North East Lincolnshire Care Trust Plus

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

2. 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

3. Overview of North East Lincolnshire Care Trust Plus Population of 168,000 89 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. What We are Trying to Achieve

11. What We are Trying to Achieve

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Financial Approach

26. 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

27. 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)

28. 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

29. 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

30. 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

31. 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

32. Where Next on Our Integrated Journey?

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

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

35. 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 Judging success • Individuals influencing their own care • Improving employment • Users more satisfied with the service • Reducing the use of institutions • Users able to become more independent • Reducing inequalities • Affordable services

36. Questions?