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Detailed business case proposal: A single integrated Triborough

Community Independence Service (CIS)

September 2014

Version 4.1

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Amendment History

Version Date Author Reason

0.1 5 August 2014 Deborah Jenkins & PPL / PA Team

Detailed Business case developed

1.19 29 August 2014 PPL/ PA Team Updates and revisions following feedback and review

2.1 29 August 2014 PPL / PA Team Final revisions prior to SRO update

3.0 31 August 2014 PPL / PA Team Significant redraft following SRO feedback

3.4 2 September 2014 PPL / PA Team Revisions following CCG executive feedback

4.1 4 September 2014 PPL / PA Team Final revisions ahead of publication

Draft distribution list

Name Role in BC production

PPL / PA team Co-producers / reviewers

Circulation for first draft

Elizabeth Youard SRO for Group A Triborough BCF projects

Robert Sainsbury SRO for Group A Triborough BCF projects

James Cuthbert SRO for Group A Triborough BCF projects

Daniel Elkeles Chief Officer; CWHHE

Liz Bruce ASC Executive Director; Triborough ASC

Claire Parker Chief Financial Officer and Deputy Chief Officer; CWHHE

Jenny Platt Deputy Out of Hospital Delivery Manager; HFCCG

Adele Yemm Project Manager, Out of Hospital Care; WLCCG

Rachel Wigley Director of Finance; Triborough ASC

Louise Procter Managing Director; WLCCG

Philippa Jones Managing Director; HFCCG

Matthew Bazeley Managing Director; CLCCG

Liz Bailey External reviewer

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Contents

Foreword .....................................................................................................................................4

Executive summary ......................................................................................................................6

1. Introduction ........................................................................................................................... 17

1.1 High level CIS outcomes ............................................................................................................. 18

1.2 Population Needs ....................................................................................................................... 19

1.3 Whole Systems Context ............................................................................................................. 20

1.4 Opportunities for strategic alignment ....................................................................................... 22

2. The Current Position ............................................................................................................... 23

2.1 Attributes of existing CIS services - Triborough ......................................................................... 24

2.2 Baseline – spend ........................................................................................................................ 32

2.3 Baseline – current contractual arrangements with CIS providers ............................................. 32

3. Proposed Integrated CIS ......................................................................................................... 35

3.1 Service specification................................................................................................................... 39

3.2 Gap analysis ............................................................................................................................... 39

4. Activity Modelling and Financial Implications .......................................................................... 41

4.1 Introduction to the CIS financial and activity model ................................................................. 41

4.2 The Conceptual Model ............................................................................................................... 43

4.3 Key Findings ............................................................................................................................... 45

4.4 Conclusions from the financial and activity modelling .............................................................. 45

5. Options Appraisal ............................................................................................................... 46

5.1 Discussion of Options ................................................................................................................. 47

5.2 Recommended Option ............................................................................................................... 49

6. Transition and implementation planning ............................................................................. 53

6.1 Developing the CIS through incremental change ...................................................................... 54

6.2 Transition plans .......................................................................................................................... 56

6.3 Design and Preparation – September 2014 to March 2015 ...................................................... 56

6.4 Risk management ....................................................................................................................... 56

7. Conclusions and next steps ................................................................................................. 61

7.1 Next steps .................................................................................................................................. 61

Appendices ................................................................................................................................ 63

Appendix A. Index of Figures and Tables ......................................................................................... 63

Appendix B: List of key stakeholders ............................................................................................... 64

Appendix C: Enablers for the core CIS components ........................................................................ 70

Appendix D: IT/ IG considerations ................................................................................................... 71

Appendix E: Detailed Gap Analysis .................................................................................................. 73

Appendix F: LOS reduction by CCG .................................................................................................. 78

Appendix G: List of acronyms .......................................................................................................... 79

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Foreword The purpose of this document is to set out the proposed way forward for commissioners to jointly develop a single Community Independence Service (CIS) across the Triborough and to gain agreement to this from all six sovereign bodies. The CIS will deliver more rapid and responsive out of hospital care for people with acute needs which will be provided by health and social care teams working together in a co-ordinated way.

This business case demonstrates the anticipated costs and benefits, phased over time, of the proposed CIS and outlines its implications, in particular, the further work required to make these new ways of working a reality in 2014/15 and in the next financial year 2015/16.

The programme to develop a standardised CIS care pathway lies at the core of the Triborough Better Care Fund (BCF) plan. This plan was collaboratively developed across all six partner organisations in the Triborough at the beginning of 2014. The BCF is a national policy directive which seeks to create a pooled, multi-year fund to catalyse investment into integrated services across health and social care. The CIS initiative is the critical piece of whole system change which will enable and support the shift of activity from expensive acute settings into the community and is a tangible example of bringing better organised care and services as close as possible to people’s homes.

Following combined work between health and social care commissioners and wider system leaders, the Triborough BCF Plan achieved approval from all sovereign bodies and the 3Health and Wellbeing boards in April 2014 and is currently ranked second nationally following an external assurance process in July 2014. As such, this gives us a strong platform from which to press ahead with the commissioning direction set out in this business case.

This business case will be scrutinised and signed off by the following governance bodies, and hence these are the main audience for this business case:

Health and Wellbeing Boards: Hammersmith and Fulham , Kensington and Chelsea and Westminster

Clinical Commissioning Group Governing Bodies: Hammersmith and Fulham, West London and Central London CCGs

Cabinets: London Borough of Hammersmith and Fulham, Royal Borough Kensington and Chelsea and Westminster City Council

London Borough of Hammersmith and Fulham Policy and Accountability Committee and London Borough of Hammersmith and Fulham Business Board

This business case is being recommended for agreement at this time because findings will be translated into commissioning and contracting intentions for 2015/16 which are published at the end of September 2014. Agreement to the recommendations within, will enable immediate consultation with existing health and social care providers on the most

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effective way of bringing about the necessary operational and service transformation. This will also allow a period of six months during October 2014 to March 2015 for providers to prepare the workforce for new ways of working. These timescales will ensure that in April 2015 we start to reap the benefits of the new service, improving people’s experience of care and delivering system wide savings.

Approval is sought for the direction of travel proposed; a single, integrated and standardised care pathway developed with providers over time. Sign off of the financial and costs and benefits approved will be through CCG Finance and Performance Committees and Local Authority Cabinets.

Daniel Elkeles Chief Officer Central London, West London and Hammersmith & Fulham CCGs Liz Bruce Executive Director of Adult Social Care Triborough Local Authorities

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Executive summary

This business case proposes the way forward to develop a Triborough Integrated Community Independence Service (CIS) which will integrate and enhance existing local models and delivery frameworks to achieve common and improved outcomes for the local population.

The Community Independence Service (CIS) The Community Independence Service provides a range of functions including rapid response services to prevent people going into hospital and rehabilitation and reablement which enables people to regain their independence and remain in their own homes.

The service is currently delivered by a multidisciplinary team of community nurses, social workers, occupational therapists, GPs, geriatricians, mental health workers, reablement officers and others.

What is in scope? Figure A provides a simple visual of the proposed CIS model from the perspective of a person using the service. Summary descriptions of each of the core services can be found in Figure B.

Figure A: Overview of CIS

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Figure B: Descriptions of core services

It is important to note that CIS is only one part of the intermediate care pathway. “Intermediate care is a range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital and premature admission to long-term residential care, support timely discharge from hospital and maximise independent living.”1 What is out of scope? There are a number of other services and parts of the intermediate care pathway with key interfaces to the CIS to which this service will need access to. These services may move into scope in a later phase of development if considered appropriate. Many of these form separate projects within the Group A (Integrated Services) and Group C (Integrated Commissioning) workstreams of the Better Care Fund (BCF) programme for Triborough.

The services / functions which are out of scope are:

All bedded care (including community neuro rehabilitation beds)

Homecare

Nursing Home and Residential Home care

7 day social work hospital discharge team

1 Source: DH; Intermediate Care – Halfway Home, 2009

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Whilst the above services are out of the scope of this business case, all are being developed in detail elsewhere, and the ways in which CIS will work across the boundaries of each out of scope area has been taken into account.

Relationship to wider services The design of the single integrated model for the CIS aims to achieve simplification in delivery and ensure that a person’s journey is integrated with smooth and rapid flow of knowledge and safe clinical transfer between interfacing services. For example, professionals working in the homecare service could refer a person into the CIS if a potential crisis or reablement need is identified. Likewise, following an assessment of needs, the CIS may request equipment/ adaptations in a person’s home to help keep their independence or refer them to bedded care for a short period of time. Homecare is the service that cares for people with less complex needs in their own home on a long-term basis, before, during and after any crisis that may see them undergo a period of reablement with CIS. It is expected that the combined effect of a single integrated CIS and a refreshed homecare provision with a reablement focus, hybrid health and social care working and smoother transition pathways. This will reduce the use of residential and nursing home placements, as community services become better equipped to handle more complex cases in people’s homes.

The same design principles will equally apply across all the areas identified above as ‘out of scope’: inpatient bedded care, nursing and residential home care, 7 day social work hospital discharge team and homecare. There will be future opportunities for providers to discuss organisational development and where local roles such as care co-ordination and care navigation resources fit in. There is wide recognition of the importance of the GP in this model of care although this is not addressed directly in this case for change. Why is a single integrated CIS so important? There are a number of key strategic drivers in both the internal and external environment. Together these create a compelling case for change and present a unique opportunity to deliver a core component of out of hospital care in an innovative and integrated way.

a) Population Need The demographic pressures of an ageing population with increasingly longer term, complex care needs and the downward pressure on public finances have compounded and require innovative responses from the health and social care sector. There is a clear need for integration to support the shift in the centre of gravity away from treating people in expensive and often inappropriate acute settings and a move towards treatment and support for people in their own homes. A Needs Assessment analysis conducted by Triborough Public Health leads in July 2014 focused on intermediate care and identified that demographic change is likely to increase intermediate care need by around 40% over the next 20 years, as the number of older people and the number of people with long-term conditions (LTCs) increases.

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b) Whole Systems Context The Triborough Councils and CCGs are uniquely placed to be in the vanguard of health and social care integration nationally, not only due to the partnership amongst the Local Authorities and combined approach to commissioning, but also due to the multiple change programmes already in progress across North West London which are transforming and reshaping the local health and social care economy. The landscape is ripe for implementing initiatives such as the CIS. The sophistication and maturity with which commissioners and system leaders already work together under whole systems Integrated Care and the Health and Wellbeing Boards creates a powerful springboard for change. Across the Triborough health and social care environment, there is already a shared commitment that:

people are enabled and supported to stay as healthy and as independent as possible for as long as possible

people are supported to live in the most appropriate place according to their choice and needs and are able to maintain maximum control over their lives

All of the major change programmes have consistent and complementary visions and are discussed in more detail in Section 1.3. Over the next 5 years their planned impacts include: improving access to primary care, joining up, standardising and improving processes for delivery of social care across Triborough, the reconfiguration of the acute sector and a combined and holistic approach to mental health commissioning. The BCF which creates a pooled fund to catalyse integrated working and is entirely compatible with whole systems Integrated Care Programme, both of which deliver tangible multidisciplinary and integrated services and teams focused on delivering benefits to distinct cohorts of the population.

Current position and gap analysis Across the 3 Triborough areas the total current cost of those services defined as belonging to the CIS is £16.8 million. There are approximately 6000 referrals per year and there is a multidisciplinary workforce in place of c186 WTE. A strategic review of the 3 Triborough areas community independence services highlighted various inconsistencies in service management and delivery. Each borough has a very different starting point from which to change.

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Figure C: CIS starting positions

Further breakdown of service differentiation by Triborough area can be found in Section 2.1. In order to achieve the ambition of a single integrated CIS, these gaps must be closed and the journey for each borough will be different. We have assessed each borough in terms of how far existing services have to go to reach the parameters outlined in the single standardised and integrated service specification and provide a summary below.2 Proposed solutions and a more detailed breakdown can be found in Section 6.2 and Appendix E.

Triborough area

Distance to travel Explanation

HFCCG/ LBHF

Low

HFCCG/LBHF have the shortest distance to travel to meet requirements for 2015/16 delivery. The model in place broadly aligns to the proposed 2015/16 CIS specification, and plans are already in place for further development in line with the requirements set out in this business case.

WLCCG/ RBKC

Medium

WLCCG/RBKC intermediate care model meets some of the requirements set out in the CIS specification, but still has distance to travel to meet all 2015/16 intentions. WLCCG/RBKC are listed as medium rather than low due to the current level of investment and contractual position in comparison to CLCCG/WCC which must overcome more complex contractual arrangements stated below.

