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INTEGRATED COMMISSIONING COMMITTEE OPEN MEETING

Wednesday, 19 June 2019 3.00 pmG:03 - Wigan Town Hall

AGENDA

Agenda Item Time Presenter Pages/Verbal

Action Required

1 Welcome and Apologies 3.00 pm Chair

2 Declarations of Interest Chair Record

Individuals will declare any interest that they have, in relation to a decision to be made in the exercise of the commissioning functions of the Integrated Commissioning Committee, in writing to the CCG, as soon as they are aware of it and in any event no later than 28 days after becoming aware.

3 Minutes of the Previous Meeting Chair Not Applicable

4 Actions from Previous Meeting Chair Not Applicable

5 Strategic Commissioning Business 3.05 pm

5.1 ICC Terms of Reference Tim Collins 1 - 10 Receive

5.2 Committee Forward Plan Tim Collins 11 - 14 Receive

5.3 Crisis Resolution and Home Treatment Business Case

Julie Crossley 15 - 32 Approve

5.4 Community Services Programme - Closure Report Phase 3 and next steps

Julie Crossley/

Stuart Cowley

33 - 44 Approve

5.5 Integrated Community Neuro and Stroke Rehabilitation Services

Julie Crossley 45 - 70 Approve

/Gill Rowlands

6 Performance and Quality 3.40 pm

6.1 Council and CCG Financial Outturn Positions 2018/19 Craig Hall 71 - 74 Receive

6.2 Better Care Fund Position 2018/19 Mark Rotheram 75 - 84 Receive

6.3 Single Quality System Briefing Lynn Mitchell 85 - 96 Approve

6.4 Integrated Performance Framework Rachel Robinson 97 - 116 Receive

6.5 Drug and Alcohol Service CQC Report Lisa Ball 117 - 122 Receive

7 Greater Manchester Updates 4.00 pm

7.1 GM JCB Update & 100 Day Commissioning Review Tim Dalton 123 - 146 Receive

8 Any Other Business 4.05 pm

9 Date and Time of Next Meeting

Wednesday 28 August, 2019, 3pm

Contact: [email protected]

Integrated Commissioning Committee

Agenda Item Number: 5.1 Date: 19 June 2019

REPORT TITLE: ICC Terms of Reference

REPORT AUTHOR: Bevan Brittan LLP

PRESENTED BY: Tim Collins, Assistant Director, Governance (CCG)

RECOMMENDATIONS/DECISION REQUIRED: Receive

EXECUTIVE SUMMARY:

Following a process of joint working and consultation involving the Council, CCG and other stakeholders and based on legal advice from Bevan Brittan LLP the Integrated Commissioning Committee (ICC) is established as a committee of the CCG Governing Body.

The ICC will make decisions within the constraints of the budget set by the Council and the CCG and operate as the formal decision making authority of the section 75 pooled budget.

The terms of reference are presented for the committee to receive and provide focus for its business as it seeks to improve population health outcomes and commission quality, integrated services for the borough’s residents.

FURTHER ACTION REQUIRED: None

EQUALITY AND DIVERSITY: Confirmed that any changes to service or procedure introduced as a result of this report do not impact adversely on any of the protected groups covered by the Equality Act 2010.

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Wigan Place Based Strategic Commissioning FunctionIntegrated Commissioning Committee

Terms of Reference

1. Introduction

1.1.Wigan Borough CCG and Wigan Council (the Partners) have agreed to the establishment of a Place Based Strategic Commissioning Function (SCF) for the borough. The intention of the SCF is to maximise the deployment of the health and care budget in the place to improve population health outcomes and secure quality and integrated services for the benefit of Wigan Borough residents.

1.2.The Integrated Commissioning Committee (ICC) is the decision making body for the SCF. The ICC is a committee of the Governing body of the CCG and it is supported by a dedicated team of council and CCG officers; itself drawing on the expertise of shared enabling capacity from teams such as integrated finance, business intelligence, programme management, communications and engagement and others that support the commissioning function.

1.3.The ICC does not replace the statutory responsibility of Wigan Borough CCG and Wigan Council, which continue to exist as independent statutory agencies. However, both organisations wish to ensure the ICC is recognised as the place where decisions are made jointly and in partnership about the deployment of the total budget for the place.

2. Responsibility for a Pooled and Aligned Budget

2.1. In framing the work of the ICC, the total budget is identified as falling in to one of three categories:

2.1.1. A pooled budget – formal agreement provided for under Section 75 of the NHS Act 2006 and subject to the decision making governance of a Section 75 agreement. The CCG will act as lead commissioner in relation to the pooled budget.

2.1.2. An aligned budget - all other related health and social care services (that are not categorised as in-view budgets) that are not currently legally possible to pool or that the locality is not yet in a position to pool. The recommended utilisation of the aligned funds is to be agreed by the ICC. The ICC will take decisions on behalf of the CCG in relation to CCG aligned budgets and the relevant Council member or officer present at the meeting will have the delegated authority to take decisions in relation to Council aligned budgets. These decisions are subject to the Council’s Standing Orders and Constitution. Any decision made by a Council

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member or officer will be recorded in the ICC minutes but also recorded separately as a Council decision. For the avoidance of doubt the budget delegated by NHS England for Primary care commissioning, is not an aligned budget, but an In View budget.

2.1.3. Budgets that are In View – Covers all other revenue budgeted resource of the Council and CCG that does not fall within any other the other areas. These budgets in the main and over time are likely to be those that are not immediately connected health and care but recognisably make a contribution to population health gain in the wider sense (for example around economic growth).For the avoidance of doubt, the ICC does not have authority over spend of in-view budgets but may make recommendations to the relevant Partner. The Partners are not required to consult with the ICC before making decisions in relation to the In View budgets.

2.2.Notwithstanding the formality of pooled budget arrangements, the spirit of the ICC dictates that a shared view and ambition, reflective of the objectives of the agreed Locality Plan, should drive consideration of the whole budget for the place. All parties to the ICC recognise the opportunity of deploying a larger pool of funding, potentially across multi-year investment programmes, to drive the locality plan ambitiously to secure a substantial improvement in population health and service outcomes.

2.3.The ICC needs to influence and understand the impact of, decisions made by other commissioners of health and care services including NHS England and the GM Joint Commissioning Board for the people of Wigan Borough.

3. Membership

3.1.The voting membership is to be drawn from both Wigan Borough CCG andWigan Council as follows:

3.1.1. The Chair of the CCG and the Leader of the Council

3.1.2. Four clinical executives of the CCG as follows:

3.1.2.1. Unplanned Care Lead3.1.2.2. Out of Hospitals Care Lead3.1.2.3. Prevention and Wellness Lead3.1.2.4. Children, Young Persons and Maternity Lead

3.1.3. Four political leads of the Council as follows:

3.1.3.1. Portfolio Holder for Adult Social Care3.1.3.2. Portfolio Holder for Children and Families

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3.1.3.3. Portfolio Holder for Resources, Finance and Transformation3.1.3.4. Portfolio Holder for Planning and Environment

3.2.The following officers shall attend as non-voting members :-

3.2.1. Director of Adult Social Care3.2.2. Director of Children’s Services 3.2.3. Director of Public Health 3.2.4. The Accountable Officer of the CCG3.2.5. Chief Executive of the Council3.2.6. Joint Finance Director of the CCG and Council

3.3.The ICC reserves the right to extend the invite to other officers of the CCG, Council and other external parties as needed. A representation for service users can also be invited.

. 3.4.The Chair of the Committee will rotate on a bi-monthly basis between the

Chair of the CCG and the Leader of the Council.

