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Greater Manchester (GM) Transformation Fund

SALFORD – POPULATION HEALTH BID

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GM TRANSFORMATION FUND LOCALITY PROPOSAL FORM GUIDANCE

Completing the proposal form Only forms completed in entirety will be considered for further

evaluation. Please complete the form in Calibri font, size 12. Please do not alter the formatting of this form.

Details for submission All proposals must have been approved via the Health and

Wellbeing Board prior to submission Send to Thomas.daines@nhs.net

Documents to be submitted (supporting evidence)

1 Locality proposal form 2 Financial analysis

o Proposal financial templateo CBA

3 Draft investment agreement schedulesThe supporting documentation to be submitted:

o Locality plano Implementation plano Governance arrangements o Programme plans with key milestones and deliverableso Programme risk log o Benefits realization plan

o Each proposal will be subject to independent evaluation. o The Transformation Fund Oversight Group (TFOG) will provide

system oversight on the findings of the independent evaluation team and provide recommendation to SPBE

o Each proposal should be aligned with the five overarching principles of the Transformation Fund:

o Value for moneyo Enabling transformational changeo Consolidating resourceso Long-lasting impacto Learning for others

Each proposal will be assessed against the five Transformation fund criteria:

o Alignment to GM strategyo Readiness to delivero Wider stakeholder supporto Robust financialso Foundation for further transformation

The assessment will be based on

1 Locality proposal form and supporting documentation2 Financial analysis

o Proposal financial templateo CBA

3 Discussions with the locality

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GM TRANSFORMATION FUND (TF) LOCALITY PROPOSAL FORM

SECTION 1: INFORMATION ABOUT THE LOCALITY

1.1 Locality SALFORD

1.2 Lead organisation name Salford City Council on behalf of the Salford Locality

1.3 Accountable officer (s) (Accountable officers from all key partners / transformation theme Director lead)

Name: Anthony HassallPosition: NHS Salford CCG Chief Accountable OfficerEmail: anthony.hassall@nhs.netTel: 0161 212 6159

1.4 Lead officer (Locality SRO / transformation theme support) contact details

Name: David HernePosition: Director of Public Health, Salford City CouncilEmail: david.herne@salford.gov.ukTel: 0161 793 3527

1.5 Date submitted 18th October 2017

SECTION 2: INVESTMENT CASE INFORMATION

2.1 Programme of work for which TF monies are requested

Population Health

2.2 Which GM transformation theme(s) does your work programme align with?

Theme 1 - Radical Upgrade in Prevention

2.3 Structure of funding request(breakdown anticipated receipt of funding, ie full amount in year 1 or split over multi years)

Programme Area

Year Start Well

Person Centred

and Community Approaches (spanning

the Life Course)

Live Well

Total

2017/18 252,200 0 30,000 282,200

2018/19 877,100 530,000 100,000 1,507,100

2019/20 712,300 555,000 100,000 1,367,300

2020/21 228,400 35,000 20,000 283,400

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TOTAL REQUIREMENT 2,070,000 1,120,000 250,000 3,440,000

2.4 Anticipated work programme start date (month and year)

Quarter 4 2017/18

2.5 Total programme budget? (the total cost of delivering the programme for which Transformation Fund monies are requested)

£3,440,000

2.6 How much funding are you requesting from the GM transformation fund?

£3,440,000 over a four year period

100% of total programme budget

2.7 What other sources of funding have been or will be secured to support this programme?

Person Centred and Community Approaches – Matched Funding (2018/19 – 2023/24) equates to £3,691,000.

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SECTION 3: INVESTMENT CASE OUTLINE

What is the proposed work programme and vision? Please keep your answer to 500 words or lessPlease cover the following topics:

Type of scheme(s) Programme vision (population served and programme objectives) Alignment with at least one of the GM transformation themes

3.1

BackgroundIn early 2016, Salford’s Locality Plan was developed and judged as the most investible proposition in Greater Manchester. This was due to the strong local partnership working and the extensive amount of work already achieved to develop the Integrated Care Programme (ICP) in the City and the agreement of funding through the national Vanguard scheme. As the Greater Manchester devolution arrangements took shape, the locality team were able to utilise this strong foundation to put forward an investment proposition for the City, which would maintain the momentum already behind the ICP programme, and allow further development and realisation of those plans. This led to a total of £18.3 million being allocated to the locality to focus on activity primarily aligned to Themes 2 to 4 of the Greater Manchester Plan, with some preventative work identified around issues such as falls, developing community assets to support older people, and better self-care support.

Theme 1: Radical Upgrade in Population Health PreventionAt that time, there was an explicit recognition both locally and with the Greater Manchester team that there would be further work to do in Salford to supplement the first wave Transformation Funding with a second phase bid that would expand and enhance the population health and preventative aspects of the Locality Plan (i.e. the activities that broadly align with Theme 1 of the Greater Manchester “Taking Charge” plan). The Salford Locality Plan had aims that were far reaching, and truly embraced the vision about investment not only in programmes of work that would reshape the system and deliver a return in the five years of the Greater Manchester and our Locality Plan duration, but that would truly transform the lives of local people over the longer term, to change the environment in which people lived and tackle the wider determinants of ill health. Much of this work sits outside of the ICP, and therefore has required extensive consultation and partnership development to gain a scope of what this would include.

Our Locality Plan vision, “Salford people will start well, live well and age well” is based upon the ambition that people in Salford will get the best start in life, will go on to have a fulfilling and productive adulthood, will be able to manage their health well into their older age and die in a dignified manner in a setting of their choosing. Our vision is for people across Salford to experience health on a parallel with the current “best” in Greater Manchester, and the gaps between communities will be narrower than they have ever been before. It aligns closely to the Greater Manchester vision, strategy and Transformation Fund criteria.