2 It is important to highlight that the boundaries for CLCCG/WCC and WLCCG/ RBKC are not co-terminus. Analysis has found that 23% of the WCC activity sits within the WLCCG/ RBKC boundary. Therefore in Figure C below and throughout the document; when referencing WLCCG/ RBKC this also includes a proportion of the WCC population. This assumption has also been applied to the financial model and is reflected in the detailed assumptions log in Appendix D.

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Triborough area

Distance to travel Explanation

CLCCG/ WCC

High

CLCCG/WCC has the furthest to travel to align their service model with that proposed for 2015/16. This is primarily because reablement care delivery is outsourced to Allied Healthcare and other spot purchased providers, which adds additional complexity to funding, contracting and delivery arrangements. It also means a significant volume of work is delivered by staff not directly part of and managed by the core CIS team.

Figure D: Distance to travel by borough

Specification for future CIS A single integrated service specification for the CIS starting in 2015/16 has been drawn up. This specification is for health and social care providers to work to one standard. The specification proposes an integrated, multidisciplinary model of care that includes:

• A Single Point of Referral (SPoR) and referral (triage)

• 7 day support to help people leave hospital

• A rapid response multidisciplinary team (MDT) providing community care within 2 hours and for up to 5 days

• Integrated reablement with access to short term community beds between 6 and 12 weeks

• Non-bedded community rehabilitation, treating non-complex conditions in a community setting

This improved, integrated and standardised service aims to address an anticipated increase in demand for intermediate care services. It will create demand for care and support services in the community, especially home care and, for people with acute and complex needs. As a consequence, demand for residential care might increase where suitable alternative housing cannot be found. The lack of availability of appropriate housing for older people across the Triborough may therefore influence the delivery of intermediate care services in the home. This is being looked at more widely in Triborough through extra care housing provision and the SHSOP programme.

The integrated CIS will improve the person’s and practitioner’s experience of community-based care and drive improved quality and savings by treating people outside of the acute hospital setting.

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The services within scope are selected on the basis of evidence including needs analysis, local best practice and learning from innovation. More information on how best practice has been incorporated is available in the stakeholder summary report in Appendix B. Incorporated findings are consistent with the feedback from local end users and clinical and social care practitioners. This all points to the need to enhance these in scope areas, especially out of hours and over 7 days.

Significantly, this will mean the following differences from April 2015 onwards:

Single entry point into the service which is clinically led

Single assessment process

Rapid access to reablement, including 2 hour rapid response

Standardised hours for all functions

7 day working

Medical input across all 3 services

Integrated multidisciplinary team working to a common set of standards

Single set of KPIs and outcomes monitoring framework

Joint workforce and competency framework agreements established across each of the Triborough areas and providers

Model and findings A funding model has been developed through engagement with CCG and LA leads working with key provider partners through existing consultation and engagement mechanisms such as the CCG / Local Authority centred whole systems Integrated Care (WSIC) consultation process and Triborough Urgent Care Board. It is built from evidence of what currently exists using data sources identified in Section 2. A detailed financial appraisal of the costs and benefits will be carried out by relevant leads from the CCGs and LAs immediately. The evidence base upon which this business case has been developed and the baseline assessment, creates a stock take and a foundation upon which all future planning can be based. It builds upon local clinical and social care practitioner experience and ambition. It creates a tool for a system which can be adapted for the future and form the basis for benefits tracking. Figure E1 below shows a simplified conceptual model for the person flows within different parts of the system. The core CIS service is shown in the purple box in the middle. The black arrows are the current people and financial flows which the model seeks to reduce. The grey arrows are those which the model seeks to increase, redirecting flows of both people and money away from expensive and inappropriate hospital and care homes and into the CIS to be supported and reabled in their own homes. The blue pathway gives an example of a pathway without the CIS intervention and the green pathway gives an alternative flow. These pathway are described in more detail in Figure 4.2.

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Figure E1: Simplified conceptual model

Figure E2: The benefit of the new CIS

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Financial results The current level of investment (£16.8m p.a.) is not sufficient to maintain a stable service and meet the need of the local population as evidenced by the repeated bids for winter pressure funds each year to supplement the existing service. Undue reliance upon non-recurrent funding is not sustainable and limits the ability of the providers to establish a stable workforce plan. Financial modelling of the new integrated service shows that new investment costs in 2015/16 year 1 of [£xm] and that benefits achieved are in the range of [£xm]. This gives us high level net benefits of [£xm] in 2015/16. The detail is to be scrutinised within existing LA and CCG process, for example the CCG Finance and Performance Committees.

[Phasing of overall costs and benefits]

[Attribution of costs and benefits]

It is proposed that NHS commissioners fund all the incremental costs in getting CIS up to a consistent standard in 2015/16 and that this then forms part of wider considerations as part of BCF risk and reward discussions. Hospital Length of Stay (LOS) reductions as a result of the CIS Inreach service are calculated to be £1.09m over the first four year period. This forms part of the benefits to the wider health and social care economy and helps acute providers to achieve efficiencies.

Triborough Inreach LOS Reduction FY15/16 FY16/17 FY17/18 FY18/19

Projected in reach Referrals 2215 3460 4206 4403

Total Days Saved 918.66 1440.76 1754.38 1839.16

Total Saving (£) £168,061 £264,512 £322,105 £337,495

Total Saving (FY15/16 to FY19/19) £1,092,173

Figure 4.1: Triborough Inreach LOS reduction

Options Analysis 3 options were considered for the delivery of the new CIS model from April 2015/16:

1) Do nothing: Continue with existing fragmented services

2) Single co-ordinated approach with existing providers: Continue with existing multiple providers, however standardise provision under one single specification and focus on integration & interoperability improvement initiatives

3) Prime Contractor: Single provider working under a single service specification (potentially including TUPE’d workforce)

These options are considered in detail in Section 5.

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The recommended option is Option 2: Single co-ordinated approach with existing providers. For 2015/16, to ensure stability, it is proposed that the service continues to be delivered with multiple existing providers but through a single co-ordinated approach and specification.

To enable transformational change without creating instability, the recommended approach for 2015/16 is to enter a year of transition during which a phased approach can be taken and incremental improvement brought about. The provider community is best placed to advise commissioners on the most effective way of bringing about operational and service transformation. It is planned that subject to agreement of this business case, that necessary 6 months of transition will start from end September 2014. Section 6 gives further details including high level risks. Implementation and transition There needs to be one clear framework upon which to build. This could be for instance by a Memorandum of Understanding which covers all Local Authorities, all CCGs and all existing health and social care providers contributing CIS services within Triborough in 2015/16. One way of addressing this and incentivising providers, is to package up the new investment of [£xm] and to consult with existing health and social care providers during September 2014 on the simplest contractual arrangement to enable providers to work together to manage incentive and risk. This arrangement needs to enable commissioners and providers to work together under a common framework. See section 6 for more details of the set of principles for engagement to which all commissioners must agree to work together. The way in which the investment offer is packaged up for existing health providers must be linked to an agreement which allows providers and commissioners to track impact and benefits. For the immediate future, the conclusions and recommendations from this business case will be translated into commissioning and contracting intentions for 2015/16. The work over the next 6 months will prepare the ground, to allow providers the time to prepare for change, and commissioners time to translate the investment case into new contract agreements A high level transition plan and summary of required changes can be found in Section 6.

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Figure F: Transition Plan

Summary The new CIS service will be integrated and multidisciplinary, provide proactive and reactive care and support to people at risk of admission to hospital and enable recovery. Through detailed and robust modelling, using an approach agreed across health and social care commissioners, we envisage that implementation can achieve [gross financial benefits totalling £xm in 2015/16. Taking into account the investment costs of £xm, this delivers net benefits of £xm in year 1.]

The new approach has been developed from existing ways of working and has system-wide consequences. That is why it is better to achieve simplification and standardisation, on a co-ordinated basis. If there is a particular reason or local condition to be met, the model can be used as the basis for adaptation to the local situation. A standardised service better meets the operational needs of acute providers who discharge individuals across all 3 Triborough areas and is a better experience for the individual customer, patient and carer. The new enhanced and integrated service will be much more empowering for people using services; bringing better organised care and services as close as possible to people’s homes. That is why it is so important to achieve a co-ordinated agreement across 6 sovereign bodies to move forwards. We recommend the endorsement of this business case and Option 2: Single co-ordinated approach with existing providers to take forward this new CIS in 2015/16. PLEASE NOTE: Throughout this document text formatted [as such] is subject to confirmation and will be updated in the near future.

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1. Introduction The purpose of this business case is to set out the case for the development of a Community Independence Service (CIS) across the Triborough. This document outlines the preferred commissioning approach for 2015/16 and makes the case for an expansion of CIS activity in subsequent years. The proposed CIS lies at the core of the Triborough Better Care Fund proposals which were developed in context of wider strategic plans agreed in and across each of the CCGs and the Local Authorities that constitute the Triborough. These 6 partner organisations agree that an integrated CIS will underpin the realisation of a number of strategic and operational goals, and provides an opportunity to:

reduce the number of unnecessary admissions to hospital and residential and nursing care

improve people’s journey across secondary, primary and community services by offering integrated care in the community

move care closer to home and ensure high quality care that is co-ordinated across the region and between providers and delivered in a range of community settings

keep people independent and supported in their own homes for as long as possible As the work undertaken to develop this business case demonstrates, it is preferable that the single specification is delivered, at least initially, by existing delivery partners, who are able to develop their services during 2015/16, which will act as a transition year. This transition year will ensure that the development of an integrated CIS across the Triborough is well managed and reviewed regularly to ensure it achieves intended objectives and outcomes. Subject to the approval of this business case, commissioners will move forward with the proposals and will work with providers from September 2014 to March 2015 to implement service change. The CIS is at the heart of joined up working between health and social care and dealing with increasing volumes of people who have complex health and social care needs. Challenging financial and non-financial targets have been set for 2015/16 and beyond, emphasising the need for a swift and effective development of community services. This business case considers the development of 4 core CIS functions (i.e. Rapid Response, In Reach, Non-Bedded Rehabilitation and Reablement) and tests the following 4 hypotheses that CIS functions work more effectively within and across Triborough areas when it is:

coordinated: the health and adult social care components are better co-ordinated

integrated: the health and adult social care components are better integrated

delivered over 7 days: available 7 days a week

delivered at scale: services will work more effectively when both volume and activity and the breadth of service available are increased

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This business case presents detailed activity and cost modelling and analysis of the trajectory for change within each authority and across the Triborough for 2015/16 and beyond.

1.1 High level CIS outcomes

The service specification is being commissioned with the intention of improving the outcomes of people with above moderate levels of need. At a national level, the direction of travel is towards an outcomes based service. The shift to commissioning for outcomes recognises the need to move away from simply commissioning quantities of activity and to shift towards measuring desired outcomes, as defined by the people using the services. Regardless of whether a formal outcomes-based contract is designed, clear outcomes should form the basis for commissioning decisions in order to meet the needs of the local population. The NHS Outcomes Framework3 contains a number of indicators, selected to provide a balanced coverage of NHS activity. The Adult Social Care Outcomes Framework4 has a clear focus on promoting people’s quality of life and experience of care, and on the provision of care and support that is both personalised and preventative. Following stakeholder engagement at a workshop of senior health and social care commissioners and providers in October 2013, a set of high level outcomes for the Triborough CIS model have been identified, as shown in Figure 1.1 below. Please see Appendix B for more information on stakeholder engagement.

a) To enable people to be as healthy and independent as possible maintaining / or regaining /

or improving their quality of life and well being.

b) To support people choice to live in the most appropriate place for them, according to their

needs and to have control over their lives.

c) To ensure that people’s experience is a positive one by ensuring the service is personalised

and seamless within the system.

d) To ensure that the treatment, care and support that is provided is right for the person’s

needs, in the right setting and respects their individuality and dignity.

e) To increase integration and efficiencies across health and social care to ensure strategic

investment of funds and resources to maximise value for money.

Figure 1.1: Agreed high level outcomes for the Triborough CIS

3 Department of Health, 2013; http://www.england.nhs.uk/resources/resources-for-ccgs/out-frwrk/ 4 Department of Health, 2013; https://www.gov.uk/government/publications/the-adult-social-care-outcomes-framework-2013-to-2014

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These outcomes will produce benefits across the entire breadth of stakeholders including commissioners, providers, the people using services and the future CIS workforce. Work is in progress to create a set of KPIs to measure these outcomes and monitor performance of the CIS service across Triborough.

