REPORTItem No: 9

C, Health&SociaI Care\ U t h Lanarkshire

SUBJECT: Progress on locality Modelling

TO: Integration Joint Board

Lead Officer Chief Accountable OfficerforReport−Author(s)

of Medical Director, Health & Social Care North Lanarkshire.Report Nurse Director, Health & Social Care North Lanarkshire

DATE: 20/10/2016

1. PURPOSE OF REPORT

This paper is coming to the

For approval For endorsement z To note

The Strategic Plan for the IJB is based around services delivered in localities. Localitymodelling has been a significant workstream during the planning for integration and will becentral to the Strategic Commissioning Plan for 2017. This paper sets out a broad overviewof the locality, the services that will be directly managed within it, and the principles that willgovern locality working. It also proposes that we plan to implement a significant change inthe way teams currently sited in the community work together through development ofintegrated Locality Health and Social Work Teams.

2. ROUTE TO THE BOARD

This paper has been:

3.

3.1

4.

4.1

Prepared Reviewed By Z Endorsed BySLTSLT

The paper was authored by a small group but builds on extensive work on locality modellingthat has involved multiple stakeholders over a prolonged period. The paper has been widelyconsulted on and has been discussed and approved by the Strategic leadership team ofH SC N L.

RECOMMENDATIONS

That IJB note the progress in development of model for locality working and endorse plan tomove towards implementation of the integrated Locality Health and Social Work Teams in2017.

BACKGROUND/SUMMARY OF KEY ISSUES

The attached paper describes a model and principles of working for Locality services. Itdescribes the plan to develop integrated Health and Social Work Teams.

5. CONCLUSIONS

5.1 The locality model and its implementation will be one of the main objectives of the StrategicCommissioning Plan. The model and principles described here are based on work that hasbeen ongoing in North Lanarkshire for several years. The paper has been widely welcomedand there is a desire to move towards implementation as described.

6. IMPLICATIONS

6.1 NATIONAL OUTCOMESPaper addresses model that is designed to meet all the national outcomes

6.2 ASSOCIATED MEASURE(S)Implementation plan to be prepared for January 2017.

6.3 FINANCIAL

This paper has been reviewed by Finance:

Yes E No L I N/A LIThere are no financial implications arising from the paper at this point but a future paperdetailing plans for implementation will need a financial framework attached.

6.4 PEOPLE

6.5 INEQUALITIES

EQIA Completed:

Yes No N/A

7. BACKGROUND PAPERS

None

8. APPENDICES

Appendix A: Locality Health & Social Work Team,

CHIEF ACCOUNTABLE OFFICER (or Depute)

Members seeking further information about any aspect of this report, please contact Alastair Cookon telephone number 01698 858115

APPENDIX A

Progress in development of North Lanarkshire Locality ModelAIMThe North Lanarkshire Locality Model is a model of working for integrated health, social care andother relevant services based in localities that best serves the population of that locality. This papersets out definitions and principles around which that model is based and describes the proposeddevelopment of integrated Locality Health and Social Work Teams as a part of that model.

LOCALITIESLocalities are discrete geographical areas around which many public services are planned andorganised. It is the intention of Health and Social Care legislation that localities play an increasingrole as services and supports integrate. In North Lanarkshire there are six well established localitiesthat are largely centred on the main towns but include surrounding areas. In most cases the serviceand supports that an individual will expect to access if they require a health or social care input willbe determined by the locality in which they live.The needs of a locality population are diverse and complex. An integrated Health and Social Workteam as described in this paper will be a key component of a locality model but cannot encompassall the functions that are needed within a locality to serve that population.The locality is made up of a number of teams, services and people that are linked together toprovide services and supports to those that live within its geographical boundaries. A locality willinclude integrated health and social work teams, practice teams including GPs, children's services,criminal justice services, third sector organisations, independent sector providers and also secondarycare or specialist services serving the locality. The locality concept is fluid and allows inclusion ofother services such as education, leisure, police etc where it is appropriate to do so, providedappropriate information sharing arrangements are in place

PRINCIPLESThe prime purpose of the locality is to help the people in that locality live safer, healthier,independent lives.

