aged 18
or over that have a high risk of emergency admission. This service is provided as part of
the Avoiding Unplanned Admission Directed Enhanced Service national agreement and
requires the practice to identify the patients via a web reporting system and discuss the
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patient at an MDT (multi-disciplinary team). Patients identified as high risk are given a
care package and are assigned to a healthcare professional.
In addition, Primary Care providers in Doncaster have also utilised the additional
resource identified in Everyone Counts; Planning for Patients 2014/15 to 2018/19 to
support service transformation for patients over the age of 75 and reduce non-elective
admissions. In response to this, practices have agreed to stretch the targeted patient
population up to 4%.
A number of conditions are used to identify high risk patients including age, unplanned
hospital admission history and current clinical health (such as number of Long Term
Conditions, Smoking History, Mental Health history). In order to undertake this all GP
Practices in Doncaster are currently using the Doncaster Risk Stratification system to
identify which patients, from all those patients registered with the practice, have a high
risk of emergency admission for a chronic condition. The particular population focussed
on is all patients with one or more long term conditions. Percentages risk is calculated
for each patient and is the % chance of an emergency chronic admission. Risk is scored
as follows;
a. Very High Risk: Band 1 - 0.5% of Doncaster population
b. High Risk: Band 2 - 4.5% of Doncaster population
c. Med. Risk: Band 3 - 15% of Doncaster population
d. Low Risk: Band 4 - 80% of Doncaster population
The Doncaster Risk Stratification system is provided by NHS South London
Commissioning Support Unit (previously known as East Sussex Health Information
Service). Over the last 12 months NHS Doncaster CCG has implemented the web tool
including the flow of secondary care data to the system provider as well as 121 training to
Doncaster GP Practices. The data for risk stratification is downloaded by a member of
staff in the Performance and Intelligence team at NHS Doncaster CCG (the CCG has
ASH status) and sent to NHS South London Commissioning Support Unit (CSU). The
datasets are Inpatients, Outpatients, A&E and all NHS numbers of patients who have
opted out of the summary care record and the electronic data sharing model. This
process ensures that risk stratification is only undertaken for those patients that have
agreed for their data to be used. Once NHS South London Commissioning Support Unit
receives this file, they process this information with a national demographic file which is
only available to DSCRO staff employed in NHS South London Commissioning Support
Unit.
NHS Doncaster CCG are also working towards including wider primary care data and
community care data in the Risk Stratification System, as well as evaluating the current
selection of risk stratification system.
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ii) Please describe the joint process in place to assess risk, plan care and allocate a lead professional for this population
Current Process
Once patients have been identified, as described above, providers will act as lead care
co-ordinator. A range of initiatives to support patients and avoid unnecessary hospital
admissions are also being tested. Examples include;
- Reviewing the most vulnerable patients with daily enhanced involvement from the
practice based care co-ordinator
- Use of Telehealth solutions to identify and manage any changes in condition
supported by care-coordinator
- Improve communications between patient (and their family) and the Practice with
the care-coordinator as the link. Looking at alternative methods of communication
i.e. e mail, texting
- Improve access to the Community services including Social Services.
- Liaison with secondary care
- Coordinate MDT meetings
- Undertake direct case management
- Develop and implement technology solutions for improving proactive case
management
- Liaise with appropriate health and social care professional and the voluntary
sector to develop comprehensive packages of care.
Moving forward
The ambition for a Lead Accountable Professional model is clear in Doncaster across the
partnership.
The vision is that one professional will have responsibility to co-ordinate the care of the
individual and lead a team of other named professionals that work in a number of
different organisations. This system will identify a Lead Accountable Professional whilst
also supporting the development of an integrated approach to working across
organisations. The aim is to ensure that the patient is at the centre of a co-ordinated
approach to care planning – even if this is across multiple care providers.
iii) Please state what proportion of individuals at high risk already have a joint care plan in place
Using the Doncaster risk stratification tool, 9,927 patients have been identified as being
at high risk of non-elective admission. The current population registered with Doncaster
GPs is 311,844.
In line with the Directed Enhanced Service to avoid unplanned admissions, each
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identified patient will have a personalised care plan. There are national contractual
requirements stating what a personalised care plan should include. The named
accountable GP is responsible for the creation of the personalised care plan and the
appointment of a care co-ordinator (if different from the lead accountable GP).
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8) ENGAGEMENT a) Patient, service user and public engagement Please describe how patients, service users and the public have been involved in the development of this plan to date and will be involved in the future
The BCF Plan has been developed using a range of existing patient, user and public
engagement intelligence and feedback as part of on-going extensive user and citizen
engagement activity across health and social care in Doncaster. Key to the success of
the Doncaster BCF will be the on-going conversations with the people of Doncaster
about the priorities of our local communities.
A full and meaningful engagement programme with a range of patient and service user
groups, for example Health Watch, the over 50‟s parliament, Doncaster CVS, New
Horizons (Doncaster Council‟s infrastructure partners), GP and patient forums have
already shaped the headline BCF Plan programmes and in particular the approach to
building the strong and inclusive communities strand. Each of these key representative
groups are part of the Doncaster HWBB arrangements and is fully involved in the
development of and awards made from the Doncaster Innovation Fund. Doncaster
Council community based Wellbeing Officers are also a significant resource in the
continuous loop back from communities to key decision-making and change structures
and were highlighted as an example of good practice in the recent LGA review of
Doncaster Council‟s Adult and Community services.
We have also agreed that the BCF communications and engagement plan will now form
a key work stream of the Stronger Communities planning structure, ensuring that BCF is
part of mainstream engagement rather than a bolt on activity.
b) Service provider engagement Please describe how the following groups of providers have been engaged in the development of the plan and the extent to which it is aligned with their operational plans i) NHS Foundation Trusts and NHS Trusts
Engagement
The Doncaster HWBB has promoted the development of partnership groups, joint
working, integrated commissioning arrangements and shared investment of resources.
NHS Foundation Trust Chief Executives are members of the HWBB and as such, are
integral to the development of Doncaster‟s three transformational programmes.
NHS Foundation Trust Chief Executives are also members of the SHSCPB. This group
also supports the delivery of the BCF Plan, oversees the delivery of the three
Transformational Programmes and agrees key principles to support partnership working
in Doncaster.
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Provider Operational Plans
The Doncaster & Bassetlaw Hospitals NHS Foundation Trust Operational Plan for
2014/15 - 2015/16 clearly recognises the BCF as an opportunity to build on existing
integration achievements, such as the Integrated Hospital Discharge Pathway and to
develop new ways of working to meet BCF ambitions.
„We have existing strong relationships within the local health economy
including CCGs, other providers and local authorities in the Doncaster &
Bassetlaw area. We have a history of working together to provide integrated
services consistent with the national conditions identified in the Better Care
Fund guidance. An example of this is our Doncaster Rapid Access Process
Team (RAPT) which was cited in the Keogh Report, which works as part of the
Integrated Discharge Team providing a joint approach to assessment and
care planning over seven days a week. We will build on these relationships
and shared successes with the implementation of the Better Care Fund that
provides unique challenges and opportunities, specifically in 2015/16 and
2016/17.
One of the main risks created by the Better Care Fund is the scale of the
financial resources transferring to this fund which equate to £24m for
Doncaster & £8m for Bassetlaw. From 2015/16, it is also a concern that 50%
funding is performance related. It is therefore vital that we are actively
engaged in discussions around performance criteria and achievability. The
Integrated Care Board at Bassetlaw and Intermediate Care Board at Doncaster
are monitoring the potential impact of the Better Care Fund.
To mitigate the above risks and to achieve the transformation requirements
we have co-operated fully with our local authorities and commissioners in
development of the Better Care Fund plans. In Doncaster this is through
active participation as a member of the Health & Wellbeing Board.‟
In addition, the Rotherham, Doncaster and South Humber (RDaSH) NHS Foundation
Trust 2014/15 Operational Plan provides the following supporting statement for the BCF
Plan.
„It is absolutely clear to the Trust, its partners and its stakeholders, that the
health and social care needs of its local communities will only be met in the
future through a „whole system‟ approach to service delivery and
engagement with these communities to propagate new, innovative and
sustainable forms of support for its citizens. The Trust is engaged with the
CCGs, local authorities, acute trusts, third sector consortia, NHS England
representatives, Police, other service providers and key stakeholders in
taking this work forward under the coordination of the respective Health and
Wellbeing Boards.
The impact of the Better Care Fund is likely to be greater in Doncaster. The
Trust is however committed to supporting the Better Care Fund developments
across all of its localities as part of an increasingly effective „whole system‟
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approach to meeting Health and Social Care needs.‟
ii) Primary care providers
Primary Care colleagues in Doncaster have been involved in the development of the
vision, ambition and transformation programmes since the HWBB started to meet in April
2011.
The NHS Doncaster CCG is a member of the HWBB and the governance arrangements
that sit underneath that Body.
In addition, NHS Doncaster CCG Governing Body GP representatives have been
informed and have also influenced the development of the BCF Plan.
All member practices have received information via Governing Body briefings and also
during GP Governing Body locality meeting discussions.
iii) Social care and providers from the voluntary and community sector
The Director of Adults, Health and Wellbeing, Doncaster Metropolitan Borough Council
has both a commissioner and provider aspect to their role and responsibilities. As such,
Adult Social Care provider services have been engaged throughout the process and
have directly influenced the BCF Plan and the development and agreement of the three
Transformational Programmes.
A range of workshops and events have also taken place with wider stakeholders to
specifically consider a number of key service provision issues such as service quality
improvement, commissioning for outcomes and help to live at home services.
Further workshops are planned to take place to develop relationships and ensure this
sector has the opportunity to influence and shape the BCF Plan in the future.
Moving forward
A Communications and Engagement Plan is in development and will ensure a structured
approach to strategic input from all partners in Doncaster. The aim is that this will focus
on both a practical role in relation to the delivery of the three Transformational
Programmes and strategic input into the overarching development of the BCF Plan.
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c) Implications for acute providers
Please clearly quantify the impact on NHS acute service delivery targets. The details of this response must be developed with the relevant NHS providers, and include;
- What is the impact of the proposed Better Care Fund schemes on activity, income and spending for local acute providers?
- Are local providers‟ plans for 2015/16 consistent with the Better Care Fund plan set out here?
Support
DBHNHSFT provides acute hospital services patients in Doncaster. The hospital
operates from 3 sites;
- Doncaster Royal Infirmary
- Bassetlaw Hospital
- Mexborough Montagu Hospital
In addition, RDaSH NHS Foundation Trust provide Mental Health and Community based
services in Doncaster. The Trust also provides services in Rotherham, North and North
East Lincolnshire and Manchester.
Both NHS Foundation Trust providers in Doncaster are active partners in the
development of the BCF Plan and are supportive of the short term service plans and
longer term transformation programmes of work.
Impact
In addition, both providers are supportive of the Doncaster partnership ambition to reduce
non-elective admissions by 3.5%.
The strategic aim of the HWBB is to improve the health and social care system to support
patients in the community, prevent patient deterioration and reduce non-elective
admissions to hospital by developing integrated community based services.
The anticipated impact on the local acute provider is;
- A reduction in attendance at the Emergency Care Centre as primary care
prevention services positively impact on health and wellbeing
- A reduction in non-elective admissions as Intermediate Care Services support
patients closer to home
- Richer case mix of patients accessing urgent care hospital based services
- Workforce skill mix change due to increased complexity of patients when they
access hospital services
- Reduced length of stay for patients as Intermediate Care Services support earlier
discharge from acute hospital based services
In addition, any reduction in non-elective admissions will directly impact on the local
acute provider financially. If the HWBB achieves a 3.5% reduction in non-elective
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admissions, this will equate to a reduction of £663,000 in income.
Also, as a consequence, the Doncaster partnership will have the opportunity to reinvest
this resource back into Doncaster services.