3.5.Any member can nominate an alternate to attend a meeting on their behalf, provided that 7 days’ notice is given to the Chair.

3.6.Any voting member can nominate a proxy to attend a meeting and vote on their behalf. A nominated proxy must vote in accordance with the instructions given by the member who has nominated them. The nominated proxy must be a voting member of the ICC and 7 days’ notice must be given to the Chair.

4. Voting

4.1.Any resolution must be approved by the CCG voting members and the Council voting members. Each organisation shares one vote.

4.2. In order for a resolution to be passed, both votes must be in favour.

4.3.Decisions must only be taken after appropriate debate has taken place within the ICC forum and when members are satisfied that sufficient feedback has been sought from the public and/or service users, which may involve either engagement or consultation on the issues, or a presentation on the views of service users at the meeting as the Chair of the committee considers appropriate.

4.4. In the event that a decision is supported by the representatives of only one organisation the issue shall be adjourned, and the Chair of the CCG and Leader of the Council shall meet to discuss how the disagreement may be resolved, and shall bring the matter back to the next meeting of the ICC. If

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not resolved at that meeting, the resolution shall be deemed to have been defeated

4.5. In the event that an urgent decision is required, the Chair of the last meeting shall meet with the Chief Officers of each organisation and provided that consultation with members has taken place, a decision can be taken. If the decision in question is a matter for the Council, the same can be taken by the relevant portfolio holder.

5. Agenda Setting

5.1.The agenda will be agreed by the Joint Chairs of the ICC through an agenda setting meeting and forward plan managed by the SCF Team. The agenda will include details of any decisions to be made by the relevant Council member or officer in relation to aligned budgets.

5.2.The agenda will be circulated one week in advance of the meeting to bothSenior Leadership Teams.

5.3.The meeting and papers for the meeting will be made publicly available. The meeting will reserve the right to hold a “part 2” in private in the event of commercially sensitive information.

5.4.The ICC will be serviced by the SCF Team.

6. Frequency of meetings

6.1.The ICC will ordinarily meet bi- monthly.

6.2.The ICC reserves the right to schedule additional meetings, as required by the Chair of the last meeting, if required to deal with urgent business. If an additional meeting is held, the Chair of the last meeting will Chair the additional meeting.

7. Remit and responsibilities of the committee

7.1.Develop, refine, and adhere to the SCF Operating Model of the Place BasedStrategic Commissioning Function.

7.2.Develop and endorse the Joint Commissioning Intentions in partnership with providers in the Wigan Borough.

7.3.The ICC will support the new partnership structures in the borough including the Population Health Strategy Board, the Secondary Care Transformation Board and emerging infrastructure around Wigan’s Local Care Organisation to ensure the priorities set out within the Locality Plan are delivered.

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7.4. The scope of the pooled budget will be decided by the Council and the CCG. The ICC will then make decisions within the constraints of the budget set by the Council and the CCG and operate as the formal decision making authority of the Section 75 pooled budget.

7.5. Ensure a single commissioning perspective of the deployment of the budget that is aligned and in view. The scope of the aligned budgets and in-view budgets will be decided by the Council and the CCG and the ICC will operate within the set parameters.

7.6. The ICC will make commissioning decisions as required and any other decisions necessary to implement the same, subject to any delegation to Council officers or members within the strategic commissioning function. The ICC will make decisions regarding the management of commissioning contracts and report back to the CCG and Council.

7.7. The ICCs functions include the functions delegated to the Primary Care Commissioning Committee (PCCC). Those functions must be delegated to the PCCC as the ICCs sub-committee. Any other matters that require consideration by the ICC which are in the scope of the PCCC, (other than reports from the PCCC), must be carefully analysed in advance to identify any conflicts of interests.

7.8. Have a shared understanding of the health and social care system wide outcomes and quality assurance framework for Wigan Borough, and will support system providers for delivery against these.

7.9. The ICC has responsibility for addressing performance and quality issues within the health and social care system and therefore has the right to take corrective action as required, up to and including the re-commissioning or decommissioning of services.

7.10. To create the conditions that allows the emergence of an integrated and binding alliance of providers in accordance with the Locality Plan ambition to move towards a single local care system/organisation.

7.11. To ensure the partnership system of the Borough (as described in the Locality Plan) operates as effectively as possible.

7.12. To co-ordinate the development propositions that secure investment into the transformation of the Wigan Borough in support of the Locality Plan.

7.13. To set strategic development of health and social care, including primary care services, within Wigan.

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7.14. The ICC must ensure that appropriate consultation and engagement with service users or their representatives has taken place. This will involve close scrutiny of all papers that have been developed for consideration by the ICC, to identify the level of service user engagement. The ICC will send any papers that have not adequately demonstrated service user engagement back to the appropriate officer group for further work. The ICC may develop a list that identifies relevant patient groups that may be consulted. The list will be kept by the Secretary to the ICC.

8. Authority of the Committee

8.1.The ICC operates as a committee of the CCG where both the CCG and Council discharge its statutory function. Decisions made at the ICC are final and are not subject to further ratification by the Council Cabinet or Governing Body of the CCG.

8.2. It is noted and recognised that some statutory functions cannot be delegated to the ICC, including for example the CCG Audit Committee and Remuneration Committee. These committees must continue to report to the CCG Governing Body and as such will continue to meet quarterly in line with expectations from internal audit.

9. Conduct of the committee

9.1.The committee will conduct its business in accordance with Operating Principles for the SCF agreed at its establishment.

9.1.1. Good quality communication with residents and staff9.1.2. Clear plan with milestones9.1.3. Positivity to make a difference9.1.4. Open and Honest9.1.5. Solution focused9.1.6. Collaborative with providers9.1.7. Innovative9.1.8. People Focused

9.2.Furthermore the ICC will conduct its business in line with the Nolan Principles (The Seven Principles of Public Life).

9.2.1. Selflessness9.2.2. Integrity9.2.3. Objectivity9.2.4. Accountability9.2.5. Openness9.2.6. Honesty9.2.7. Leadership

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9.3.Save where inconsistent with these terms of reference the ICC shall operate in accordance with the standing orders of the CCG.

10.Dispute Resolution

10.1. In the event a dispute should arise within the ICC that cannot be resolved informally within the ICC itself, the following processes will be adopted:

10.1.1. For disputes that are within the scope of Section 75, the ICC will refer to the Section 75 dispute resolution procedures;

10.1.2. For disputes that fall within the scope of areas classed as in view or aligned, the ICC will refer to the dispute resolution process for the responsible sovereign body.

11.Supporting Group

11.1. The work of the ICC is supported by an Officer led Operational Group which will meet monthly and ensure all necessary papers are developed by the ICC. The membership of the Officer led Operational Group is to be appointed by the ICC

11.2. The CCG shall provide the administrative support for the Committee, including secretarial support and shall liaise with the Council to ensure that any records of decisions are fit for purpose for the Council. The CCG will be responsible for preparing and circulating draft minutes following each meeting of the ICC, with draft minutes being approved at the next meeting of the ICC.

11.3. The CCG will circulate the draft minutes to the Governing Body, subject to any redactions for confidentiality e.g. conflicts of interests etc.

12.Review of these Terms of Reference

12.1. The CCG and Council will jointly undertake a 6 month review of these Terms of Reference, membership and performance. Thereafter, an annual review will take place.

