Item 7 - Appx 2 - Calderdale - Better Care Fund Submission - Part 1

8/12/2019 Item 7 - Appx 2 - Calderdale - Better Care Fund Submission - Part 1

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Calderdale Better Care

FundPlanning Template 1 (First Cut Submission)

Sets out our shared Health and Well Beingcommissioning intentions to deliver integrated health andsocial care which will reduce health inequalities, and atscale and pace extend people exercise choice andcontrol over their health and self-manage their care andsupport needs.

Debbie Graham, Head Service Improvement Calderdale CCG

Elaine James, Commissioning & Strategy Manager, Adult,Health & Social Care, CMBC

2/2/2014


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Better Care Fund planning template Part 1

Please note, there are two parts to the template. Part 2 is in Excel and contains metricsand finance. Both parts must be completed as part of your Better Care Fund Submission.

Plans are to be submitted to the relevant NHS England Area Team and Localgovernment representative, as well as copied to:[email protected]

To find your relevant Area Team and local government representative, and for additionalsupport, guidance and contact details, please see the Better Care Fund pages on theNHS England or LGA websites.
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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1) PLAN DETAILS

a) Summary of Plan

Local Authority Calderdale Council

Clinical Commissioning GroupsNHS Calderdale Clinical CommissioningGroup

Boundary DifferencesThe Local Authority and the CCG havecoterminous boundaries.

Date agreed at Health and Well-BeingBoard:

11/02/2014

Date submitted: 12/02/2014

Minimum required value of BCFpooled budget: 2014/15

4,062,000

2015/16 15,449,000

Total agreed value of pooled budget:2014/15

4,062,000

2015/16 15,449,000

b) Authorisation and signoff

Signed on behalf of the ClinicalCommissioning Group

NHS Calderdale Clinical CommissioningGroup

By

Matt Walsh

Position Chief Officer

Date 11/02/2014

Signed on behalf of the Council Calderdale Council

By

Position Director Adults, Health & Social Care

Date 11/02/2014

Signed on behalf of the Health andWellbeing Board Chair

By Chair of Health and Wellbeing Board

Date 11/02/2014


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c) Service provider engagementPlease describe how health and social care providers have been involved in thedevelopment of this plan, and the extent to which they are party to it

Since the Autumn of 2011 seven health and social care partner agencies: the local healthcare provider organisations, CCGs and local Councils, have each been developing theirresponse to the challenges facing the health and social care economy in Calderdale andthe Greater Huddersfield area. The partnership has formed through collaboration onthe part of local commissioning agencies and health provider agencies:

Calderdale Council

Calderdale Clinical Commissioning Group (CCG)

Kirklees Council

Locala Community Partnerships

South West Yorkshire Partnership NHS Foundation Trust

Greater Huddersfield Clinical Commissioning Group

Calderdale & Huddersfield NHS Foundation Trust

The partners have agreed to undertake a shared strategic transformation programme todevelop ways of working together to deliver service improvements while achievingfinancial sustainability. The shared objective is to secure the right support, at the righttime in the right place while providing the best possible outcomes through integrating thetotal resource for health, social care and welfare around the individualperson-centredintegration. This Plan has been designed to build on the outcomes from the StrategicReview Process and take forward the model of person-centred integration which isemerging as a local priority in response to:

The strategic case for change which identified increased demand, a challengingfinancial situation, a need to safeguard (and in some case improve) quality of care;and to improve patient pathways through the whole health and social care system.

On current projections, the programme is aiming to achieve savings of over 80Macross the whole health and social care system

The vision (and benefits framework) required to reflect the financial reality and thescale of change required (i.e. creating a fully integrated response to the case forchange)

To develop options for reconfiguration of hospital based care that reflect thefinancial reality (as acute accounts for 49% of CCG spend)realistically thisincludes some challenging debates around what is possible in the current situation

and recognising the whole system impact this will have on all aspects of thepatient pathway

Potential change of that scale in acute services will also require a shift inresources in primary and secondary care to the areas where the spending can beshown to have most impact in reducing demand in other parts of the system (e.g.public and community based health and social care which systematically identifiesand targets interventions to prevent and avoid the need for hospital or acute carehome admissions.

Further consultation has been taken on the detail of the Plan with HealthwatchCalderdale, housing, voluntary and other civic society sector Local Infrastructure

Organisations through the Health & Well Being Board to ensure that they are engagedwith and contributing towards shaping our future plans. The detail of our consultationactivity is described in our Better Care Engagement Calendar.


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d) Patient, service user and public engagementPlease describe how patients, service users and the public have been involved in thedevelopment of this plan, and the extent to which they are party to it

The Plan responds to local voices of patients and service users who have been heardthrough two major communications and engagement processes which took place in thelast 12 months. The Strategic Services Review has secured consultation feedback from2000 local people who have provided feedback on the health and social care system whosaid that:

Early and effective diagnosis and intervention is really important

Care needs to be effectively planned and co-ordinated care across organisationalboundaries

Support needs to timely, consistent and available when people need it

People value effective communication

Continuity of care, staff and services is a priority and people would like services to

be delivered closer to home People think better use can be made of technology

A single access point to different services can be really helpful

People want to be involved in decisions about their individual care and treatmentand any decisions about how services should be planned

Between June and December 2013 a further 800 people who receive social care supportto enable them to remain independent and safe within their home were visited to askthem how they wanted us to improve the arrangements to meet their support needs.They told us they wanted safer services where their capacity was recognised and theirdignity respected and that:

There is currently too much focus on time and task in the delivery of careand support: Services are orientated around the delivery of a specific task withina specific amount of time rather than on meeting the outcomes Individuals want forthemselves.

There is a need for greater flexibility: The time, duration and requirements forevery visit are agreed and documented when the package of care begins. Allparties are expected to stick to the information, which is rarely reviewed orchanged. This creates a double problem of information that may not reflect thecurrent needs of the Individual and a system that does little to encourage or create

flexibility. There is a need for stronger focus on quality:It is very difficult to work closely

with all current Providers working in Calderdale and build up a picture of thequality of their services and how they could be improved. Therefore, the focus ofquality and performance contract management by commissioners tends to be onthe few Providers where things have gone wrong, not on the many Providers thatare good but could be even better. Partners needs to work in a way that helpsimprove quality, and build a culture of striving for excellence, amongst allProviders.