Consistency with Provider Plans
Both NHS Foundation Trust providers in Doncaster, via recently published operational
plans, acknowledge the importance of the BCF. They also highlight their support for the
process, direction of travel and identify potential key risks relating to their particular
organisation. Please see section 8bi for an extract of provider operational plans.
Please note that CCGs are asked to share their non-elective admissions planned figures (general and acute only) from two operational year plans with local acute providers. Each local acute provider is then asked to complete a template providing their commentary – see Annex 2 – Provider Commentary.
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
1 Community and Universal
Scheme name;
Community Capacity
(information and advice, advocacy, community capacity building, community connectors,
community day service offer, community innovation fund, help to live at home)
What is the strategic objective of this scheme?
The strategic intent of this scheme is to release personal, community, state, private and
third sector assets to increase community self-help and increase the effectiveness of
coproduction to improve health and wellbeing and build stronger more inclusive
communities with the expected impact of increased strengths and assets of communities
with reduced demand on services. Stronger more mutually supportive communities, who
look after each other, should reduce social isolation and enable people to stay in their
own homes. This scheme identifies those individuals and communities in the lowest risk
group.
Fig.13. Community Capacity Building Logic Model
Source; Developing the power of strong, inclusive communities; draft HWB framework, December
2013
Overview of the scheme
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Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
This scheme is the Doncaster response to Community Capacity Building and the draft
framework produced by Think Local, Act Personal. It is also the local response to people
powered health. This scheme identifies those individuals and communities in the lowest
risk group. It complements the targeted scheme which identifies and targets individuals
and communities with higher risks.
Phase 1 of the scheme focuses on
- Commissioning new services to complement clinical care through the community
innovation fund (commissioning prospectus). The innovation fund has identified a
number of outcomes that potential providers can apply to improve. In the first
instance 3 elements have been prioritised social prescribing, signposting and
ensuring a balanced portfolio of community based services. New services and
alliances are being developed through the community innovation fund (seed fund
and making it real)
- As a result of this and the external evaluation of the fund we will develop and agree
a joint approach to the voluntary, community and faith sectors
- Consolidating, clarifying and communicating our approach to co-ordinated
information and advice and advocacy
- Identifying and developing our community connectors and developing community
navigators
- Help to live at home.
Phase 2 of the scheme will include reviewing and scaling up self-management support for
those with long term conditions through care planning and shared decision making.
Increases in social prescribing and peer support should pilots currently underway be
successful.
Information, Advice and Advocacy
To ensure people have good quality, appropriate information and advice to make informed
choices about the care and support provision that best meets their needs and
circumstances.
To ensure that information and advice is available about;
- How the care and support system works
- How to access care and support
- The choice of types of care and support, and the choice of care providers available
- How to access independent financial advice on matters relating to care and support
- How to raise concerns about the safety or wellbeing of an adult with care and
support needs.
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In doing so we will ensure we meet our statutory duties under the Care Act 2014.
To ensure peoples voices are heard in making those choices and experiencing/benefitting
from the care and support provision they have chosen.
The model of care and support is managed care with some distance travelled towards
personalisation. This wholesale model will be replaced by a retail model in which people
who need care and support can micro-commission their own care and support solutions
using good quality information and advice to inform their choices.
The cohort being targeted is the whole Adult population of Doncaster. This has been
stratified;
- Whole population – general message about maintaining health and wellbeing and
the promotion of independent living
- People making contact with the Council and Partners about care and support
needs – information, advice and signposting to help reinforce resilience to maintain
wellbeing and keep living independently
- People being assessed as needing a care and support intervention – information
and advice about how the care and support system works, their options from the
range of potential interventions that are relevant and how to complain if they are
not satisfied with their experience
- People already experiencing a care and support intervention - information and
advice about how the care and support system works, their options from the range
of potential interventions that are relevant and how to complain if they are not
satisfied with their experience.
We will ensure high quality information is available and meets core principles;
- Involves people who use services and carers in determining what is needed and
how it is provided
- Is available at the right time for people who need it, in a range of formats and
through a range of channels
- Meets the needs of all groups
- Is clear, comprehensive and impartial
- Is consistent, accurate and up-to-date
- Meets quality standards
- Is based on a detailed analysis of the needs of the local population served by the
Council
- Enhances existing provision and signposts people to sources of further good
information.
Actions in progress to improve the current system and offer and to ensure compliance
with the Care Act 2014 in April 2015;
- Define what we need
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- Identify what we have
- Map information pathways and customer journeys
- Identify gaps
- Assess the quality and relevance of commissioned services
- Make the most of existing resources whilst reviewing their relevance;
- Comply with the Care Act by April 2015
- Audit our offer against Think Local Act Personal Making It Real standards
- Develop standards, processes, systems and tools for staff to gather and give
information
- Learn from best practice examples.
Work with people who use services, Public Health, NHS Doncaster CCG, the Voluntary
and Community Sector, Independent and Private Care Providers, User Led
Organisations, Communities and other relevant stakeholders.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
The Council is the main commissioner of these services; increasingly these approaches
are being commissioned together with the NHS Doncaster CCG.
The Community Innovation Fund is administered by New Horizons the Council‟s third
sector infrastructure provider. A range of third sector providers are commissioned via a
prospectus to deliver services.
Information, Advice and Advocacy
Social Care commissioners have taken forward work to address the social care specific
requirements the policy agenda and forthcoming Care Act require. Broader joint
commissioning has taken place to put in place Advocacy provision that is now accessible
across all client groups.
Information and advice is available to residents of Doncaster in a range of formats;
- Web based on key websites – DiAL Doncaster, connecttosupport.org, Doncaster
Council Website, Dementiacarers.net, Healthwatch Doncaster
- Paper based – Independent Living Guide, Care Home Guide, Carers Information
Pack, across a wide network of partner organisations and community settings
- Verbally and visually via skilled professionals and volunteers– Social Workers,
Assessment Officers, Wellbeing Officers, Council customer service workers and
libraries staff, community workers, Disabled Peoples User Led Organisation
members, rehabilitation officers and others trained in BSL , Healthwatch Doncaster
paid staff and volunteers.
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Some of these services are commissioned and delivered by VCS partners
The Doncaster Community Funding Prospect 2013/14 – 2015/16 has three funding
streams that collectively provide a real opportunity for creative and innovative market
development across the spectrum from grassroots development to service delivery. One
of the funding streams – Innovation Fund provided an opportunity to encourage the
community to take a different approach to the delivery of information and advice.
Innovative provision is being piloted by VCS organisations, extending our reach, through
the use of community radio, digital technology trials in people‟s homes, niche community
contact points and networks and via a social prescribing approach
The Adult Contact Team (ACT) is promoted to the public as the main point of contact for
all Adult Social Care queries, receiving approximately 28000 calls a year and around 5000
other contacts electronically via the public, Health and other Partners
The promotion and offer of information and advice products is being embedded within the
service user pathway for example in reablement teams across health and social care and
as part of the social work rescript at the point of community care assessment.
Healthwatch Doncaster provide an overarching commissioned function across Health and
Social Care regarding information advice and advocacy, specifically Health complaints
Advocacy, though their commissioned work supports service users voice their concerns
about services in a variety of ways.
Voice ability has recently been commissioned to provide advocacy for adults across all
client groups including carers.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
People Powered Health; Health for people, by people and with people. NESTA (2013)
Help to Live at Home Service – an outcome –based approach to social care. Case Study
Report. IPC (2012)
What is the evidence on the economic impacts of integrated care? Nolte and Pitchforth
WHO (2014)
Developing the power of strong, inclusive communities. A draft framework for Health and
Wellbeing Boards. Think Local, Act Personal.(2013)
Building Community Capacity. Evidence, efficiency and cost-effectiveness. Wilton on
behalf of Think Local Act Personal (2012)
Community Engagement. NICE PH guidance 9 (2008).
Information, Advice and Advocacy
The Care Act 2014 places specific duties on the Council regarding information advice and
advocacy. The guidance (currently in draft) is specific about what how who where and
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when this should be provided
http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted
A comprehensive review of information advice and advocacy evidence was completed by
the Improvement and Development Agency to underpin the implementation of
Personalisation in Adult Social Care (Putting People First). This included a literature
review.
http://www.local.gov.uk/c/document_library/get_file?uuid=4eb0f9f9-b4f8-4344-892d-
8c893f806746&groupId=10180
Developing a whole systems approach to information advice and advocacy
http://www.jrf.org.uk/system/files/information-systems-for-older-people-summary.pdf
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£1,938,000 £953,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
The headline metric for this scheme is reduction in non-elective (general & acute). This is
supported by good evidence that whole population approaches can be cost effective.
The New Economics foundation showed for every £1 invested in community development
delivers £3 of social value.
Information, Advice and Advocacy
- Development and enhancement of Partnerships
- Nurturing of grassroots informal networks and community groups
- Market development
- Enhancing Direct Payment Offer
- Increase choice and control.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
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following;
- HWBB Governance Structure (supported by a dedicated system wide performance
group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Subsequently each sub scheme has its own performance indicators and has a co-
ordination group. We are establishing an overarching group for this scheme and the
targeted theme.
Information, Advice and Advocacy
The annual Adult Social Care User Survey contains questions that populate the Adult
Social Care Outcomes Framework indicator 3D, proportion of people who use services
and carers who find it easy to find information about services. This is subdivided into 3D
(1) and (2) for service users and carers respectively.
Broader engagement work consistently surfaces poor satisfaction with the provision of
information and advice, though this perception is not mirrored in the ASCOF indicator as a
result of the user survey.
Contract monitoring arrangements are in place for all commissioned services. All
contracts in place focus on outcomes and ensure information about performance is both
quantitative and qualitative. Healthwatch Doncaster are adopting LGA recommended
tools for performance management
Google analytics provides detailed information about the things people are searching for
on connecttosupport. This will be able to inform commissioning activity in the future in the
Councils market oversight and facilitation roles formalised in the Care Act.
What are the key success factors for implementation of this scheme?
Establishing concrete outcomes
Agreeing strategic direction
Information, Advice and Advocacy
People staying healthy and well for as long as possible
People finding their own support solutions to stay healthy and well
People purchasing their own support solutions on connecttosupport
People reporting their experience of social care support in a variety of ways
Peer support growing and people using this lived experience to inform purchasing
decisions
Equity of Opportunity
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
2 Community and Universal
Scheme name:
Targeted Support
Sexual Violence Advocacy, Domestic Violence Co-ordination, Veterans‟ health, Winter
Warmth)
What is the strategic objective of this scheme?
The strategic intent of this scheme is to release personal, community, state, private and
third sector assets to increase community self-help and increase the effectiveness of
coproduction to improve health and wellbeing and build stronger more inclusive
communities with the expected impact of increased strengths and assets of communities
with reduced demand on services. Stronger more mutually supportive communities, who
look after each other, should reduce social isolation and enable people to stay in their
own homes. This scheme identifies those individuals and communities at highest risk
group.
Fig.13. Community Capacity Building Logic Model
Source; Developing the power of strong, inclusive communities; draft HWB framework, December
2013
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Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
This scheme is the Doncaster response to Community Capacity Building and the draft
framework produced by Think Local, Act Personal. It is also the local response to people
powered health. This scheme identifies those individuals and communities at highest risk
group. It complements the community capacity scheme which identifies and targets
individuals and communities with lower risks.
In the first phase 3 areas have been identified, sexual/domestic violence, winter warmth
and veterans‟ health.
Sexual/domestic violence includes increasing the current capacity of the service in order
to respond to the increasing number of reported cases. Half these cases and nearly 1 in
20 will develop mental health problems and/or self-harm or attempt suicide respectively.
Earlier identification, signposting and intervention should reduce the number of people
developing these health issues.