Achievement of these outcomes will represent a positive change for the residents of Triborough and significant step along the path outlined by the strategic programmes in wider North West London. There is also a need to ensure that the proposed change is viable and sustainable for commissioners within Triborough.

1.2 Population Needs

National drivers The demographic pressures of an ageing population combined with budgetary pressures and increasing costs exacerbates an already challenging environment. At present, care is fragmented across the health and social care provision and the approach to managing long-term conditions is outdated.5 Local population need for Intermediate Care Figure 1.2 illustrates that the pressures are faced not only the health and social care economy in Triborough, but also nationally. The intention for community care, of which the proposals for CIS is a part, is that resources will be made available to support the delivery of high quality care, with people in control of their care, within a viable and sustainable health and social care economy.

Figure 1.2: Pressures and potential solutions for the local health and social care economy6

In July 2014, an assessment of the population need for Intermediate Care in the Triborough was completed. It considered:

5 Source: NHS England; A Call to Action, 2013 6 Source: Triborough ASC vision

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What is the need for intermediate care services in the local population?

Do existing services meet this need?

What are the key gaps in service provision?

How will need change over the next 20 years? The aims of intermediate care are to:

help people avoid going into hospital unnecessarily

help people be as independent as possible after a stay in hospital

prevent people from having to move into a residential home until they really need to The highlights include the following key findings:

Intermediate care services are mainly (but not exclusively) used by older people. Based on data from Hammersmith & Fulham, three-quarters are 71+ and 92% are 56+.

Demographic change is likely to mean that need for intermediate care will increase by around 40% over the next 20 years, as the number of older people and the number of people with long-term conditions increases.

1.3 Whole Systems Context

The proposed changes to CIS are not being developed in isolation. Rather, they are part of a radical overhaul to the way in which health and social care services are delivered in the Triborough and more widely in North West London. This section provides a brief overview of the national and local context of the transformation that is occurring across the entire health and social care economy, of which the proposed changes to the Triborough CIS is just a part. Across North West London, the removal of acute beds from the system is being offset by investment and new capacity in out of hospital care. The movement of care closer to home is a key priority for the near future. There are a number of key transformational programmes in the Triborough (and wider North West London) which aim to improve the future health and wellbeing of 600,000 people who live in Hammersmith & Fulham, Kensington & Chelsea and the City of Westminster including:

Out of Hospital Strategies

Adult Social Care Transformation (ASC Transformation)

Whole Systems Integrated Care (WSIC)

The Better Care Fund (BCF)

Primary Care Transformation (PC Transformation)

Mental Health Programme (MHP)

There is strong alignment between the visions of all six programmes. The overall objective is to work as a single team across health, adult social care, public health, housing, mental health, primary care, community care, hospital care and other allied services.

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The existence of cross-cutting interlinked strategies means that:

all stakeholders are already used to working together in partnership

end users and providers have been working together through whole systems Integrated Care (WSIC) co-production by CCG / LA partnership through 2014

this approach together with the LA customer journey programme has informed the rationale and proposals for moving forward

Strategic programmes in Triborough

Vision and impacts

Triborough Adult Social Care Transformation Programme

Tri-borough Adult Social Care transformation programme is an overarching 3-year change programme that will:

Help achieve savings of £45m over three years,

Meet the increased demand for care services from an aging population and new Care Act

Improve the experience of people by making services clearer and easier to use and more joined up.

The programme focuses on aligning assessment and care management services within ASC to create a consistent core service offer and operating model; building more personalised community delivered care services that help people to be more independent; integrating social services with health, focusing on intermediate short-term care and care for people with disabilities and long-term health conditions.

Whole Systems Integrated Care

NW London WSIC programme aims to redesign models of care to make better use of the total available resource within the system – to achieve effective and cost effective outcomes through implementation of integrated care models co-designed through multi-stakeholder collaboration. It involves 31 collaborating organisations across 8 boroughs and has been selected as one of 14 national pioneer networks. The programme stratifies the total NW London population into cohorts based on care need and service utilisation. Initial cohorts of particular interest are the over 75s and adults with long-term conditions (LTC). There are 10 early adopter sites in NW London; 4 within the Triborough area.

Better Care Fund7

National Policy initiative to create a pooled fund to develop integrated services across health and social care.

7 A proportion of the performance allocation (the local share of the national £1bn performance element of the £3.8bn fund) will be payable for delivery of a locally set target for reducing emergency admissions (they suggested at least 3.5% reduction). The balance of the allocation will be available upfront to spend on out of hospital NHS commissioned services, as agreed by the Health and Wellbeing Board. This provides greater assurance to the NHS and mitigates the risk of unplanned acute activity. If the target for reducing admissions is not met, a proportion of the £1bn funding will remain with the NHS and not transfer to the BCF for joint use. The reduction in unplanned admissions indicator will be the only indicator underpinning the pay for performance element of the BCF. Hospital providers are being asked to confirm agreement with the proposed reduction in non-elective activity.

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15 constituent programmes of which this CIS is a core part in supporting and enabling the shift of activity to out of hospital settings The recent national changes to BCF have clarified that the pay for performance element is linked to successful reduction of Non-elective admissions.

Primary Care Transformation

PMCF is a national scheme set up to test access to primary care; NW London is one of the largest of 20 pilot PMCF sites. The programme includes work to:

(i) Extend access and continuity in the short term (by end of 2014/15)

(ii) Support the development, and grow, GP networks that can hold contracts (in 2014/15 onwards)

(iii) Put in place IT infrastructure, streamline appointment booking, broaden access and networked working.

(iv) Provide the NWL workforce with training and education to deliver the new model of care.

Mental Health Programme

NWL recognises the importance of parity of esteem that is looking at people’s wellbeing as a whole. This recognition of emotional and physical health needs is also recognised in the CIS planning.

Figure 1.3: Strategic programmes in Triborough

1.4 Opportunities for strategic alignment

There are a number of opportunities created by the above described strategic environment:

To focus on a co-ordinated approach across health and social care that maximises the benefits of the single integrated care pathway from the point of view of those using services. This is entirely compatible with the whole systems approach to care planning for people with long-term conditions and complex needs

To continue to ensure this work is fully embedded in whole systems design, owned and sighted by whole systems design clinical / social care leads that has been worked up with each area’s key stakeholders.

To make the most of working together to standardise through one single specification across Triborough where standardisation creates the best solution at scale, e.g. for mapping across acute sites such as Imperial or Chelsea and Westminster

To design the best workforce solution that identifies the most confident clinical / social care leadership and care response possible to drive integrated multidisciplinary team working forward. This needs to focus on a co-ordinated, integrated competency framework for out of hospital care

To incorporate best practice and learning into our work, and to make sure we’re clear where and how this works. The process to date has referred to innovations in and outside London. Wherever relevant it has built on existing experience and depth of learning within Triborough of developing a Virtual Ward within HF. Lessons have been learnt from local best practice in Greenwich, Brent STARRS (Short-Term

Assessment, Rehabilitation and Reablement Service model, Camden and the Local Government Association value cases as noted in Appendix B.8

8 Sources for additional information: www.royalgreenwich.gov.uk; www.nwlh.nhs.uk; www.local.gov.uk/health

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2. The Current Position Commissioners across health and social care are building upon system wide learning from 2014/15 winter initiatives. This learning and associated planning has been extended to the CIS business case. This business case takes that knowledge and projects that forward into 2015/16. We are building upon a system and process already in development. There is a natural stakeholder group and process already in place – Triborough Urgent Care Board (UCB) and its local UCB subgroups working together on system capacity and pressures. This has created an identified need for a better process and standardisation through collective effort of commissioners and providers, health and social care, assessing what works and what is required. UCB system leads have followed an agreed system-wide process for selecting and prioritising initiatives which will improve capacity and ways of working. These initiatives are compatible with the long-term proposals for integration and standardisation through the application of the Triborough BCF and proposed integration and co-ordination of functions under the CIS. Providers have highlighted the need for better feedback across commissioners and providers about what capacity is available, what is working, and what needs improvement, for system-wide gain. This insight, together with the need for all parties to find ways of tracking and evaluating system changes, impact, and areas for development, create an opportunity for enhancing the 2015/16 CIS model should it be taken forward in transition planning. In summary there is a great opportunity within whole system change for this initiative, which also works at scale. This is supported by the learnings derived from assessing the current position which are described in the following sections. Assessment of the baseline. What is in existence already? Significant work has been undertaken to understand the attributes of existing CIS services in each Triborough area. In developing this business case we have worked with commissioning managers from each CCG and social care leads to answer a number of key questions about existing CIS services in the Triborough area. Key information presented in the rest of this chapter is divided into two sections:

Attributes of existing CIS services: this summarises the key features of existing CIS models, captured for each Tri-borough CIS service

Baseline data: data on current activity and spend which acts as a baseline for the activity and cost modelling presented in Section 4

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2.1 Attributes of existing CIS services - Triborough

The 4 service components core to each CIS model are:

Rapid Response

In Reach/ Supported discharge

Non-bedded intermediate care (Rehabilitation)

Reablement Analysis There is significant variation in management structures, operational process, care delivery and staff roles and ways of working across the 3 existing CIS services. Figure 2.1 below highlights the key areas.

Figure 2.1: CIS starting positions

The extent to which CIS teams are already co-ordinated and integrated varies. At present, the Virtual Ward model in Hammersmith and Fulham is the most integrated with joint management posts and a S113 agreement9 in place. In all models, providers currently have their own referral routes and undertake their own assessment; again there is collaboration between staff but further work would be required to streamline processes and integrate these functions.

9 Section 113 of the Local Government Act 1972 allows a local authority to enter into an agreement with another authority to place its officers at the disposal of the other authority, subject to consultation with the staff concerned and negotiation

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The following diagrams (Figures 2.2, 2.3 and 2.4) set out the parameters of each Triborough areas’ service model to outline the different starting points for the journey of change to a single standardised service. Figure 2.5 draws on the data captured in the detailed baseline mapping and summarises the key features of each existing CIS service (as at July 2014).

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Figure 2.2: RBKC/WLCCG as-is depiction

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Figure 2.3: LBHF/HFCCG as-is depiction

Figure 2.4: WCC/CLCCG as-is depiction

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“As-is” – key attributes of existing Triborough CIS models

RBKC/ WLCCG WCC/ CLCCG LBHF/ HFCCG

Commissioning

arrangement

Core CIS services are commissioned

separately by CCG and LA

CIS services are commissioned separately by

CCG and LA

The CIS/Virtual Ward service is jointly

commissioned by CCG and LA

Core

components Rapid Response, In Reach, Non-bedded Intermediate Care/Rehabilitation and Reablement

Teams RBKC: Reablement: Advice, Information

and Assessment (AIA) service; reablement

care delivery teams

CLCH: Rapid Response; In Reach; Non-

bedded Intermediate Care/Rehabilitation.

Additionality:

GP

Community Psychiatric Nurse

WCC: Reablement: Access, Assessment; Care

management

CLCH: Rapid Response; In Reach; Non-bedded

Intermediate Care/Rehabilitation

Allied Healthcare/ spot purchased providers:

Reablement Care delivery contracts with

Allied Healthcare and spot purchased

providers

Additionality:

Intermediate Mental Health and Physical Care

team (IMPs)

LBHF/ HFCCG: All core components now

form part of the Virtual Ward. This is

operationally managed as a single service

under a jointly (CCG & LA) funded Head of

CIS

The Service Manager’s team includes

both health and social care staff as well as

hybrid roles

Additionality -Virtual Ward:

Social Workers

Health and Social Care Case Managers

GP and Geriatrician

Mental Health worker

Referral routes Referrals come into the CIS from GPs, hospitals, social workers and other community-based staff, nursing and residential homes and

through self-referral or referral by family, friends or carers. People using services are also identified by the In Reach team

Referrals to Rapid Response come only from health and social care professionals who contact the RR Nurses directly on their mobile

phones.

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Access and

triage

RBKC Council Advice Line

RBKC AIA team

CLCH SPoR desk

WCC Council Advice Line

WCC Reablement access service

WCC CIS OT care managers (assessment)

CLCH SPoR

CIS duty desk (all providers)

Single team – CLCH SPoR and LBHF CIS

assessment

LBHF Council Advice Line

LBHF Community and hospital assessment

service

Assessment CLCH SPoR initial assessment and RBKC AIA

initial assessment. Staff confer, most

appropriate professional dispatched.