There is a need for greater emphasis on reablement outcomes:There iscurrently no focus on reablement in the delivery of care and support at home.

There is no incentive or encouragement for Providers to work with Individuals in away that will reduce their level of dependence on home care services.

Providers and commissioners need to work together to secure a more diverse


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talent pool of care workers who are employed on better terms and conditions andas a result deliver better care. Some Providers employ care workers on contractsthat do not offer the rights that most people in employment receive as a minimume.g. staff are not paid for the time they are travelling between individuals and areon a contract that offer no guaranteed hours of work / pay (zero hour contracts).Care workers spend a large amount of time travelling between home visits due tothe geography of Calderdale. This leads to higher costs, greater risk of delays,greater traffic congestion and environmental harm. This could be addressed ifproviders were connected to the local community and recruit local staff to workwith Individuals within their locality.


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e) Related documentationPlease include information/links to any related documents such as the full project plan forthe scheme, and documents related to each national condition.

Document or information title Synopsis and links

Calderdale Health & Well BeingBoard (2013). Calderdales JointWell Being Strategy 2012-2022

The Well Being Strategy sets out the priorities andactions which the Health & Well Being Board areplanning to carry out in the period 2012 - 2022 inCalderdale.

http://calderdaleforward.org.uk/calderdale-wellbeing-strategy/

Calderdale Joint Strategic NeedsAssessment

Joint local authority and CCG assessments of thehealth needs of a local population in order toimprove the physical and mental health and well-being of individuals and communities in Calderdale.

http://www.calderdalejsna.org.uk/homeNHS Calderdale ClinicalCommissioning Group (2013).Commissioning Prospectus 2013-14

Sets out the commissioning intentions for healthservices in Calderdale and the long term strategy toreduce health inequalities. The Prospectus will beupdated in March 2014 following a refresh of theCCGs priorities for 2013/14 -2017/18

http://www.calderdaleccg.nhs.uk/wp-content/uploads/2013/03/NHS-Calderdale-Clinical-Commissioning-Group-Prospectus-2013-14-v5.pdf

Calderdale Council (2013). Adult

Social Care: Meeting the FutureNeeds of People in Calderdale

Sets out the strategy for increasing the extent to

which people with social care needs have choiceand control over their lives whilst ensuring that we aremeeting our responsibility to safeguard vulnerablepeople in our communities.

http://www.calderdale.gov.uk/socialcare/social-services/care-vision/index.html

Calderdale Council (2014). DraftBusiness & Economy Strategy20142020

The Business & Economy Strategy sets out the longterm priorities and actions which the Council willfacilitate into order to secure economically vibrant andfinancially resilient communities in Calderdale.

http://www.calderdale.gov.uk/business/Draft-Business-and-Economy-Strategy-2014-2020.pdf

Calderdale Council (2011).Strategic Housing MarketAssessment and EconomicViability Assessment

Examines how the housing market operates inCalderdale, the performance of sub-markets withinthe district and seeks to define the level of need forboth open market housing and affordable homes.

http://www.calderdale.gov.uk/environment/planning/local-plan/evidence-base/housingmarket-assessment.html

Calderdale & Greater HuddersfieldIntegrated Health & Social CareStrategic Review Draft Information

Sets out the direction for Information Technologyacross health and social care partners, describestechnical architecture across health and social care,
http://calderdaleforward.org.uk/calderdale-wellbeing-strategy/http://calderdaleforward.org.uk/calderdale-wellbeing-strategy/http://calderdaleforward.org.uk/calderdale-wellbeing-strategy/http://www.calderdalejsna.org.uk/homehttp://www.calderdalejsna.org.uk/homehttp://www.calderdaleccg.nhs.uk/wp-content/uploads/2013/03/NHS-Calderdale-Clinical-Commissioning-Group-Prospectus-2013-14-v5.pdfhttp://www.calderdaleccg.nhs.uk/wp-content/uploads/2013/03/NHS-Calderdale-Clinical-Commissioning-Group-Prospectus-2013-14-v5.pdfhttp://www.calderdaleccg.nhs.uk/wp-content/uploads/2013/03/NHS-Calderdale-Clinical-Commissioning-Group-Prospectus-2013-14-v5.pdfhttp://www.calderdaleccg.nhs.uk/wp-content/uploads/2013/03/NHS-Calderdale-Clinical-Commissioning-Group-Prospectus-2013-14-v5.pdfhttp://www.calderdale.gov.uk/socialcare/social-services/care-vision/index.htmlhttp://www.calderdale.gov.uk/socialcare/social-services/care-vision/index.htmlhttp://www.calderdale.gov.uk/socialcare/social-services/care-vision/index.htmlhttp://www.calderdale.gov.uk/business/Draft-Business-and-Economy-Strategy-2014-2020.pdfhttp://www.calderdale.gov.uk/business/Draft-Business-and-Economy-Strategy-2014-2020.pdfhttp://www.calderdale.gov.uk/business/Draft-Business-and-Economy-Strategy-2014-2020.pdfhttp://www.calderdale.gov.uk/environment/planning/local-plan/evidence-base/housingmarket-assessment.htmlhttp://www.calderdale.gov.uk/environment/planning/local-plan/evidence-base/housingmarket-assessment.htmlhttp://www.calderdale.gov.uk/environment/planning/local-plan/evidence-base/housingmarket-assessment.htmlhttp://www.calderdale.gov.uk/environment/planning/local-plan/evidence-base/housingmarket-assessment.htmlhttp://www.calderdale.gov.uk/environment/planning/local-plan/evidence-base/housingmarket-assessment.htmlhttp://www.calderdale.gov.uk/environment/planning/local-plan/evidence-base/housingmarket-assessment.htmlhttp://www.calderdale.gov.uk/environment/planning/local-plan/evidence-base/housingmarket-assessment.htmlhttp://www.calderdale.gov.uk/business/Draft-Business-and-Economy-Strategy-2014-2020.pdfhttp://www.calderdale.gov.uk/business/Draft-Business-and-Economy-Strategy-2014-2020.pdfhttp://www.calderdale.gov.uk/socialcare/social-services/care-vision/index.htmlhttp://www.calderdale.gov.uk/socialcare/social-services/care-vision/index.htmlhttp://www.calderdaleccg.nhs.uk/wp-content/uploads/2013/03/NHS-Calderdale-Clinical-Commissioning-Group-Prospectus-2013-14-v5.pdfhttp://www.calderdaleccg.nhs.uk/wp-content/uploads/2013/03/NHS-Calderdale-Clinical-Commissioning-Group-Prospectus-2013-14-v5.pdfhttp://www.calderdaleccg.nhs.uk/wp-content/uploads/2013/03/NHS-Calderdale-Clinical-Commissioning-Group-Prospectus-2013-14-v5.pdfhttp://www.calderdalejsna.org.uk/homehttp://calderdaleforward.org.uk/calderdale-wellbeing-strategy/http://calderdaleforward.org.uk/calderdale-wellbeing-strategy/