The winter warmth approach involves identifying individuals that are admitted to hospital
with a „cold-related‟ condition and after assessment issuing high risk individuals with
ambient temperature gauges. The gauges are connected to the remote monitoring team
and trigger a range of interventions.
For veterans we are developing a veteran‟s volunteer policy and co-ordinator that should
increase connectedness and reduce isolation.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
Sexual domestic violence services commissioned by the Council and provided primarily
by the Council
Winter warmth services. Ambient temperature gauges commissioned by the Council and
provided by the hospital discharge team. Remote monitoring provided by the Council
along
Veteran‟s health commissioned by the NHS Doncaster CCG with additional information
and support commissioned by the Council from a range of providers. Volunteer co-
coordinator commissioned by the Council.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
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People Powered Health; Health for people, by people and with people. NESTA (2013)
Help to Live at Home Service – an outcome –based approach to social care. Case Study
Report. IPC (2012)
What is the evidence on the economic impacts of integrated care? Nolte and Pitchforth
WHO (2014)
Developing the power of strong, inclusive communities. A draft framework for Health and
Wellbeing Boards. Think Local, Act Personal.(2013)
Building Community Capacity. Evidence, efficiency and cost-effectiveness. Wilton on
behalf of Think Local Act Personal (2012)
Community Engagement. NICE PH guidance 9 (2008).
Crime Survey for England 2011
TLAP Building community capacity. Evidence, efficiency and cost-effectiveness 2012
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3
2014/15 2015/16
£111,000 £111,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
The headline metric for this scheme is a reduction in non-elective (general & acute)
between quarter 4 2014/15 and 2015/16 will reduce by 10.
In addition, for these schemes there is a good evidence of social return on investment.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners
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Subsequently each sub scheme has its own performance indicators and has a co-
ordination group. We are establishing an overarching group for this scheme and the
community theme.
What are the key success factors for implementation of this scheme?
Establishing concrete outcomes
Agreeing strategic direction
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme Reference Programme Area
3 Community and Universal
Scheme name
Falls Programme (Including Falls Development Programme and Falls Community
Exercise Programme)
What is the strategic objective of this scheme?
“To prevent falls and reduce the number of subsequent hospital admissions for those
who do fall”
Our vision for the Falls Programme of work is to enhance the independence, wellbeing
and quality of life of Doncaster‟s older people through reducing preventable fall-related
harm across acute, residential and community sectors.
The following four key national objectives (Department of Health; Falls and Fractures
2009) will help to realise this vision;
- Preventing frailty, promoting bone health and reducing accidents
- Providing early intervention to restore independence
- Responding to a first fracture and preventing the second
- Improving patient outcomes and efficiency of care after hip fractures.
This vision is also supported by a number of local objectives; where all people at risk of
falling and sustaining fractures and injuries;
- Know their risk and what they can do to minimise it
- Are supported by health and social care staff to minimise the risk
- Receive timely, good-quality assessment, treatment and care should they sustain
a fracture or injury through falling
- Are rehabilitated to their pre-fall mobility, health and wellbeing or even better
- Have their right to make choices and take risks respected.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
Falls are a common cause of injury and loss of independence in older people. Around 1
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in 3 people aged over 65 have one or more falls every year, many of which could have
been prevented.
The consequences of a fall and resultant fragility fracture cut across all local agencies
working with older people, including statutory and voluntary service providers therefore
assessment, and possible further development, of all current falls-related services is
essential. The human cost of falling includes distress, pain, injury, loss of confidence,
loss of independence and mortality. Falling has an impact on quality of life, health and
healthcare costs.
The highest number of falls occur in the older population so this programme will aim to
predominantly target the over 65‟s population. However, preventative measures must
also be included in lifestyle interventions for all age groups. For example, we will seek to
develop screening systems for groups such as post-menopausal women who may be at
risk of reduced bone health.
There is already good evidence-based practice taking place in Doncaster. However, a
more joined-up and systematic approach to falls prevention will ensure effective action is
taken, both across the wider community and amongst those at increased risk from falls.
Whilst many services have their specific pathways, Doncaster does not have one that is
fully integrated so a Falls Prevention Alliance has been formed to investigate current
systems and develop an effective local Falls Pathway.
In meeting the outcomes of the Integrated Falls prevention Strategy consideration will be
given to;
- The development of an effective falls pathway and ensuring effective integration of
the different services involved
- The potential need for a central referral point to facilitate access and manage
demand
- The adoption of a shared falls risk assessment tool
- The establishment of screening systems to enable proactive „case finding‟ of
people who have fallen or are at risk of doing so
- Working with contracted domiciliary and residential/nursing home providers to
ensure they have effective policies and procedures in place to manage falls
- Working with partners to ensure that fallers are triaged to the most appropriate
part of the care pathway, which may not be Accident & Emergency
- The accessibility of strength and balance class provision
- Processes to trigger a review of medication where this may contribute to the
person‟s falls
- The provision of staff training and information as appropriate with older people
- The involvement of mainstream services, such as pavement repairs, transport,
leisure, in supporting the prevention of falls
- The need to establish rigorous monitoring and evaluation procedures to
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demonstrate the effectiveness in delivering strategic outcomes.
The falls-related services we currently commission will contribute to the overall vision and
implementation of the strategy. For example, the Active in Later Life programme will
increase the physical activity levels of Doncaster‟s Older People (aged 50+yrs) and
contribute to;
- Supporting Older People to stay healthy and independent
- Reducing number of falls in older people
- Combating loneliness/ Encouraging social inclusion.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
Currently, Public Health commission Age UK Doncaster to provide the Active in Later Life
programme (AiLL). This programme aims to increase physical activity levels in older
adults (over 50‟s), thereby increasing strength, stamina & flexibility which in turn reduce
risk of falling and fractures. The service also delivers postural stability sessions for those
who have fallen and who are at risk of falling.
However, this programme forms only a small part of the overall work to be done to meet
our local objectives as falls is a complex, multidisciplinary subject. As such, much of the
work being done sits traditionally through more clinical routes. We are working with
partners including NHS Doncaster CCG, and providers such as RDaSH and DBHFT to
collate data that can be used to inform current needs and future commissioning decisions
on falls services.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
Each year, 1 in 3 people over 65 and almost 1 in 2 people over 85 experience one or
more falls, many of which are preventable. A single fall at home that leads to a hip
fracture costs the state £28,665 on average – over 100 times the cost of installing hand
and grab rails in the average home. Hip fractures are the event that prompts entry to
residential care in up to 10% of cases.
Viewpoint 21 2011 Report, for the Housing Learning and Improvement Network Housing,
prevention and early intervention at work; a summary of the evidence Base.
In Doncaster, over seven in every ten people aged over 55yrs are inactive (Active People
Survey 2) and falls are the biggest cause of accidental death in older people. It is
estimated that in Doncaster a quarter of people aged 65-74 and nearly half of over 75yrs
were unable to manage at least one self-care activity such as bathing, showering or
dressing. Therefore, the benefits of physical activity for older people are substantial
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especially in relation to maintaining independence and quality of life.
AiLL service delivery is informed by and consistent with relevant national strategies and
evidence for physical activity & older people (e.g. National Guidelines for Physical
Activity, BHF National Physical Activity Centre etc), adhering to best practice outlined in;-
NICE CG 21 – Falls
NICE PH 9 – Community Engagement
NICE PH 16 – Mental Wellbeing & Older People
NICE TA160 – Osteoporosis; Primary prevention guidance (2011)
The vision and aims of the Falls Prevention Alliance are driven by the Public Health,
NHS and ASC Outcomes Frameworks and have utilised data provided from NHS
Doncaster CCG on hospital admissions and discharge, and on evidence-based research
including Department of Health – Falls and Fractures (2009); Projecting Older People
Population Information (2013); NICE TA160 – Osteoporosis; Primary prevention
guidance (2011); The National Hip Fracture Database National Report (2013); NICE 161
– Falls; assessment and prevention of falls in older people (2013).
The Falls Prevention Alliance has identified a number of people using HEART pendant
alarms who are falling frequently. Whilst this service is not directly commissioned as part
of the falls programme, the outcome of the investigations with partners involved in the
fallers‟ care pathways aims to break down barriers to accessing support services that
may prevent or delay further falls, and therefore potential hospital and care home
admissions. The findings, along with the afore mentioned evidence-based research, will
then be used to inform future service delivery and possible commissioning intentions.
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£75,000 £125,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
The headline metric for this scheme is a reduction in non-elective (general & acute)
between quarter 4 2014/15 and 2015/16 will reduce by 135.
In addition in 2013/14, the average cost of a falls-related non-elective hospital admission
in Doncaster was £2,769. In the same year there were 2682 falls which resulted in
admission to hospital. The Falls Programme aims to reduce admissions due to falls
(primary or secondary) by 5% in 2014/15. This equates to 135 cases and a total cost of
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£373,815. However, this cost saving cannot be wholly contributable to the AiLL
programme, which is only one aspect of the overall falls work intervention required to
reduce the numbers of falls locally.
For example, the HEART team have a client base of 6,500. A responder will require
approximately an hour to attend to the client‟s needs. The unit cost per client per annum
is £33.48. However, through the work of the Falls Prevention Alliance, several frequent
fallers have been identified - some requiring having 16 falls within a 3 month period. If
this were to continue, such a case would cost in excess of £400 per year to this service
alone, over and above additional health and social care costs still to be costed. This
service aims to attend to clients at home to avoid hospital admission so contributes to the
overall Falls programme aim of a 5% reduction in admissions. However, this data may
also allow the HEART service to work more effectively, earlier, to prevent them falling
frequently – this could also produce cost savings to the service itself, or allow for the
funding to be used more innovatively by the service.
The potential cost savings are considerable, however further work is required to quantify
the total cost saving that can be attached to this wide-reaching area of work.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
AiLL is managed through quarterly contract meetings though which both quantitative and
qualitative feedback allow for continual measurement of programme outcomes.
The overall Falls programme, which AiLL compliments, will be measured through
continual checkpoint reporting into the BCF programme. It does rely somewhat on the
provision of data from providers, most of whom are members of the Falls Prevention
Alliance although they are generally not commissioned by the Council, which adds to the
complexities of monitoring success.
What are the key success factors for implementation of this scheme?
The following success indicators have been agreed by the Falls Prevention Alliance;
- Increased numbers of people returning to independent living after a fall (so
reduced admissions to care/residential homes)
- 5 % reduction in non-elective admissions (with a primary/secondary diagnosis of
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falls)
- Improvement in service user uptake of referral after a fall by HEART to CICT/TRH
from 10% to 20%
- 5 % reduction in re-admissions within 30 days as a result of a further fall
- 5 % reduction in number of all fractures from falls in > 65s
- Number of multifactorial risk assessments completed by healthcare professionals
for people presenting after a fall
- Increased uptake of rehabilitation services (from all sectors).
The success of the programme will depend on strong partnership working to initially
collate data from all providers to assess current service provision and then use this
information to inform development of current services and assess need for new services.
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
4 Short Term
Scheme name;
Admission Avoidance Schemes
What is the strategic objective of this scheme?
To avoid admissions to hospitals in particular non-elective admissions
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
Current Focus
A range of services have been commissioned and piloted to support the current core
service offer in Doncaster. The services have been designed and implemented in line
with evidence that demonstrates high admissions, in particular non-elective admissions
and readmissions, and where Doncaster is an “outlier”.
Examples of schemes include;
- Front end liaison and Rapid Assessment Project Team services in A&E to avoid
admission through signposting/ redirection to appropriate community based
services, facilitating rapid access where required. The service takes a holistic
approach to service delivery and considers patients for all health and social care
needs
- A range of schemes are also in place to support patients who have a number of
long term conditions. Examples include a new COPD pathway and home oxygen
service and services provided by the pharmacy colleagues to encourage
appropriate inhaler use
- Further schemes targeted at other specific cohorts such as the lower urinary tract
infection pathway and acute retention pathway, where management is provided in
the community and avoids non-elective admissions
- A new approach to community nursing provision has been developed focussing on
holistic care. Improvements in access and system integration are also being
implemented
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- The provision of 12 step up beds in the community to avoid hospital admission
from primary care.