RBKC AIA will undertake comprehensive

assessment (as required) at the outset. This

produces a holistic assessment and may

result in referrals to services outside the

core CIS (for example the Memory Clinic,

Podiatry, Carers Assessments, Age UK)

during the initial six-week period.

CLCH SPoR initial assessment and WCC initial

assessment. Staff confer, most appropriate

professional dispatched.

Frameworki provides the WCC team with a

structured process and CLCH have tried to

align their initial assessment forms with this

process.(see Appendix D for more information)

Single team assessment (CLCH and LBHF

staff).

People are assigned to a ‘virtual bed’. This

categorisation also reflects the services

required.

‘Red bed’ users are those at high risk of

immediate (re)admission to hospital or

those in need of rapid access nursing or

rapid access therapy. ‘Amber bed’ users

are those requiring 6-12 weeks of support

from the CIS/VW rehabilitation and

reablement teams. ‘Green bed’ users are

those who can (re)enter core services.

Duration of CIS

service

Standard service: 0 – 6 weeks

People will exit the service before the end

of the 6 week period if they have reached

their goals.

Standard service: 0 – 6 weeks

People will exit the service before the end of

the 6 week period if they have reached their

goals.

The CIS/VW is piloting a 12 week standard

duration time in 14/15.

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CLCH and RBKC use the 6 week period

flexibly and if it is clear someone will

achieve their goals in week 7 or 8, will work

with them beyond the 6 week period.

CLCH and WCC use the 6 week period flexibly

and if it is clear someone will achieve their

goals in week 7 or 8, will work with them

beyond the 6 week period.

Joint working Joint visits by health and social care staff

are often undertaken. CLCH and RBKC use

a common screening tool for first visits.

Internal multidisciplinary meeting once a

week to discuss people’s care plans and

goals.

Delivery teams tend to deliver care separately,

although CLCH staff will feed information back

to the WCC Assessment and Care

Management team.

Co-location and joint management

supports integrated working and the team

work together to identify both health and

social care needs.

Figure 2.5: “As-is” – key attributes of existing Triborough CIS models

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2.2 Baseline – spend

The total baseline spend for the current CIS services across the Triborough is £16.8m.

Commissioner Core CIS service line(s) Total spend core CIS

service line

HFCCG Rapid Response, In Reach, Rehabilitation £3,033,651

Contributions from reablement grant £571,000

WLCCG Rapid Response, In Reach, Rehabilitation £3,736,668


CLCCG Rapid Response, In Reach, Rehabilitation £3,594,220


LBHF Reablement £1,335,000

RBKC Reablement £1,691,000

WCC Reablement £1,644,022

TOTAL COST £16,842,863

Figure 2.6: Summary of CCG and Local Authority spend on CIS services (2013/14)

2.3 Baseline – current contractual arrangements with CIS providers

The baseline mapping captured information about current contractual arrangements for CIS

services across the Triborough area. It is proposed that contract agreements are co-

ordinated in the future, to simplify process and facilitate better tracking of cost and impact

of investment.

The information gathered to date is summarised in Figure 2.7.

Commissioner Providers Service type Contract type Contract end date

CLCH In Reach Block contract March 2015

Rapid Response Nursing

Block contract March 2015

IC Therapy - (non-bed) based

Block contract March 2015

LCW Rapid Response Fixed term contract

Extension of contract to April 2015

CNWL Intermediate MH Fixed term contract

Not known

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WLCCG-RBKC RBKC Adult Social Care

Reablement In-house RBKC staff

Grant to March 2015

HFCCG-LBHF

CLCH In Reach Block contract S113 between community provider and LA social care

March 2015


Block contract S113 between community provider and LA social care

March 2015


Block contract S113 between community provider and LA social care

March 2015

WLMHT Intermediate MH Fixed term contract

Pilot – end date not known

LBHF Adult Social Care

Reablement In-house LBHF staff S113 between community provider and LA social care

Grant to March 2015

CLCCG-WCC

CLCH In Reach Block contract

March 2015


Block contract

March 2015


Block contract

March 2015

WCC Adult Social Care

Reablement (assessment and care planning/ care management only)

In-house WCC staff

Grant to March 15

Allied Health and spot purchased providers

Reablement and reablement spot contracted care delivery

Allied Healthcare 3 year contract, no automatic renewal, no contractual provision for

Allied Healthcare expires May 2015

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extension beyond that date. Contract isn’t exclusive. Spot purchasing of care when Allied Healthcare do not have resources to address need

CNWL Intermediate MH Intermediate Mental and Physical Health team (IMPs)

Not known

Figure 2.7: Baseline mapping of contractual arrangements 2014-15 (captured July 14)

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3. Proposed Integrated CIS Figure 3.1 shows a simple overview of the core CIS functions from the perspective of people who are using the services.

Figure 3.1: Overview of CIS

Relationship to wider services The specification for a single integrated model for CIS aims to achieve simplification in delivery and ensure that a person’s journey is integrated with smooth and rapid flow of knowledge and safe clinical transfer between interfacing services. For example, professionals working in the homecare service could refer a person into the CIS if a potential crisis or reablement need is identified. Likewise, following an assessment of needs, the CIS may request equipment/ adaptations in a person’s home to help keep their independence or refer them to bedded care for a short period of time. Homecare is the service that cares for people with less complex needs in their own home on a long-term basis, before, during and after any crisis that may see them undergo a period of reablement with CIS. It is expected that the combined effect of a single integrated CIS and a refreshed homecare provision with a reablement focus, hybrid health and social care working and smoother transition pathways will reduce the use of residential and nursing home placements, as community services become better equipped to handle more complex cases in people’s homes.

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The same design principles will equally apply across all the areas identified above as ‘out of scope’: inpatient bedded care, nursing and residential home care, 7 day social work hospital discharge team and homecare. There will be future opportunities for providers to discuss organisational development and where local roles such as care co-ordination and care navigation resources fit in. There is wide recognition of the importance of the GP in this model of care although this is not addressed directly in this case for change. What will be different in 2015/16? The following attributes will be different in 2015/16:

Single entry point into the service which is clinically led

Single assessment process

Rapid access to reablement, including 2 hour rapid response

Standardised hours for all functions

7 day working

Medical input across all 3 services

Integrated multidisciplinary team working to a common set of standards

Single set of KPIs and outcomes monitoring framework

Joint workforce and competency framework agreements established across each of the boroughs and providers

Overall statement of vision and model of care The proposed integrated service will be delivered by single multidisciplinary team who will work together in a collaborative approach to ensure each person’s pathway is seamless, reduces duplication of assessment and ensures the correct outcomes are achieved. Efforts and resources will be directed towards enabling services to work together, aligning incentives and measuring performance in ways that reward early intervention and prevention and in the long-term – promoting sustained wellbeing for local people.

There are 4 overall features to this model of care:

1. Intensive support to deliver care at home – a service which provides immediate intensive support in a co-ordinated and comprehensive health and social care package, with the flexibility to enable people to move across service interfaces according to people’s individual needs

2. Collaborative multidisciplinary working – professionals will work in integrated multidisciplinary teams across health and social care with a case management function that closely involves GPs

3. Effective information sharing - promote collaborative working to reduce duplication, improve care coordination, planning and management.

4. Best use of workforce skills – integrated team with a balanced and appropriate mix of medical, nursing, social care, therapy, mental health reablement workers and non-clinical members of the team to deliver intensive support at home provided 7 days a week

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Who is the CIS for? Based on CWHH risk stratification data, it has been assumed that all of the moderate and high and approximately 30% of the very high risk cohorts would be eligible for care and support from the service. On this basis, the proposed Triborough CIS is aimed at a section of the population equating to approximately 70,000 people or 11.5% of the Triborough population however, only a small proportion of this population will need to use it within a year. The positive impact and benefits of a Triborough service will however extend much wider than the immediate circle of people receiving care and support, to those people’s carers, family, friends and the local community.

Figure 3.2: CWHH risk stratification diagram

The CIS will provide support and care for:

a) People with long-term care requirements who need support to prevent crises or deterioration

b) People who require support following discharge from hospital/ care homes

c) People who need support to prevent (or delay) admission into hospital.

d) People who want to regain their independence at home or in another community setting.

e) People who require urgent care

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The long-term vision for the service (as developed to date) includes the alignment of the 4 ‘core’ CIS service components and the potential inclusion of local additionality.

In-reach

Rapid Response

Intermediate Care

Reablement

Core CIS

Step-up/step-down

Homecare

Care co-ordination

Neuro beds

Equipment

Friends

Family

Neighbours

Carers

Religious community

Supporting services: Coordinated to CIS

Outer Core:CIS network of services

Inner Core: Individual’s informal network

Key interfaces: with wider health/ social care sector

Otherinterfaces: with wider statutory services

Figure 3.3: Picture of the integrated Triborough CIS10

Primary care services will be instrumental to ensuring that the CIS is a success. GPs will play a key role in case management and care planning alongside care co-ordinators in the CIS. This will deliver a number of benefits to both GPs and people using the service by providing a single point of contact to ensure consistency throughout the care pathway.

10 Note: figures in this section been translated from the draft service specification as of August 2014

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3.1 Service specification

Specifications of the CIS core components

Rapid

Response

A multi-professional (medical, nursing and social care) Rapid Response service,

operating 8am to 8pm; 7 days a week), that can provide face to face assessment at

home within 2 hours of referral, support up to 5 days following referral and provide

referrals to ongoing support.

In Reach

An integrated case finding and in reach service, operating 8am to 8pm; 7 days a

week, with a presence in A&E. The Inreach service links to the wider urgent care

system, community beds, care homes urgent care and out of hours services

(including NHS 111). Provides proportionate assessment and referrals to ongoing

support

Non-

bedded

IC/Rehab

A delivery team, working as part of an integrated CIS (medical and social care),

operating 8am to 8pm; 7 days a week, that provides time-bound rehabilitation

(therapies) for referrals via the SPoR service by treating people with non-complex

conditions in a community setting with the aim of goal attainment. Responds to all

referrals within 24 hours and commencement of care within 72 hours

Reablement

A delivery team, working as part of an integrated CIS (medical and social care), that

provides reablement services for referrals via the SPoR for people for up to 12

weeks (as required). Responds to all referrals within 24 hours and commencement

of care within 72 hours. Includes specialist falls input within CIS timeframe (6-12

weeks over time). Where longer term care is required, includes links to additional

reablement services including assistive technology provision such as telecare

Figure 3.4: Specification of core CIS components The transition year of 2015/16 will also ensure that 11 ‘enablers’ for the service meet the requisite standards to support the 4 core areas (see Appendix C).

3.2 Gap analysis

Using the current baseline in each Triborough area (as at July 2014) and understanding the proposed future model, it is possible to assess the ‘quantum shift’ required in each Triborough area to reach a single standard specification. Figure 3.4 compares the current position of the CIS services with the position specified for the 2015/16 transition year. It is not reflective of the effectiveness of existing services in each area, but rather indicates the distance to travel to meet the service model outlined in the specification.

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Tri-borough area

Distance to travel

Explanation Proposed solutions/next steps

HFCCG/LBHF Low

HFCCG/LBHF have the shortest distance to travel to meet requirements for 2015/16 delivery. The model in place broadly aligns to the proposed 2015/16 CIS specification, and plans are already in place for further development in line with the requirements set out in this business case.

HFCCG/LBHF will continue resourcing the Virtual Ward model – recruitment of additional medical cover is underway. Work is underway to streamline and integrate the referral, triage and assessment process. Hybrid health and social care delivery roles are being developed. Work is underway to develop core and specialist CIS skills amongst team members. Joint management posts underpin the development of an integrated team.

WLCCG/RBKC Medium

WLCCG/RBKC intermediate care model meets some of the requirements set out in the CIS specification, but still has distance to travel to meet all 2015/16 intentions. WLCCG/RBKC are listed as medium rather than high due to their funding and contractual position in comparison to WCC/CLCCG as described below.

WLCCG/RBKC will continue work to date to develop integrated ways of working within CIS. More work is required to align referral, triage and assessment processes to the requirements of the new specification. More work is needed to develop integrated working amongst delivery teams and to develop hybrid roles. Additional resource may be required to meet proposals for 2 hour response with multidisciplinary input. Older Adults Support Team being recruited during 2014/15 which will provide 2.5 WTE consultants (1 WTE psycho-geriatrician) during 2014/15 and 3 WTE consultants by April 2015/16 to support the reactive and proactive care pathways as a core element of CIS service.