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REPORT TITLE: ICC Forward Plan 2019/20

REPORT AUTHOR: Tim Collins, Assistant Director, Governance (CCG)

PRESENTED BY: Tim Collins

RECOMMENDATIONS/DECISION REQUIRED: Receive

EXECUTIVE SUMMARY:

The attached schedule provides an indication of the headline items of business that will be presented to the Committee during this year. In addition to the detail in the table it is suggested that standing items for information may also include:

North West Sector Commissioning Group minutes HWP Board minutes Secondary Care Board minutes Mental Health Board minutes Population Health Board minutes

Members and officers are asked to consider the plan and advise the [email protected] of any changes including additions.

FURTHER ACTION REQUIRED: Advise/request changes


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mailto:[email protected]

INTEGRATED COMMISSIONING COMMITTEE FORWARD PLAN 2019-20

JUNE AUGUST OCTOBER DECEMBER FEBRUARYIntegrated Community Neuro and Stroke Rehabilitation Business Case

Draft Primary and Secondary care Commissioning Intentions 2020/21

Finalised Commissioning Intentions 2020/21

Service Redesign Business Cases

Finance & Commissioning Draft Plans 2020/21

Crisis Resolution and Home Treatment Business Case

Winter Planning and Investment

Complex Care Rehabilitation Pathway Proposal

National Contracting Guidance and Allocation

Community Services Programme – Closure and Next Steps

Community Response Team Business Case

Mental Health Strategy Refresh 2019/21

Strategic Commissioning Business

Strategic Commissioning Function Operating Model

Council and CCG Financial Outturn Positions 2018/19

Pooled, Aligned and In View perspective of the Integrated Commissioning Fund.

Risk Register/Assurance Framework

Transforming Care Progress

Risk Register/Assurance Framework

Better Care Fund Outturn 2018/19

Better Care Fund 2019/20 Finance Report Finance Report Finance Report

Drug and Alcohol Service CQC

King’s Fund Report Integrated Performance Framework

Integrated Performance Framework


Integrated Performance Framework Update


Quality System Quarter 2 Report

Communications and Engagement Update

Quality System Quarter 3 Report

Single Quality System Briefing

Quality, Equality and Safeguarding Annual Report 2018/19

Primary Care Standards Performance

Primary Care Standards Performance

Quality and Performance

Communications and Engagement Update

Greater Manchester Updates

GM Commissioning Review and 100 Day Commissioning Review

GM Joint Commissioning Board Business




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REPORT TITLE: Wigan Crisis Resolution and Home Treatment Business case

REPORT AUTHOR: Caroline Cain –Head of Operations North Locality (NWBH)

PRESENTED BY: Julie Crossley-Director of Commissioning

RECOMMENDATIONS/DECISION REQUIRED:

1) The Mental Health Programme Board recommends the ICC receive and approve the business case.

2) The Mental Health Programme Board request approval to progress implementation of the service with oversight provided by the Urgent and Emergency Care Improvement and Transformation Board and Healthier Wigan Partnership.

EXECUTIVE SUMMARY:IntroductionThe attached business for a Crisis Resolution and Home Treatment service is a pivotal component of the boroughs plan to transform mental health urgent care pathways and to improve the response and experience of people presenting to the system in need of urgent support.BackgroundLate in 2018 the Boroughs Urgent and Emergency Care Improvement and Transformation Board (UECITB) the Urgent and Emergency undertook a mapping exercise around the mental health urgent care pathways. The mapping exercise identified a number of gaps in the pathway, these were:

A lack of a 24 hour Crisis Resolution and Home Treatment Service as defined initially in the Five Year Forward Plan, Greater Manchester Health and Wellbeing Strategy and latterly in the NHS Long Term Plan.

A lack of alternatives to hospital admission for people presenting with acute distress and risk issues. Lengthy response time to assessing people brought into the section 136 suite by the police resulting in

significant loss of police time and distress for the patient. Safety issues for the Out of Hours assessment team based at Claire House.

A Mental Health Urgent Care Improvement plan was developed between the partners.GovernanceThe improvement plan was presented for approval at the following Boards;

The Wigan Borough Urgent and Emergency Care Improvement and Transformation Board The Wigan Borough Mental Health Programme Board

Cont./

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And went for information and discussion at; WWL Quality Safety and Safeguarding Board(QSSB) System Resilience Operational Group (SROG)

The plan met with approval from all forums.The benefits of the service

Reduction in mental health attendances at A&E Reduction in non-elective admissions to WWL Improvement in patient flow across the system and increasing bed availability at WWL An immediate response to a Section 136 reducing the associated police time 24/7 response to individuals experiencing acute distress Reduction in admissions to and increasing bed availability at Atherleigh Park Reduction in out of area admissions Improved multi-disciplinary ward team to support early discharge Reduction in length of stay on the mental health inpatient unit Provide 72 hour follow up appointment from discharge Support the reduction in suicide rates in line with National Suicide Prevention Strategy by 10%

The resources to fund the service are identified in the CCG Mental Health Investment plan.Recommendations

1) The Mental Health Programme Board recommends the ICC receive and approve the business case.2) The Mental Health Programme Board request approval to progress implementation of the service with oversight

provided by the Urgent and Emergency Care Improvement and Transformation Board and Healthier Wigan Partnership.

FURTHER ACTION REQUIRED: As above


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Business Case

Crisis Resolution Home Treatment Team 24/7Wigan

Date of Submission to Wigan Borough Clinical Commissioning Group Mental Health Programme Board 23 May 2019

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Document Control Page

Author(s): Caroline Cain, Head of Operations, Wigan North Angela Greslow, Business Development LeadEmma NazurallyBorough Assistant Director of Operations, Wigan, Bolton and Greater Manchester Approved by: Sarah PreedyBorough Assistant Clinical Director of Operations, Wigan, Bolton and greater Manchester

Verified by: Natasha LeeNWBH Finance Business Partner

Version Number: 15.0

Date of Bid Consideration Forum:

Wednesday 27 February 2019

Lee McMenamyDirector of Operations and Integration

Director Approval:Alice ForkgenAssistant Director of Finance

Chief Operating Officer

Chief Finance OfficerExecutive Director Approval:

Chief Executive

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Business Case:

Contents

Page

Executive Summary i

1. Purpose 1

2. Introduction 1

3. Current Service Provision 4

4. Proposed New Service Provision 5

5. Benefits and Risks Appraisal 7

6. Performance and Activity Measures 9

7. Financial Analysis 10

8. Recommendation 11

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Business Case: Page i

EXECUTIVE SUMMARY

North West Boroughs Healthcare NHS Foundation Trust provides a range of mental health services for people living in Wigan and Leigh.

Following the refresh of the Wigan Locality plan ‘ Further Faster Towards 2020’, the publication of the Greater Manchester Health and Social Care Partnership (GMH&SCP) Mental Health and Wellbeing strategy and the national planning guidance Five Year Forward View (FYFV) and Long Term Plan, the Wigan Joint Mental Health Strategy has been updated. Wigan Alliance have published a service specification to provide an urgent care system (one system multiple facilities) that is capable of delivering equitable access to the right care, first time for all aged patients through a networked model with services provided along robust pathways 24/7. (Appendix A).

Wigan borough has an adult population (18 years and above) of approximately 255, 867. Within this population, there are a significant large number of people who are at risk of having poor mental wellbeing in Wigan due to the high levels of deprivation. There are a high number of people who have alcohol and drug problems in the area, which has a significant link to mental health problems. It is estimated that 30.3% of adults in Wigan live in areas that are classified as being in the ‘most deprived’ group, and this is significantly higher than the England average of 0.3%.