Future Focus
In line with the agreed Health and Wellbeing Board strategic direction, the long term
objective is to integrate health and social care services, services will be provided much
closer to home with an early focus being placed on intermediate care services.
With regards to community nursing services the new design has been developed and
integrates 3 previously separate services (district nursing, community matrons and the
crisis intervention service) to cover 24/7 with work-streams split between planned and
unplanned care. The focus of the new model is to provide holistic care to patients with a
move away from transactional orientated care.
With regards to intermediate care H&WB and partners are supporting a significant piece
of work to identify the future service offer required for Doncaster patients, based on
patients‟ individual health and social care needs. It is envisaged that the model will be
focussed on maintaining independence, avoiding hospital admission, and rehabilitation.
A needs analysis is currently being undertaken and a partnership response will be
agreed following recommendations from this work. This piece of work forms a significant
element of the short term transformation programme.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
Current Focus
NHS Doncaster CCG is the lead commissioner for these services; the Council are a
partner to the contract through associate arrangements.
These services are commissioned from a range of providers, in particular DBHFT,
RDASH, the Council and other sector providers of community services.
Future Focus
It is anticipated that an integrated commissioning model will be agreed, with an integrated
service offer being commissioned. Services will be delivered by a range of providers
from all sectors.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
Current Focus
The evidence for these schemes has been based on benchmarked outcomes data, with
local analysis being undertaken to understand where Doncaster is an outlier. NHS and
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Adult Social Care Outcomes Frameworks data have been used to pull together local
spine charts indicating the Doncaster position in relation to England and peers; see
example under section 2 Vision for Health and Care Services. Ways to address the
issues identified have then been locally clinically determined, using the national and local
evidence available e.g.
COPD Commissioning Toolkit, A Resource for Commissioners (2012)
Urology Pathway Redesign 2nd Report (2014)
Future Focus
The future intermediate care service model will be agreed in partnership across
Doncaster. The model will be developed using 3 key pieces of information;
- A detailed desktop analysis after collating local data, to build up a picture of the
current status of intermediate care provision
- A statistically valid and significant clinical audit of need around discharge/
admissions with a full multi-disciplinary team providing reference and direction
- A comprehensive evidence review of academic and practical approaches
(national) being taken elsewhere.
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£1,095,000 £1,085,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
Current Focus
The headline metric for this scheme is that non-elective admissions between quarter 4
2014/15 and 2015/16 will reduce by 370.
This is comprised of the following;
- Reduction in non-elective admissions (as per original operational planning
submission)
- LUT/acute retention pathway redesign implementation – early data indicates an
increased number of avoided admissions are expected
- Implementation and expansion of COPD- pulmonary rehab programme
- Further developments regarding use of local step up – 12 beds
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- Further developments regarding RAPT team at DBHFT- based on an increase in
number of users seen an increase in proportion resulting in admission avoidance.
This has been modelled on the service data for 2013/14 and quarter 1 2014/15.
Future Focus
In the longer term, expected success indicators include;
- Reduction in non-elective admissions
- Reduction in admission to long term care
- Increase in user satisfaction levels
- Increase in the number of patients receiving rehabilitation and reablement in their
own home.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Current Focus
No additional data is required for these schemes. Performance and delivery data is
collected through contractual mechanisms. A community services data set has been
developed to support performance and delivery management. This will now be
populated with live data.
Future Focus
As the new intermediate care service offer is developed and patients are given
alternative options to acute hospital bed based services, a performance and service
delivery reporting framework will be required.
What are the key success factors for implementation of this scheme?
For both the current and future scheme key success factors are;
- Partnership working; there are a range of existing forums that nurture this way of
working (see above) and in addition there is a programme team in place to support
this further
- Integration between acute, community and social care staff to deliver the service
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- External expertise is being sought with regards to service design for the future to
support the service developments noted above
- Good communication with patients and carers.
Page 86 of 136
ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
5 Short Term
Scheme name;
Reablement Services
What is the strategic objective of this scheme?
This scheme is targeted at helping people to recover their skills and maintain
independence and as a result avoid potential further non-elective admissions or
readmissions.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
Current Focus
- Additional investment made into community nursing services to specifically
enhance the rehabilitation and reablement service already in place
- Review undertaken of Council social care rehabilitation service (STEPs) focussing
on improvement in service efficiency
- Investment in bed based social care assessment services to avoid long term care.
The primary aim of each scheme is to maximise independence and mobilisation.
Future Focus
In line with the agreed Health and Wellbeing Board strategic direction, the long term
objective is to integrate health and social care services and ensure the offer will be
commissioned to support service users in their own home to manage their condition and
maintain independence.
With regards to community nursing services the new design has been developed and
integrates 3 previously separate services (district nursing, community matrons and the
crisis intervention service) to cover 24/7 with work-streams split between planned and
unplanned care. The focus of the new model is to provide holistic care to patients with a
move away from transactional orientated care.
With regards to intermediate care H&WB and partners are supporting a significant piece
of work to identify the future service offer required for Doncaster patients, based on
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patients‟ individual health and social care needs. It is envisaged that the model will be
focussed on maintaining independence, avoiding hospital admission, and rehabilitation.
A needs analysis is currently being undertaken and a partnership response will be
agreed following recommendations from this work. This piece of work forms a significant
element of the short term transformation programme.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and providers involved
Current Focus
NHS Doncaster CCG and the Council are lead commissioners for these services.
These services are commissioned from a range of providers, in particular DBHFT,
RDASH, the Council and other sector providers of community services.
Future Focus
It is anticipated that an integrated commissioning model will be agreed, with an integrated
service offer being commissioned to be delivered by a range of providers from all sectors.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
Current Focus
- Clinically led patient flow modelling undertaken to determine potential pathways
for patients, informing the capacity across the system – both bed based and
community based.
- Detailed analysis and review of steps service undertaken resulting in
recommendations to the partnership
- Analysis of current “non-elective” readmissions in comparison with peers, based
on NHS Outcomes Framework data.
Future Focus
The future intermediate care service model will be agreed in partnership across
Doncaster. The model will be developed using 3 key pieces of information;
- A detailed desktop analysis after collating local data, to build up a picture of the
current status of intermediate care provision
- A statistically valid and significant clinical audit of need around discharge/
admissions with a full multi-disciplinary team providing reference and direction
- A comprehensive evidence review of academic and practical approaches
(national) being taken elsewhere.
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Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£4,370,000 £3,751,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in headline metrics below
Current Focus
The headline metric for this scheme is that non-elective admissions between quarter 4
2014/15 and 2015/16 will reduce by 73 (to be amended to reflect social care assessment
beds and STEPs).
It is expected that through enhancing the rehabilitation and reablement services already
in place the number of non-elective readmissions in particular will be brought in line with
the Doncaster peer group.
Future Focus
In the longer term, expected success indicators include;
- Reduce the number of patients placed in long term care
- Reduction in non-elective admissions
- Increase in user satisfaction levels
- Increase in the number of patients receiving rehabilitation and reablement in their
own home.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Current Focus
No additional data is required for these schemes. Performance and delivery data is
Page 89 of 136
collected through contractual mechanisms.
Future Focus
As the new intermediate care service offer is developed and patients are given
alternative options to acute hospital bed based services, a performance and service
delivery reporting framework will be required.
What are the key success factors for implementation of this scheme?
For both the short and long term schemes the key success factors are;
- Partnership working; there are a range of existing forums that nurture this way of
working (see above) and in addition there is a programme team in place to support
this further
- Integration between acute and community and social care staff to deliver the
service
- External expertise is being sought with regards to service design for the future to
support the service developments noted above
- Good communication with patients and carers.
Page 90 of 136
ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
6 Short Term
Scheme name;
Discharge Schemes
What is the strategic objective of this scheme?
To ensure that patients are discharged at the optimum point in their journey in order to
support the maintenance of their independence.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
Current Focus
An integrated discharge team has been developed, which includes both health and social
care staff. This supports effective and timely discharge for patients with complex needs.
This service has been developed during 2013/14 but it has been identified that there is a
need for an increased resource overall and an extension in service to work over 7 days in
conjunction with hospital based services (7 day ward rounds, 7 day admissions to bed
based rehab and intermediate care services). This will align with the newly
commissioned integrated community equipment service which is also 7 days per week.
Future Focus
The future service offer will be developed to support timely discharge directly into the
patients‟ home or into the newly developed intermediate care service offer to support
mobilisation and independence. The current service model will be developed and
adapted to meet the needs of the health and social care system as the new model of
care is developed and implemented.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
Current Focus
NHS Doncaster CCG is the lead commissioner for these services; the Council are a
partner to the contract through associate arrangements. Current discharge
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arrangements are funded from a current pooled budget arrangement.
These services are commissioned from a range of providers, in particular DBHFT,
RDASH, the Council and other sector providers of community services.
Future Focus
It is anticipated that the future service model will be delivered in partnership across all
health and social care providers in Doncaster. This will be determined once the future
model is clear and as the commissioning process progresses.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
This work was initiated as a result of an external review commissioned locally.
The development of the service to date has been supported through a pooled budget
arrangement between health and social services, and although not fully developed it has
won a number of national awards.
A local review of the impact of extending the service to 7 days was undertaken in May
2014, following a 3 month pilot during quarter 4 2013/14. This showed that the number
of discharges over a weekend on average significantly increased during the period;
- Sat - 17 per month (31% increase)
- Sun - 9 per month (125% increase)
- Mon - 36 per month (13% increase).
In addition the length of stay reduced;
Fig.20. Doncaster Average Length of Stay and Number of Referrals
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£1,256,000 £1,261,000
Impact of scheme
Average length of stay
2013 2014
January 9 7
February 11 9
March 9 7
Total average 10 8
No. of referrals
2013 2014 Grand Total
January 304 310 614
February 245 247 492
March 217 272 489
Grand Total 766 829 1595
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Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
Current Focus
The headline metrics for this scheme are;
- Reduced number of delayed discharges days by 90 between Q4 2014/15 to Q3
2015/16
- Reduced average length of stay.
Future Focus
In the longer term, expected success indicators include as a result of timely discharge
include;
- Reduction in non-elective re-admissions
- Reduction in admission to long term care
- Increase in user satisfaction levels.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Current Focus
No additional data is required for the short term schemes
Future Focus
New data will be required – and will be addressed with providers through the forums
noted above.
What are the key success factors for implementation of this scheme?
For both the short and long term schemes the key success factors are;
- Partnership working; there are a range of existing forums that nurture this way of
working (see above) and in addition there is a programme team in place to support
this further
Page 93 of 136
- Integration between acute and community and social care staff to deliver the
service
- External expertise is being sought with regards to service design for the future to
support the service developments noted above
- Good communication with patients and carers.
Page 94 of 136
ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
7 Short Term
Scheme name;
Intermediate Care
What is the strategic objective of this scheme?
The strategic objective of the intermediate care scheme has two elements.
In the near future the ambition is to maintain and improve the service provision model to
support the wider system. In addition, a future service model will be developed to avoid
unnecessary hospital admissions, support early discharge from hospital based services
and maintain independence and support rehabilitation.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
Current Focus
Community based step up and step down intermediate care services are in place to
avoid hospital admission and support hospital discharge. This service model has been
developed over time and includes a number of step-up and step down beds in a
community setting. These bed based services provide health or social care support
dependent upon patient need. In addition, there are a number of community based
rehabilitation based services provided by health or social care services. Recently, a
number of complex assessment beds were commissioned to support the discharge of
patients from acute care whilst also ensuring that patients are in the optimum
environment for assessment of future needs. This service model is providing support to
patients in Doncaster but the Health and Wellbeing Board have agreed that this service
tier needs to be reviewed and remodelled based on the needs of Doncaster patients now
and in the future.