CLCCG/WCC High

CLCCG/WCC has the furthest to travel to align their service model with that proposed for 2015/16. This is primarily because reablement care delivery is outsourced to Allied Health and other spot purchased providers, which adds additional complexity to funding, contracting and delivery arrangements. It also means a significant volume of work is delivered by staff not directly part of and managed by the core CIS team.

CLCCG/WCC will prioritise the recruitment of medical cover and the integration of health and social care CIS team members. The development of a CIS Duty Desk for referral and triage led by a jointly funded CIS Lead will help facilitate change. The immediate focus for WCC/CLCCG will be the development of future plans for the outsourced reablement care delivery contract, which expires April 2015.

Figure 3.5: High level gap analysis and transition plan

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4. Activity Modelling and Financial Implications

4.1 Introduction to the CIS financial and activity model

An initial review in September/October 2013 examined national and international best practice including strong evidence from other areas such as Greenwich, Northamptonshire and Greater Manchester.11 During 2014, significant resource and effort has been spent developing a financial and activity model to inform decision making and support the case for new investment in the CIS in 2015/16 and beyond. The model estimates the financial costs and benefits of the new CIS service, incorporating links to and impacts on associated services (e.g. homecare, nursing and residential care home placements). It has been developed with significant involvement from CCGs and LAs. As activity shifts from a hospital setting into the community it is logical that extra pressures and costs will be created for those organisations who deliver care in the community setting including but not limited to; primary care, community health services, voluntary and third sector organisations and the local authority providing social care. Evidence from London Borough of Greenwich who implemented their integrated care team with similar service functions showed a saving of £900k on residential and nursing home placements and the number of people entering long-term social care reduced by 50% in the first year in addition to delivering significant non-elective admissions (NEL) to hospital. Inevitably, however there is likely to be an increased need for homecare packages over time and it is likely that as the model evolves and grows the level of complexity of people’s care needs at home will increase. The balance of activities, costs and related risk share across health and social care commissioners will be the subject of a negotiation process as part of the BCF planning process and the financial model will inform the decision making process. The model has been co-designed with senior managers and built with the best possible available and most recent data sources from across health and social care. It has been developed through a structured process involving technical specialists and clinical input to verify the data and assumptions. However, it is a representation of reality and as with any model it has certain limitations and detailed assumptions are being recorded. There are 3 key things to understand about the model:

The model adapted the approach and assumptions used in the HF Virtual Ward modelling. Drawing upon data provided by CCGs, the Local Authorities and providers working across Triborough and utilising a range of assumptions developed with senior managers, service leads and health and social care professionals we have developed a robust financial model.

The savings in CIS are delivered by supporting people in the community rather than in hospital or in care homes. The financial assumption underpinning the CIS is that it is less expensive to support someone in the community and in their home and

11 Source: LGA Integrated Care Value cases; www.local.gov.uk/health

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therefore, savings can be made by shifting activity from (more expensive) hospital and care homes to (less expensive) community-based settings.

The model is predicated on a NEL savings cap of 5% – this is to ensure a challenging but realistic target for reduction of admissions but ensures that the provider is not destabilised in the process.

There are 2 key parts to the model:

1) Conceptual model showing the flow of people (reference section below) 2) Detailed Excel spreadsheet (summary of findings provided in Section 4.1)

The objective of the model is to provide more robust evidence for the BCF business case, and a more detailed platform to build upon for ongoing work (e.g. transition plans, cost and benefit monitoring / reporting). The financial model has confirmed that the new CIS service will deliver savings through shifting activity from (more expensive) hospital and care homes to (less expensive) community-based settings. The financial benefits are derived from the reduction in activity of the following:

NEL admissions (CCG benefit)

ASC residential and nursing care home placements and LOS (LA benefit)

A&E attendances (CCG benefit)

Homecare hours for new clients with reablement support (LA benefit)

LOS and DTOC (Acute providers benefit) Length of stay (LOS) savings and Delayed Transfers of Care (DTOCs) will accrue as benefits to the providers and will support the ability of the acute providers to deliver efficiency savings. We estimate these to be £168k in year 1 2015/16. Appendix F provides a breakdown of these figures by CCG. In the next phase of development we aim to clarify these.

Triborough Inreach LOS Reduction FY15/16 FY16/17 FY17/18 FY18/19


Total Days Saved 918.66 1440.76 1754.38 1839.16

Total Saving (£) £168,061 £264,512 £322,105 £337,495

Total Saving (FY15/16 to FY19/19) £1,092,173

Figure 4.1: Triborough in reach LOS reduction The main drivers of expenditure are:

Investment in workforce and skills (cost to CCGs and LA)

Investment e.g. IT/IG and PMO Change Management (CCG cost)

Ongoing delivery costs e.g. Growth in homecare hours through avoiding care home demand through the CIS service (LA cost)

CR/ CIS Resource Costs (CCG and LA cost)

Intermediate Care Equipment (LA cost)

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4.2 The Conceptual Model

The Community Independence Service (CIS) lies at the heart of integrating care across health and social care. It is critical to enable the shift in the care of people requiring services from acute to community settings. It is both the largest source of investment and benefits (financial and non-financial) in the Triborough Better Care Fund (BCF) plan. We outline below the overall model for financial costs and benefits in the BCF plan. The Conceptual Model The conceptual model explains, visually, how the savings and costs will be generated based on the future flow of people across a number of interlinked services. It shows how benefits may be realised in acute and care home provision through crisis prevention, discharge support, homecare and reablement.

Figure 4.2: Conceptual Model – flow of people within the CIS system

Within the conceptual model, the services within the purple box represent the core components of the CIS service:

In reach/ Supported discharge (through hospital discharge team)

Rapid Response (RR)

Intermediate Care Rehabilitation

Intermediate Care Reablement The conceptual model also shows the services that will directly be impacted as a result of the new service, e.g. nursing care, residential care, acute admissions and homecare. These services will be included within the financial modelling to ensure all costs and benefits directly associated with CIS model are captured appropriately.

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It highlights the existing flows of people that are to be reduced by the CIS service, represented by the black arrows. At a high level, the model shows that the CIS service will result in a reduction in care home placements and acute admissions, which in turn will increase the flow of people into the CIS and homecare as more people are treated in the community. The grey arrows indicate the targeted flows that will result in an increase in activity and costs. Working assumptions of conceptual model The following diagram shows the projected flows of people (based on the conceptual model) and the core assumptions underpinning this:

Figure 4.3: Working assumptions of conceptual model Key Assumptions The development of key assumptions is critical to the approach and methods underpinning the financial model. Activity was modelled through understanding the impact the CIS will have on the flow of people. The total number of projected referrals were modelled through drawing upon the HF Virtual Ward assumptions. Figure 4.4 identifies the high level assumptions.

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Figure 4.4: High level assumptions

The assumptions underpinning the financial model have been developed in line with the CCGs QIPP as their long-term financial plans and for LAs the mid-year financial planning process.

4.3 Key Findings

[The findings and outputs of the model will be included following finalisation of the model.]

4.4 Conclusions from the financial and activity modelling

The savings in CIS are delivered by supporting people in the community rather than in hospital or in care homes. The financial assumption underpinning the CIS is that it is less expensive to support someone in the community and in their home. Savings can be made by shifting activity from (more expensive) hospital and care homes to (less expensive) community-based settings. The evidence from the financial modelling supports this premise. [The CIS is forecast to deliver net benefits of X in 2015/16 and rising to X in 2018/19 and confirms that the implementation of the CIS service is financially beneficial across Triborough.]

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5. Options Appraisal Section 3 outlined the current baseline of activity across the 3 boroughs. Subsequently, Section 4 presented a summary of the single specification for the future state of CIS which is fully integrated and standardised across the Triborough. The gap analysis to compare current models against the future state then demonstrated the distance to travel for each of the services in the Triborough areas (Please note that this is not an assessment of the effectiveness of the current service but a measure of maturity of the service against the desired future state). The journey to integrate and achieve the significant benefits of a single model will be different for each borough. Consequently, the challenge for commissioners is to establish the best available route to deliver the required service transformation and consider the contractual mechanisms available to drive this forward. 3 options for change were assessed and Option 2 was selected as the preferred option, on the grounds that it would achieve the most integrated care pathway as early as possible and was judged to give the greatest likelihood of releasing the opportunities and benefits modelled. The 3 options are described below and Figure 5.1 provides a summary description of each option considered.

Option # Option Description

1 Do nothing

Continue with existing fragmented services. No investment in to

enhance or integrate existing models of the CIS.

2 Single co-

ordinated

approach with

existing providers

Continue with existing multiple providers, however standardise

provision under one single specification through appropriate

contract amendment to existing health and social care

contracts. This would involve implementation of commissioner

principles of engagement translated into provider collaboration

agreements. Potentially this could be achieved through

development of a Memorandum of Understanding. To underpin

this, there will be a need to build strong levels of trust and good

relationships across organisational boundaries in order for step

change to be delivered. Programme of change across the

provider landscape will be required to focus on integration to

work as a single team. Financial incentives in the form of the

proposed new investment in 2015/16 could be used to

incentivise integrated working. This will be discussed with

providers throughout the transition period.

47

3 Prime Contractor

Single provider organisation following a competitive

procurement process working under a single service

specification which may include a TUPE’d workforce. This is a

contracting model which enables commissioners to transfer the

responsibility and risk for the delivery of specific services to a

single provider.

The commissioning organisation holds the commissioning

contract with the Prime Contractor who may subcontract some

of the services to Third Party Provider(s).

The Commissioners can protect patient choice through careful

management of Prime (in the way it uses its supply chain and

refers activity to them).

Figure 5.1: Options descriptions*

*The above three options are not exclusive and do not rule out the consideration of other

contracting mechanisms in the future.

5.1 Discussion of Options

Figure 5.2 shows a detailed consideration of the advantages, disadvantages, risks / issues and timescales associated with each option. Consideration was also given to the complexity of solution and whether benefits would be achieved in 2015/16.

OPTION 1: Do nothing: Continue with existing fragmented services

While good models of care already exist across the 3 boroughs the strategic review in September / October 2013 showed that there are a number of known and acknowledged issues:

Inconsistent opening hours

Different ways of referring people into the system (multiple points of contact)

Inconsistency in what care is offered, when and for how long

Inconsistency in customer / patient outcomes

The same or similar services are called different things which can cause confusion amongst both health and social care professionals and people

Varying costs for similar services

Duplication in assessments and delivery of services

Patchy knowledge and understanding of the service by both patients and professionals referring into the service

In addition, the services are not sustainable financially as evidenced by repeated bids for winter pressures funding to support the services.

48

The option to ‘Do nothing’ is considered incompatible with the opportunities created by the BCF and whole systems integrated design. It would not deliver better co-ordinated integrated care out of hospital nor customer journey transformational benefits. This option was ruled out as the preferred option.

OPTION 2: Single co-ordinated approach with existing providers: Continue with existing multiple providers, however standardise provision under one single specification and focus on integration and improvement initiatives.

By working with existing health and social care providers on a system-wide basis, commissioners will enable delivery partners to build upon the body of expertise already built up around addressing capacity gaps in resilience and winter pressures planning. Working on a co-ordinated basis with existing teams preserves existing focus on improving the single integrated customer and patient care pathway that is at the centre of the customer journey and whole systems integrated care vision. Expertise can be channelled on creating a single competency framework for workforce planning, organisational development, and making the most of the opportunities to improve efficiency and productivity created by standardisation. Focus and momentum around transformation initiatives already underway and pilots already in place can be sustained without diversion. By avoiding the disruption created by uncertainty, existing commitments to working collaboratively in local areas can be applied at scale. Selecting this option is most compatible with the implementation of whole systems integrated care and achieving the intent of the BCF at any earlier stage, without ruling out future developmental change. This option offers the greatest opportunity and preserves the benefits of continuity for 2015/16.

OPTION 3: Prime Contractor: Single provider organisation following a competitive procurement process

Because of the lead-in time associated with a procurement exercise there is greater potential to disrupt or defer integrated care pathway planning and this is associated with greater likelihood of creating instability. This was assessed as more likely to disrupt engagement and create an uncertain timeline for the release of opportunities and benefits.

In addition, the diversity of employment arrangements assessed in the 2014/15 baseline points to the likelihood that a major consultation and consolidation exercise would have to take place before significant progress around the integrated care pathway could happen. This creates greater likelihood of creating instability. This option was assessed as having greater potential to disrupt or defer integrated care and was not selected as the preferred option for 2015/16 because of its potential to delay release of Better Care Fund and whole systems integrated care benefits.