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Technology Strategy the projects to be delivered to enable integrationand coordination of care and the process by whichchanges will be implemented.

Individual CCG QIPP Plans andLocal Authority Budget SavingsProgramme Plans

Detailed plans by Calderdale CCG and the Councilfor the funding and delivery of services andassociated efficiency targets for 2014/15 and2015/16.


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2) VISION AND SCHEMES

a) Vision for health and care servicesPlease describe the vision for health and social care services for this community for2018/19.

What changes will have been delivered in the pattern and configuration of servicesover the next five years?

What difference will this make to patient and service user outcomes?

In response to the views of local people we have adopted the ambition below forIntegrated Health & Social Care Services:

Better Lives, Imp roving Health. Working Together for Effect ive Support .

As a partnership we want to improve the health, well-being and safety of all ourcommunities by supporting people to be independent. We will do this by having the rightpeople deliver the right care, in the right place at the right time.

To do this we need to change the way we coordinate arrangements to secure thefollowing 5 outcomes for people:

1. People can easily access the right information and guidance so that they canmake informed choices for themselves and their family

2. People are able to tell their story once and are then supported to make positivechoices to manage their own health and that of their family

3. Wherever possible good quality and personalised care will be delivered close tohome to help people stay as safe, well and as healthy as possible, for as long aspossible

4. Every child will have a healthy start and continue to lead a safe, happy life withevery opportunity to achieve their potential within their families and communities

5. High quality, safe, specialist care will be available when people and their familyneed it.

Building on the Strategic Services Review outcomes we have committed to workingtogether to deliver the following three key improvements to meet our outcomes:

1. Identifying who would benefit from person-centred, coordinated care andsupportthrough: Use of risk stratification tools in General Practice to identify in

advance patients requiring support to avoid crisis. Use of interdisciplinary SinglePoints of Access to allow professionals, individuals and carers access to the rightcare and support when their health and wellbeing is deteriorating.

2. Developing workforce capacity and capabilityto deliver person-centred andcoordinated assessment and reviews which respect autonomy and promote self-care: Embed a quality improvement culture across the whole health and socialcare system based on personas which describe the individuals journey.

3. Coordinating care and support around recognised communities whichinclude General Practices to further build resilience in communities andindividuals, preventing unplanned crisis: Establishing locality health and socialcare teams, coordinated around General Practices, which integrate care and

support whilst respecting professional support lines back to a vibrant and diversehealth and social care economy and which draws on specialist expertise asneeded to meet differentiated personal needs.


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For Maureen, Andrew and Amalawho are Calderdale residents being supported by arange of local health and social care providers today, but who have been identified asbeing at high risk of losing their independenceour focus is on helping them to managetheir physical or mental health conditions, and enabling them to live safe, well andcomfortably in their own homes and communities for as long as possible.

This means in practice that from 2015/16 we will work towards the following Vision:

The care I receive is designed by and around me: Maureen and Amala have anamed GP and someone from the surgery co-ordinates all the different serviceswithin their coordinated Support Plan. A single care record which they can accessand control is used by the clinicians, other professional workers and the peopleproviding their support, to ensure they only ever have to tell their story once. Theyknow they will have continuity of care and support, seven days a week, even ifthey need to go into hospital for a short spell.

I am able to maintain control over my health conditions: Maureen, Andrewand Amala each have a single care plan and have been provided with simpledevices and support that allow all three of them to self-manage their conditions ona daily basis. With clearer information and advice, and knowing that professionalsupport is there if they need it through a single phone call to Gateway to Care whoknow them and their history, they feel in control of their lives.

I feel part of my community: Amala is part of the Shared lives scheme inCalderdale and she regularly visits with her adopted family who share her culturalbackground and enjoy spending time together. Maureen and Andrew are linkedinto local voluntary schemes for older people and adults with disabilities, whichallow sharing of experiences and for mutual support.

I have systems in place to help get early help to avoid a crisis: Whencircumstances change, Maureen, Andrew and Amala are contacted by theirGeneral Practice to arrange for someone re-assess their needs. The personcoordinating their care is proactive in ensuring that support is available to themwithin their home and community when they experience difficult times.

My neighbours are willing and able to help me: Local community organisationsare able to provide lifts to take Maureen and Andrew shopping once a week andensure that they were accompanied to get back and forth for hospital and GPappointments. Local shops and other community-based services play their part inhelping to ensure that they are able to live healthy, well lives in their own homes.Amala goes bowling and to the cinema with her friend she first met at school. Sheuses her Personal Budget to cover the expenses for these activities.

My well-being and independence is respected: When Maureen fell andfractured her hip, the locality Support & Independence Team (a health and socialcare team including Community Nurses, Reablement Assistants, TrustedAssessors, Physiotherapists and Occupational Therapists) provided bothpreventative care and planned support to Maureen before and after her hospitalstay, all helping her quickly to get back on her feet. Her GP was involved evenwhilst she was in hospital, supporting Maureens ongoing careand ultimatedischarge back home to her network of support from her family and friends.