Future Focus
H&WB and partners are supporting a significant piece of work to identify the future
service offer required for Doncaster patients, based on patients‟ individual health and
social care needs. It is envisaged that the model will be focussed on maintaining
independence, avoiding hospital admission, and rehabilitation. A needs analysis is
currently being undertaken and a partnership response will be agreed following
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recommendations from this work.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
Current Focus
NHS Doncaster CCG and Council colleagues currently commission a range of services.
These services are commissioned from a range of providers, in particular DBHFT,
RDASH, the Council and other sector providers of community services.
Future Focus
It is anticipated that the future service model will be delivered in partnership across all
health and social care providers in Doncaster. This will be determined once the future
model is clear and as the commissioning process progresses.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
Current Focus
- Clinically led patient flow modelling undertaken to determine potential pathways
for patients, informing the capacity across the system – both bed based and
community based
- Detailed analysis and review of STEPs service undertaken resulting in
recommendations to the partnership
- Analysis of current “non-elective” readmissions in comparison with peers, based on NHS Outcomes Framework data.
The future intermediate care service model will be agreed in partnership across
Doncaster. The model will be developed using 3 key pieces of information;
- A detailed desktop analysis after collating local data, to build up a picture of the
current status of intermediate care provision
- A statistically valid and significant clinical audit of need around discharge/
admissions with a full multi-disciplinary team providing reference and direction
- A comprehensive evidence review of academic and practical approaches
(national) being taken elsewhere.
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
Page 96 of 136
£3,347,000 £3,307,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
Current Focus
The headline metric for this scheme is that non-elective admissions between quarter 4
2014/15 and 2015/16 will reduce by 266.
This is comprised of the following;
- Further developments regarding use of local step up and step down beds
- Continued implementation of complex assessment beds, ensuring that patients
are in the optimum environment for assessment of future needs, thereby reducing
the potential for future non-elective admissions.
Future Focus
In the longer term, expected success indicators include;
- Reduce the number of patients placed in long term care
- Reduction in non-elective admissions
- Increase in user satisfaction levels
- Increase in the number of patients receiving rehabilitation and reablement in their
own home.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Current Focus
No additional data is required for the short term schemes
Future Focus
New data will be required – and will be addressed with providers through the forums
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noted above.
What are the key success factors for implementation of this scheme?
For both the short and long term schemes the key success factors are;
- Partnership working; there are a range of existing forums that nurture this way of
working (see above) and in addition there is a programme team in place to support
this further
- Integration between acute and community and social care staff to deliver the
service
- External expertise is being sought with regards to service design for the future to
support the service developments noted above
- Good communication with patients and carers.
Page 98 of 136
ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
8 Short Term
Scheme name;
End of Life
What is the strategic objective of this scheme?
To enhance the end of life care provided for patients in their last 12 months, 3 months
and 72 hours of life.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
Current Focus
Last 12 months of life;
Enhance training across all providers to ensure that the right skills are in place to meet
the needs of patients and carers.
Last 3 months of life;
As part of the revised community nursing service develop a responsive domiciliary care
service that can meet the needs of individual patients and carers and can be flexible in
the use of resources to meet needs.
Last 72 hours of life;
- Linking to the revised community nursing service, the development of a more
proactive unplanned care service to support patients in the last 72 hours of life,
dependent on need
- To support hospital discharge where appropriate
- To develop and co-ordinate pain relief services in the community and private
sector care homes via one locally based, quality assured process.
Future Focus
The development of a partnership strategy to improve end of life services across all
sectors.
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The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
Current Focus
NHS Doncaster CCG is the lead commissioner for these services; the Council are a
partner to the contract through associate arrangements.
These services are commissioned from a range of providers, in particular DBHFT,
RDASH, the Council and other sector providers of community services.
Future Focus
It is anticipated that an integrated commissioning model will be agreed, with an integrated
service offer being commissioned to be delivered by a range of providers from all sectors.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
The National bereavement services survey shows that 81% of patients would prefer to
die at home.
NHS Doncaster CCG care profile shows that a higher than average number of deaths
occur in hospital each year at 55.87% of all deaths (England 50.71%), this equates to
152 more deaths in hospital than the England average per year.
Doncaster also has significantly lower deaths in care homes at 15% (England 19.1%).
An improvement to the England rate would result in 120 more deaths taking place in care
homes as a result of patient choice
Doncaster also has lower deaths in hospices at 4.3% (England 5.6%). An improvement
to the England rate would result in 38 more deaths taking place in a hospice as a result
of patient choice
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£0 £100,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
Page 100 of 136
The headline metric for this scheme is that non-elective admissions between quarter 4
2014/15 and 2015/16 will reduce by 177. This is as a result of fewer deaths taking place
in hospital and a reduction in non-elective admissions to hospital for end of life patients.
This reduction will be secured through changes in services for end of life patients in the
last 3 months and 72 hours of life as described above.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Current Focus
No additional data is required for the current schemes
Future Focus
New data will be required – and will be addressed with providers through the forums
noted above.
What are the key success factors for implementation of this scheme?
Ensure all organisations are signed up to developing the approach to end of life care in
Doncaster – there is already significant support for doing so.
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
9 Long Term
Scheme name
Equipment, Technology and Adaptations Programme
Key projects include;
- Telehealth and Telecare
- Heart
- ICES
- Community aids and adaptations (Including Disabled Facilities Grant)
- Doncaster Therapy Services.
What is the strategic objective of this scheme?
Equipment, Aids and Adaptations and Technology (EAAT) help to overcome the
environmental barriers that limit the potential of people who are disabled, have a long term
or life limiting illness and older people to take part in mainstream employment, educational,
social and recreational opportunities . Timely and appropriate EAAT can have a significant
and positive impact on people's lives, and those of their carers, and can influence the
reduction in need for other care services. They help people of all ages to carry out ordinary
activities of daily life that have become difficult or impossible due to impairment, ill health,
traumatic injury, the effects of ageing or a change in circumstances and can promote real
alternatives for those people at risk of entering Residential Care or Hospital admission.
However to maximise capability people also need the support of a skilled and accessible
therapy resource to exploit the potential of aids and adaptations, access to effective
response services when things go wrong and to be connected to a wider system that also
harnesses the assets and skills of community and preventative resources.
Although recent service improvement and re-engineering work in Doncaster has
increased response, productivity, flexibility, access and efficiency, there is a need for a
much wider and longer-term improvement agenda for the availability of equipment,
adaptations ,technology and the associated support services within the community. The
ambitions of the EAAT programme are extensive and interconnected, and if addressed, will
have a significant impact on raising awareness, increasing general availability, and
improving and supporting service delivery.
The strategic objectives of the EAAT programme are as follows;
- Equipment, technology, adaptations, therapy and response services that are
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integrated with one another, integrated within health and social care, through joint
resourcing and joint service management, single shared assessment and care
management
- A service that is person centred enables decisions to be taken jointly over a wider
use of resources and directs a broader range of services and resources to needs
- Where people require assistance that includes equipment and adaptations there
should be simple processes to access integrated and holistic local information,
advice, demonstration, support, products and services within an appropriate
timeframe
- A service which harnesses the best technology available, both in the service offer
and in enabling an effective and responsive workforce.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
The strategy aims to achieve a connected model of Telecare, Telehealth, aids and
adaptations, supported by an integrated Doncaster wide therapy and response service that
can deliver a swift and timely service through a single point of access within social care,
health and housing services in Doncaster. Our main priority groups will be both the top
10% of people identified through risk stratification at being of risk of admission to long term
services of hospital and those with medium risk as follows;
- People at risk of falls
- People with Dementia
- People with learning disabilities, both for people who live independently and people
in residential care who could live more independently with assistive technology
- People leaving hospital
- Carers
- Individuals living at home.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
The Doncaster EAAT offer will be developed and delivered by Doncaster Adults and
Commissioning and provider services with NHS Doncaster Clinical Commissioning Group,
with a range of assistive technology providers.
The development of the EAAT service will be overseen by robust governance
arrangements put in place through the Doncaster EAAT Strategy Group.
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The current provision of Telecare is provided through Tunstall on the Yorkshire and
Humber Housing Framework; however, it is likely that Health and Social Care Partnership
will aim to re-tender the service in early 2015.
A full review of Doncaster Therapy services will begin in October/November 2016.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
In understanding the evidence for the implementation of Telecare across Doncaster the
Council on behalf of the partnership commissioned a review of Doncaster‟s Assistive
Technology Services by Dr Royce Turner and Dr Andrea Wigfield through the Centre for
International Research on Care, Labour and Equalities (CIRCLE) at the University of
Leeds.
The Council has also commissioned an internal report on the delivery of alarm systems
across the partnership which has further been enhanced by commissioned reports through
Tunstall PLC.
Telecare is of increasing importance in Government policy on health and social care
provision. It is now widely accepted that it has a major role to play in delivering a
transformed and personalised social care system. Nationally, a vision is emerging of a
more cost-effective, assistive technology-supported, health and social care system that is
able to deliver care where it is most appropriate, increasing the flexibility of care packages
and improving the quality of peoples‟ lives. Telecare has huge potential to support a
diverse range of individuals to live at home. It can also give carers more personal freedom,
meet potential shortfalls in the workforce and complement the work of health, social care
and housing providers to achieve outcomes that improve the health and well-being of
people using services.
The DOH Whole System Demonstrator (WSD) programme is the largest randomised
control trial of Telehealth and Telecare anywhere in the world. It was set up in 2008 to look
at the clinical and cost effectiveness of Telehealth and Telecare across three sites (Kent,
Cornwall and Newham) involving 6,191 participants, and 238 GP practices. The Telehealth
part of the study focused on three diseases, COPD, diabetes and heart disease. Data was
collected over a minimum of 12 months.
The headline findings from the Whole System Demonstrator (Dec 2011) were;
- 20% fall in non-elective admissions
- 15% fewer visits to A&E
- 14% fewer elective admissions
- 14% fewer bed days
- 8% reduction in tariff costs
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There are also significant reductions in mortality (up to 45%) however the demonstrator
review highlights that the findings are subject to the implementation and service being
delivered properly. In the development of each scheme, we are working closely with our
colleagues within Public Health and the CCG to implement evidence based practice.
Doncaster‟s Telecare service installed a range of its equipment for 719 clients in 2013/14,
51% (370) of clients required Telecare intervention to support them in preventing hospital
admission. Looking at a cohort of these clients in 2013/14, we discovered that 44% of
clients had reduced/avoided admissions to hospital, where 30% of clients experienced the
same activity level (approximately 60% had no admissions to hospital).
Locally, we undertook a pilot scheme for Telecare Solutions within a Residential Setting for
People Living with Dementia where key outcomes were;
- Significant reduction in Falls management and A and E admissions
- Residents choice and independence is maximised
- Allowed staff to respond more effectively to issues, thus allowing residents more
independence but also managing the risks to the individual.
In addition, a recent pilot of Just Checking (activity based system) evidenced significant
outcomes;
- Prevented 2 residential admissions
- Delayed hospital admissions
- Facilitated early hospital discharge.
Supporting a technology based workforce
Wide ranging evidence highlights the benefits of mobile working across both the health and
social care sector. Evidence suggests that productivity savings in the region of 30% to
40% would be achievable once mobile working is fully implemented.
(Source – http://www.capita-totalmobile.co.uk/ROI_calculator.php)
Microsoft identify areas that benefit the organisation who adopt mobile working as;
- Constant availability
- Reduced commuting time
- Productive working
- Business continuity
- Improved customer service
The timeliness of data input also enables a more proactive response to care rather than
reactive as information on service users is widely available to all teams providing support to
individuals.