Option 3 was not selected as the preferred option due to its complexity and potential for disruption to service delivery, which was considered was too great to be delivered within the timescales available (i.e. for service go-live date of April 2015).

This option was discarded for 2015/16 because of its potential to delay to release of BCF and whole systems integrated care benefits.

49

5.2 Recommended Option

The recommended option is Option 2: Single co-ordinated approach with existing providers. For 2015/16, to ensure stability, it is proposed that the service continues to be delivered with multiple existing providers but through a single co-ordinated approach /specification.

To enable transformational change without creating instability, the recommended approach for 2015-16 is to enter a year of transition during which a phased approach can be taken and incremental improvement brought about. The provider community is best placed to advise commissioners on the most effective way of bringing about operational and service transformation, and as soon as this case is agreed, that necessary 6 months of transition will be brought about. These options are considered in more detail in Figure 5.1. Section 6.4 contains a summary of risks and mitigations. New investment for 2015/2016 The challenge remains of what contractual tools to use in order to transform the service delivered by existing providers in the year of transition 2015/16 and how to ensure they work collaboratively as one single team. Contract leads will need to work to one collaborative agreement for implementing change in contracts. This could also involve the development of a Memorandum of Understanding which covers all boroughs, all CCGs and all existing health and social care providers contributing CIS services within Triborough in 2015/16. One way of addressing this and incentivising providers, is to package up the [new investment of £xm] and to consult with existing health and social care providers during September 2014 on the simplest contractual arrangement to enable providers to work together to manage incentive and risk. This arrangement needs to enable commissioners and providers to work together under a common framework.

50

Option Advantages Disadvantages Risks/Issues Timescale

required Complexity

Benefits

2015/16

Option 1 –

Do Nothing

Least effort and cost Does not address the increased

requirement for intermediate care

services in the Triborough nor

inconsistencies in the current

service models nor deliver further

integration services. No delivery of

benefits or impact on NELs and

length of stay in nursing home and

residential home care, no

additional impact on health and

wellbeing outcomes.

Misses key opportunities to deliver

improved care and integrated

services offered by the Better Care

Fund.

Also impacts negatively on the

ability of other inter-related

schemes (such as 7 day hospital

discharge) to deliver benefits.

Failure to simplify and standardise

and to improve customer and

patient journey drives up health

and social care cost, impacting on

CCG and LA long-term financial

plans.

Unsustainable financial model

currently, supported by winter

pressures funding.

Immediate Low X

51


required Complexity

Benefits

2015/16

Option 2 –

Single co-

ordinated

approach

with

existing

providers

Minimal impact on providers and

hence minimum disruption in care

delivery and patient / customer

experience.

Maintains focus on improving

people’s experience through

progressing ASC customer journey

and WSIC focus on single front

door.

Continued focus on improving

existing care pathways, referral

routes, functions and teams and

integration initiatives still under

development.

Sustains focus and momentum

around integration through

emerging GP networks and whole

system provider network

initiatives.

Transitional change can be

implemented for 2014-15 and

2015-16 with earlier delivery of

specified benefits.

Leaves options open for future

models of contracting.

Insufficient assurance of step

change to deliver single front door,

improved customer journey and

experience.

Relies on trust and good

relationships between

commissioners and providers.

Relies upon collective approach to

culture change to underpin

delivery, as well as contractual or

workforce changes. This will rely on

successful engagement process

over 6 months’ transition period

and into the long-term to deliver

MOU.

Relies on transparency and close

co-operation from all parties to

address specific local areas of

improvement. For example, if

workforce skill set needs

enhancement in one area or

recruitment needs to be tackled in

another area, relies on a mature

approach to prioritization.

Fragmentation across boroughs /

CCGs could continue unless

collaborative working and

partnership agreements are put

in place.

May not deliver sufficiently

robust step change to deliver

consistent benefits including

contract efficiencies. Continued

overhead from duplication if

partners fail agree single tracking

of productivity gain.

Accountability and clinical

responsibility may be unclear

because of different starting

points across the CCGs and

boroughs. To mitigate this risk,

close monitoring and feedback

on progress must flow across all

strategic and operational levels

of commissioner and provider

partnerships.

Risk and reward agreements i.e.

contract incentives or penalties

fail to deliver accountability for

performance and outcomes.

6 months Medium

52


required Complexity

Benefits

2015/16

Option 3 –

Prime

Contractor

Potentially opens up market place to new

entrants.

Opportunity for competition to test for

innovation and new ways of working.

Opportunities to access a wider pool of

talent and wider track record.

Clear governance and simplicity of

contracts.

Steps up the focus on improving people’s

experience through progressing ASC

customer journey & WSIC focus on single

front door.

Drives on integration step-change to

enhance focus on improving existing care

pathways, referral routes, functions and

teams and integration initiatives still

under development.

Opportunity to redesign key points to

support acuity out of hospital i.e.

supported care at home to avert crisis /

admission.

Could simplify care pathway wrapped

around WS GP & GP-focused MDT.

Accommodates transition and

incremental improvement alongside

phased benefits release.

Provider lead acceptance and support

across all providers untested; possible

disengagement of some providers;

willingness of single provider to take

on risk uncertain.

Provider impact would be high.

Provider lead acceptance and support

across all providers untested; possible

disengagement of some providers;

willingness of single provider to take

on risk uncertain.

Step change in keeping with LA

customer journey transformational

change and WSIC transitional change.

Non delivery of key BCF

benefits in 15/16 would

results in payment for

performance element of

plan being restricted.

Uncertainty could be

very disruptive for staff

morale and hence

delivery of services may

suffer.

Destabilisation of

existing providers.

18 months High X

Figure 5.2: Detailed options appraisal The development of the CIS business case, specification and financial model is characterised by

53

6. Transition and implementation planning Next steps for commissioners Following agreement of the recommendations, it is timely and right to move on to work with providers on translating the implications into practical and implementable steps. As a first step, there will be immediate consultation with existing health and social care providers on the use of the proposed 2015/16 investment in a way that works best for the system, as a whole systems approach. In return, there must be a set of principles for engagement to which all commissioners sign up to. The way in which the investment offer is packaged up for existing health and social care providers must be linked to an agreement which allows providers and commissioners to track impact and benefits and holds providers to account. For the immediate future, findings will be translated into commissioning and contracting intentions for 2015/16. The work over the next 6 months will prepare the ground, to allow providers the time to prepare for change, and commissioners to make translate the investment case into new contract agreements Principles of engagement for commissioners The overall Better Care Fund Plan submissions supported by CCGs and LAs reflect overarching principles for the joint approach under the Better Care Fund by CCG/LA area within Triborough. Beyond the principles of fairness and transparency that should accompany any risk-sharing arrangement, the agreement must:

1) Compensate a commissioner that does not get intrinsic benefit from their investment in CIS (In this case, intrinsic benefit means "a saving from their own budget" in ASC's case, the budgets for long-term care services)

2) Provide an incentive not just reimbursement. (Compensation must pay for more

than the difference between investment and return. i.e. the payment must cover the risk and the opportunity-cost of undertaking this initiative in favour of other alternatives)

3) Pay for all work that reduces activity, whether or not the activity is taken as cash

savings

4) Commit to a monitoring framework that can spot problems with costs and returns quickly and reliably

5) Give clear conditions for withdrawal if losses are unacceptable (The agreement

should be clear how and when withdrawal is possible if the services is not achieving its stated aims)

54

In the next steps, these will be discussed with health commissioners as part of the wider discussions around Better Care Fund. The integrated approach to crisis response / community independence service through a year of change in 2015/16 necessitates a particular need for commissioners to sign up to set of consistent commissioning principles across all six authorities, CCGs and LAs. To minimise bureaucracy and maximise partnership benefits, commissioning partners across the Triborough will agree and sign up to the principles and rules of engagement with respect to the CIS. A joint commissioning approach should therefore apply the following proposed principles:

One approach to planning and building upon demonstrable achievement – joint commissioning intentions in 2015/16 and beyond

Transparency, consistency and accountability taking an open book approach

Taking and applying one approach to measuring progress

Assessing the achievements of the integrated CIS

Tracking through one consistent methodological approach actual benefits and savings by LA / CCG

Testing on one single basis overall value for money from the pooled Better Care Fund budget

6.1 Developing the CIS through incremental change

There are 4 key stages to delivering this programme. The 4 phases are:

Design – confirming the need for change and agreeing the future service model (CURRENT PHASE)

Preparation – planning for changes required and building shadow capability

Transitional improvement – making interim changes to how services are delivered

Single service – running sustainable and cost effective service as envisioned

Figure 6.1 provides a pictorial overview of these different stages and the key objectives and deliverables for each stage.

This section also considers the key risks to the successful delivery of the CIS.

55

Figure 6.1: Overview of incremental change to CIS

56

6.2 Transition plans

There are 2 main factors impacting the resource each CIS service will require to deliver services as planned from 2015 onwards:

the single specification (operational requirements)

activity (the volume of referrals coming into the service)

Subject to the approval of this business case, further work will be required in each authority to refine these plans. The initial descriptions of the transition requirements and trajectory for change identify:

gaps and development requirements

suggested solutions (e.g. ways to bridge the gap)

resource implications (financial) phasing Transition arrangements for each area are summarised below, as are the transition requirements common across the Triborough.

6.3 Design and Preparation – September 2014 to March 2015

The core aim of the period between September 2014 and April 2015 is to ensure alignment by both commissioners and providers across the Triborough to commence delivery of the single service specification from April 2015. At the heart of this will be the need for commissioners and providers to work together to undertake more detailed design work and operational development work to set up systems, processes and ways of working to achieve the deliverables as set out in the service specification.

6.4 Risk management

An initial view of the key risks that may occur during the preparation and transition stages of the programme has been captured. Following the assessment of all identified risks, those scoring the highest for impact and/or likelihood have been further evaluated and are highlighted in Figure 6.4. They focus on the central areas of needing to shift activity, ensuring alignment with other programmes, developing the necessary contractual arrangements and issues around workforce and systems that are most likely to limit the ability of the CIS to fully meet the requirements of the single specification. [These risks are subject to costs and benefits model and a risk/reward agreement being negotiated]

57

RISK MITIGATION

Ris

k #

Risk Description

Imp

act

(ou

t o

f 5

)

Like

liho

od

(o

ut

of

5)

Ove

rall

risk

sco

re

(ou

t o

f 2

5)

RA

G

Mitigation

Imp

act

(ou

t o

f 5

)

Like

liho

od

(o

ut

of

5)

Ove

rall

mit

igat

ion

sco

re (

ou

t o

f 2

5)

RA

G

B1 Insufficient activity is

referred by GPs and

other parts of the

health and social care

system due to a lack

of confidence in the

CIS services

5 4 20 RED 1. Transition and preparation period

from September 2014 includes

thorough assessment and provider

advice on capacity and capability

requirements to build referrer

confidence includes thorough

assessment and provider advice on

capacity and capability requirements

to build referrer confidence

2. Capacity and capability

requirements are translated into

ramp up plans for recruitment and

stabilisation of teams

3. CCG and LA leads ensure that

referrers are kept well advised of

service availability during ramp up

period and beyond, with close

monitoring and feedback of referrer

experience of using the service

5 3 15 AMBER

58

RISK MITIGATION

Ris

k #

Risk Description

Imp

act

(ou

t o

f 5

)

Like

liho

od

(o

ut

of

5)

Ove

rall

risk

sco

re

(ou

t o

f 2

5)

RA

G

Mitigation

Imp

act

(ou

t o

f 5

)

Like

liho

od

(o

ut

of

5)

Ove

rall

mit

igat

ion

sco

re (

ou

t o

f 2

5)

RA

G

B4 Required alignment

and integration of CIS

as set out in the

service specification

is not achieved to a

sufficient degree to

support increased

volumes of activity

and realisation of

benefits

5 4 20 RED 1. Accountable commissioner and

provider leads are identified for

programme transition and

implementation phases, and

management of change is realistic

and robust

2. During transition and beyond,

commissioners and providers remain

fully engaged in evaluating and

tracking outcome measures to

ensure that the service specified is

delivered on the ground

3. CCG and LA leads to remain

responsible for ensuring there is

good collaboration. Across all three

boroughs, programme planning to

capture ramp up plans which ensure

that the opportunities for

standardisation are translated into

benefits from working at scale.

Sharing and working to one process

permeates through all operations to

avoid reverting to local variation.