Wigan Home Treatment Team currently provides 8am to 8pm, seven days a week intensive home support for adults 18 years and above with mental health problems in Wigan to support them to manage their conditions in a community setting and prevent admission to hospital providing a gate keeping assessment within 24 hours. The service currently is not sufficiently resourced to operate 24/7. It is envisaged by 2020/21 that Crisis Resolution Home treatment teams in all areas should be delivering in line with best practice standards as described in the Crisis Resolution Team Fidelity criteria. (Appendix B)

This business case proposes a new model for a 24/7 Crisis Resolution Home Treatment Team for the borough of Wigan based at Atherleigh Park Hospital, to improve the care of people aged 18 years and over who have a functional mental health illness and who are in crisis, by providing a 24 hour, seven days a week gatekeeping function for acute mental health beds as well as delivering intensive support within the person’s home to reduce the risk of admission to a hospital inpatient bed and providing a crisis response within the community.

In order to move to this new model recurrent resource of £804,273 is required. The aim is to commence a phased implementation from July 2019 therefore the investment required from July 2019 – March 2020 will be £603,204.

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1. PURPOSE

This proposed business case provides a supporting rationale for the need to increase the staffing establishment of the Wigan Home Treatment Team to become a 24/7 Crisis Resolution Home Treatment Team. This will enable the current service to maintain delivery of a safe, sustainable and quality service and also meet the increase in demand in line with Core Crisis Resolution Team Fidelity Scale produced and developed by Camden and Islington NHS Foundation Trust. The Core Crisis Resolution Fidelity scale is supported by the Independent Commission on Acute Adult Psychiatric Care, Five Year Forward Plan and the NHS Long Term Plan which states by ‘2020/21, all areas will provide crisis resolution and home treatment teams (CRHTTs) that are resourced to operate in line with recognised best practice as described in the Core Crisis Resolution Team Fidelity Scale to deliver a 24/7 community-based crisis response and intensive home treatment as an alternative to acute in-patient admissions.

Following the refresh of the Wigan Locality plan ‘Further Faster Towards 2020’; the publication of the Greater Manchester Health and Social Care Partnership (GMH&SCP) Mental Health and Wellbeing strategy; and the national planning guidance Five Year Forward View (FYFV), the Wigan joint mental health strategy has now been updated.

Wigan Alliance have published a service specification to provide an urgent care system (one system multiple facilities) that is capable of delivering equitable access to the right care, first time for all aged patients through a networked model with services provided along robust pathways 24/7.

The development of a 24/7 Crisis Resolution Home Treatment Team for the borough of Wigan, will improve the care of people aged 18 years and over who have a functional mental health illness and who are experiencing acute distress, by providing a 24 hour, seven days a week gatekeeping function for acute mental health beds as well as delivering intensive support within the person’s home to reduce the risk of admission to a hospital inpatient bed.

2. INTRODUCTION

2.1 Background

North West Boroughs Healthcare NHS Foundation Trust (NWBH) is a specialist Trust providing treatment, support and guidance for a wide range of health issues. These include physical and mental ill-health issues and learning disabilities for people of all ages living in the boroughs of Wigan, Bolton, Halton, Knowsley, St Helens, Sefton, Warrington and Greater Manchester. The Trust offers services in community clinics, day care centres, health and justice settings, and in-patient care for people with mental ill-health.

The Trust provides a range of mental health services for people living in Wigan and Leigh for example:

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Accident and Emergency Liaison Services within the A&E department of Royal Albert Edward Infirmary (Wigan and Leigh) to support patients with mental health problems. The team assesses the mental health of people who attend the A&E department with a mental health problem.

The Assessment Team provides specialist assessment, advice and signposting for adults with moderate to severe symptoms of mental illness such as severe depression and anxiety, as well as conditions like schizophrenia and bipolar disorder.

The Trust also provides an Early Intervention in Psychosis service for people age 14 to 65 in the borough of Wigan.

The Trust provides mental health inpatient services for adults in Wigan and Leigh - male inpatient unit Sovereign Unit and female inpatient unit Westleigh Unit. The Trust also provides inpatient services for older persons which include organic unit Golborne and functionality frailty unit Parsonage. The inpatient units provide a safe and comfortable environment to promote recovery and mental wellbeing, and meet individual needs.

Provision of a psychiatric intensive care unit at Atherleigh Park, Priestner's Unit for adults with the highest level of mental health needs.

2.2 Demographics

The Wigan Borough population for people 18 years and above (excluding people with a confirmed diagnosis of dementia) is 255, 867. However, the number of people who are at risk of having poor mental wellbeing in Wigan is high due to the levels of deprivation. There are a high number of people who have alcohol and drug problems in the area, which has a significant link to mental health problems. It is estimated that 30.3% of adults in Wigan live in areas that are classified as being in the ‘most deprived’ group (Index of Multiple Deprivation 2010). This is significantly higher than the England average of 20.3%. (Joint Mental Strategy for Adults 2014-2019, Wigan Council and Wigan Borough CCG)

From 2010, English Indices of Deprivation, Wigan is 85 on the average of layer support output areas (LSOA) rank, 1 being the Local Authority district most deprived and 326 the least deprived. Hence the case numbers for Home Treatment are expected to be significantly greater than that predicted by general population figures only.

2.3 Strategic Context

2.3.1 National Strategic Context

This business case fully supports the required transformational changes outlined in a number of key national, regional and local strategies including:

The NHS Five Year Forward View for Mental Health (Implementing the Mental Health Forward View: Adult mental health: Community, Acute, and Crisis Care);

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http://www.nwbh.nhs.uk/mental-health-intensive-care

3

Core Crisis Resolution Team Fidelity Scale – Version 2 by Camden and Islington NHS Foundation trust

Home Treatment Accreditation Standards (HTAS); NHS Long Term Plan (3.95 Emergency Mental Health Support) GP Five Year Forward View (including the high impact actions) Wigan Borough Locality Plan (refreshed August 2018); Primary Care Strategy (vision for general practice) Wigan Borough Mental Health Strategy (aligns & contributes to the 4 main

work programmes); The Deal for Health & Wellness

2.3.2 Local Strategic Context

Following the refresh of the Wigan Locality plan ‘Further Faster Towards 2020’; the publication of the Greater Manchester Health and Social Care Partnership (GMH&SCP) Mental Health and Wellbeing strategy; and the national planning guidance Five Year Forward View (FYFV), the Wigan joint mental health strategy has now been updated.

Wigan Alliance have published a service specification to provide an urgent care system (one system multiple facilities) that is capable of delivering equitable access to the right care, first time for all aged patients through a networked model with services provided along robust pathways 24/7.

The proposed new model for urgent care outlined in the Wigan Borough Mental Health Strategy has early intervention and prevention as a central theme. This will include additional intensive support for people within the community mental health teams to help maintain people’s health and wellbeing and also an enhanced crisis team who will be able to offer a range of support for people in or at risk of a crisis. This support will include day time centres and cafés, additional support in peoples home and the offer of a 24/7 bed based service within the community with trained staff, specialist practitioners and people with lived experience.

These services will be developed with partners from ambulance and police services, health and social care, service users and carers and voluntary organisations across the borough and will require further investment to enable the strategy to be fully implemented. Investment and the development of these community services across the urgent care pathway is essential to fully realise the benefit of a 24/7 Crisis Resolution Home treatment team.

A recent pilot of out of hours services across the Wigan borough including mental health, Greater Manchester Police and health and social care has highlighted the benefits of a multi-agency support team with a focus on early intervention and prevention. Work is now underway to mobilise and implement out of hours work as business as usual.