Salford’s Population Health Plan

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As a consequence of our overarching ambitions, Salford partners have been working to develop a Population Health Plan and have undertaken extensive public engagement to scope the approach to delivering a “radical upscale in prevention” at the local level in Salford. The publication of the Greater Manchester Population Health Plan has enabled the local plan to be reshaped to align more closely with the Greater Manchester approach.

Under the oversight of the Salford Health and Wellbeing Board and Locality Plan Programme Management Board, a population health task and finish group has been coordinating the development of the plan to achieve the significant population health improvements targeted within the Locality Plan as well as the estimated £15m of recurrent savings.

Extensive public and wider stakeholder engagement events over the last 12 months have been used to test and refine priority themes and ensure a co-designed approach to development of the plan which will then follow into its implementation and delivery. Consequently, the plan is structured into themes which align directly to the Greater Manchester Population Health Plan themes, namely Start Well, Live Well, Age Well, Person Centred and Community Approaches (supported by System Reform).

Transformation in Salford’s Locality Plan is built around three domains: Prevention, Better Care and Enablers. The relationship of these to our aim of managing demand is illustrated in Figure 1 below. This illustration also highlights the additional funding requirement in respect of Theme 1, a radical upgrade in population health prevention, not previously received.

Figure 1: Salford’s Locality Plan – Transformation Domains

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SECTION 4: ALIGNMENT TO TRANSFORMATION FUND CRITERIAPlease keep your answer to this section to a maximum of 4-5 pages. Please attach relevant documents (where possible, you should highlight where this information can be found in existing documents such as your locality plan documentation, financial template, underlying analysis or CBA model).

How will the proposal align to the GM strategy?Please cover the following topics:

How does the programme and your locality plan align to the short and long term GM vision & strategy? (In particular, discuss how your programme will deliver part of the how your plan will help to close the financial gap by improving outcomes for the locality population, increase independence and reduce demand on public services)

Which of the transformation themes does it align to and why? How will the programme contribute to wider transformation across GM? Is there any cross-collaboration with other localities or GM transformation themes?

4.1

Alignment to The Greater Manchester Population Health Plan Concurrently to the development of Salford’s Population Health Plan, Greater Manchester has developed a Population Health Plan that was published in January 2017. This plan outlines the vision and approach for population health across the City region. It states that:

“Population health means making things better for all of them, throughout their lives. It means tackling what causes poor health and providing the right help at the right time to stop health problems developing. It focuses on key points in people’s lives when there is an opportunity to make a big difference to their mental and physical health.”

The Greater Manchester Population Health plan is aligned to the Greater Manchester Health and Social Care Partnership’s “Taking Charge” plan and the wider reform objectives for the conurbation from the Greater Manchester Strategy as illustrated in Figure 2. Whilst it mainly covers Theme 1 (Radical Upgrade in Population Health Prevention), the plan also articulates the vision to embed population health across all health and social care activity.

As highlighted in Section 3 above, the proposals contained within this bid directly relate to Theme 1: Radical Upgrade in Population Health Prevention and are in addition to those currently covered by our current Investment Agreements. The programme of work contained within these proposals seamlessly align with those covered by the Greater Manchester Population Health Plan, however they are explicitly additional to those addressed and funded at the Greater Manchester level. As a consequence, this programme will contribute to the wider transformational agenda across Greater Manchester, addressing supplementary priorities.

Salford leaders were heavily involved in shaping the development of the Greater Manchester Population Health Plan. Furthermore, Salford are leading on a number of the 26 identified programme areas, and are involved with several other key workstreams. Of particular note, Salford is leading, or contributing to the leadership of, the agendas with regards to Lifestyles & Wellness, Health Intelligence and Eradication

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of HIV (Figure 3).

Figure 2: Greater Manchester Taking Charge Transformation Themes

Figure 3: Greater Manchester Population Health Plan Themes

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Solid circles = Salford has implemented (nutrition and hydration) or is leading/contributing to leading the themeDashed circles = Salford is working with GM to implement locally or develop at GM level

In addition, Salford has already implemented the Nutrition and Hydration workstream so we are unable to access further funding for this project, but it is a recognition of the strength of the local model that it will be rolled out across Greater Manchester. As such, Salford is contributing to the wider transformational agenda across Greater Manchester via early adoption, local implementation and shared learning.

Closing the Financial GapCost benefit analyses have been calculated for each of the 6 Project Overview Documents (PODs). The estimated contribution of the activities detailed in this bid is £619k net at 2020/21. However, it should be noted that longer term benefits outside this timeframe have also been identified and total £19 million over a 25 year period (before discounting). Full details of this are provided in Section 4.4 of this form.

Alignment to Theme 1Salford’s Population Health programme aims to deliver a radical upgrade in population health through stratification and needs identification, engagement, prevention and activation of its plans. It will support people in Salford to live healthy independent lives, managing their own conditions through a community asset based approach, tackling factors that influence the decline in health, function and wellbeing. Our plan is locally owned and co-created, articulating population health consistent with the life stages approach.

Key elements of our programme are: Working closely with people in their communities to build resilience and promote activation to

self-care supported by community assets and resources such as health coaches and lay educators;

Working with industry experts to develop new approaches to population health in neighbourhoods; and

Co-designing new approaches with people in communities to support themselves.

Salford Population Health Plan – The ProposalAs a result of extensive public engagement and consultation, we now have a draft local Population Health Plan. This has been led by a task and finish group reporting to the existing governance structures developed to oversee the delivery of the existing Salford/Greater Manchester Investment Agreement. The plan outlines the aims and objectives of the proposed work programme. As highlighted above, these are categorised under themes (Start Well, Live Well, Age Well, Person Centred Approaches coupled with System Reform) so that we can show a clear alignment to the Greater Manchester Population Health Plan. Attached at Appendix A is the current final draft.

