North East Lincolnshire Care Trust Plus Jane Lewington Chief Executive 4 June 2010

CTP Developed in Context of… Male life expectancy – 75.9 years (below national + regional average) Female life expectancy – 80.8 years (below national average) 49% of most deprived out of the 354 local authorities in England (2007) 24% of lower level super output areas in North East Lincolnshire are amongst the most deprived 10% in England High teenage pregnancy rates High level of smoking prevalence Third worst area in England for alcohol abuse High dependency ratio

Overview of North East Lincolnshire Care Trust Plus Population of 168, GPs and 34 General Practices 1,500 directly employed staff 4 Commissioning Groups 2010/2011 budget – NHS is £287 million and Adult Social Care is £47 million 37 contracts for provision of health care 130 providers of social care

Care Trust Plus Established September 2007 Three elements: ─Delegation of planning, purchasing and delivery of Adult Social Care (Council to CTP) ─Delegation of planning, purchasing and delivery of health improvement (CTP to Council) ─Development of Children’s Trust ─Council as preferred provider of Community Child Health Services

Care Trust Plus – Accountabilities NHS Care Trust Local Authority Children’s Trust Commissioning Board Adult Social Care Health Improvement

Characteristics of the CTP A health and well-being organisation Commissioning groups: front line integration An organisation rooted in its community Working as part of a wider care community

CTP – Role and Functions Planning and purchasing of health and adult social care - £320m Planning and purchasing at the level of the individual, the locality and the population Contract management and procurement ie contract consortia for main Acute Hospital provider Delivery of community health and personal care services

CTP Current Provision Adult Mental Health services Learning Disability District Nursing and complex case management Integrated Tier 2 services Palliative Care and Specialist Nursing Drug Intervention Programme Meals on Wheels and transport services Day Care – Older People and Physical Disability Supported employment schemes

Four Commissioning Groups Based on GP Practice populations Hold budgets for: –Hospital care –Prescribing –Community nursing Care Management Teams aligned Community nursing Teams fully aligned Community membership scheme Lay Boards Integration

What We are Trying to Achieve Goal 1 - Creating a healthy community The initiatives to deliver this goal are:  Increase access to screening by 10%  Reduce childhood obesity by 10%  Reduce CVD mortality by 4% (NELC will be lead for initiatives 2 and 3 under our legal partnership agreement) Goal 2 - Accessible, responsive, quality care The initiatives to deliver this goal are:  Reduction in the number of avoidable emergency admissions by 50%  Increase the number of stroke patients receiving effective, timely treatment

What We are Trying to Achieve Goal 3 - People in control of their own care The initiatives to deliver this goal are:  Increase by 35% the number of people diagnosed with dementia that receive early intervention  Increase by 20% the number of personalised care plans  Increase the number of people by 3% that feel they are treated with dignity and respect Goal 4 – Build a sustainable care system The initiatives to deliver this goal are:  To manage within available resources  To actively promote community leadership  Contribute to reducing climate change locally

The Integration Journey Driving forces: –Co-terminosity –Greater and faster progress needed in delivering better outcomes –Long and strong history of collaboration –Local stability within the NHS system –High trust relationships amongst local leaders –Strong sense of place and sound financial performance

The Integration Journey Key challenges: –View of the region and DoH –Robust but lengthy application process –Building local political and lay member support – Managing the impacts of organisational change –Building on belief rather than hard evidence

Joint Governance Legal Partnership Agreement Three Year Strategic Agreement Financial Risk Share Agreement Continuing dialogue: –Executive Officers Group –Good Governance Group –Performance Group

Key Governance Issues Handling reserved matters Political representation The role of the Director of Adult Social Services Communication and awareness Answering the difficult questions at the start of the journey

The CTP: What Has Worked Putting in the building blocks: –Harmonisation of terms and conditions –Working alongside as a precursor to integration –Integrated management structure and integrated support services –Developing a new language –Commissioning Groups at the heart of the new organisation