I live safely where I want to live: Following a road traffic accident Andrew

recovered and rebuilt his confidence to live independently in the HeatherstonesSupported Care Scheme. Whilst temporarily living there he came to terms withthe outcomes from his holistic, environmental assessment which showed he would


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no longer be able to manage in his home. Andrew was supported to find a newhome which was fully adapted to meet his needs, close to his good friend and withaccessible routes to shops and sports facilities so he could continue with hisprogramme of rehabilitation and recovery.My care and support helps me live the life I want: Maureen, Andrew and Amalahave set up a Personal Budget which pools together money from health and socialcare into a dedicated care account held by a bank and accessed through a pre-payment card. They have a support planner from a local community organisationwho help them make good use of their care account to live happy, productive andsafe lives which maintains their well-being and health.

As a result of these changes, Maureen, Andrew and Amala, their friends and familyfeel confident in the care they are receiving in their home and communities. Theirconditions are better managed and their attendances and reliance on acute services,including their local A&E departments, are significantly reduced. If they do require a stayin hospital then they are helped to regain their independence and are appropriately

discharged as soon as they are ready to leave, with continuity of care before, during andafter the admission. They routinely report that they feel in control of their care, informedand included in decision-making, are supported in joined-up way, and are empoweredand enabled to live well.

Overall pressures on our hospitals and health budgets have reduced, as we shift fromhigh-cost reactive to lower cost preventative services, supporting greater self-management and community based care; and our social service budgets are goingfurther, as new joint commissioning arrangements deliver better value and improved careat home reduces the need for high-cost nursing and care home placements.

People will be empowered to direct their care and support, and to receive the carethey need in their homes or local community.

Over the next five years community health care, primary care and social care teams willwork together in an increasingly integrated way, with single assessments for health andsocial care and rapid and effective joint responses to identified needs, provided in andaround the home. Our teams will work with the voluntary and community sector toensure those not yet experiencing acute need, but requiring support, are helped toremain healthy, independent and well. We will invest in empowering local people throughsystematic identification of those at risk of poor outcomes, targeting public healthinterventions to improve well-being and combat loneliness and social isolation. Through

our Single Point of Access we will effectively connect with General Practices, buildingpeer and carer networks which develop the roles of mentors who are able to act asexperts by experience. Our Single Point of Access will help others who are needing toarrange care and support for the first time and we will optimise the use of assistivetechnologies to enable people to maintain control of their health conditions through self-management.

At the centre of our arrangements to access care and support will be our single point ofaccess, Gateway to Care, which will coordinate access to our integrated Support andIndependence teams providing a rapid response to support individuals in crisis and helpthem to remain at home. Support and Independence will also work with individuals within

their own home or with our national exemplar Supported Intermediate CareHeatherstones rehabilitation and reablement scheme who have lost their independencethrough illness or accident and support them to build confidence, regain skills and, with


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appropriate information and support, to self-manage their health conditions andmedication. All individuals who access Support and Independence will also be navigatedthrough Gateway to Care towards considering the potential of assistive technologies and,where these are to be employed, will ensure individuals are familiarised and comfortablewith their use.

Underpinning all of these developments, the BCF will enable us to start to release healthfunding to extend the quality and duration of our reablement approach to support peopleat home, coordinated through Gateway to Care, to further developing capacity for holisticenvironmental, well-being and social care assessment which reconnects people to theirnatural networks of support within their community and avoids the need for statutoryhealth and social care assessment. By establishing universally accessible communitybased support provided by a diverse and differentiated network of voluntary and civicsector society organisations we shall target public health interventions towards peoplewho are high risk of the determinants poor health and well-being. Irrespective of socialcare eligibility criteria we will be able to:

Improve our management of demand within both the health and care systems,through earlier and better engagement and intervention;

Work sustainably within our current and future organisational resources, whilst atthe same time expanding the scope and improving the quality of outcomes forindividuals;

In doing so our plan is to go far beyond using BCF funding to back-fill existing social carebudgets, instead working jointly to reduce long-term dependency across the health andcare systems, promote independence and drive improvement in overall health andwellbeing.

Through our Integrated Health & Social Care Strategic Review we will describewhat success in this area will require of, and mean for, our hospitals, with servicesadapting to ensure the highest quality of care is delivered in the most appropriatesetting.

The volume of emergency activity in hospitals will be reduced and the planned careactivity in hospitals will also reduce through alternative community-based services. Amanaged admissions and coordinated discharge process which integrated specialist carenurses with social workers will interface with an integrated discharge holistic supportteam provided through our Support and Independence provision. This will mean we will

eliminate delays in transfers of care, reduce pressures in our A&Es and wards, andensure that people are helped to regain their independence after episodes of ill health asquickly as possible.

We recognise that there is no such thing as integrated care without mental health. Ourplans therefore are designed to ensure that the hospital is able to access rapid mentalassessment and diagnostics and the work of community mental health teams isintegrated with community health services and social care teams; organised aroundgroups of General Practices; and enables mental health specialists to support GeneralPractices and their patients in a similar way to physical health specialists. By improvingthe way we work with people to manage their conditions, we will reduce the demand notjust on acute hospital services, but also the need for nursing and residential care.

Communities will be at the centre of how primary care, including General Practice,


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is organised

Through investing in communities and primary care, we will ensure that patients can gethelp and support in a timely way and via a range of channels, including email andtelephone-based services. The GP will remain accountable for patient care, but withincreasing support from other health and social care staff to co-ordinate and improve thequality of that care and the outcomes for the individuals involved.

We will deliver on the new Primary Medical Services contract provisions, includingnamed GP for patients aged 75 and over. Flexible access to social work assessments tofacilitate hospital discharges will be available over 7 days, accompanied by greatercoordination with General Practice, primary care and mental health assessment and acloser relationship with pharmacy services. Our General Practices will collaborate innetworkswithin a community model that reflects hierarchy of place as experienced andunderstood by local people. Community nursing and social work assessment, care andsupport provider services and pathways into specialist health provision will be organised

to support our General Practice networks. This will ensure effective coordination andnavigation for people with long-term conditions, complex health needs or who are beingsupported for advanced care planning in preparation for end of life.