Appendix B provides a Mapping Matrix which articulates in more detail the alignment to both the Greater Manchester approach and Salford’s Locality Plan coupled with our aspirations as laid out in this bid.

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Engagement with Salford CitizensWe have robustly engaged with our population on their meaning of prevention and what the community feels they need support with, to improve their own wellbeing. This will be used as the plan develops to check that we are delivering to the community needs, not only what the evidence suggests we should do.

Salford Population Health Plan – The Design PrinciplesSalford’s Population Health Plan has been developed with the following principles:

All suggested work must reference relevant local plans and strategies to minimise duplication; Areas of work that relate to the Greater Manchester Population Health Plan should be outlined

and no additional Transformational Funding sought unless there is a significant additional / related piece of work that the Greater Manchester plan does not cover, and in developing this, it would not run against the plans for Greater Manchester;

Leads have been identified for each area, and these leads are responsible for ensuring the work area is sufficiently developed into a business case to the level of detail required for a funding approval; and

Proposed areas must work on the principle that any funding applied for is a time limited opportunity only and will not be available following the end of the Investment Agreement period. Therefore, proposals must be transformational, and not use a model that would recruit staff who could not be mainstreamed, unless a clear cost benefit rationale is given with cashable savings identified which could be used to sustain the approach. Staff can be recruited on a temporary basis to complete transformational pieces of work, e.g. train the trainer type approaches, or specific development “task and finish” type work.

In addition, a number of local design principles have been applied as follow:

A Whole system partnership prevention approach; Based upon the evidence that health is an outcome of building resilient communities; Development of the VCSE sector, creating community led movements of change; Focused effort on the “anchor institutions” – those that are sure to remain in the City: the

hospital, the Council, Media City, the University, City West Housing Trust, The Lowry, Port Salford, RHS Garden Bridgewater, Salford City College, and Salix Homes; and

Target resources to where they will make the greatest impact and not universally distribute funds.

Salford Population Health Plan - The AskWe now have a clear vision and partnership agreement about the content of the local population health plan. We also have strong leadership for each of the proposed areas of works, and leads for the overall themes (Start, Live, Age, Person-Centred, System Reform). We are requesting funding of £3m to implement the suggested work programme to more rapidly realise the benefits for our local population. PODs are included at Appendix C (i-iv), D and E. These documents provide detail of six defined programmes of work. For ease of reference they are grouped as follow:

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Start Well – Early Intervention and Prevention; Start Well – Vulnerability and Safeguarding; Start Well – Parenting; Start Well – Children are Thriving; Live Well – Obesity and Cancer Prevention; and Person and Community Centred Approaches.

Supporting Cost Benefit Analyses (CBAs) and Financial Roll up details are also included as part of this submission at Appendix F (i & ii).

We recognise that Transformation Funding will enable us to go further, faster in unlocking the potential within our communities and to realign our recurrent resources to support sustainable services able to meet the future needs of our population from 2020/21 and beyond, in line with the Greater Manchester Strategy and wider reform.

Contribution to Wider Transformation and evidence of Cross-collaborationMuch of Salford’s cross-collaboration and leadership has come through its leadership across areas of the Greater Manchester Population Health Plan (Figure 3). However, Salford will ensure that any outcomes of this work are disseminated across partners and other authorities in Greater Manchester as part of our commitment to work towards achieving the ‘Taking Charge’ vision. For example, we have engaged with the Person and Community Centred Approaches team from Greater Manchester which sit with the Theme 2 area of the partnership, and have utilised this as an opportunity to share what we plan to do should we be successful in achieving this TF ask, and have offered to continue to work with the team as our plans are implemented. The learning from the 0 – 25 work will contribute to the system redesign at GM and our Director of Children’s Services is leading on this and so can ensure this is fed in to the system.

4.2 Does the proposal have a robust delivery plan?Please cover the following topics:

What project management infrastructure is in place to support delivery of the programme? (i.e. workforce and governance)

What enablers have been put in place to support delivery of the programme? What resources are required (equipment, people and money)? Specify requirements of the enabling work programmes (IM&T, Contracting and Pricing, Estates,

Workforce) at a GM and locality level What are the key risks and mitigating actions linked to the proposal? Does the local system have a proven track record in delivery of strategic initiatives, or an existing

platform for delivery of new models? Please demonstrate how you have considered and understand any impacts on system resilience

and business as usual as a result of implementing the work programme. What mitigating actions have you put in place/planned as a result?

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We do not underestimate the population health challenge that lies ahead. Nonetheless, Salford has a strong track record in delivering strategic change. As partners we have been working together since 2013 on an ambitious programme to integrate care for older people, including a £112m pooled budget for older people’s services. We are already in receipt of £18.3m Greater Manchester Transformational Funding to support the delivery of our Locality Plan and the proposed additional funding of £3m in relation to population health will dovetail into the existing governance and project management support that currently provides a robust and transparent framework for delivery.

Governance and AssuranceIt is our intention to incorporate the programme of population health work detailed in this submission and beyond, into the Locality Delivery Framework in terms of milestone plans, progress reports and risk registers etc with the creation of appropriate governance to support the Locality Plan Programme Management Board and Health and Wellbeing Board.

Figure 4 illustrates the Health and Wellbeing Board governance structure and Locality Plan reporting arrangements which highlights the inclusion of the proposed Population Health Advisory Board.

Figure 4: Health and Wellbeing Board Governance Structure

Appendix G details the Health and Wellbeing Board approved Terms of Reference for the Population Health Advisory Board. As noted in the Terms of Reference, this group will have decision making powers

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in relation to the £3m population health transformational funding and in addition, will advise Lead Members’ Briefings on population health ‘business as usual’ matters.