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
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2014/15 2015/16
£4,352,000 £5,056,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
The headline metric for this scheme is a reduction in non-elective (general & acute)
between quarter 4 2014/15 and 2015/16 will reduce by 190
EAAT services will help contribute to achieving a reduction in the number of non-elective
hospital admissions.
Fig.21. The Impact of Telecare and Telehealth on the Acute Sector
On a secondary level, it will also help to achieve a reduction/delay in the number of people
moving into residential care, by supporting individuals to live at home independently in the
community for longer.
Fig.22. The Benefits of Telecare and Telehealth on Patients and Service Users
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The implementation of mobile working will bring efficiencies in productivity and process and
reduce the risk of growing the staff base as the Telecare customer base increases.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide performance
group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Specifically quarterly Performance Reports are produced for the Doncaster Assistive
Technology Strategy Group and robust governance arrangements are in place that feed
into the Long Term Programme group.
Regular checkpoint meetings deliver highlight and exception reports.
Will also feed into the Strategic Housing Reference group that will report directly to the
Health & Wellbeing Board.
Community equipment governance structure is being developed.
Approved performance metrics relating to mobile working will be reported via Doncaster
ETA Strategy Group.
What are the key success factors for implementation of this scheme?
The success of the scheme will depend upon having effective and robust governance
structures in place, with timely performance information and data. Effective partnership
arrangements between all stakeholders will be essential in delivering the scheme and
ensuring it is successful. The development of a Communication and Marketing Strategy
will also be crucial in terms of delivering appropriate information/training to both the
workforce, stakeholders, third sector and the wider public.
We have set robust targets that will be reported through the governance arrangements
described above.
Targets
It is clear that both health and social care will require various metrics to satisfy the needs of
their organisation. Upon approval of this scheme Doncaster Assistive Technology Strategy
Group will approve the necessary metrics for this workstream.
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Fig.23. The BCF measures of Success for the use of Telecare
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
10 Long Term
Scheme name;
Mental Health Including Crisis Services
What is the strategic objective of this scheme?
Mental Health Pathway re-design
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
Mental Health Crisis Services
The Doncaster Partnership agencies are in the process of review and redesign of the
crisis care pathway. The aspiration is to redesign the front end of the care pathway to
ensure that it is as responsive as possible to people who are experiencing a mental
health crisis and then co-ordinating that response which meets individual need. This will
include appropriate treatment when/where necessary, advice and support and sign-
posting to other support services that may not necessary deliver medical assistance i.e.
benefits advice, accommodation support etc. This pathway redesign will also include the
Crisis House (community bed) provision and how this can be more responsive to people
who need advice and support before they reach the pinnacle of their crisis and provide
prevention and management support.
Mental Health Development Programme
The wider Mental Health Development Programme will also include redesign of specialist
care pathways including Perinatal Mental Health, Eating Disorder and Personality
Disorder services. These pathways will be developed to ensure that people are
managed in Doncaster and do not have to travel out of area, sometimes having extended
in-patient stays, as we do not have these in place locally. Community Teams are
currently being structured so that complex care can be provided and ensure recovery
focused services.
A review of primary care mental health services are underway that have already
identified a need for more, cohesive support services to be in place to prevent mental
illness and emotional distress. The service gaps identified include access to housing and
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benefits advice, family support and employment/social activities. The review will
therefore work closely with the Better Care Fund/Universal Service developments.
Peer Support for People with Mental Health
The Peer Support training service will be flexible, borough wide service. It will use a
range of approaches and methods to engage, recruit, train and support local groups and
communities of interest in order for them to then deliver effective peer support to
individuals within their local community.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
Joint business cases developed across health and social care. The business cases were
submitted to BCF Joint Adult Commissioning Forum for review and approval.
The services are jointly commissioned by a partnership of Doncaster Council and NHS
Doncaster CCG. These services are provided by RDaSH.
The „Training to embed Peer Support‟ service was jointly commissioned and procured
using Doncaster Council‟s processes. This is provided by an organisation called People
Focused Group (PFG)
The Commissioners for this scheme area are Doncaster Council and NHS Doncaster
CCG.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
A review of mental health services in Doncaster commissioned by NHS Doncaster CCG
outlining the following recommendations and findings;
- 4 key pathways; urgent and inpatient care; secondary care community mental
health services; primary care mental health services; specialist mental health
services
- And 5 underpinning themes ; there needs to be a major shift away from use of
specialist placements to building local pathways that meet people‟s needs;
contracting and contract management, including PbR; the estate from which
mental health services are provided; relationships with stakeholders; and a quality
and outcomes framework for planning and delivery.
In addition, there appears to be an over reliance on secondary care in meeting people‟s
needs. Further work needs to be done to find the solutions in primary care settings
where they would appear to be the root to overall pathway and outcome improvements.
The Coalition Government released the Mental Health Crisis Care Concordat - Improving
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outcomes for people experiencing mental health crisis – in February 2014.
Mental health touches everyone and it is the responsibility of every organisation to work
together to ensure high quality and effective services for people who experience
episodes of poor mental health.
Our local partnership of Council, health and criminal justice organisations will focus
- Universal and Prevention services - access to support before crisis point
- Short term treatment services - urgent and emergency access to crisis care
- Long term reablement services that feedback into universal services - recovery
and staying well and preventing future crises.
We will agree, locally, how these different services can best work together and it
establish key principles of good practice that local services and partnerships should use
to raise standards and strengthen working arrangements.
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£1,956,000 £1,956,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
The headline metric for this scheme is reduction in non-elective (general & acute),
achieved through;
Mental Health Crisis Services
- Crisis prevention
- People being supported to self-manage before crisis occurs
- Early intervention and immediate response to service users experiencing a crisis
episode
- Reduced inappropriate activity on A&E, Police and Ambulance
- Co-ordinated Care management.
Mental Health Development Programme
- Robust community based services
- Specialist services and case management provided in Doncaster
- Recovery focused treatment and care services
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- Reduced stigma and parity of esteem with physical health services.
Training to embed Peer Support
The key outcomes for the Training to embed Peer Support service will include;
- Sustainable and flexible peer support training programme
- Trained peer supporters with skills and knowledge
- A train the trainer programme (to be developed in Year 2 in order to support
sustainability)
- Create and facilitate a Peer Support network for peer supporters who have been
trained.
Outcomes for service users will be personalised and dependent on the service user‟s
needs and abilities, broadly however the service will evidence how it contributes to the
following „I‟ statements;
"I am supported by people who help me to make links in my local community."
“I understand my health and know what to do to keep myself healthy and to live my
life to the full”
“I enjoy my life.”
“I am in control; I have choice I am listened to.”
“I am happy and independent.”
“I get the right amount of support.”
“I am provided with information in the way I want, or directed to reliable sources of
information that is evidence based, timely, easy to understand, personalised,
transparent and honest.”
"I do not feel lonely, I feel safe and secure."
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Mental Health Crisis Services
The redesign of the pathway is being developed in collaboration with;
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- The Council
- RDASH
- Service Users
- 3rd Sector partners.
Mental Health Development Programme
Continued consultation us taking place through;
- NHS Doncaster CCG Internal Governance Structure
- Mental Health Strategic Alliance
- HWBB
- Primary Care Practitioners
- RDASH
- The Council.
Training to embed Peer Support
The service provider will be required to demonstrate clearly how the service has
contributed to achieving the outcomes described in this specification.
The frequency of Progress Review meetings will be agreed with the service provider at a
meeting at the Award of Contract stage.
The Service provider will submit performance and output monitoring information quarterly
based upon the agreed Peer Support Training Key Performance Indicators (KPIs) and
will also provide information should the Council make ad hoc requests.
What are the key success factors for implementation of this scheme?
Mental Health Crisis Services
- People will experience less episodes of mental health crises
- Reduced attendance at A&E/reduced episodes of self-harm
- Improved self-management.
Mental Health Development Programme
- Improved access to recovery based services
- Improved physical health jointly with mental health/emotional wellbeing (parity of
esteem)
- Improved self-management and support re housing/accommodation, employment
etc.
Training to embed Peer Support
Success of this part of the scheme is based on the following key principles and values;
- Flexible – training which utilises different models of peer support including one-to –
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one, group, formal and informal
- Inclusive - working inclusively with local groups and communities of interest
- Person Centred - training demonstrates a Person Centred approach
- Peer support training that is based on giving and receiving help founded on the
key principles of respect, shared responsibility, and mutual agreement of what is
helpful
- Tailored - to meet the different needs of individuals and communities (including
communities of interest)
- Demonstrates a commitment to the “I” statements described in the Outcomes
section
- Seeks to improve the resilience and capacity of local communities to provide
support for people with specific health concerns
- Encourages sustainable partnerships between peer supporters and individuals.
Outcomes
Continuing quality improvement and innovation in peer support training
- Highlighting, celebrating and disseminating best practice in peer support to
support learning and development between individuals, groups and organisations
- Genuine engagement and involvement of individuals, groups and communities of
interest - finding out what quality peer support means to them.
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
11 Long Term
Scheme name;
Dementia Schemes covering;
- Dementia Schemes (RDaSH)
- Dementia Cafes (Alzheimer‟s Society)
- Dementia Friendly Communities Programme (SMIP)
- Dementia Peer Support Network (Sue Ryder)
What is the strategic objective of this scheme?
People with Dementia will live well.
- To provide acute assessment and treatment of people with or suspected of having
cognitive impairment due to organic disease
- To provide on-going support, education, advice, information and signposting to
both the person with diagnosed Dementia and their carer
- To demonstrate Doncaster is working towards being Dementia friendly
- To produce a community framework for peer support for those people with
Dementia.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
People with Dementia will live well.
- People of all ages either with, or suspected of having, a diagnosis of Dementia,
access the service through a SPA for assessment and where appropriate
treatment following NICE Guidance and best practice. The model of care is based
on a holistic needs assessment
- People with a Dementia diagnosis, normally 65 and over however not exclusive.
There is a Young Onset Dementia team/service that provides “end to end”
services. The model of care is holistic involving carers and family
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- The population of Doncaster is the target audience though the different elements
of this scheme focusing on statutory and non-statutory agencies and the general
public
- People with a diagnosis of Dementia. The model of care is to facilitate self-control
and determination despite the diagnosis of Dementia.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
RDaSH - Commissioners are the NHS Doncaster CCG through a NHS Contract a
currently supported by the Council and pooled budget arrangements. There is a NHS
Doncaster CCG delivery plan and performance framework covering Dementia. The
elements of the NHS Doncaster CCG plan are also included in the partnership plan
(HWB Dementia OBAT).
Alzheimer’s Society - Commissioners are currently the NHS Doncaster CCG and
services are managed through a NHS contract. There is a NHS Doncaster CCG delivery
plan and performance framework covering Dementia. The elements of the NHS
Doncaster CCG plan are also included in the partnership plan (HWB Dementia OBAT).
SMIP - Commissioners are joint NHS Doncaster CCG and the Council. Delivery is
performance managed and reported to the JACF operational group. The elements of the
SMIP are also included in the partnership plan (HWB Dementia OBAT).
Sue Ryder - The Peer support elements are commissioned by the Council currently
however the provider is also commissioned by the NHS Doncaster CCG for elements of
the Dementia pathway – awareness, signposting, information advice and promoting
independence. The provider is also commissioned by the Council for Dementia
befriending.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
RDaSH - national Dementia strategy, nice guidance and Doncaster JSNA for Dementia
2013. Demand for diagnosis through effective and timely assessment. Quality treatment
to improve outcomes and prevent readmission and escalation of need.
Alzheimer’s Society - national Dementia strategy, nice guidance and Doncaster JSNA
for Dementia 2013. Increasing and ageing population will mean more people will present
and be diagnosed with Dementia. People with Dementia who are not supported access
urgent care services more frequently than people without Dementia; they have more
admissions and readmissions, longer length of stays and poorer outcomes and
experience.