• Prevention, early intervention and self management are promoted and supported within thelocality.

• Where support or treatment is required this will be person centred, drawing on the differentparts of the locality supports and services required by the individual.

• All parts of the locality will deliver supports and services that are safe, effective and timely.

• The locality is designed to ensure that where needs are identified then individuals can accessthe supports or service best suited to those needs through a single gateway.

• There is "no wrong door" to the locality. If somebody enters the system but are assessed asrequiring information, advice, a support or service delivered by a different team within thelocality they will be able to access the support or service that can best meet their needs with

no additional barriers.

FUNCTIONS OF LOCALITY MANAGED SERVICESThe services directly managed within localities need to be designed to fulfil the following functions:In all cases these functions refer to physical or mental health or social care needs for people of allages within the locality:Screening, prevention and the promotion of improved health and well−being for the wholepopulation with a focus on reducing inequality. This includes intensive analysis of needs within thelocality, health promotion, welfare rights support and linkages to community education, leisure andother relevant services.

Rapid response (low level) People that require rapid advice, support or low level intervention todeal with an immediate or emerging issue. The development of technology enabled care will beimportant both for this group and for those with more complex needs.Rapid response (more complex) that People that require a more complex intervention to help themmanage a situation. This will include prevention of admission and facilitation of early discharge fromhospital in many cases.Targeted support and where necessary interventions for at risk groups within the locality population,this to include child, adult and public protection functions.Management of long term conditions over prolonged periods of time, this to include promotingchoice and control through Self Directed Support.Rehabilitation and/or Reablement following an illness or injury.Palliative or end of life care for those that need it

MANAGED TEAMS ENVISAGED AS PART OF A LOCALITY. Locality Health and Social Work Team (see next section)

Locality Child Health and Social Work Team (health visitors, children's social work, children's

nurses, community paediatrics)

• Locality Mental Health Team (CMHT, ECMHT, psych therapies team, Mental Health Officers)

• Locality Addiction team

All these teams would over time be managed by the locality management team, the core of whichcurrently comprises a Health and Social Work Manager who directly line manages two Locality SocialWork Managers, one for Children Families and Justice, the other for Adult Community Care, and aHealth Service Manager.

LOCALITY HEALTH AND SOCIAL WORK TEAMThe Locality Health and Social Work Team (LHSWT) is an integrated team comprisingAs a minimum the integrated team will comprise of district nursing, allied health professionalsworking in the locality, locality social work staff and home support staff with the scope to extendthose staff groups depending on the needs and resources available within the locality.GPs and other practice−employed staff will be incorporated in the "team" surrounding eachindividual patient, liaising closely with all disciplines in the LHSWT. The team will therefore broadenthe range of competencies available within the locality as part of an extended Primary Care Team.Locality lead GPs will have a key role in guiding the development of these teams and theirinteraction with GPs and practice employed staff as well as providing clinical guidance in thedevelopment of operational policies. In time it is likely that the teams will have dedicated medicalinput.The team will provide assessment, rapid response and longer term care management of adults of allages in the locality who have identified health and/or social care needs that require assessment andsupport or intervention. There will be a single gateway to the LHSWT. People entering the servicethrough multiple access points such as their GP practice, via Making Life Easier, Social Work Accessteam, and Fast track or referred from hospital or other secondary care service will pass through thatgateway and first assessment will then be picked up by the most appropriate professional for thatindividual's needs. As outlined in the principles there will be "no wrong door" to locality services andif initial assessment suggests another team or professional could better meet that individual's needsthen there will be rapid access to that service. In addition the team will proactively engage withEmergency Departments and GPs to identify patient regularly utilising unscheduled care with a viewto developing person specific plans to better meet their requirements.In due course LHSWTs will absorb the roles currently offered by Hospital at Home, CARS and otherservices that outreach from hospitals, moving us from a model that sees the hospital reaching out toone of localities reaching in to the hospital and maintaining a degree of responsibility for peoplefrom the locality wherever they happen to be in the system.