In the new model for urgent care there will be an enhanced community team which will include North West Boroughs Healthcare NHS Foundation Trust mental health link workers, working much closer with GPs and physical health and social care colleagues in the community. This will ensure that the pathways in and out of

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services are joined up and effective and communication between agencies and teams is improved providing a seamless service.

The new urgent treatment centre based at Christopher Home, developed in partnership with a wide range of organisations including Wrightington Wigan and Leigh NHS, GPs, Northwest Ambulance, Greater Manchester Police and those that care for them will provide an improved single point of access for those people who require emergency response 24 hours a day, seven days per week directing people to the most appropriate pathway that best meets their needs.

3. CURRENT SERVICE PROVISION

The Wigan Home Treatment Team currently provides intensive home support for adults with mental health problems in Wigan to support them to manage their conditions in a community setting and prevent readmission to hospital. The team involves families and carers, using a flexible approach which provides an alternative to inpatient admission and supports early discharge from hospital. The service is currently available from 8am to 8pm, seven days a week. The current team comprises of Band 6 staff qualified nursing staff and Occupational Therapist and Non-Medical Prescriber currently work early shift and a late shift pattern along with Support Workers. The Team Manager, Deputy Manager, Consultant Psychiatrist, Specialty Doctor, Assistant Practitioner all work Monday to Friday 09:00 – 17:00.

There are on average 6000 active open cases across Wigan Mental Health community and inpatient services including Think Wellbeing Service; anyone of which may experience acute distress and require a crisis response to support them. Acute distress is unpredictable and can happen at any time. This can be due to people experiencing adverse life events that include a psychological, physical or social element, which leads to a need for an urgent or emergency response from our services. This is evident across our community teams in particularly Wigan Recovery and Early Intervention in Psychosis Teams who are experiencing challenges to manage the increase in prevalence and acute distress. There is currently a time and motion study taking place to understand the impact of known service users experiencing acute distress.

3.1 Current Workforce Provision

The current workforce comprises of a Team Manager, Deputy Team Manager, Senior Nurse Practitioners, Occupational Therapist, Non-Medical Prescriber, Assistant Practitioner, Support Workers and access to Approved Mental Health Professional from Adult Social Care which forms part of the multi-disciplinary team.

The medical component is provided by 1 whole time equivalent (WTE) Consultant Psychiatrist and 0.3WTE Specialty Doctor this is in line with Core Fidelity Model based on the population of 255, 867. However it is envisaged that additional medical resource can be released once the Wigan Mental Health Assessment team is relocated to the Urgent Treatment Centre at Christopher Home to support the Crisis Resolution Home Treatment team to manage future demand.

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The administrative resource from the existing Wigan Mental Health Assessment Team and the existing Home Treatment team is to be reviewed to provide administrative resource across the Urgent Treatment Centre and 24/7 Crisis Resolution Home Treatment Team to ensure services have the right resource to support service provision.

The current Home Treatment Team shift patterns workforce model is detailed in Table 1.

Table 1: Current Home Treatment Team Workforce

Specialist WTE Early Shift08:00 - 16:00

Late Shift12:00 – 20:00

STR (Band 3) 4.80 2 1Mental Health Practitioner (Band 6) 16.00 5 4

This shift pattern is based on existing staffing establish taking into consideration annual leave, sickness and staff training.

4. PROPOSED NEW SERVICE PROVISION

The 24/7 Crisis Resolution Home Treatment Team will be developed using the Core Crisis Resolution Team Fidelity Scale model. There are 39 points to support the service to ensure they are equipped to deliver the core functions.

Key areas include the following:

Provide a 24 hour, seven day a week service which is short term, timely, intensive treatment to help the person manage their mental health crisis so that once they are stable they can start ongoing care planning with the appropriate team;

Respond to a referral from community specialist mental services which include: Recovery teams, Early Intervention in Psychosis Team, Mental Health Liaison Service and Later Life services within 30 minutes with assessments taking place within four hours or one hour for high risk referrals within 24 hours seven days a week

Respond to crisis phone calls within a maximum of 2 minutes;

Provide waking night staff who can and do visit known service users to provide quality care and assessments, responding to patient needs timely to support and manage their crisis preventing hospital admission providing hospital at home provision

Make new assessments at any time when needed on health service premises 24 hours a day this will include Urgent Treatment Centre and Atherleigh Park,

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Provide additional support in an identified and dedicated location as an alternative to admission, 7 days a week which will include Haven House and future Crisis Pad and Crisis Cafe ;

Ensure the length of visit meets the persons needs and allows time to give the most effective therapeutic, psychologically-informed care to help them through the crisis;

Provide a fully implemented “gatekeeping” role assessing all patients before admission to acute psychiatric wards and deciding whether they are suitable for home treatment. This includes all patients across the system who are deemed to be experiencing acute distress and will not exclude those currently being supported;

Manage acute distress for known service users and support service users assessed at the Urgent Treatment Centre (single point of access) who require intensive support;

Provide a distinct service which provides crisis assessment and brief home treatment for adults 18 years and over who have a functional mental health illness which will include motivational interviewing, medication review and prescribing, cognitive behavioural therapy, solution focused therapy, structured coping strategy, use of mood or activity diaries and structure problem solving.

Facilitate early discharge from hospital and offer a same-day home visit to service users discharged from hospital;

To respond to and assess in person people brought to a place of safety by the police on a S136 before a decision to admit to hospital is made;

To offer a gatekeeping assessment prior to/in conjunction with, an assessment of need under the Mental Health Act.

4.1 Proposed New Workforce Model

The current workforce has a Team Manager, Deputy Manager, Occupational Therapist, Non-Medical Prescriber, and access to Approved Mental Health Professional from Adult Social Care which will form part of the multi-disciplinary team. A review of the urgent care pathway will provide additional psychiatry and admin resource to support the service 24/7. In order to meet Core Crisis Resolution Team Fidelity Scale and to deliver the new proposed service provision, the following workforce will be required (Table 2).

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Table 2: Additional Workforce required supporting the New Proposed Service Provision

Proposed New

StructureCurrent

StructureAdditional Required

Early Late Night WTE WTE WTESTR Band 3 2 2 2 12.00 4.80 7.20Senior Nurse Practitioner Band 6 4 4 4 24.01 16.00 8.01Psychology/Clinical Lead 0.80 0.80Pharmacist 0.40 0.40

The workforce model is in line with the Mid Mersey Team and is based on the Crisis Resolution Team Fidelity Scale, draft criteria from NHSE National team and the Long-Term plan funding which advises a well-functioning’ CRHTT have an MDT of 14 WTE per 150,000 population and that the 14WTE staffing is for an optimal caseload of 25. Based on this workforce model and population served across the Wigan Borough, the CRHTT will support 42 service users at any one time.

5. BENEFITS AND RISKS APPRAISAL

5.1 Cost Benefits

Although some of these monetary figures are not cash releasable, they indicate where the CRHTT will have a positive impact on across the Accident and Emergency Department (AED), Greater Manchester Police (GMP) and secondary mental health services to enable early intervention and prevention across the crisis urgent care system and improve patient flow across the system through deflection of demand.

Data from the Mental Health Liaison team reports there are on average 29 avoidable attendances at A&E per week (1508 per annum). Based on NHS Improvement reference costs one attendance at A&E costs £160. If we assume the 29 avoidable attendances remain the same over a 52 week period, the annual cost saving is £241,280.