As with any programme, it is imperative that we adopt a rigorous approach to both monitoring and subsequent evaluation. We recognise that this commences with our Investment Agreement and the challenging targets we have set ourselves therein. However, as noted above, the Locality Plan Programme Management Board will provide the scrutiny both to ourselves and the Greater Manchester Portfolio Board to enable us to go much further. Individual Implementation Plans for each programme captured within the overarching Salford Population Health Plan will form the foundations of our work. These proposals have been prioritised as providing a platform for long-term sustainability coupled with both the greatest impact and alignment to our wider Locality Plan.

Implementation Plan to support our Population Health PlanOur high level Population Health Plan is supported by the development of detailed implementation documentation comprising six themed PODs. Each sets out our programme of work in support of the wider population health related system transformation. The Transformation Funding sought in this bid will enable our programme to progress at the scale and pace necessary to drive the efficiencies and change needed to address some of the affordability gap that has been identified across the City. It will provide the non-recurrent investment essential to support the transition to new ways of working including the creation of capacity for change and access to expert support.

The POD documentation confirms the key actions that we will take forward, focusing on the core area of prevention and enablement. While the outcomes we have set out to achieve will not change, the way we get there may need to adapt to reflect learning and the rapidly changing context in which we are working. We are therefore proposing to adopt an agile approach avoiding the risk of pursuing actions which are not having the impact required. We will focus instead on initiatives and approaches that are achieving the return on investment that we must achieve - specifically better outcomes and better use of resources.

Programme infrastructure We do not currently have a dedicated programme management office to support this programme of work. We do, however, have project management support and expertise aligned to our key transformational projects giving us the capacity for testing, scale up, spread and wider dissemination.

We have analytical support, data and metrics coupled with named individuals for each project and partner organisation. We have established a partnership group which is multi-organisational with strong Terms of Reference. Project management is provided via commitment in individual job plans.

Each programme of work has produced a detailed project implementation plan (including specific aims and measures).

Additional enabling workstreams are already in place to support delivery including:

Estates – Salford Strategic Estates Group is overseeing a review and utilisation of Salford’s estate which will support the implementation of our neighbourhood delivery model;

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IM&T – the Salford Integrated Record has been re-procured and has a two year rollout programme covering primary, secondary, mental health and social care across Salford alongside digitally enabling Care Homes;

Workforce – Salford’s Workforce Strategy Group which includes all partners including primary care is overseeing workforce development and alignment with our transformation plans; and

Finance – opportunities for testing new finance, pricing and contracting models will be incrementally tested over time as the structural changes mature.

Resource requirementsResource requirements are planned to optimise support and maintain ‘business as usual’ during testing and scale up phases of our model’s implementation. Funding for each programme of activity has been phased in line with the detail highlighted in our high level PODs and has been focused to deliver the benefits set out in our CBAs included as part of our submission.

Programme Area

YearStart Well

Person Centred and Community

Approaches (spanning the Life Course) Live Well Total

2017/18 252,200 0 30,000 282,200

2018/19 877,100 530,000 100,000 1,507,100

2019/20 712,300 555,000 100,000 1,367,300

2020/21 228,400 35,000 20,000 283,400TOTAL PROGRAMME REQUIREMENT 2,070,000 1,120,000 250,000 3,440,000

Key Risks and MitigationsBoth local and system wide risk registers assess and monitor relevant risks. Major risks related to the population health aspect of the Transformation Fund programme are:

RISK MITIGATIONLack of robust evidence and cost benefit measures for innovative behaviour change programmes, this could delay implementation and programme

Use of cost benefit analyses provided by New Economy supported by ongoing evaluation and tests of change.

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development.Lead time for effective co-production and community engagement approaches will delay outcomes or redesign.

Co-production and community engagement takes additional time to develop effective programmes for longer term behavioural change. Utilise existing system programmes that have been co-produced and enhance where feasible. Initial engagement and consultation should help to mitigate this risk.

Avoiding duplication with Locality Plan and integrated care programme plans.

Regular updates with Integrated Care Advisory Board and Locality Plan Programme Board.

Outcomes are measurable and contribute to the strategic plan. Risk of longer term prevention benefits not being realised versus short term gains.

Escalate issues that are also being tackled at GM level. Evaluation plans included within each programme. Recognition that prevention outcomes will be realised over a longer period of time.

Duplication of Greater Manchester Plan. Regular meetings and liaison with Greater Manchester Population Health Team.

Population growth/change may minimise cost benefit realization over longer time period.

Maintain a watching brief. In addition, work with Greater Manchester and neighbouring boroughs to address cross boundary issues.

Inability to sustain funding after transformation funding expires.

Early identification of areas of concern supported by proactive actions to address.

In summary, Salford has a proven track record in delivering system wide transformation. We believe that we have clear rationale and an appropriate evidence base to support the delivery of the defined population health activities and interventions articulated in this bid. We have an agreed delivery plan with a profiled investment strategy contained within the transparent parameters of robust governance arrangements.

Does the proposal have wider stakeholder support?Please cover the following topics:

What public engagement has been undertaken? Please provide evidence of Health and Wellbeing Board, relevant GM stakeholder and key partner

sign off of the programme. What clinical and patient engagement has been undertaken, and how has this influenced the

design of the programme? What is the engagement plan over the course of the programme?

4.3

Engagement PlanAcross Salford, we recognise that deep and widespread engagement is critical to successful change management. Importantly, if our prevention transformation programme is to be successful we will need to win the hearts and minds of staff and citizens.