As a result of all of these changes, some General Practices may have a smaller list sizebut with more complex patients. Elements of their basic care will be delivered by nursepractitioners; and in the acute sector, our specialist clinicians will work increasinglyflexibly, within and outside of the hospital boundaries, supporting GPs to holisticallymanage complex needs in a person centred way.

Our systems will enable, and not hinder, the provision of integrated care. Our providers

will assume joint accountability for achieving a person's outcomes and goals and will berequired to show how this delivers efficiencies across the system.

Our CCG and Social Care commissioners will be commissioning and procuring jointly,focussed on improving outcomes for individuals within our communities.

In partnership with NHS England we are identifying which populations will most benefitfrom coordinated care and support approaches; the outcomes for these populations; thebudgets that will be contributed and the whole care payment that will be made for eachperson requiring care; and the performance management and governance arrangementsto ensure effective delivery of this care.

In order that our systems will enable and not hinder the provision of integrated care, wewill introduce payment systems that improve coordination of care by incentivisingproviders to coordinate with one another. This means ensuring that there is accountabilityfor the outcomes achieved for individuals, rather than just payment for specific activities.It also means encouraging the provision of care in the most appropriate setting, byallowing funding to flow to where it is needed, with targeted public health interventions,investment in primary care and community support.

This means coordinating the full range of public service investments and support acrossthe whole range our Health & Well Being partnership, including not just NHS and adult

social services but also housing, public health, the voluntary, community and privatesectors. As importantly, it means working with people, their carers and families to ensurethat people are enabled to manage their own health and wellbeing insofar as possible,


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and in doing so live healthy and well lives.

In order to track the results, we will leverage investments in data warehousing, includingtotal activity and cost data across health and social care for individuals and wholesegments of our local populations. We are developing the business case to invest ininteroperability between systems, learning from our social care Integration Pioneer,Leeds City Council, who share our social care Client Information System. This willenable us to establish coordinated information and managerial analytics, starting byensuring that General Practice Clinical Systems and Social Care Client InformationSystem is integrated around the NHS number, and individual information shared in anappropriate and timely way.

Our Strategic Review Executive Steering Group is providing advice on the alignment ofdevelopment of our Investment Programme for the Better Care Fund to the wholesystems model of transformation of the health and social care economy. Our Health &Well Being Board provides oversight of the process of developing our plans.

b) Aims and objectivesPlease describe your overall aims and objectives for integrated care and provideinformation on how the fund will secure improved outcomes in health and care in yourarea. Suggested points to cover:

What are the aims and objectives of your integrated system?

How will you measure these aims and objectives?

What measures of health gain will you apply to your population?

Our aim is to provide care and support to people in their own homes and communities,

with services that:

co-ordinate around individuals to target their specific needs, improve outcomes,reducing premature mortality and reducing morbidity;

improve the experience of care, with the right services available in the right placeat the right time;

maximising independence by providing more support at home and in thecommunity, and by empowering people to manage their own health and wellbeing;

through proactive and joined up case management, avoid unnecessaryadmissions to hospitals and care homes, and enable people rapidly to regain their

independence after episodes of ill-health.

There is strong and growing evidence that community-based approaches which ensurethat people have real control over the resources allocated to meet their care and supportneeds can be cost-effective, deliver better outcomes and help to prevent health andsocial care needs arising. From 2014/15 we will be working with our Health and WellBeing partners to:

1. Integrate commissioning for well-being: the partners are committed to workingtogether to change the health and care system by shifting resources towardscoordination of preventative actions which promote wellbeing through early

intervention.2. Integrate person-centred models of community support which include GPs:

to improve efficiency by removing duplication and streamlining management of


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services. Our General Practices will be collaborating in networks within localities.Community, social care services and specialist mental and physical healthservices will be organised to work effectively with these networks, enabling GPs toensure their patients are getting the very best person-centred care. We will deliveron the new provisions of primary medical services contracts, including named GPfor patients aged 75 and over.

3. Make the most of existing capacity and capability: Our community providerswill be implementing new models of service delivery, driven by clinical staff on theground, and coordinated with our broader public health and well-being strategiesto systematically identify and target individuals at high risk of poor outcomes. Thiswill involve a single approach towards holistic environmental, social care andhealth assessment to meeting the needs of individuals in their homes andcommunities, with seamless delivery of housing support, health and carefunctions. We will ensure that social work and specialist nursing care assessmentis fully coordinated and is available seven days a week which will reduce delayedtransfers in care.

4. Digitise the Health and Social Care economy: to support people to liveindependent lives for longer through assistive technologies which underpin acoordinated approach towards self-care and support at home; and usingtechnology to support remote working to enable staff to be more productive andreduce travel times

5. Deliver systemisation of best-in-class: The volume of emergency and plannedcare activity in hospitals, together with the number of residential and nursing careplacements, will be reduced through enhanced preventative and communityindependence functions, and improved support in the community and in the home.

In order to manage and track outcomes, we will leverage investments in data

warehousing, including total activity and cost data across health and social care forindividuals and whole segments of our local populations. We will develop a full businesscase and deliver interoperability between systems to provide both real time informationand managerial analytics learning from our strategic partner and Integration PioneerLeeds City Council.

Through the Strategic Review Digitisation Programme we will implement process to unifyour systems and develop the capacity for care and support delivery partners to use thesame patient record; the BCF will help ensure this happens by joining up Health andSocial Care data across the Borough, linked via the NHS number.

We will guarantee that individual information is shared in an appropriate and timely wayto maximise safeguarding, well-being and user experience; and aggregated to alloweffective identification and management of need and outcomes across our health andcare economy as a whole.

In parallel, we will be investing in developing our infrastructure around understanding theexperience of care, including continuing the process of regular customer satisfactionsurveying across social care for those in receipt of care and support to understand howthey experience those arrangements.


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c) Description of planned changesPlease provide an overview of the schemes and changes covered by your joint workprogramme, including:

The key success factors including an outline of processes, end points and timeframes for delivery

How you will ensure other related activity will align, including the JSNA, JHWS,CCG commissioning plan/s and Local Authority plan/s for social care

We recognise that achieving our vision will mean significant change across the whole ofour current health and care provider landscape. Whilst our General Practices will play apivotal role within this, all providers of health and care services will need to change howthey work, and particularly how they interact with patients and each other. The CCGs andlocal authority commissioners are committed to working together to create a diverse andvibrant marketplace, and effect the required behavioural and attitudinal change in theacute sector, to ensure that this happens at scale and at pace.