Data from the Mental Health Liaison team reports there are on average nine avoidable non-elective admissions per week at WWL. Of the nine, five require admission to a mental health unit. Based on NHS Improvement reference costs, each non-elective admission costs £1603. Therefore if we make the assumption there are four avoidable non-elective admissions at WWL over 52week period (208 per annum), the annual cost saving is £333,424. The combined annual cost saving will be £574,704. Based on the above assumptions, the demand on staff resource within AED will be reduced, improve patient flow and increase bed availability at WWL.

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Currently there is a delay in Wigan Mental Health Assessment team (based at Claire House) responding to a Section 136 due to the geographical position of the 136 Suite (based at Atherleigh Park). This delay impacts on Police time spent waiting with patients at the 136 Suite. On average over the year there are 72 Section 136’s resulting in two Police officer waiting on average three hours. The overall cost to Greater Manchester police time is 432 hours or 11.5 weeks per annum (based on a 37.5hr week). The new 24/7 CRHTT will be based at Atherleigh Park therefore response to the 136 Suite will be immediate.

The 24/7 CRHTT will be able to respond to individuals experiencing acute distress across the system and provide specialist interventions to support individuals and their families to avoid attendance at AED, admissions to a mental health inpatient bed, reduce out of area admissions and reduce suicide rates in line with National Suicide Prevention Strategy by 10% (see Appendix C).

The role of the 24/7 CRHTT will be vital in reducing the length of stay on the mental health inpatient units working with the ward multi-disciplinary team to support safer discharges back in to community mental health services ensuring a follow up appointment within 72hours of discharge.

5. 2 Re-Investment of existing Funding and Resources

The re-investment of existing funding and resources demonstrates a cash saving to support the implementation of the 24/7 CRHTT

Re-investment of existing funding into the 24/7 CRHTT includes: the Bluelight pathway, Surge Nurse and Sanctuary. (see table 3 Financial Breakdown)

The relocation of the Wigan Mental health Assessment team to the Urgent Treatment Centre will release Consultant Psychiatry resource which is to be invested into the 24/7 CRHTT. Therefore no additional investment for psychiatry resource is required.

5.3 Risks

The 2018 Community Mental Health Survey (Care Quality Commission, NHS Patient Survey Programme) reported that whilst there has been a positive trend in the proportion of respondents knowing who to contact out of hours when experiencing crisis, 18% of respondents who tried to make contact when experiencing crisis said they did not get the help they needed. Additional 3% were unable to make contact at all. The impact of not receiving help at the right time, by the right service leaves individuals and their families dissatisfied impacting on other services across the Crisis Urgent Care Pathway which includes: AED, GMP and Urgent Treatment Centre.

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According to the latest figures from NHS England’s Mental Health Five Year Forward View dashboard, only 24% of crisis resolutions home treatment services were able to meet the selected ‘core functions’ in 2016/17. Core functions include an urgent and emergency community response and intensive home treatment, available 24 hours a day, seven days week.

Emergency referrals to Wigan secondary mental health services have significantly increased. In April 2019, there were 210 emergencies referred to the Wigan Mental Health Assessment team. This is the highest number of emergency referrals received from across the system to date which includes General Practice, Greater Manchester Police, Northwest Ambulance service and self-referrals. The increase in emergency referrals impacts on the capacity to manage non-emergency referrals and overall patient flow. This results in individuals experiencing acute distress leading to increased attendance at AED which impacts on the wider health system.

There is a risk to a potential delay in recruitment for qualified nurses due to national shortage and a highly competitive job market regionally.

If full investment is not received, the service will not be able to achieve the Core Fidelity Standards to deliver a safe, effective and quality service 24/7 Crisis Resolution Home Treatment team for the Borough of Wigan in line with the Five Year Forward View and the Long Term Plan.

Without investment there will be a detrimental impact on the Wigan Alliance service specification to provide an urgent care system (one system multiple facilities) that is capable of delivering equitable access to the right care, first time for all aged patients through a networked model with services provided along robust pathways 24/7. This includes crisis pads, crisis cafes, mental health link workers across the SDFs, and the relocation of the Assessment Team to the urgent treatment centre.

6. PERFORMANCE AND ACTIVITY MEASURES

Quality Measures In line with North West Boroughs Healthcare NHS Foundation Trust Quality Strategy the following will be measured using the electronic patient record, information management system and staff survey:

Positive Patient Experience – Friends and Family Test to be completed to capture patient and carer experience and increase in compliments

Value Added Care and New ways of Working – HoNOS/routine outcome measures to be agreed in order to measure the effectiveness of the interventions score will be reduced

Quality Assurance and Reducing Harm – decrease in the number of patient harm incidents of moderate severity that are as a result of patients experiencing crisis in the community;

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Happy Team – reduction in sickness and staff retention

Operational Measures The electronic patient record RiO and the information management system will be used to monitor the following objectives:

Number of referrals to CRHTT Response times from referral to contact by CRHTT Number of same day assessments delivered for new referrals Number of same day assessments supporting early discharge Total number of contacts per patient and length of time Total number of admissions to inpatient Delayed Discharges Offer of NICE recommended interventions

Length of stay in service 2-4weeks, 4-6weeks and 6>weeks

These measures are based on new measures to provide assurance the service is providing and effective service in line with the Core Crisis Resolution Team Fidelity scale; existing key performance indicators for seven day follow up from discharge will also continue.

7. FINANCIAL ANALYSIS

The current workforce has an Occupational Therapist, Non-Medical Prescriber, and access to Approved Mental Health Professional from Adult Social Care which will form part of the multi-disciplinary team. A review of the urgent care pathway will provide additional psychiatry and admin resource to support the service 24/7.

Table 3: Financial Breakdown of Investment Required for July 2019 – March 2020

Table 32019/20 - July 19 -

March 20 WTE £Direct 16.41 524,749Indirect 78,455Total 603,204

Set up costs 24,612

Less Current Provision for –

Sanctuary sub contract ended 31st March 20192019-20 Resilience Scheme MH Surge Capacity Service 2019-20 Resilience Scheme MH Pathways Claire House6mth Sanctuary covered internally Additional Investment

147,854 92,696 61,162301,492

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Table 4: Financial Breakdown of Recurrent Investment Required from April 2020 – March 2021

Table 42020/21 - Annual WTE £Direct 16.41 699,666Indirect 104,607Total 804,273 * subject to uplift

Less Current Provision for –

Sanctuary sub contract ended 31st March 20192019-20 Resilience Scheme MH Surge Capacity Service 2019-20 Resilience Scheme MH Pathways Claire House

Investment Required

147,854 92,696 563,723

8. RECOMMENDATION

NHS Wigan Clinical Commissioning Group are recommended to discuss and approve this Business Case to support the increase in the staffing establishment of the Wigan Home Treatment Team to become a 24/7 Crisis Resolution Home Treatment Team. This will enable the current service to maintain delivery of a safe, sustainable and quality service and also meet the increase in demand in line with Core Crisis Resolution Team Fidelity Scale.

We recommend close liaison and consultation with Commissioners to continue to direct service delivery, be responsible to local need and inform the continuous development of the 24/7 Crisis Resolution Home Treatment Team.

On approval of the business case the Trust will aim to commence a phased implementation from July 2019. The contract will form part of the block contract for the existing Home Treatment Team.

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APPENDIX A

Wigan Crisis Model 1.docx

APPENDIX B

fidelity-scale-final-pdf.pdf

APPENDIX C

Suicide Prevention Slide.docx

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REPORT TITLE: Update on Transition of Community Services and close down of phase 3 of the programme – June 2019

REPORT AUTHOR: Adele Markland and Julie Crossley

PRESENTED BY:Stuart Cowley, Director for Adult Social Care and Health

Julie Crossley, Director of Commissioning


Report is provided for information and a decision is required on how phase 4 will be managed.