Specifically the team will provide:The team's ethos will be to support and enable independence enabling people to maintainresponsibility for their own health and wellbeing for as long as possible. Interventions will rangefrom simple sign posting and advice to complex assessment and care. This will be driven by theneeds of individuals accessing the service ensuring any subsequent interventions are designed tomeet their needs and aspirations promoting independence and personal responsibility.

Assessment −an assessment forms the cornerstone of effective intervention and will be undertakenby the most relevant professional, this may be a simple assessment or a fuller, comprehensiveassessment.

Locality Response − a rapid response that can be deployed to support GPs or other parts of thelocality that offers assessment and can within hours set up support and care for a short period toallow a person to return to normal activities as soon as possible, the aim being to avoid progressionto higher level interventions including hospital admission. Consideration should be given to thisteam having a "gatekeeping" role in the locality, with all decisions about admission needing to beagreed with the team before a bed is accessed.

Discharge support—The team will be aware of all people from the locality who have been admittedto hospital and will pro−actively engage with hospital teams to pull people back to their communitiesas soon as it safe to do so. If a need for support, care or treatment on discharge is identified theteam will have the authority to set this up on the same day and/or make appropriate links orsignposts.

Rehabilitation and Reablement − after a period of illness or injury people will frequently requiresupport to enable them to reach their maximum potential. This function will sit within the LHSWTs.

Care management of people with complex needs— Some people with long term health conditions ormulti−morbidity require ongoing monitoring and support to prevent exacerbations. Care for suchindividuals should be managed in a multidisciplinary team with clear communication within andbetween teams involved in the individual's care. The LHSWT will take the lead in care managementwhere there is an identified need for this but will work in partnership with locality mental health oraddiction teams where there are co−morbidities. Proactively data such as SPARRA will be utilised toidentify individuals frequently utilising unscheduled care services with a view to working with themto improve their health and wellbeing reducing their reliance on unscheduled care services.Additionally as part of the prevention agenda, appropriate links or signposts will be made toappropriate community supports.There will be elements of the team that will be required to function 24/7 and the links to Out ofHours hub services will need to be explored to ensure there is a level of service availableproportionate to assessed need at all times. There will be scope to explore a model that extends thehours of locality services into late evenings but that through the night a North Lanarkshire wideservice linked to GP, Social Work and Home Support and community nursing out of hours would beavailable.Once the needs of the person have reduced to the level that the LHSWT is no longer required thenexpectation would be that the practice team would resume their role as main point of contact if theperson has further needs. Transitions in support and care between teams will be smooth and joinedup with the individual being part of the discussion with the LHSWT and Practice Team

IMPACTIt is essential that in fulfilling the team functions described earlier each Locality is able to track theirimpact in achieving the national outcomes. This will enable data to be used to achieve continuousimprovement ensuring that support and care meets the needs of local people. A performance datawill be further developed with the H&SW Managers.

NEXT STEPS

The model described here has been agreed with key stakeholders so next step is to scope out theimplications for each Locality in terms of workforce capacity and capability. This will form theLocality Model Implementation Plan (Paper 2) which will be prepared for January 2017. This planwill be reviewed and refreshed on a 6 monthly basis.

CONCLUSIONThe model described here has been developed with wide consultation and builds on work that hasbeen in progress for at least three years in North Lanarkshire. The paper prepares the ground for thepartnership to move towards implementation of the integrated Health and Social Work teams thatwill be a key objective of the Strategic Commissioning Plan for 2017/18.There is a need to ensure any anomalies that currently exist around differences in boundariesbetween health and social work services are resolved as early as possible in the integration process.There is considerable data available about each locality through the locality profiles and otherinformation held by locality services. This data should be used to help inform a workforce modelthat could meet the anticipated demands in each locality. If, as seems inevitable, there is a mismatchof capacity and demand then priorities for investment would need to be identified to try andincrease capacity where this will deliver the greatest impact, maintaining the Partnership'scommitment to its agreed priorities.As we move towards implementation training needs analysis will be required and there will be arequirement for Practise Development, Organisational Development and Human Resource supportto implement the changes within teams that will take place.

Alastair Cook, Anne Armstrong, Morag Dendy, Sharon Simpson