Across Calderdale, our process for achieving our vision, as set out in our joint

commissioning intentions means:

Local health and social care commissioners, in partnership with NHS Englandwhere necessary, identifying what populations will most benefit from integratedcommissioning and provision; the outcomes for these populations; the budgetsthat will be contributed and the whole care payment that will be made for eachperson requiring care; the performance management and governancearrangements to ensure effective delivery of this care.

Local health and care providers, and associated public, private and voluntaryand community sector groups, co-designing models of care and support which willdeliver our outcomes; transitioning resources into new, community based

preventative models which target support towards the outcomes required;ensuring governance and organisational arrangements are in place to managethese resources; agreeing the process for managing risks and savings achievedthrough improving outcomes; establishing information flows to support delivery;and ensuring effective alignment of responsibilities and accountability across allthe organisations concerned.

We will use the Better Care Fund to:

Systematically identify people who are at risk of poor well-being, social careand health outcomes and target public health interventions with a remit to beresourceful in connecting them to community based networks of support whichcombat loneliness and social isolation.

Help people self-manage through developing carer and peer supportnetworks, supported by voluntary, community and civic sector societyorganisations, which developing mentoring roles for experts by experience whosupport others arranging their arrange care and support for the first time

We will optimise the use of assistive technologiesto enable people to maintaincontrol of their health conditions through self-management, coordinated through anetwork of extra-care hubs connecting those living with support independently intopersonal and social support delivered close to their home. We shall also

implement the outcomes from our strategic review of the use of technology tosupport front line practitioners, freeing up their professional resources to focus onindividuals in greatest need.


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We will Coordinate Access to Social Care and Intermediate Support throughfurther developing the capacity of our integrated health and social care SinglePoint of Access to support people to remain healthy and well at home.

Invest in Reablementapproaches through our locality based approach toSupport and Independence including launching in 2014 our national exemplarSupported Intermediate Care Assessment Heatherstones rehabilitation andreablement scheme reducing hospital admissions and nursing and residential carecost.

Invest in developing integrated personalised health and social care PersonalBudgetswhich are coordinated around patients and social care services, enablingfrontline professionals to empower people to make informed decisions aroundtheir care and optimise the potential for self-care from community based supportand social prescribing.

Reduce Delayed Dischargesthrough investment in an integrated specialistnursing and social work hospital based assessment which coordinatesunnecessary admissions from A&E, short stay or medical assessment and

complex discharges from hospital and we shall further strengthen seven day socialcare provision in hospitals.

Integrate NHS and social care systemsaround the NHS Number to ensure thatfrontline professionals, and ultimately all patients and service users, have accessto all of the records and information they need.

Our systems will enable and not hinder the provision of integrated care. Our providers willassume joint accountability for achieving a person's outcomes and goals and will berequired to show how this delivers efficiencies across the system.

We are ensuring related activity will align by working in close collaboration with the other

ten Clinical Commissioning Groups across West Yorkshire coordinated by NHS Englandin co-designing approaches. This will deliver transformational change within the acutesector to realise the scale and pace of efficiencies required to implement thistransformational programme to shift the balance of investment into community and widerprimary care. This is designed to ensure that the impact on the acute sector is managedwith minimal turbulence and that providers experience a consistent approach from theirdifferent commissioners with proactive shared learning taking place across boundaries.

Our Strategic Review Executive Steering Group is providing advice on the alignment ofdevelopment of our Investment Programme for the Better Care Fund to the wholesystems model of transformation of the health and social care economy. Our Health &Well Being Board provides oversight of the process of developing our plans.


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d) Implications for the acute sectorSet out the implications of the plan on the delivery of NHS services including clearlyidentifying where any NHS savings will be realised and the risk of the savings not beingrealised. You must clearly quantify the impact on NHS service delivery targets includingin the scenario of the required savings not materialising. The details of this responsemust be developed with the relevant NHS providers.

The Calderdale & Greater Huddersfield Strategic Review is a key vehicle for drivingforward significant and radical transformational change across the system and delivering167m of efficiency savings over next five years. The work is aimed at integrating healthand social care services through the collaboration between its seven partners - to shiftthe balance from unplanned hospital based care to planned community based servicescoordinated around General Practice where appropriate. The seven partners are formallycommitted to this collaboration and the approach to realising system efficiencies whichare critical to system change.

In addition, Calderdale CCG is leading a piece of work which is working in co-production

with communities in Calderdale to develop new models of unplanned community andprimary care support. The aim of the work is to provide a needs-led, community basedresponse to unplanned carewhich shifts the balance of provision from hospital intocommunities. In addition, it is intended that we maximise the opportunities from the newGeneral Practice responsibility aimed at improving the care of people aged 75 plus. Theapproach within Calderdale is to ensure that the 1m fund that has to be created for thispurpose locally will be aligned to ensure it supports the resource shifts required.

The CCGs 2-Year Financial Plan (2013/14-2014/15) sets a strong financial position inwhich the creation of the BCF can take place. Through its prudent approach to financialplanning, and its strong contractual approach with its main provider (CHFT)the CCG is

confident in its ability to create the fundparticularly the 8m additional funding neededin 2015/16without financially destabilising the acute trust. The completion of thecontracting round with CHFT in February will confirm this position. The financial riskassociated with this approach is captured as part of our 2-Year Financial Plan.

We can confirm that CHFT would recognise the content of this section of template andwould be comfortable with the approach outlined.

e) GovernancePlease provide details of the arrangements are in place for oversight and governance for

progress and outcomesAn Integrated Commissioning Operational Group has been formed with representationfrom the Council and the Clinical Commissioning Group to coordinate and progress theactions within the Plan and closely monitor impact on key metrics which are beingreported on quarterly to the Health and Well Being Board. Strategic governance will beprovided through the Calderdale Health and Wellbeing Board which since April 2013 hasfunctioned as a statutory committee of Calderdale Council. The Board operates withmajor contributions by the Local Authority and the Calderdale Clinical CommissioningGroup (CCG).