EXECUTIVE SUMMARY

This is the final report following the transition of Community Services. The sections of the report cover:

1. Closure of the Community Services Transition Programme2. Lessons learnt from the Community Services Transition Programme implementation3. Governance process for outstanding actions, risk and issue that need to be resolved4. Phase 4 transformation5. Summary of next steps6. Recommendation

The ICC is asked to:

1. Accept the phase 3 is completed and to note the reflection that has been provided of the programme.

2. Support the governance to take forward the outstanding actions from the programme.3. Support HWP taking forward phase 4 of the programme and how it will be managed and

reported.



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Update on the Transition of Community Services and close down of phase 3 of the programme – June 2019

1. Background

1.1. This paper provides an update to the Integrated Commissioning Committee (ICC) on the Community Services Transition Programme. The following areas will be covered in the paper:

Closure of the Community Services Transition Programme; Lessons learnt from the Community Services Transition Programme

implementation; Governance process for outstanding actions, risk and issue that need to be

resolved; Phase 4 transformation; Summary of next steps; Recommendation.

1.2. The reporting period for this paper covers mid-March to June 2019.

2. Closure of the Community Services Transition Programme

2.1. As the ICC is aware the transition of Community Services has been successfully completed within the timescales set by the Joint Commissioners.

2.2. The Community Services Transition Programme has been delivered in 4 phases as described below:

Phase 1 – To determine the scope of the services to transfer and select the stability provider. (Completed)

Phase 2 – To complete a full due diligence on services transferring (including finance, operational issues, HR and workforce and ensure mitigation against all risks). (Completed)

Phase 3 – To safely transfer the service to the stability partner(s). (Completed) Phase 4 – To develop and progress towards the LCO (Provider). (Commenced

April 2019)

2.3. The purpose of this paper is to provide a fixed point of acceptance that phase 3 has now been closed and that any ongoing actions are being managed as ‘business as usual’. These are summarised in section 4 of this paper.

2.4. Phase 3 of the programme was successfully completed by the agreed timescale of the 31st March 2019. In the last programme update report presented to the March 2019 shadow Joint Commissioning Committee key deliverables were outlined which required completion. The table below summarises the progress to date:

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Action Date Progress

Agree final staff transfer list

21st March 2019

All staff have now been aligned to services. There are a number of vacant posts which Community staff can apply for. (Complete)

Deliver staff engagement sessions

21st March 2019

Three staff engagement were held on the 21st March and were attended by a variety of staff. (Complete)

Recommendation on Community Services contract length

26th March 2019

The recommendation for a 2+1+1 contract was approved at the March CCG Governing Body and shadow Joint Commissioning Committee. (Complete)

Decision from WWL Board on the Community Service transfer

27th March 2019

The WWL met on the 27th March and agreed the transfer would go ahead on the 31st March. (Complete)

Commissioning and legal leads need to complete the Community Services Transfer Agreement

31st March 2019

The Commissioning and WWL leads signed the Community Services Transfer Agreement (CSTA) on the 29th March. (Complete)

Provider and legal leads need to complete the Business Transfer Agreement (BTA)

31st March 2019

WWL have signed the BTA, however, a signature is still required from Bridgewater. NHS Improvement is managing the arbitration process between the 2 parties. Responses need to be drafted to NHS Improvement by the 5th June. (Outstanding and subject to separate discussions)

Transfer of business assets to WWL pending Board decision and Business Transfer Agreement (BTA) signing

31st March 2019

This action cannot be completed until the BTA has been signed by Bridgewater as that is the legal transfer of assets. However, staff can still access building and equipment. (Outstanding and subject to separate discussions)

Finalise and approve SLA’s

31st March 2019

The Infection Control and Adult Safeguarding SLA’s were not required as WWL recruited to vacant posts or seconded to vacant Community posts.

The Medicines Management SLA was only required for 3 months post transfer as this has not been progressed and finalised. This is now being managed by WWL.

The IT and Informatics SLA is still not completed.(Outstanding and subject to separate discussions)

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2.5. There is a final Community Services Transition Programme Board on the 19th June and this will pick up any updates on the outstanding actions listed above.

3. Lessons learnt from the Community Services Transition Programme implementation

3.1. This section of the paper records the closure of phase 3 of the programme, summarises the feedback and lessons learnt. Information has been captured throughout the duration of the project to populate this paper.

3.2. Leads involved in the Community Services Transition Programme were asked to provide their views on the delivery of the programme. This will be discussed in more detail on the 19th June and any additional information will be shared along with the presentation of this paper to ICC.

3.3. The table below summarises the positive feedback received from officers involved in the programme:

Theme Positive feedbackLeadership Fortnightly informal senior leadership meeting to resolve

outstanding issues was positive and provided the opportunity for current issues to be discussed.

Appropriate Senior Responsible Officers led the task and finish groups.

The whole programme supported the approach to deliver the Healthier Wigan Partnership vision.

Real buy in from WWL and the Joint Commissioners. The programme leaders demonstrated energy and resilience

to deliver this programme.Relationship Relationships were positive regarding programme delivery

from WWL and the joint Commissioners.Governance It was felt that having a clear programme structure was

beneficial i.e. SRO leads, ToR outing roles of task and finish groups provided a blueprint that people can work to.

Issues escalated at Programme Board were resolved timely to support the tight timescales of the programme.

Appropriate attendance at meetings and actions were followed up.

Involvement of the internal legal team was helpful and reduced the requirements for external support.

Directors of Nursing provided assurance on day 1 to ensure safe transfer of services.

Timescales Phase 3 of the programme was delivered on time and it supported contract discussions with the new Provider.

Programme management

Regular reporting to sJCC/ICC, CCG Governing Body, Cabinet were well received and provided regular updates.

Recognition of the support provided from the PMO provided transparency and the regular updates to the Boards.

The PMO facilitated the follow up of actions and risks on an ongoing basis.

Milestones Milestones were reviewed regularly from both a Provider and

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Commissioner perspective.Risks and issues

Risks and issues were discussed by all groups and escalated to the Programme Board, reported and shared with the sJCC.

Contract management

Collaborative working produced service specification to reflect the new models of care for Children’s and Adults to be delivered by the Community Services.

Quality and Contract monitoring processes designed and implemented post transfer, including KPI’s.

Really positive that both the Resilience Operations and Delivery and Contracts and Commissioning groups have been closed down with any outstanding business transferring across to the WWL Community Services Contract Monitoring Group meetings.

Workforce Multi organisation leadership team delivered staff engagement sessions to brief the workforce.

Information shared with staff internally at Bridgewater. Engagement with staff side throughout the programme.

3.4. The table below summarises feedback where we can learn for future programmes:

Theme Description of lessons learnt for future programmeLeadership There were changes in key leads during the programme which

was problematic at times.Relationships Overall the work and outcomes were successful but the

process at times were extremely challenging. Engagement by all key parties is crucial and this was not

always the case. The programme required the intervention of NHS

Improvement.Governance Due diligence wasn’t as complete as required for the transfer

i.e. IM&T was too light touch and didn’t go into enough granularity. This has had knock a knock on affect to the estimation of work, resource and time needed.

Disappointment that the SLA’s were not completed on time.Timescales Slippage in the due diligence completion which impacted on

the programme.Programme management

Preparation for the SRO’s to lead the groups to understand role, responsibilities to deliver the programme objectives.

Milestones At the outset of the programme it was felt that the timescales were overly ambitious, but they were delivered.

Risks and issues

Reporting and performance was an issue from the outset further progress has been made during the programme but it wasn’t concluded.