5 3 15 AMBER

59

RISK MITIGATION

Ris

k #

Risk Description

Imp

act

(ou

t o

f 5

)

Like

liho

od

(o

ut

of

5)

Ove

rall

risk

sco

re

(ou

t o

f 2

5)

RA

G

Mitigation

Imp

act

(ou

t o

f 5

)

Like

liho

od

(o

ut

of

5)

Ove

rall

mit

igat

ion

sco

re (

ou

t o

f 2

5)

RA

G

B7 It becomes

increasingly difficult

to achieve sufficient

rises in referral rates

in later years (and to

achieve the 5%

reduction in NEL

admissions) due to

the cases having

higher levels of acuity

and the CIS needing

higher levels of

medical skills, making

it increasingly

difficult to maintain

growing benefits

realisation

4 5 20 RED CCG and LA leads implement and

sustain long-term feedback

mechanisms to ensure that referrers’

experience continues to be captured

and tracked, and provider service

capability and capacity across the

boroughs is targeted on the

appropriate case mix over time, and

that risks are appropriately resolved

4 3 12 AMBER

60

RISK MITIGATION

Ris

k #

Risk Description

Imp

act

(ou

t o

f 5

)

Like

liho

od

(o

ut

of

5)

Ove

rall

risk

sco

re

(ou

t o

f 2

5)

RA

G

Mitigation

Imp

act

(ou

t o

f 5

)

Like

liho

od

(o

ut

of

5)

Ove

rall

mit

igat

ion

sco

re (

ou

t o

f 2

5)

RA

G

W2 Providers struggle to

recruit sufficient staff

to meet capacity

requirements

5 4 20 RED CCG and LA leads implement and

sustain long-term feedback

mechanisms to ensure that the

combined provider workforce to

deliver the service is evaluated so

that provider service capability and

capacity across the boroughs is

targeted on the appropriate case mix

over time, and that risks are

appropriately resolved.

5 3 15 AMBER

O2 Lack of IT system

across health and

social care providers

leads to a lack of co-

ordination and lack

of integration

between providers

4 5 20 RED CCGs and LA to sustain a single

approach through its BCF programme

leadership, to aim to implement

interoperability across IT systems,

building on an NHS interoperability

programme already being rolled out

in NWL

4 4 16 AMBER

Figure 6.3: Summary of highest scoring draft risks for CIS implementation

61

7. Conclusions and next steps

This document has summarised the case for the implementation of a single CIS across the Triborough area. There is a strong case to invest in this single integrated service. The recommendation is to begin alignment of the 4 core CIS service components in order to recognise benefits within 2015/16. The local and national pressures on the health and social care system, coupled with the savings that the model has anticipated, give a clear mandate for change.

7.1 Next steps

The evidence base upon which this business case has been developed, the baseline assessment that has been collated and the future direction, creates a stocktake and a foundation upon which all future planning can build. It builds upon local clinical and social care practitioner experience and ambition. It creates tools for a system which can be adapted for the future. For the immediate future, findings will be translated into commissioning and contracting intentions for 2015/16.

To enable transformational change without creating instability, the recommended approach for 2015/16 is to enter a year of transition during which a phased approach can be taken and incremental improvement brought about. The provider community is best placed to advise commissioners on the most effective way of bringing about operational and service transformation, and as soon as this case is agreed, that necessary 6 months of transition will be brought about

As a first step, it is proposed that there will be immediate consultation with existing health and social care providers on the use of the proposed 2015/16 investment in a way that works best for the system. This consultation will be conducted on a whole systems approach and will prioritise discussion with existing providers on investment sum available to implement year of transition and preferred contracting mechanism, to ensure balance of incentive and risk. This discussion will capture the learning from winter pressures planning on the best way to drive forward improvement across the system. To enable this work to progress, agreement to the direction outlined is sought to move forward and for the immediate next steps: 1. Achieve consensus to sign off the strategic direction of travel outlined in this business

case to develop a single integrated CIS across Triborough 2. Agree to implement the recommended option

3. Subject to scrutiny and approval of the outputs of the costs and benefits model,

undertake a period of negotiation between the local authority and the health

62

commissioners to reach consensus on a risk and reward agreement and such that all 6 organisations are satisfied on the level of investment required and expected benefits.

4. Develop and initiate a planned programme of engagement with providers and clinical

engagement to further develop the outcomes and service specification and associated service indicators. This should include GPs, acute hospitals, community providers, adult social care and mental health.

5. Develop a detailed joint transition plan for next 6-12 months

63

Appendices

Appendix A. Index of Figures and Tables

Section Detailed business case figures

Executive

Summary

Figure A: Overview of CIS

Figure B: Descriptions of core services

Figure C: CIS starting positions

Figure D: Distance to travel by borough

Figure E1: Simplified conceptual model

Figure E2: Benefits of the new CIS

Figure F: Transition plan

Section 1

Figure 1.1: Agreed high level outcomes for the Triborough CIS

Figure 1.2: Pressures and potential solutions for the local health and social care

economy.

Figure 1.3: Strategic programmes in Triborough

Section 2

Figure 2.1: CIS starting positions

Figure 2.2: RBKC/WLCCG as-is depiction

Figure 2.3: LBHF/HFCCG as-is depiction

Figure 2.4: WCC/CLCCG as-is depiction

Figure 2.5: “As-is” – key attributes of existing Triborough CIS models

Figure 2.6: Summary of CCG and Local Authority spend on CIS services (2013/14)

Figure 2.7: Baseline mapping of contractual arrangements 2014/15 (as captured July 2014)

Section 3

Figure 3.1: Overview of CIS

Figure 3.2: 3.2: CWHH risk stratification diagram

Figure 3.3: Picture of the integrated Triborough CIS

Figure 3.4: Specification of core CIS components

Figure 3.5: High level gap analysis and transition plan

Section 4

Figure 4.1: Triborough in reach LOS reduction

Figure 4.2: Conceptual Model - flows within the CIS system

Figure 4.3: Working assumptions of conceptual model

Figure 4.4: High level assumptions

Section 5

Figure 5.1: Options appraisal summary

Figure 5.2: Detailed options appraisal

Section 6

Figure 6.1: Overview of incremental change to CIS

Figure 6.2: CIS high level implementation plan

Figure 6.3: Summary of highest scoring draft risks for CIS implementation

64

Appendix B: List of key stakeholders

The development of the CIS business case, specification and financial model is characterised by co-design and co-delivery across health and social care. This has been achieved through extensive stakeholder engagement and facilitation, including with CCGs, Local Authorities, providers, governing bodies, clinicians and operations managers.

Throughout the development of this business case, we have undertaken the following:

Co-production workshops to design BCF schemes (including cost and benefits)

Stakeholder engagement workshops

Weekly SRO group calls

Monthly SRO meetings

Clinical engagement meetings

Reporting at key governance bodies including JET, IPB and ASC Steering Groups Regular meetings with Daniel Elkeles and Liz Bruce to ensure alignment and

integrated leadership

Senior stakeholders across Triborough have been extensively involved the planning and review of this business case. CCG Leads have been instrumental in driving engagement with a wide range of stakeholders in their area, including clinical leads, CCG chairs and whole systems representatives. Similarly, effort has been undertaken in the LA to ensure that Cabinet Members and senior stakeholders have been informally briefed on details of, and progress with the CIS programme. Through the course of the programme, advice has also been sought from related services across London. In particular, thanks should be given to Greenwich, Brent STARRS and Camden CNWL, whose invaluable insight into their models of intermediate care helped to shape proposals for CIS in the Triborough. A summary of groups and individuals consulted over the course of the CIS programme can be found in this appendix

65

Groups engaged in the development of CIS model

Group Engagement

CCG Governing

Bodies

CCG Governing Bodies are yet to see the CIS business case. However, key

members from each body have been briefed individually or through involvement

in JET / Whole Systems groups, as outlined below.

LA Cabinet Members

Informal briefings have taken place with Cabinet Members in the 3 Local

Authorities, focussing on the BCF and social care CIS staff who will be part of

Customer Journey reforms. Further communication is planned with this group in

the week commencing 08/09/14.

JET

Monthly papers on CIS have been taken to JET, which is attended by Chief

Officers, CCG Managing Directors, Finance Officers and Programme Leads, as

outlined below.

Whole Systems

Design Groups /

Locality Meetings

Including GPs/CCG clinical leads and service users.

CCG Leads have acted as a conduit between CIS and Whole Systems groups.

Urgent Care Board Forum for providers, including acute hospitals and community, to come together.

CIS has been discussed a number of times.

Wider services

Advice taken from related services in other London geographies, including

Greenwich, Brent STARRS and Camden CNWL, through individual requests for

information and the learning session held at the University of Westminster on

11/06/14.

Adult Social Care

Leadership

Conference

Engagement and consultation event during which the SROs and ASC leads met and spoke to about 100 leaders in ASC regarding CIS and wider integration initiatives.

WSIC engagement

groups

Engagement has taken place, and more is planned with wider WSIC engagement

groups, Including community, mental health and acute providers, service users,

Healthwatch and the third sector.

Related BCF

programmes

Some engagement has taken place through joint workshops and attendance at

programme meetings. Further engagement is planned, particularly with leads in

Homecare and BCF Group C.

Healthwatch Engagement has taken place, further engagement is planned.

Kensington and

Chelsea Social

Council

Third sector organisation.

Engagement has taken place.

WL OOH Committee Engagement has taken place, further engagement is planned.

66

Senior stakeholders consulted

Name Role Organisation

Dr Tim Spicer CCG Chair HFCCG

Dr Ruth O’Hare CCG Chair CLCCG

Dr Fiona Butler CCG Chair WLCCG

Daniel Elkeles Chief Officer CWHHE

Liz Bruce ASC Executive Director Triborough ASC

Clare Parker Chief Financial Officer CWHHE

Rachel Wigley Director of Finance Triborough ASC

Thirza Sawtell Director of Strategy and Transformation CWHHE

Martin Waddington Director of Procurement, Commissioning and Business

Intelligence Triborough ASC

Stella Baillie Director of Provided Services and Safeguarding Triborough ASC

Philippa Jones Managing Director HFCCG

Louise Procter Managing Director WLCCG

Matthew Bazeley Managing Director CLCCG

James Cuthbert* SRO, Assistant to Executive Director Triborough ASC

Caroline Maclean Interim Director of Operations Triborough ASC

Rob Sainsbury * SRO, Deputy Managing Director & Out of Hospital

Programme Manager HFCCG

Kiran Chauan Deputy Managing Director CLCCG

Elizabeth Youard * SRO, Community Services Programme Director CWHHE

Jonathan Webster Director of Patient Safety & Quality CWHHE

Ben Westmancott Director of Compliance CWHHE

James Eaton Head of Performance CWHHE

*SROs have also been extensively involved in the production and review of the business case.

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Key stakeholders engaged in the CIS Programme

Name Role Organisation Project

involvement Consulted

Helen Troalen Deputy Chief Financial Officer CWHHE

Penny Magud Head of Community Independence Services, Adult Social Care

LBHF

Karen Clark

Service Manager - Adults

Access, Hospital Discharge & Reablement

Westminster

ASC

Jenny Platt Deputy Out of Hospital Delivery Manager H&F CCG

Alison Miller Delivery Manager CLCCG

Adele Yemm Project Manager (older people) WLCCG

James

Hebblethwaite Senior Business Analyst

Triborough

ASC

Ray Boateng Senior Joint Commissioning Manager Joint Commissioning Team

NWL CSU

Simon Hope Deputy Managing Director WLCCG

Jayne Liddle Assistant Director of Strategy WLCCG

Alan Hakim Secondary Care Advisor to CCGs and Chair

of the Triborough Urgent Care Board Clinical ×

Krishan

Aggarwal Clinical Representative CLCCG ×

Surjit Bhandal Senior Programme Lead CLCCG

Marina

Muirhead

Programme Lead – Whole Systems

Integrated Care CLCCG

Afsana Safa Clinical Representative CLCCG ×

Farid

Fouladinejad IT Strategy Lead CWHHE

Andrew McKeon Project Manager CWHHE

Clare Jarman Clinical Lead H&F CCG ×

Craig Griffin Strategy Consultant LBHF

Elisabeth Moore Senior Business Analyst, ASC Procurement

and Business Intelligence LBHF ×

Kate Lawrence Strategy & Transformation Team NWL

Cath Attlee Whole Systems Lead Triborough ×

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ASC

Michael Gray Project Manager Triborough

ASC ×

Pauline Mason Service Development Project Manager Triborough

ASC

Steve Mellor Finance Lead Triborough

ASC

Sarah Newton Senior Commissioner Triborough

ASC

Paul Rackham Head of Community Commissioning Triborough

ASC ×

Mike Rogers Head of Business Analysis, Planning and

Workforce Development

Triborough

ASC ×

Sherifa Scott Head of Procurement and Contracting Triborough

ASC ×

Charles

Stephens Procurements and Contracts Manager

Triborough

ASC ×

Ann Stuart Head of Community Assessment and

Social Work

Triborough

ASC ×

Rachel Boston Finance WCC ×

Chris Dale Change & Programme Management Unit WCC

Natalino

Esposito Business Analyst WCC ×

Iain Blake Clinical Representative WLCCG ×

Yvonne Fraser Practice Manager WLCCG ×

Rachel Garner Clinical Representative WLCCG ×

Richard Hooker Clinical Representative WLCCG ×

Shazid Karim Clinical Representative WLCCG ×

Naomi Katz Clinical Representative WLCCG ×

Puvana Rajakulendran

Clinical Representative WLCCG ×

Imran Sajid Clinical Representative WLCCG ×

Andrew Steeden Clinical Representative WLCCG ×

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Mark Sweeney Clinical Representative WLCCG ×

Sarah Wheeler Head of Finance WLCCG ×

We are aware that our team of stakeholders in turn engaged with wider groups and individuals not named above. We acknowledge and thank these many contributions for their advice and assistance in our work.