Although the statutory duty rests with the Local Authority, the Council decided early on totake a partnership approach towards commissioning Healthwatch through the Health andWellbeing Board. Healthwatch acts as the independent consumer champion for thepublic and to promote better outcomes in health for all and in social care for adults. A


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local Healthwatch representative is a standing core member of the Board. Thephilosophy is that people have a right to be involved in decisions that affect their livesand Healthwatch will give equal priority to health and social care issues, only pursueissues that are supported by the evidence and will commission independent researchwhere appropriate.

The Strategic Review Programme governance structure provides the infrastructure forthe seven partner organisations to make collective decisions and drive progress at thesame time as the national health system architecture undergoes substantial change andinform the Health and Well Being Board of the potential impact of changes.

The CCGs Finance and Performance Committee has confirmed its approval to proceedwith submission and has reviewed the content of this submission, in advance of formalsign off at the CCGs Governing Body in March, prior to a refreshed submission in April2014.

3) NATIONAL CONDITIONS

a) Protecting social care servicesPlease outline your agreed local definition of protecting adult social care services.

Yes the eligibility criteria will remain the same.

Please explain how local social care services will be protected within your plans.Protecting social care services in the Borough means ensuring that those in need withinour local communities continue to receive the support they require, in a time of growingdemand and budgetary pressures. Whilst maintaining current eligibility criteria is oneaspect of this, our primary focus is on developing new forms of person centred,coordinated support which help ensure that individuals remain healthy and well, and havemaximum independence, with benefits to both themselves and their communities, andthe local health and care economy as a whole. By proactively intervening to supportpeople at the earliest opportunity and ensuring that they resilient, resourceful, areengaged in the management of their own wellbeing, and wherever possible enabled tostay within their own homes, our focus is on protecting and enhancing the quality of care

by tackling the causes of ill-health and poor quality of life, rather than simply focussing onthe supply of services.

Calderdale Council has maintained eligibility under Fair Access to Care Services (DH2010 Prioritising Need in the Context of Putting People First). In anticipation of theintroduction under the Care Bill (2013) of a national eligibility threshold and enhancedstatutory responsibilities relating to implementing the Dilnot recommendations, the localPlan aims to prioritise resources towards delivering care closer to home and significantlyreducing the numbers of people who are avoidably placed into residential care settings.Investment in the capacity for professional social work and income optimisation supportfor self-funders will need to be increased, within the funding allocations for 2014/15 andbeyond to maintain eligibility levels, to deliver seven day assessment to facilitate hospitaldischarge and in particular as the Care Bill introduces eligibility entitlements for carersand self-funders in residential and nursing care homes.


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b) 7 day services to support dischargePlease provide evidence of strategic commitment to providing seven-day health andsocial care services across the local health economy at a joint leadership level (JointHealth and Wellbeing Strategy). Please describe your agreed local plans forimplementing seven day services in health and social care to support patients beingdischarged and prevent unnecessary admissions at weekends.

Calderdale Council has continually provided seven-day working for social care for 13years through provision of qualified social workers who are able to assess for eligibility,restart and authorise packages of care. As of November 2013 this strategic commitmenthas been further extended to full 364 days of a year qualified social worker cover (onlyexception being Christmas Day). The hospital social work team has extended weekendcover to operate from 9am - 5pm on Saturday and Sunday, backed up by Out of Hourscover from the Emergency Duty Team who are qualified staff with enhanced PostQualifying awards. A full management cover rota operates every day of the year to

support decision making through the agreed processes within the Surge and EscalationPlan.

c) Data sharingPlease confirm that you are using the NHS Number as the primary identifier forcorrespondence across all health and care services.

Health services in Calderdale use the NHS number as the primary identifier incorrespondence. The NHS Number is used by Gateway to Care as the primary identifierfor all new cases being referred for support from the integrated health and social careintermediate tier of services. There are plans in place through the Digitisation StrandInformation Technology Strategy of the Health & Social Strategic Review to extend use of

the NHS Number to all social work referrals.

If you are not currently using the NHS Number as primary identifier for correspondenceplease confirm your commitment that this will be in place and when by

Use of the NHS number will be fully enabled across social care through investment in theinfrastructure as detailed in this Spending Plan by April 2015.

Please confirm that you are committed to adopting systems that are based upon OpenAPIs (Application Programming Interface) and Open Standards (i.e. secure emailstandards, interoperability standards (ITK))

Yes we are committed to adopting systems that are based upon Open APIs and OpenStandards (i.e. secure email standards, interoperability standards (ITK)).

We are committed to adopting systems based upon Open APIs and Open Standards. Wealready use:

System One, a clinical computer system that allows service users and clinicians toview information and add data to their records;

Emis Web, a tool that allows primary, secondary and community healthcare

practitioners to view and contribute to a service users cradle to grave healthcarerecord;

CIS, a software solution to provide a range of services and content to social care,


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while allowing the involvement of health care partners.

To enable cross-boundary working, we will improve interfaces between systems. Further,we are creating an innovation hub between commissioning agencies which will aggregatedata from different sources. This will improve data quality by identifying gaps orinconsistent records and provide for more evidenced based interventions.

Whilst not all our General Practices will all be using the same clinical IT system, throughthe Digitisation Strand of the Strategic Review we are seeking to provide the opportunityfor our care providers to all use the same patient record; the BCF will help ensure thishappens by joining up Health and Social Care data across the Borough, linked as abovevia the NHS number.

Please confirm that you are committed to ensuring that the appropriate IG Controls willbe in place. These will need to cover NHS Standard Contract requirements, IG Toolkit

requirements, professional clinical practise and in particular requirements set out inCaldicott 2.

Our overall aim for Information governance - as set out in the Health & Social CareStrategic Review Draft IT Strategy for the Strategic Review is 'We will provide reliableinformation at the point of need; where individuals understand the importance of usingcorrectly, sharing it lawfully and protecting it from improper use'.