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SMIP - covers 9 specific tasks;
- Continuous awareness campaign
- Roll out of Dementia friends and Dementia champions training
- Production and rollout of the Dementia “pledge” and “commitment” programme
- Commissioning a hub and spoke model of Dementia volunteering
- Launching, promoting and raising awareness of the carers‟ resilience toolkit
- Commissioning the design and deliver a series of innovative and interactive
workshops with users and carers and the community
- Consultation and engagement with users, carers and the community
- Exploring the potential for assistive technology, through evaluated pilots for
example through products such as the „my life‟ software package designed to
provide interactive access to and production of life story‟s
- Celebration of success/progress event march 2015.
Sue Ryder - national Dementia strategy, nice guidance and Doncaster JSNA for
Dementia 2013. Increasing and ageing population will mean more people will present
with possible Dementia. They will need information advice and signposting but also
support to remain independent and in control. People with diagnosed or undiagnosed
Dementia who are not supported access urgent care services more frequently than
people without Dementia; they have more admissions and readmissions, longer length of
stays and poorer outcomes and experience.
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£1,871,000 £1,735,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
The headline metric for this scheme is reduction in non-elective (general & acute)
between quarter 4 2014/15 and 2015/16 will reduce by 23.
In addition the „Understanding out of hospital care for people with Dementia „ report
commissioned by healthcare at Home in 2011 suggests that at least 12% of admissions
to hospital for people with Dementia can be avoided by implementation of robust and
comprehensive home based services, care and support. Based on work carried out by HaH in NHS
Birmingham East and North
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25% of all inpatients have a diagnosis of Dementia2 although usually this is not the
reason they come into hospital. It is widely accepted that many of these admissions could
be prevented if patients and their carers' were better supported at home. The challenge
will be to ensure that any new service model gets to the heart of the unmet needs. Counting
the cost; caring for people with Dementia on hospital wards. (2009)www.alzheimers.org.uk
In supporting our work with Dementia, we have developed the following dashboard to
inform commissioning priorities and decisions.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
RDaSH - Contract management. Current year of shadow for new currency system using
clusters, clustering tool and quality metrics. Governance structure includes a Finance,
Information and Performance group (FPIG) a Care Quality Reference group (CQRG) and
a Data Management Group. These groups report to a Strategic Contract Meeting.
Currency development moves monitoring away from activity based to outcome based
monitoring.
Alzheimer’s Society - Through NHS contract management and quarterly reporting.
Reporting covers both quantitative (activity) metrics and Quality (outcomes) metrics.
SMIP - Through checkpoint reporting to JACF operational group. Performance also forms
part of the HWB quarterly performance report.
Sue Ryder - Through NHS contract management and quarterly reporting. Reporting
covers both quantitative (activity) metrics and Quality (outcomes) metrics.
What are the key success factors for implementation of this scheme?
Success factors are included in both the NHS Doncaster CCG Dementia plan and the
partnership HWB plan.
There will be an increased awareness of people with Dementia and reduced stigma
regarding Dementia.
- Awareness campaigns and measurement of impact.
- 3000 Dementia Friends in Doncaster
- 200 members of Doncaster Dementia Acton Alliance.
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Fig.24. Graph of the activity of Dementia Friend recruitment in Doncaster
Dementia Friends are currently over target reaching 56.3% for the year within Q1.
More people will receive a Dementia diagnosis.
- Ambition of Doncaster having a 67% diagnostic rate.
Fig.25. Graph of the increase in the Dementia diagnosis rate in Doncaster
People with a Dementia diagnosis will live well.
- Number of people living independently
- Quality of Life scores will improve after intervention
- Less acute activity.
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
12 Long Term
Scheme name;
Supporting Carers
(Including Respite Services)
What is the strategic objective of this scheme?
To respond to the Care Act 2014 in order to ensure that the Council supports carers
appropriately and in accordance with its legal responsibilities/duties.
To ensure that the National priorities set out in specific Carers legislation and the
National Carers Strategy are aligned with locally identified needs.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
The current model is Managed Care. However, going forward the Personalisation
agenda is designed to replace this wholesale model by replacing it with a retail model in
which empowered citizens make informed choices about care and support solutions that
fit their circumstances best. It is citizen centric and citizen led. It targets all those who
currently receive a community care assessment and community based support as a
result. The Care Act extends entitlement to carers to receive support on the same footing
as their cared for, formalising this entitlement that has locally been extended to Carers
through practice.
The Government are already trialling Direct Payments for those in residential care. On
implementation of the Care Act in April 2015, Personal Budgets will be extended to those
in residential care settings as a first step in changing the system for all.
The wellbeing and prevention principles necessitate this support to be extended more
broadly than just to carers of people assessed as needing care and support.
The Census 2010 indicates that there are up to 33500 Carers in Doncaster who may
benefit from support. Often the initial point of contact at which a Carer is identified is at a
time of crisis. Early identification and engagement is a key objective to ensure Carer‟s
resilience is reinforced so that crisis or carer relationship breakdown can be avoided for
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as long as possible.
We intend to;
- Enhance the early identification of Carers
- Provide up to date, timely relevant and appropriate information advice
- Increase Carers awareness to their entitlement to a Carers assessment in their
own right
- Ensure access to advocacy support where appropriate
- Ensure Carers are seen as expert partners both in the development of services for
Carers and in the individual care and support planning arrangements for the cared
for
- Improve the choice, flexibility and timeliness of breaks for Carers
- Support Carers to make difficult decisions about their role as a Carer
- Respond to the emotional support needs of Carers
- Help more Carers to maximise their income as appropriate.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
Jointly commissioned across Health and Social Care preventative and early identification
services are already established and working well as is an information and advice
service.
Carers‟ needs are identified at assessment although it is recognised there is need to
work towards a more consistent equitable offer based upon outcomes.
Advocacy support is available to carers across all client groups via a recently appointed
provider (Voiceability) operating a hub and spoke model.
Currently the main offer of a break which is taken up is by way of a short break voucher
scheme whereby the cared for person takes up respite provision in residential/nursing
homes.
They can also access a flexible support fund which is designed to offer them a service in
their own right as an outcome of a separate Carers assessment.
Other specific provisions offer tailored support to Carers whose cared for person fall into
specific client categorisations.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
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Care Act 2014
Doncaster Adult Social Care Modernisation Strategy
Doncaster Adult Commissioning Strategy
Doncaster Adult Prevention Strategy
Carers Strategy
Carers UK
SPRU
Healthwatch Doncaster
Contract Management of commissioned providers
Insights gained through bi-annual Carer‟s Survey, POET Survey, focus groups
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£2,605,000 £2,605,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
The headline metric for this scheme is a reduction in permanent residential admissions
between quarter 4 2014/15 and 2015/16 will reduce by 4.
In addition this scheme will deliver the following;
- Increased number of Carers identified
- Increased Carer satisfaction with information and advice
- Carer take up of advocacy service
- Increased number of outcome focused Carers assessments undertaken
- Increased number of break opportunities for Carers
- Increased number of Carers taking up break opportunities
- Carers satisfaction with services
- Increased carer satisfaction with involvement in care planning process.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
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what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Specifically a bi-annual Carers survey is undertaken as part of the ASCOF framework.
We have completed a detailed analysis of the results locally and added local questions to
inform local priorities.
The Personal Budgets Outcome Evaluation tool (POET) survey is being embedded into a
performance framework to monitor progress in improving the experience of Carers in
assessment of need and provision of support.
Doncaster Healthwatch has identified Carers needs as a priority and is working with the
Council to develop an appropriate action plan to address gaps in provision.
A local Carers Forum feeds into broader strategic development activity.
What are the key success factors for implementation of this scheme?
Increased number of Carers identified
Increased Carer satisfaction with information and advice
Carer take up of advocacy service
Increased number of outcome focused Carers assessments undertaken
Increased number of break opportunities for Carers
Increased number of Carers taking up break opportunities
Carers satisfaction with services
Increased carer satisfaction with involvement in care planning process
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
13 Long Term
Scheme name;
Personalised Support
What is the strategic objective of this scheme?
This scheme seeks to improve the service user experience in assessing need and care
planning for those needing long term care and support determined through a Community
Care Assessment.
The scheme is designed to enable achievement of the Governments vision for social
care outlined in the white paper „Caring for our future‟ regarding long term support;
„We will transform people‟s experience of care and support, with high quality
services that respond to what people want. This means that people will have
control over their own budget and their own care and support plan. They will be
empowered to choose the care and support that best enables them to meet their
goals and aspirations. We will put people, and not institutions, in control.
We will legislate to give people an entitlement to a personal budget as part of
their care and support plan, and will strengthen our ambitions on direct
payments.‟
This vision is re-iterated in the Doncaster Adult Social Care modernisation vision,
„Building the Road to Independence‟.
Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
The model of care and support is currently Managed Care.
The Personalisation agenda is designed to replace this wholesale model by replacing it
with a retail model in which empowered citizens make informed choices about care and
support solutions that fit their circumstances best. It is citizen centric and citizen led. It
targets all those who currently receive a community care assessment and community
based support as a result.
The Government are already trialling Direct Payments for those in residential care. On
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implementation of the Care Act in April 2015, Personal Budgets will be extended to those
in residential care settings as a first step in changing the system for all.
In 2014/15 Personalised Support in Doncaster will;
- Deliver a wholesale Shift in organisational culture in respect of long term
community based provision, from a deficit model to an outcomes and asset
focussed ethos
- New approach, systems and process for delivering personalised social care „social
work rescript‟
- refreshed market position statement and e-market place - expands the local
market to provide choice for Direct Payment recipients as well as suitable support
services for Direct Payment management- Improve Direct Payment uptake
through expanding support for a range of access options
- New systems and process for increasing uptake of direct payments-
including review of policies and practices that are undermining the take up of
direct payments and move towards personalisation
- Deliver a new direct payment support service - increasing the availability of
independent assistance with support planning and money management
- Take a planned approach to improving personal budget uptake by mental health
service users.
Fig.26. Wellmart model of care in Doncaster
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The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
The commissioner is the service user themselves. They are the primary determinants of
quality and value. A move to micro-commissioning in a retail market.
They are supported by a range of Council staff who ensure that a diverse market of high
quality support solutions are available from which to choose, and that mechanisms are
available to make choosing and managing support straightforward.
This is achieved through building community capacity, by reconfiguring the current
Domiciliary Care contract, further developing the eMarketplace, modernising day services
to move to a model of helping people to have a good day through a range of day
opportunities, improving the offer to carers to help them have a break from their caring
role, consistently offering Personal Budgets to people with Mental Health issues.
Service users can be effective commissioners themselves; work completed in Yorkshire
and the Humber demonstrated that effective support plans can be developed by service
users themselves, with the support of family, friends and peers, and paid workers where
necessary. This ethos has been embedded within the statutory guidance issued in draft
underpinning the Care Act 2014.
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
Architecture for personalisation
http://www.centreforwelfarereform.org/uploads/attachment/243/architecture-for-
personalisation-report.pdf
Caring for our future; reforming care and support DoH
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/136422/W
hite-Paper-Caring-for-our-future-reforming-care-and-support-PDF-1580K.pdf
Care Act 2014
http://www.legislation.gov.uk/ukpga/2014/23/part/1/enacted
POET Survey
http://www.in-control.org.uk/media/154591/poetnationalreport.pdf
Cultural Web, Johnson and Scholes 1992
http://www.scup.org/asset/66244/culture
Doncaster Adult Social Care Modernisation Strategy
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Doncaster Adults Commissioning Strategy
Doncaster Adult prevention Strategy
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£596,000 £796,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
The headline metric for this scheme is reduction in permanent residential admissions
between quarter 4 2014/15 and 2015/16 will reduce by 6.
In addition this scheme will deliver the following;
- Increased uptake of Personal Budgets
- Increased uptake of Direct Payments
- A system focused on outcomes.