This proposal and the wider context within which it is positioned have been developed in partnership with an extensive range of stakeholders. A significant amount of public engagement was undertaken to

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create the platform for this programme. Of specific relevance was a recent review of citizen engagement with the Health and Wellbeing Board. Six key engagement themes were identified of which prevention was highlighted as a theme, the aspiration being to determine a clearer understanding of what the diverse population of Salford feel about a particular issue at a given point of time. Furthermore, this intelligence was used to inform future planning coupled with the implementation of strategies identified within Salford’s Locality Plan.

Members of the engagement team worked with several key groups over a two month period to better understand what the notion of being healthy meant to them both collectively and as individuals, what they felt they should do to keep themselves healthy, what help they needed from Salford organisations and finally what format(s) information should take to the general public in relation to staying well and preventing illness.

A full report on the findings of this exercise coupled with workshop write-ups is available at Appendix H, however a key conclusion within the responses received was that of a wide ranging view of what being healthy actually means to Salford citizens which encompassed more than a simple absence of disease and good mental health and wellbeing. It further incorporated a sense of control over their lives and being seen as an equal part of a resilient community.

We will continue to engage local populations in significant conversations relating to positive behaviour change, building community resilience and asset based support networks.

4.4 Proposal finances? Please attach your completed financial template, including underlying analysis or CBA model

Please cover the following topics: Please summarise here the contents of your attached financial template, including underlying

analysis or CBA model o What is your do nothing financial gap, how far do the interventions in your locality plan

address the gap and what contribution does this work programme make?o What are the financial and activity impacts of this work programme?

(Please outline the expected milestones for each quarter over the period of funding – see investment agreement schedules for level of detail expected)

o Included metrics from the CBA modelling of the expected impact on demand or activity levels

o Please outline the return on investment of your programme: Cumulative gross fiscal ROI to 2020/21 (discounted values) Net Present Value at 2020/21 (gross, actual values before discounting) Cumulative gross fiscal ROI to 2020/21 (discounted) based on TF investment only Net Present Value at 2020/21 (gross, actual values before discounting) based on TF

investment onlyo The TF is non recurrent, ring fenced revenue funding. Please explain how the proposed

programme is sustainable in this context.

Please set out how the investments will lead to:o Expected reductions in demand

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o Improvements in population health outcomes and impacts (specific metrics)o Expected decommissioning of existing resources, how resources will transfer between

different organisations and used differentlyo Efficiency savings

Transformation Fund ask and wider cost base1

Full detail of all the data quoted in this section is presented in the CBA templates, including a detailed breakdown of all costs and benefits. A summary CBA has been produced (Salford Population Health TF bid - aggregate CBA – Appendix F (i)), which aggregates the input data from the constituent workstream CBAs to quote overall return on investment and other required metrics. The submission includes underlying CBAs for Start Well (four separate CBAs: Thriving; Parenting; SALT; Safeguarding), two for Live Well (Obesity; Cancer) and one for Person and Community-Centred Approaches (PCCA).

The table below outlines the ask of the Transformation Fund over the period 2017/18 – 2020/21, which comprises the first four years of the Salford programme. The total funding requested is £3.44m, of which 8% is allocated in Year 1, 44% in Year 2 and 40% in Year 3. The Year 4 Transformation Fund ask represents only 8% of overall funding, indicating the intention to mainstream the programme once initial start-up and double-running pressures have been addressed.

Yr1 Yr2 Yr3 Yr4 Total2017/18 2018/19 2019/20 2020/21 2017/18-2021/22

Children in Salford are Thriving

65,800£ 452,100£ 452,100£ 40,000£ 1,010,000£

Parenting and Start Well

53,800£ 260,200£ 123,000£ 103,000£ 540,000£

Early Identification and Prevention

112,800£ 52,400£ 52,400£ 52,400£ 270,000£

Safeguarding and Vulnerability

19,800£ 112,400£ 84,800£ 33,000£ 250,000£

Obesity 10,000£ 55,000£ 55,000£ -£ 120,000£ Cancer 20,000£ 45,000£ 45,000£ 20,000£ 130,000£

-£ 530,000£ 555,000£ 35,000£ 1,120,000£

282,200£ 1,507,100£ 1,367,300£ 283,400£ 3,440,000£ Total TF ask pa

Programme Workstream

Start Well

Live Well

Person and Community-Centred Approaches

Transformation Fund resource is concentrated on Start Well, which accounts for 60% (£2.07m) of the total funding request. PCCA accounts for a further third (33%, £1.12m) and Live Well 7% (£250k). The required resource is largely to support staffing costs and volunteer capacity, alongside: overheads and administration; equipment; training; delivery of specific interventions; marketing; management and governance; and monitoring and evaluation.

The overall cost base over the six year period from 2017/18 to 2022/232 is an estimated £7.6m. As shown in the table below, in addition to Transformation Fund resource, the Parenting and Start Well and

1 The costs detailed in this section exclude the optimism bias correction that is applied as part of the return on investment calculation.2 Costs for each workstream are modelled over a period of up to five years, but Year 1 for PCCA is 2018/19.

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PCCA workstreams will benefit from mainstream funding (including reinvestment of cashable savings in the final years of delivery) and local match including voluntary and community sector resource. The Transformation Fund ask comprises some 45% of the total funding envelope over the period.