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Appendix C: Enablers for the core CIS components

Specifications of the CIS core components

IT/IG

(care record)

IT interoperability and Information sharing agreements: formal arrangement

between CIS providers within localities for data sharing supported by IT or

appropriate non-technical workarounds. Includes formal IG arrangements

Single Point of

Access

A single point of access, per locality, for all professionals (medical and social)

referring into the CIS, with just one referral brokered through the SPoR. Co-

ordinates all referrals and provides clinical triage using consistent eligibility criteria.

Informs assessment and ensures appropriate response (care delivery). Tracks

people’s progress through the service, including monitoring and actioning delayed

transfers of care

Assessment /

Care Planning

A single, multidisciplinary assessment and integrated care plan

Interfaces with a single assessment in acute settings (operational function for

discharge)

Case

Management /

Co-ordination A single, named care manager and case co-ordinator for each person in the service

MDT reviews A regular set of MDT review meetings

Assistive

Technology Improved use of assistive technology in the delivery of care

Voluntary

Sector Improved utilisation of and interface with the Voluntary Sector

Mental Health Improved formal links with Mental Health Services

Hubs (OOH) Potential / possible co-location or centralisation of the CRT around Hubs

Access to

supporting

(diagnostic)

services

Improved access to services such as Rapid Access/ACS clinics & diagnostics

Access to

supporting

(care delivery)

services

Improved access to services such as bedded intermediate care (step-up) and

hospital discharge.

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Appendix D: IT/ IG considerations

Information systems Integration of IT systems will ultimately avoid the use of multiple systems by staff and double entry. This will involve multiple technical challenges that need to be addressed during the project. Funding for this component of the project has yet to be confirmed and is factored into the business case costings. SYSTMOne is used by all primary care providers across the Triborough. Assuming consent is given, it is anticipated that community providers, such as CLCH, will be able to access SYSTMOne to ensure that the records get updated with information relevant to the CIS service. In addition, A&E departments can also have “view only” access to SYSTMOne, thereby ensuring that all professionals involved in a person’s treatment have access to up to date information. There is also potential for A&E services to have “write access” to SYSTMOne to update the person’s clinical record. Social services providers use the Frameworki system. To support joined up working in the CIS it will be preferable for social services staff to have access to SYSTMOne. Unfortunately, a live flow of information between Frameworki and SYSTMOne will not be possible in the short term. The same inter-operability issue exists between West London Mental Health NHS Trust’s system; Rio. There are however developments underway. Adult social services have a project initiated to standardise on the use of the NHS number as a unique identifier. This development aims to instigate this process at the time of client registration and throughout their record. Information Sharing and Information Governance There is a memorandum of understanding (MoU) in place for health providers (as a legacy from the Integrated Care Pilot) which provides guidance on how information should be shared in a safe and appropriate way. Essentially, this states that GPs share people’s information into and out of a central information pool (SYSTMOne in this case) by default whereas other provider institutions (Urgent Care Centres, Mental Health Trusts etc.) must gain the person’s approval when sharing their information. There are limited circumstances in which these other providers can override a person’s decision not to share their information and these decisions are made in the person’s best interest (e.g. an assessment indicates a serious underlying condition). This MoU has been endorsed by Dame Fiona Caldicott as aligned with the Caldicott review. It is understood that updating and widening this MoU to be fully fit for purpose and to include the Local Authorities will be complex and require a significant amount of work. Workarounds are likely to be required, and consideration will need to be given as to whether these workarounds limit benefits realisation. The updating of the MoU will be led by the Whole Systems Integrated Care programme.

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Alignment of the proposed IT and IG arrangements with the BCF The use of an NHS number is essential for effective information exchange flows between health and social care. The use of a single identifier helps to ensure there is no ambiguity about the identity of the person being treated prevent the delivery of inappropriate care to these people. Effective information sharing is essential for integrated and 7 day working to work. As the different parts of the health and social care system across community, primary, secondary and social care are increasingly joined up, all professionals involved in a person’s treatment will require information that is as up to date as possible.

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Overall Rating

H&F

Improvements for case co-ordination

and pathway communication back to

primary Care needed.

RBKC/WL

Improvement in service co-

ordination/Integration required with

workforce requirements and WSIC

alignment

WCC/CLSignificant integration & workforce

requirements and alignment to WSIC.

Appendix E: Detailed Gap Analysis

The analysis below compares the current position (as of July 14) within each CIS service to the position specified in the description below of the key elements in the 2015/16 specification.

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Gap Analysis

Description - specification to 15/16

(RS/EY) Borough

Service (functions)

Staff Funding Contracts

Rapid Response

A multi-professional (medical, nursing and ASC) Rapid Response service, operating 8am to 8pm 7 days a week, that can provide face to face assessment at home within 2 hours of referral, support up to 5 days following referral and provide referrals to ongoing support. Includes specialist falls input.

LBHF

Significant Investment already made to the service to enable core attributes £1.5m for 14/15

GP commencing Aug 2014, Geriatricians in place

Additional Funding required to sustain 14/15 base spec with some additional required

S113 in place

RBKC/WL

2 hour response isn't at optimum Specialist falls needs development Access to ASC staff is limited

1.26 WTE GPs in place since Dec 13. Access to geriatrician being established

Additional Funding required to sustain 14/15 base spec with some additional required

Non Integrated - but MOU's can be established

WCC/ CL 2hr response not in place

GP and geriatrician coverage required

Significant Funding required to bring to a base spec

Non Integrated

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Gap Analysis


(RS/EY) Borough

Service (functions)


In Reach

An integrated case finding and in reach service, operating 8am to 8pm 7 days a week, with a presence in A&E, links to the wider urgent care system, community beds, care homes urgent care and out of hours services (including NHS 111). Provides proportionate assessment and referrals to ongoing support.

LBHF

Hammersmith arrangements need to be revised

Staff reconfiguration for 15/16

Recurrent funding needs to be agreed

Confirmed as recurrent funding 2014/15 onwards

RBKC Confirm links to wider care system

Access to medical coverage



WCC Operational 5 days

Investment required



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Gap Analysis


(RS/EY) Borough

Service (functions)


Non-bedded IC/Rehab

A delivery team, working as part of an integrated CIS (medical and social care), operating 8am to 8pm 7 days a week, that provides time-bound rehabilitation (therapies) for referrals via the SPoR service by treating people with non-complex conditions in a community setting with the aim of goal attainment. Responds to all referrals within 24 hours and commencement of care within 72 hours.

LBHF 8-8 and 7 days?

Average response time (commence-ment of care) 4.9 days

Joint CCG/LA & Multiple Provider

Continued MOU-transition approach required

RBKC

Further integration required Referrals via SPoR?

Average response time (commence-ment of care) 6 days

Multiple Provider

Section 113 pending sign off (March 14)

WCC Includes falls prevention

Average response time (commence-ment of care) 6.6 days

Multiple Provider

Further integration required. CLCH and WCC staff collocated -collaborative working. Reablement home care staff separate.

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Gap Analysis


(RS/EY) Borough

Service (functions)


Reablement

A delivery team, working as part of an integrated CIS (medical and social care), that provides reablement services for referrals via the SPoR for people for up to 12 weeks (as required). Responds to all referrals within 24 hours and commencement of care within 72 hours. Includes specialist falls input within CIS timeframe (6-12 weeks). Where longer term care is required, includes links to additional reablement services including assistive technology provision such as telecare.

LBHF

8-8 and 7 days can be implemented if activity improves - investment then required. Specialist falls needed.

Formal Integrated arrangements in place with co-located team

Recurrently Funded

Transition agreement needed

RBKC

Colocation and collaborative working. Further integration required

Colocation and collaborative working. Further integration required

Improvements required in response-allocation for reablement

Section 113 pending sign off (March 14)

WCC

Reablement home care delivery outsourced

Reablement care delivery team not collocated with CLCH or WCC CIS staff

Use of spot-purchasing to enable adequate response. Overspend implications with ASC

Allied contract expires May 15. LA considering options

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Appendix F: LOS reduction by CCG

HFCCG in reach LOS Reduction 2015/16 2016/17 2017/18 2018/19


Reduction in Bed Days 391.07 529.42 610.03 612.82

Total Saving (£) £69,055.90 £93,486.51 £107,721.29 £108,213.84

WLCCG in reach LOS Reduction 2015/16 2016/17 2017/18 2018/19


Reduction in Bed Days 254.26 438.26 593.08 688.92

Total Saving (£) £46,573.70 £80,277.62 £108,635.21 £126,189.91

CLCCG in reach LOS Reduction 2015/16 2016/17 2017/18 2018/19


Total Days Saved 273.33 473.07 551.27 537.42

Total Saving (£) £52,431.49 £90,747.91 £105,748.75 £103,091.46

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Appendix G: List of acronyms

Acronym Full Name

A&E Accident and Emergency

ACS Acute Coronary Syndrome

AIA Advice, Information and Assessment

ASC Adult Social Care

BCF Better Care Fund

CCG Clinical Commissioning Group

CIA Community Independence Assistant

CHC Continuing Healthcare

CIS Community Independence Service

CJ Customer Journey

CLCCG Central London Clinical Commissioning Group

CLCH Central London Community Healthcare (NHS Trust)

CNWL Central and North West London (NHS Foundation Trust)

CSU Commissioning Support Unit

CWLHHE Central London, West London, Hammersmith & Fulham, Hounslow and Ealing

(Clinical Commissioning Groups)

DToC Delayed Transfers of Care

ECG Echocardiogram

FACS Fair Access to Care Services

FTE Full Time Equivalent

FY Financial Year

GCC Greenwich Co-ordinated Care

GP General Practitioner

GSTT Guy’s and St Thomas’ Hospital (NHS Foundation Trust)

HFCCG Hammersmith and Fulham Clinical Commissioning Group

HSC/H&SC Health and Social Care

HSCC Health and Social Care Community

HSCIP Health and Social Care Integration Programme

IC Intermediate Care

ICD International Statistical Classification of Diseases and Related Health Problems

IG Information Governance

IMP Intermediate Mental Health and Physical Care team

JET Joint Executive Team

KPI Key Performance Indicator

LA Local Authority

LBHF London Borough of Hammersmith and Fulham

LCW London Central and West (urgent care centre)

LoS Length of Stay

LTC Long-Term Condition

MAU Medical Assessments Unit

MDT Multidisciplinary Team(s)

MH Mental Health

MHP Mental Health Programme

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MoU Memorandum of Understanding

NEL Non-Elective Admission(s)

NHS National Health Service

NHSE National Health Service England

NWL Northwest London

OBC Outline Business Case

OOH Out of Hospital

OPRAC Older People’s Rapid Access Clinic

OT Occupational Therapist/Occupational Therapy

PC Primary Care

PMO Project Management Office

RBKC Royal Borough of Kensington and Chelsea

RR Rapid Response

SPoR Single Point of Referral

STARRS

(Brent)

Short-Term Assessment, Rehabilitation and Reablement Service

TBC To Be Confirmed

UCLH University College London Hospital

VW Virtual Ward

WCC Westminster City Council

WLCCG West London Clinical Commissioning Group

WLMHT West London Mental Health Trust

WSIC Whole Systems Integrated Care

WTE Whole Time Equivalent

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