The CTP: What Has Worked Development of whole system thinking Integration driven at the strategic, tactical and individual level Broader ownership and greater influence eg Carers A wider set of levers deployed

CTP: Emerging Benefits Significant increase in quality ratings of Care Homes No direct admissions to Care Homes from hospital Redesign of Tier 2 services – reduction in hospital admission Doubling the number of people helped to live at home

CTP: Emerging Benefits Use of co-production models for health and personal care Philosophy of normalisation developing within front line teams Broader set of PIs and standards in contracts reflecting total care issues Cost shunting ie NHS continuing care, transitions NHS funding of care substitution Management of winter pressures/incidents

CTP: Emerging Benefits 35% reduction in formal social care referrals Greater focus on prevention and re-enablement driving redistribution of resources Use of integrated care to reduce costs and improve quality for those with the most complex needs

CTP: Challenges We Still Face Two external regulation processes Two external performance regimes Increasing difficulty in meeting the silo processes of the wider system eg use of resources NHS policy drivers that undermine integration – TCS

CTP: Challenges We Still Face On-going commitment to relationship management The partnership journey needs constant development Ensuring progress against the full breadth of our agenda

Stakeholder Management Maintaining performance in Year 1 Improving performance in Year 2 onwards Sharing early wins and the impact on individuals Timely and robust response to issues/ concerns Staff settled into the new organisation

Stakeholder Management Council membership of the CTP Board Importance of CE to CE relationship Importance of Council Leader and CTP Chair relationship Supporting the Portfolio Holder for Adult Social Care Opening up internal processes

Financial Approach

Managing Resources Clear and explicit documentation for each budget that sets out: ─ Which partner is accountable ─ Which partner is responsible ─ Who funds the risks that arise in-year and the approach to recurrent resolution

Establishing Partnership Budgets Use 3 year costs and trends to inform partnership budgets Formally agree how the budgets will be negotiated going forward (cost pressures, inflation, savings, investment priorities)

Moving to Pooled Budgets Understanding each partner contribution but loss of identity on spend Need to have built sufficient trust Able to demonstrate accountability and delivery to everyone’s satisfaction The services really need it Start small

Language and Culture Need a common language and process/ approach for: –Assessing and demonstrating VFM –Reshaping the use of resources to support delivery of priorities and outcomes Transparency and trust need to be in place between the DOFs

Language and Culture DOFs need to meet regularly and take a lead in strategic financial management, setting the tone of the overall financial relationship and unblocking problems Expect to learn from each other and be open to this Sharing teams and TUPE of back office staff really does help

Use of Shared Services Reduces costs eg Council could reclaim VAT on community equipment purchases but the NHS couldn’t Make best use of existing expertise/systems - debt collection Can add assurance: use of LA internal audit service for Adult Social Care services Reduce residual costs: £800k of back office services bought from the Council

Where Next on Our Integrated Journey?

NHS funding and regulation Prevention Personalised Extended primary care Intermediate care Acute Specialised Interventions Citizenship Neighbourhood Information access Lifestyle Practical support Early intervention Enablement Community support Institutional avoidance Timely discharge Complex needs Substantial needs Low to moderate needs General population Regeneration Housing Transport Children's Trust Outcomes (Financial sustainability, user experience, quality) Shifts in investment Integrated Care Model

Integrated Care Organisation (ICO) Joint Strategic Commissioning Board Annual Plan ICO Delivery Arm (Personalised Commissioning and provider function) Primary Care Community Provision Acute (DPOW) (Medicine and Emergency Care)

What We Plan to Achieve The integrated care organisation is a means to improve services on how we: –generate cash release efficiency savings by increasing productivity, reduce costs and remove the duplication of services –reduce admissions to acute hospitals, improving quality and care outcomes by changing the way we deliver care –improve the experience of service users by providing better coordination of care with fewer handovers between providers –create more local engagement for users and citizens 1. Individuals influencing their own care 2. Improving employment 3. Users more satisfied with the service 4. Reducing the use of institutions 5. Users able to become more independent 6. Reducing inequalities 7. Affordable services Judging success

Questions?