Yr1 Yr2 Yr3 Yr4 Yr5 Yr62017/18 2018/19 2019/20 2020/21 2021/22 2022/23

GM Transformation Fund £ 282,200 £ 1,507,100 £ 1,367,300 £ 283,400 £ - £ - £ 3,440,000

Start WellParenting and Start Well

Salford Together (mainstream H&SC funding)

£ 121,355 £ 121,355 £ 121,355 £ 121,355 £ - £ - £ 485,420

Salford Together (mainstream H&SC funding)

£ - £ - £ - £ 407,000 £ 432,000 £ 432,000 £ 1,271,000

Local match (VCS grants & resource)

£ - £ 520,000 £ 520,000 £ 460,000 £ 460,000 £ 460,000 £ 2,420,000

£ 403,555 £ 2,148,455 £ 2,008,655 £ 1,271,755 £ 892,000 £ 892,000 £ 7,616,420 Total cost base

Programme Workstream Source of investment Total costs (£)

Person and Community-Centred Approaches

All programmes / workstreams

Benefits3

The CBA demonstrates activity and financial benefits on an annual basis; however, in preparation for the Investment Agreement, a quarterly articulation can be provided. The table below highlights the estimated activity shifts modelled in the CBA. For some of the Start Well workstreams, modelling has been undertaken over a 25 year timeframe, in order to capture outcomes that will only be achieved in the longer term once babies and young children reach adulthood.

The demand reductions modelled relate to the following areas:4

improved health outcomes (coronary heart disease; mental health disorders; asthma, type 2 diabetes; cardiovascular disease; stroke; colorectal cancer);

reduced requirement for funded community social care (home care); reduced A&E attendances; improved early years and school-based outcomes (increased school readiness; reduced persistent

truancy; reduced exclusion); increased employment (when children leave school; parental employment); and reduced crime and anti-social behaviour (committed by children).

3 Note that optimism bias correction has been applied to all the benefits quoted in this section.4 It has not been possible to quote activity shifts associated with the obesity strand of the Live Well programme (reduced incidence of stroke and colorectal cancer, and reduced demand for local authority funded community-based social care), due to the way the fiscal savings have been derived from Public Health England’s Weight Management Economic Assessment Tool (Version 2).

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Outcome Yr1 Yr2 Yr3 Yr4 Yr5 Yr6-10 Yr11-15 Yr16-20 Yr21-25 TotalReduced coronary heart disease 0 818 818 818 818 818 0 0 0 4,092Reduced mental health disorders 0 80 80 80 80 80 0 0 0 398Reduced incidence of asthma 0 2,270 2,270 2,270 2,270 2,270 0 0 0 11,348Reduced incidence of type 2 diabetes 0 1,844 1,844 1,844 1,844 1,844 0 0 0 9,218Reduced cardiovascular disease 0 120 120 120 120 120 0 0 0 598Reduced A&E attendance 3 14 26 37 45 1,576 632 0 0 2,333Increased school readiness 0 0 0 7 40 1,409 1,139 0 0 2,595Reduced persistent truancy 0 0 0 0 0 0 95 51 0 146Reduced exclusion from school 1 2 2 2 1 0 6 0 0 15Increased employment 0 11 25 39 54 157 0 21 111 418Reduced anti-social behaviour 0 0 0 0 0 0 114 68 0 182Reduced crime (child) 0 0 0 0 0 0 6 42 0 48

The following table details the benefits associated with the activity shifts detailed above. The estimated gross fiscal benefits total £19.0m over the 25 year period (before discounting), and are driven by improvements in the following outcomes:

reduced mental health disorders: £5.0m (26% of total gross fiscal benefits); increased employment: £4.4m (23%); reduced incidence of asthma: £4.0m (21%); and increased school readiness: £2.8m (15%).

However, it is worth noting that school readiness outcomes are not anticipated to accrue within the Transformation Fund timescale (up to 2020/21). During the initial four year period, improved mental health and asthma outcomes account for nearly three-quarters (72%) of the overall modelled benefits, with increased employment accounting for a further 11%. Total benefits over the 2017/18 – 2020/21 period are estimated at £7.5m.

Outcome Yr1 Yr2 Yr3 Yr4 Yr5 Yr6-10 Yr11-15 Yr16-20 Yr21-25 TotalReduced coronary heart disease £ - £ 160,380 £ 160,380 £ 160,380 £ 160,380 £ 160,380 £ - £ - £ - £ 801,898 Reduced mental health disorders £ - £ 994,733 £ 994,733 £ 994,733 £ 994,733 £ 994,733 £ - £ - £ - £ 4,973,666 Reduced incidence of asthma £ - £ 805,891 £ 805,891 £ 805,891 £ 805,891 £ 805,891 £ - £ - £ - £ 4,029,456 Reduced incidence of type 2 diabetes £ - £ 128,087 £ 128,087 £ 128,087 £ 128,087 £ 128,087 £ - £ - £ - £ 640,437 Reduced cardiovascular disease £ - £ 115,406 £ 115,406 £ 115,406 £ 115,406 £ 115,406 £ - £ - £ - £ 577,032 Reduced incidence of stroke £ 3 £ 10 £ 21 £ 35 £ 48 £ 314 £ 293 £ 107 -£ 50 £ 782 Reduced incidence of colorectal cancer £ 2 £ 9 £ 19 £ 33 £ 49 £ 448 £ 516 £ 241 -£ 29 £ 1,288 Reduced social care demand (home care) £ 2,404 £ 6,929 £ 11,276 £ 15,262 £ 16,478 £ 60,794 £ 19,809 -£ 212 -£ 749 £ 131,992 Reduced A&E attendance £ 200 £ 1,001 £ 1,801 £ 2,602 £ 3,202 £ 110,987 £ 44,478 £ - £ - £ 164,272 Increased school readiness £ - £ - £ - £ 7,762 £ 42,677 £ 1,516,784 £ 1,225,806 £ - £ - £ 2,793,028 Reduced persistent truancy £ - £ - £ - £ - £ - £ - £ 97,232 £ 52,356 £ - £ 149,587 Reduced exclusion from school £ 12,244 £ 24,488 £ 24,488 £ 24,488 £ 12,244 £ - £ 75,213 £ - £ - £ 173,163 Increased employment £ - £ 113,943 £ 265,867 £ 417,791 £ 569,716 £ 1,671,166 £ - £ 223,134 £ 1,174,535 £ 4,436,152 Reduced anti-social behaviour £ - £ - £ - £ - £ - £ - £ 42,059 £ 25,235 £ - £ 67,294 Reduced crime (child) £ - £ - £ - £ - £ - £ - £ 4,078 £ 28,545 £ - £ 32,623 Total benefits £ 14,853 £ 2,350,878 £ 2,507,971 £ 2,672,470 £ 2,848,912 £ 5,564,991 £ 1,509,484 £ 329,406 £ 1,173,707 £ 18,972,671