All of our changes will take place within our Information Governance framework, and weare committed to maintaining five rules in health and social care to ensure than patientand service user confidentiality is maintained. The rules are:

Confidential information about service users or patients should be treatedconfidentially and respectfully

Members of a care team should share confidential information when it is neededfor the safe and effective care of an individual

Information that is shared for the benefit of the community should be anonymised

An individuals right to object to the sharing of confidential information about themshould be respected

Organisations should put policies, procedures and systems in place to ensure theconfidentiality rules are followed

d) Joint assessment and accountable lead professionalPlease confirm that local people at high risk of hospital admission have an agreedaccountable lead professional and that health and social care use a joint process toassess risk, plan care and allocate a lead professional. Please specify what proportion ofthe adult population are identified as at high risk of hospital admission, what approach torisk stratification you have used to identify them, and what proportion of individuals at riskhave a joint care plan and accountable professional.

Calderdale is implementing profiling of people at risk of poor social care outcomes andrisk stratification in General Practice. Through the Better Care Fund we will invest in thecapacity to target and proactively review on a multi-disciplinary basis individuals identified

through these processes, followed by implementation of case management whereappropriate.


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Our integrated plan envisions GPs taking a lead in coordinating care as the agreedaccountable lead professionals for people at high risk of hospital admission.We intended to maximise the opportunities from the newly created General Practiceresponsibility aimed at improving the care of people aged 75 plus. The approach withinCalderdale is to ensure that the 1m fund that has to be created for this purpose locallywill be aligned to ensure it supports delivery of the BCF model and outcomes.

We have identified segments of our population based on risk. We classify people asbeing at high risk if they have (a) CVD including stroke; (b) diabetes; (c) chronicobstruction pulmonary disorder (COPD); (d) dementia (CHD); (e) cancer; or (f)musculoskeletal.

4. RISKSPlease provide details of the most important risks and your plans to mitigate them. This

should include risks associated with the impact on NHS service providers

Risk Riskrating

Mitigating Actions

1. Shifting of resources tofund new jointinterventions and schemeswill destabilise currentservice providers,particularly in the acutesector.

Medium a) Our current plans are based onthe agreed strategy for Calderdale& Greater Huddersfield as agreedin the Strategic Reviewprogramme which includes all 7health & social care agencies inthe locality.

b) The development of our plans for2014/15 and 2015/16 will beconducted within the framework ofour Strategic Review programme,allowing for a holistic view ofimpact across the providerlandscape and putting co-designof the end point and transition atthe heart of this process.

2. A lack of detailed baselinedata and the need to relyon current assumptionsmeans that our financialand performance targetsfor 2015/16 onwards areunachievable.

Medium a) The Strategic Review programmeis undertaking a detailed mappingand consolidation of opportunitiesand costs benefits analysis whichwill be used to validate our plans.

b) We are investing specifically inareas such as service usersatisfaction surveying and datamanagement to ensure that wehave up-to-date informationaround which we will adapt andtailor our plans throughout thenext 2 years.


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3. The NHS Number is notable to be fullyimplemented across allhealth and social carepartners from April 2015.

Medium a) The Strategic ReviewDigitisation work stream hassign up from all partners toimplement the Draft ITStrategy.

b) The Calderdale Council socialcare Client Information Systemis shared with Leeds CityCouncil who are an IntegrationPioneer. Through ProjectHandshake all learning isbeing shared between LocalAuthorities in relation to healthand social care IT systems

integration and the solutionwhich Leeds City Council arecurrently implementing with theCCGs for correlation andsynchronization of recordsbetween General Practice andSocial Care.

4. Calderdale CCG QIPPand Local Authorityefficiency plans fail to

realise the levels ofsavings required toestablish the fund.

High a) Our 2014/15 QIPP and SavingsProgrammes have been carefullyplanned to meet the level of

savings required to releasefunding flows.

b) We have established an integratedcommissioning team withescalation to our Health & WellBeing Board which will drivethrough implementation of theBetter Care Fund and ourtransformational reinvestmentprogramme which will receive

monthly updates on the progressof providers in meeting agreedefficiency targets.

5. Operational pressures willrestrict the ability of ourworkforce to deliver therequired investment andassociated projects tomake the vision of careoutlined in our BCFsubmission a reality.

High c) Our 2014/15 schemes includespecific non-recurrent investmentsin the infrastructure and capacityto support overall organisationaldevelopment

6. Improvements in the High a) We have modelled our


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quality of care and inpreventative services willfail to translate into therequired reductions inacute and nursing / carehome activity by 2015/16,impacting the overallfunding available tosupport core services andfuture schemes.

assumptions using a range ofavailable data, including metricsfrom other sources such as theWest Yorkshire 10CCGcollaborative and the Calderdale &Greater Huddersfield StrategicReview.

b) 2014/15 will be used to test andrefine these assumptions, with afocus on developing detailedbusiness cases and servicespecifications.

7. The introduction of theCare Bill, currently goingthrough Parliament and

expected to receive RoyalAssent in 2014, will resultin a significant increase inthe cost of care provisionfrom April 2016 onwardsthat is not fully quantifiablecurrently and will impactthe sustainability of currentsocial care funding andplans.

High a) We have undertaken an initialimpact assessment of the effectsof the Care Bill and will continue to

refine our assumptions around thisas we develop our final BCFresponse, and begin to deliverupon the associated schemes.

b) We have considered the impact oneligibility and understand how theschemes will enable us tomaintain current levels and themeet the anticipated requirementsof a National Eligibility Criteria.

c) We believe there will be potentialbenefits that come out of thisprocess, as well as potential risks.

8. The cultural changerequired to address deeplyheld assumptions abouthow people manage theircare is not able to beachieved and the shift to

self-care and prevention isnot achieved.

High a) Our Plan is predicated on a wholesystem shift of resources awayfrom acute to a public healthmodel of targeted prevention andself-management of long termconditions. The desire to make

this change has come not from usas professionals, but from patentsand social care service users whohave told us that to be in control oftheir care and health is what theywant for themselves.

b) Our Plan is underpinned by acultural change based on ethicalconcerns to embed within theworkforce the right to self-determination and autonomy forpeople with care and supportneeds within decision making.


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Item 7 - Appx 2 - Calderdale - Better Care Fund Submission - Part 1

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