A leaner operating model – fewer handoffs and removal of internal processes that do not
add value to the service user experience characterised by;
- Quicker decision making about eligibility, need, resource allocation, money
management, outcomes to be achieved
- Quicker set-up of Personal Budget with access to Direct Payment at earliest
opportunity
- Better use of resources by service user facilitated by skilled brokers using local
and peer knowledge and web based tools including our eMarketplace,
connecttosupport
- Lighter touch, proportionate approach to auditing spend with a focus on
achievement of agreed outcomes.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide
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performance group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
We are using the nationally recognised and government promoted Personal Budgets
Outcome Evaluation Tool (POET) survey. This tool is administered jointly by In Control
and Lancaster University.
We participated in the survey last year and this provides us with a solid benchmarked
baseline prior to implementation of the system design changes planned for early January
2015.
Continued use of the tool, embedded into a broader performance framework will enable
us to measure success rigorously.
In addition we are mapping culture to establish whether the systemic changes necessary
are being delivered successfully. A cultural web model is being used to establish a
baseline and to monitor progress as rollout commences by remapping.
What are the key success factors for implementation of this scheme?
Increased uptake of Personal Budgets
Increased uptake of Direct Payments
A system focused on outcomes
A leaner operating model – fewer handoffs and removal of internal processes that do not
add value to the service user experience characterised by;
- Quicker decision making about eligibility, need, resource allocation, money
management, outcomes to be achieved
- Quicker set-up of Personal Budget with access to Direct Payment at the earliest
opportunity
- Better use of resources by service user facilitated by skilled brokers using local
and peer knowledge and web based tools including our eMarketplace,
connecttosupport
- Lighter touch, proportionate approach to auditing spend with a focus on
achievement of agreed outcomes.
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ANNEX 1 – Detailed Scheme Description For more detail on how to complete this template, please refer to the Technical Guidance
Scheme ref no. Programme Area
14 Long Term
Scheme name;
Housing Options
What is the strategic objective of this scheme?
Adult Social Care is closely connected with health and housing - good quality housing that
meets individual need is a key determinant of health, wellbeing and independent living
across all vulnerable groups, including older people.
Doncaster currently has a very limited range of housing options for older people -
traditional extra care settings, sheltered housing and residential/nursing provision.
Adult Social Care needs a clear evidence base in order to influence the Council‟s Housing
Strategy to ensure the housing needs of older people are met over the coming years and
decades. In order to achieve the vision of keeping people independent and healthy in their
own homes for as long as possible, Doncaster aspires to develop a wide range of flexible
connected housing options/offers to meet the emerging needs of the current and future
generations of older people.
Fig.27. One Page Housing Overview for Doncaster
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Overview of the scheme
Please provide a brief description of what you are proposing to do including;
- What is the model of care and support?
- Which patient cohorts are being targeted?
To develop a range of holistic housing/accommodation offers that support the wider
health and wellbeing current and future needs of older people aged 55+ in Doncaster.
This will include provision that supports intermediate care, enablement, and community
living support networks and supported housing provision.
The Doncaster housing offer will look at the following model of care;
- A connected care model that supports keeping people at home and reduce impact
on acute and long term residential services and;
- Fosters peer support environments
- Maximises and encourages the use of community assets, skills and natural
networks of support
- Supports older carers
- Maximises assistive technology and minimises the need for adaptations in the long
term
- Provides innovative solutions and holistic thinking around people‟s needs and how
people want to live
- Encompasses current policy and guidance on safeguarding vulnerable adults.
The delivery chain
Please provide evidence of a coherent delivery chain, naming the commissioners and
providers involved
The Doncaster Housing Options offer will be developed and delivered by Doncaster Adult
Commissioning and Doncaster Strategic Housing with a range of health, community
sector and housing providers.
The development of the Housing Options offer will be overseen by the Doncaster strategic
housing group reporting to the SHSCPB.
Housing Services in Doncaster are provided by St Leger Homes of Doncaster, however,
other housing services are delivered by a range of other housing providers, such as;
South Yorkshire Housing Association (SYHA).
The evidence base
Please reference the evidence base which you have drawn on
- to support the selection and design of this scheme
- to drive assumptions about impact and outcomes
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Sheffield Hallam University has been contracted as our partners for developing the
evidence base and managing the development of a co-produced housing options plan.
The outcome of this scheme is anticipated to significantly increase the number and type
of;
- Extra provision specifically designed to meet current and future demographic
requirements
- New types of housing tenure to support older people 55+ to continue living in their
own homes into old age
- A connected support systems that wraps around the new type of housing tenure so
that lack of community support and care is not a reason for failing to stay at home
- A new intermediate care housing offer to support reablement and enablement.
The expected outcomes of investment in housing schemes will include;
- Speeding up patient release from hospital where housing is identified as a reason
for delay in patient transfer
- Reduction in admissions to acute services - an analysis by Care and Repair
identified that every £1 spent in adapting and providing appropriate housing
generated £7.50 cost savings to the NHS. These savings were associated with
speeded up hospital discharge, prevention of people going into hospital and
prevention of accidents and falls in the home2
- Reduce the need for residential care- Postponing entry into residential care for one
year saves an average of £28,080 per person1
- Reduce the need for domiciliary care - appropriate housing and adaptations can
reduce the need for daily visits and reduce or remove costs of home care (savings
range from £1,200 to £29,000 a year).2
1National evaluation of POPPs. Personal Social Sciences Research Unit for Department of Health (2010)
2Viewpoint 21 2011 Report, for the Housing Learning and Improvement Network Housing, prevention and
early intervention at work; a summary of the evidence Base.
Investment requirements
Please enter the amount of funding required for this scheme in Part 2, Tab 3.
2014/15 2015/16
£289,000 £1,323,000
Impact of scheme
Please enter details of outcomes anticipated in Part 2, Tab 4. HWB Benefits Plan
Please provide any further information about anticipated outcomes that is not captured in
headline metrics below
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The headline metrics for this scheme are;
- Reduction in permanent residential admissions between quarter 4 2014/15 and
2015/16 will reduce by 3
- Reduction in delayed transfers of care between quarter 4 2014/15 and 2015/16 will
reduce by 90.
The outcome of the Housing Needs Assessment is expected to identify the need for a
variety of housing and housing related support across Doncaster including short term
reablement accommodation, supported living schemes and expanding options for
delivering housing adaptations.
We anticipate an increase of up to 66 extra care places which will produce savings of up
to £507,000 in residential care costs in year 1 of the scheme
We anticipate that an expanded shared lives scheme will increase the number of people
with a learning disability avoiding residential care by 20 which will equate to an average
£88,000 per person per year saving .
We anticipate that up to 150 people where housing is a reason for delayed hospital stay,
could avoid being delayed due to new intermediate care housing provision. This could
generate between 1 and 5 days reduction in delayed transfers of care.
We anticipate that based on the best national evidence base, an increase of 50 housing
adaptations particularly those which are a rapid response to a hospital discharge will
generate a saving to the NHS of £1,875,000 and reduce or delay admissions to
residential care.
Feedback loop
What is your approach to measuring the outcomes of this scheme, in order to understand
what is and is not working in terms of integrated care in your area?
There are a number of local mechanisms in place to ensure that the outcomes of each
scheme are understood across the local health community. These are based around the
following;
- HWBB Governance Structure (supported by a dedicated system wide performance
group)
- Local multi-agency System Resilience Group
- Individual contracts placed by Commissioners.
Subsequently each scheme recipient within the housing and connected support theme will
be tracked through either the Care First or hospital recording systems through the use of
the NHS number as the shared unique identifier. This approach means that the system
will track scheme users through a minimum 1 year life journey, using pre-scheme
information as baseline to ascertain outcomes and impact of the investment.
Each service user will also have a will have a support plan. Within this plan will be
embedded a quality of life tool which will monitor the impact and effects of 5 quality of life
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domains which will track both physical and mental health impact. The unique and shared
identification code used as part of the Carefirst.
What are the key success factors for implementation of this scheme?
The success of the scheme will depend on the outcome of the housing option needs
assessment in order to ensure predictions on number and type of housing options are
accurate. Delivery of schemes will depend on a vibrant and inventive market of housing
providers and a properly connected support system to ensure a holistic approach.
The intermediate care housing offer will depend on a well organised integrated support
system and a robust reablement and enablement post hospital discharge service.
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ANNEX 2 – Provider commentary For further detail on how to use this Annex to obtain commentary from local, acute providers, please refer to the Technical Guidance.
Name of Health & Wellbeing Board Doncaster Health & Wellbeing Board
Name of Acute Provider organisation Doncaster Bassetlaw Hospital Foundation Trust (DBHFT)
Name of Acute Provider CEO Mike Pinkerton
Signature (electronic or typed)
Name of Health & Wellbeing Board Doncaster Health & Wellbeing Board
Name of Mental Health and Community Services Provider organisation
Rotherham Doncaster and South Humber (RDaSH)
Name of Mental Health and Community Services Provider CEO
Christine Bain
Signature (electronic or typed)
For HWBB to populate;
Total number of non-elective FFCEs in general & acute
2013/14 Outturn 38,008
2014/15 Plan* 37,494
2015/16 Plan** 36,180
2014/15 Change compared to 2013/14 outturn
514 (1.3%)
2015/16 Change compared to planned 2014/15 outturn
1,314 (3.5%)
How many non-elective admissions is the Better Care Fund planned to prevent in 2014/15?
328
How many non-elective admissions is the Better Care Fund planned to prevent in 2015/16?
986
* 2014/15 plan represents the period Q4 2013/14 - Q3 2014/15 in line with the Payment
for Performance planning period and NOT the full financial year. Plan figures above are
based on MAR definitions, as per template 2, not all non-elective admissions for the
resident population as is referred to throughout the remainder of the narrative
** 2015/16 plan represents the period Q4 2014/15 - Q3 2015/16 in line with the Payment
for Performance planning period and NOT the full financial year. Plan figures above are
based on MAR definitions, as per template 2, not all non-elective admissions for the
resident population as is referred to throughout the remainder of the narrative.
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For Acute Provider to populate;
Question Response
1.
Do you agree with the data above relating to the impact of the Better Care Fund in terms of a reduction in non-elective (general and acute) admissions in 2015/16 compared to planned 2014/15 outturn?
I confirm the document sets out a range of
schemes which if all fully implemented will
achieve the desired reduction. The schemes are
predicated on a range of assumptions, however,
which will require continuous assessment and
validation.
2.
If you answered 'no' to Q.1 above, please explain why you do not agree with the projected impact?
3.
Can you confirm that you have considered the resultant implications on services provided by your organisation?
Resultant implications have been assessed and
planned for. The Trust has been fully involved in
the BCF process and support the submitted plan.
For Mental Health and Community Services Provider to populate;
Question Response
1.
Do you agree with the data above relating to the impact of the Better Care Fund in terms of a reduction in non-elective (general and acute) admissions in 2015/16 compared to planned 2014/15 outturn?
Not applicable
2.
If you answered 'no' to Q.1 above, please explain why you do not agree with the projected impact?
Not applicable
3.
Can you confirm that you have considered the resultant implications on services provided by your organisation?
The involvement of RDaSH in the development of
the Better Care Fund Plan in Doncaster and our
recognition of its impact on services provided is
evidenced throughout the completed template. In
particular, our membership on the Health and
Wellbeing Board and the reference and extract
from our operational plan on page 51. The
majority of the proposed Transformational
Programmes and detailed schemes have
implications for services provided by the Trust in
the fields of community, mental health and
dementia services. We recognise and have been
engaged in the development of these schemes
and where possible the resultant implications
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have been identified and considered. For those
schemes that are subject to on-going
development, we would expect to continue to be
a proactive partner to ensure the full
understanding of implications on services,
supporting the implementation of the plan.
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Appendix 1