Return on investmentAfter optimism bias correction has been applied at the appropriate level to the costs and benefits, the gross fiscal return on investment (cumulative over 25 years to 2041/42, discounted values) is 1:2.05. Net present value at 2041/42 (gross, actual values before discounting) is an estimated £337k.

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Over the five year modelling period generally adopted for GM CBAs (i.e. 2017/18 to 2021/22), the gross fiscal return on investment (cumulative, discounted values) becomes 1:1.39. Net present value at 2021/22 (gross, actual values before discounting) is an estimated £1.9m.

The comparable metrics at 2020/21, representing the timescale for the Transformation Fund to achieve sustainability across the GM system, are outlined below:

gross fiscal return on investment (cumulative over four years to 2020/21, discounted values) of 1:1.17;

gross fiscal return on investment relative to the Transformation Fund investment alone of 1:2.00; net present value (gross, actual values before discounting) at 2020/21 is £1.3m; and net present value based on the Transformation Fund investment only at 2020/21 is £2.4m.

Under all the above timescales, and based upon the overall cost base, the analysis breaks even after four years. Based on Transformation Fund investment only, the break-even point is at two years.

Sensitivity testing has been undertaken to assess the impact of removing the optimism bias correction from all costs and benefits. The above metrics have been requoted under this scenario, giving the 2041/42 and 2021/22 five year return on investment, and the 2020/21 ‘breakout’ position for the Transformation Fund:

gross fiscal return on investment:o cumulative over 25 years to 2041/42 (discounted values) of 1:3.19;o cumulative over five years to 2021/22 (discounted values) of 1:2.38;o cumulative over four years to 2020/21 (discounted values) of 1:2.03;

gross fiscal return on investment relative to the Transformation Fund investment alone over four years to 2020/21 (cumulative, discounted values) of 1:3.42;

net present value (gross, actual values before discounting) at 2020/21 is £2.9m; and net present value based on the Transformation Fund investment only at 2020/21 is £3.9m.

Without optimism bias correction, the break-even point is achieved after two years, for both the analysis drawing on the total costs and that based solely on the Transformation Fund investment.

The return on investment for the individual workstreams is summarised below. In all instances, the analyses are headline – whilst detailed costings are available for all workstreams, the benefits modelling is, by necessity, much more assumptions based; population health outcomes are often indirect, making it challenging to quantify the demand reduction associated with them. Fortunately, a number of evidence-based return on investment tools are available, which have been drawn upon as indicated.

Start WellSeparate CBAs have been produced for the four workstreams.

Children in Salford are Thriving: the impact of the training programmes on children’s mental health is based upon outputs from Public Health England’s Mental health Promotion ROI Tool. In addition, a reduction in exclusions from school has been modelled. The fiscal return on investment is low (gross fiscal ROI over six years of 1:0.12), but is likely to be significantly

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understated given that it has not proved possible to model the full range of outcomes likely to result from the intervention. The wider public value return is much more positive (a benefit-cost ratio of 1.63 over six years), and includes economic benefits to parents who don’t have to take time off work to look after their children.

Parenting and Start Well: the gross fiscal return on investment over 25 years is 1:4.7, with payback within the first five years (the five year fiscal return on investment is 1:1.4). The overall public value return is 1:7.4 over 25 years, and 1:2.7over five years. The benefits are driven by employment outcomes for parents and (in the longer-term) children, and improvements to mental health (again for both parents and children) and school readiness.

Early Identification and Prevention: the CBA is based upon modelling undertaken for the GM Early Years programme, with similar assumptions applied to the Salford population. Over the long term (25 years), the gross fiscal return on investment is strong, at 1:4.5. The benefits largely accrue from employment outcomes (in this case, just for children) and school readiness. However, given that these outcomes will take time to realise, the benefits over five years are relatively small, and the return on investment over this period is negligible; the programme is anticipated to start paying back in Year 9.

Safeguarding and Vulnerability: it has not proved possible to monetise the outcomes from this programme, so only the costs have been included in the CBA. For this reason, the return on investment cannot be quantified.

Live WellTwo CBAs have been produced, one for the Obesity strand and another for Cancer.

Obesity: benefits modelling has drawn on outputs from Public Health England’s Weight Management Economic Assessment Tool Version 2. Over 25 years, the gross fiscal return on investment is 1:1.78, with payback achieved by Year 10. Over the same period, the wider public value return is significantly higher at 1:5.4. Fiscal benefits are derived from improvements across a range of health outcomes (type 2 diabetes, coronary heart disease, stroke, colorectal cancer), along with reduced demand for funded community-based social care. The public value benefit is driven by economic benefits to individuals associated with additional employment. Over the shorter-term (the five years to 2021/22), reflecting the time taken for outcomes to be achieved, the gross fiscal return on investment is 1:0.5; however, the public value return remains positive at 1:1.6.

Cancer: The aim of this workstream is to act as an enabler for the PCCA programme, strengthening and supporting this approach and the wider Greater Manchester Cancer Champions initiative, through development and delivery of specific awareness and prevention messages and the resources to support early cancer detection and treatment which, is now the main cause of death in Salford. The CBA includes the costs of delivery only because the detail is incorporated into the PCCA POD to avoid double counting of outcomes. The value added of achieving the specific cancer outcomes are expressed in the accompanying Live Well POD.

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Person and Community-Centred ApproachesThis workstream delivers over half (58%) of the estimated gross fiscal benefits associated with the Population Health programme as a whole.5 The gross fiscal return on investment over the five year modelling period is 1:2.1, with the benefits driven by improved mental health outcomes and reduced incidence of asthma. Benefits modelling is based upon outputs from the Realising the Value economic modelling tool developed by NESTA and the Health Foundation, which focuses on the outcomes anticipated to result from the following interventions: peer support; self-management education; health coaching; asset-based approaches; and group activities. In line with Realising the Value guidance, only benefits associated with peer support and self-management education have been modelled in the CBA, to avoid double-counting across the interventions.

In bringing the individual CBA findings together to produce the aggregate CBA, it was important to be mindful of potential overlap in benefit lines that model the same outcome for the same population group. For example, benefits associated with reduced type 2 diabetes and coronary heart disease are modelled in both the PCCA and Live Well – Obesity CBAs; mental health benefits feature in both the PCCA and Start Well analyses. To avoid double-counting, only single benefit lines for each outcome have been included in the aggregate CBA, and any duplication excluded.6

Benefits RealisationSome 62% (£11.8m, before discounting) of the estimated total gross fiscal benefits over 25 years will accrue to the Salford health and social care system; the remainder falls outside, accruing to other local partners or central government.7 Local health and social care integration is well advanced under Salford Together, with Salford Royal Foundation Trust (SRFT) playing a leading role in developing and subsequently implementing Local Care Organisation (LCO) arrangements. Although further work is required to develop approaches to future benefits realisation, SRFT has already decommissioned activity linked to successful implementation of new models of integrated care. Realisation of benefits related to demand reductions stemming from the population health interventions outlined in this proposal will need to be considered in the round, along with wider LCO benefits realisation plans and those related to other areas of health and social care transformation in the locality (including Greater Manchester-level programmes). However, the increased overall scale of benefits achievement that the population health programme will bring should increase the opportunity to realise a higher proportion of benefits.8 Furthermore, Salford already has a large pooled budget in operation across the locality health and social care system, which will be further expanded over time and will facilitate benefits realisation. As outlined below, robust monitoring and evaluation will seek to articulate the extent to which benefits across the outcomes modelled can be attributed to the population health programme, and will form a basis for a sustainable model under which cashable savings are reinvested in the constituent interventions.

5 Start Well accounts for an estimated 41% of total gross fiscal benefits, and Live Well 1%.6 The exception is overlap in outcomes across the Start Well CBAs. These draw upon modelling for the GM Early Years programme, in which double-counting has already been addressed.7 Benefits falling to schools in relation to school-readiness outcomes account for 15% of overall gross fiscal benefits, and 1% of benefits fall to the police and wider criminal justice system. Benefits from reduced worklessness falling to central government (from reduced benefits payments, increased tax receipts, etc.) constitute a further 22% of the total benefits.8 Although it will be important to consider potential double-counting of cashable benefits with those anticipated through Salford Together and related initiatives.

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The default assumption in the GM CBA model is that 50% of savings in acute and other health settings will be cashable towards the end of the modelling period, and 90% of social care savings. The aggregate CBA shows that the cashable net present value at 2020/21 is an estimated £151k, indicating that the cashable benefits outweigh the costs at this point (albeit marginally, due to the medium to longer-term timescale associated with achievement of many of the outcomes). The award of Transformation Fund investment will enable pump-priming of the population health programme until it reaches this sustainable position, with future resourcing comprising locality mainstream funding (much of which will be sourced by decommissioning current reactive provision under ‘business as usual’), reinvested savings, and support from local voluntary and community sector partners.

Contribution to the Locality and Greater Manchester Financial GapAs discussed above, the CBA indicates an estimated long-term/large scale cashable net present value (actual values before discounting) at 2020/21 of £151k. This has been recalculated to assess contribution to the GM gap, removing the optimism bias correction from across the cost and benefit modelling (on the premise that optimism bias does not feature in derivation of the Greater Manchester or locality gaps), and excluding benefits that fall outside of the locality health and social care system. This gives a net present value of £621k at 2020/21, which might effectively be considered as the population health programme’s estimated contribution to the Salford, and by extension, Greater Manchester gap.

Does the proposal provide a foundation for further transformation?Please cover the following topics:

How will progress be evaluated and learning provided to other localities? How will this programme build on or support other elements of your locality plan? How will this programme enable continuing transformation beyond 2021?

4.5

Evaluation Partners in Salford have a strong track record of innovation and improvement that we share and spread at a national level. We have designed an approach to support learning and replication in other local health economies across Greater Manchester.

We have identified four routes for replication: direct transfer and adaption; support and spread within Greater Manchester; knowledge capture and sharing; and evaluation and evidence.

We have also commissioned Haelo, our local improvement and innovation centre, to help capture learning and create a range of resources to support others in replicating similar models.

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LIST OF APPENDICES IN SUPPORT OF APPLICATION

Appendix A Salford’s Population Health PlanAppendix B Mapping MatrixAppendix C (i – iv) Project Overview Document – Start Well (Four Documents)Appendix D Project Overview Document – Live WellAppendix E Project Overview Document – Person & Community Centred ApproachesAppendix F (i and ii) Cost Benefit Analyses and Financial Roll Up Appendix G Population Health Advisory Board: Terms of ReferenceAppendix H Engagement Report and Workshop Feedback