Not completing the SLA for IM&T and Business Intelligence has created further risks.

4. Governance process for outstanding actions, risk and issue that need to be resolved

4.1. It was agreed that some of existing programme governance would continue post March 2019. The Programme Board, Commissioning and Contracting and Resilience, Operations and Delivery Group continued to meet until the groups

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agreed they had reached an end position. The actions from the HR, Communication and Finance task and finish groups were all closed.

4.2. The table below captures all residual actions, where they were raised and how they are being managed and progressed from June 2019 onwards:

Meeting name where an action was raised

Action description Meeting where action is now managed

Lead

Managing the waiting lists for patients waiting for treatment <40 weeksLearning Disability Service specification development Implementation of the Walk in Centre action planManaging the communication process for new patient referrals during the transition period

Resilience, Operations and Delivery Task and Finish Group

Community Services KPI development

CCG Contract Monitoring Group

CCG Commissioning Lead

Novation of the sub contracts

WWL Ops group

WWL

Data quality cleansing process on open ended Community referrals



Commissioning and Contracting

Service Development Improvement Plan



Community Services Programme Board

BTA to be signed and to be escalated to NHS Improvement and ICC if not signed


System Leaders

4.3. A number of risks were closed in March 2019; however, there are still some

outstanding risks to resolve and some of the risks scores have increased since the transfer. Therefore to support mitigation a further column has been added to the table below to advise on how the risk will be addressed and where the risk will be managed from June 2019 onwards.

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4.4. The open programme risks are summarised below:

Risk Score Mitigation Score after mitigation

Risk owner

Likely outcomes /Timescales to resolve risk

Risk 1:Financial stranded costs and apportionment of overheads

16

Escalation to DoFs, issue to be discussed and addressed at Finance Task and Finish Group. Bridgewater need to provide assurance to the Finance Task and Finish Group on what actions have been undertaken and what is being undertaken to mitigate these costs.The system recognises that there are existing principles that have been used to address stranded costs.

12

WWL Financial position is now subject to NHSI arbitration.

Risk passed to operational meetings at WWL.

Risk 2:Availability of information for performance framework KPI's

12

Discuss and manage through the commissioning and contracting task and finish group. Mapped out ICS services and current KPIs.All partners are working together to ensure that an outcomes framework which includes Asset Based principles is developed.Significant progress has been made to develop KPIs which reflect the current service. Work is ongoing to ensure this is part of the performance report.

6

WWL Data quality and associated improvement work is a priority. This is subject to further due diligence.


Risk 3:WWL unable to complete statutory returns if

20

Ongoing meeting happening between BI/Analytics teams to ensure that data and reporting requirements are understood.

15

WWL Delays to developing SLA have meant mitigation risk score has increased from 12 to 15. IM&T SLA remains unsigned and isn’t agreed. Data quality is a significant risk to WWL and the wider system.

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Data/Information is not accessible from Day 1 post transition

Opportunity to get TPP to meet with WWL colleagues to gain a better understanding of system capabilities prior to transition.


Risk 4:Estates Statutory Compliance. There is a concern that there is an absence of statutory compliance within some/all Bridgewater properties. The due diligence undertaken by EY has identified little or no evidence to suggest otherwise. This is a safety, legal and financial risk to WWL.

20 WWL to undertake statutory compliance surveys/ inspections in advance of 1 April 2019 to either address or fully understand extent of risks.

12 WWL WWL Estates are in the process of completing a range of statutory compliance surveys using external specialists. Work to date includes; Asbestos survey of all freehold premises, Water Safety survey and risk assessment and gas safety compliance. Good progress is being made and no asbestos problems have been identified. The water safety RA's have identified a range of issues which have been sent to EW FM for immediate action and provision of evidence. There is an issue with Atherton HC (LIFT) which was surveyed by mistake, however, a range of issues have come to light that have been escalated to CHP for urgent action. WWL are meeting with CHP to obtain assurances on all other LIFT premises. WWL are in the process of assessing all environmental issues with a view to prioritising the limited financial resources available (£670k). It should also be noted that Infection Control are also identifying issues which require attention. These are outside of the original E&F funding request and will require additional non-recurrent resources to eliminate.

Risk passed to operational meetings at WWL.Risk 5:Novation of Contracts/ Assignment of Leases. There

20 Bridgewater and WWL Estates to urgently agree schedule.Bridgewater to novate/assign as required urgently.

12 WWL WWL Estates continues to work closely with Browne Jacobson solicitors to progress the property transactions. There has been good progress, however still a number of issues remain. The unsigned BTA is impacting on

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is a concern that this will not be completed by 1 April 2019. Potential risk of occupancy/service continuity.

WWL’s ability to revolve and complete this process. WWL are still working with suppliers of services to put new agreements in place and so far this has gone well due to their cooperation. WWL are finding a number of contracts that are not satisfactory and will require additional elements to ensure a compliant resilient service.


RISK ASSESSMENT SCORING MATRIXLIKELIHOOD

RARE UNLIKELY POSSIBLE LIKELY ALMOST CERTAIN

IMPACT / CONSEQUENCES

(1) (2) (3) (4) (5)ALMOST NONE (1) 1 2 3 4 5MINOR (2) 2 4 6 8 10MODERATE (3) 3 6 9 12 15MAJOR (4) 4 8 12 16 20CATASTROPHIC (5) 5 10 15 20 25

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5. Phase 4 transformation

5.1. Phase 4 of the programme is to deliver transformation as set out in the Wigan Locality Plan. This model will promote:

Out of hospital working across the 7 SDFs; Local access in each locality for Community Services; Admission avoidance.

5.2. Community Services working with Primary Care within each locality will the deliver the model via:

Community Rapid Response; Active Care; Complex Care.

5.3. As part of this community model it will align physical and mental health to support people in the community. This work has started following the completion of the transition of Community Services. A separate division within WWL and the new contracting arrangements will support the further development.

5.4. Phase 4 of the programme will require the system to work together to develop the Healthier Wigan Partnership into the LCO for Wigan Borough. The implementation plan for Phase 4 still needs to be scoped out and timescales agreed on when this will be delivered by the HWP Board. This work will be led by Healthier Wigan Partnership, working with Providers and Commissioners to develop the future model. The independent Chair or HWP has proposed this model will be developed in a workshop over the summer.

6. Summary of next steps

6.1. The programme to support the transition of Community Services has been completed. Separate discussions are still ongoing in relation to the BTA and SLA between the Provider organisations (WWL and Bridgewater).

6.2. All risks have been closed with the exception of the 5 listed above which have been transferred to the WWL Programme Operations meeting.

6.3. The new Community Services contract is signed and contract monitoring framework is in place to monitor the contract and quality of service provision.

6.4. Phase 4 has commenced and this will be further developed as part of the HWP workstreams.

7. Recommendation

7.1. The ICC is asked to:

Accept that phase 3 is completed and to note the reflections that have been provided for the programme.

Support the governance to take forward the outstanding actions from the programme.

Support that HWP will take forward phase 4 of the programme and how it will be managed and reported.

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REPORT TITLE: Wigan Borough Integrated Community Neuro & Stroke Rehabilitation Model

REPORT AUTHOR: Gill Rowlands, Assistant Director Community Commissioning, WBCCG

PRESENTED BY: Gill Rowlands – Assistant Director Community CommissioningJulie Crossley – Director of Commissioned Services


The ICC are asked to approve this business case.

EXECUTIVE SUMMARY:

Introduction

The purpose of this paper is to provide the ICC with an update on progress being made around the delivery of the Integrated Community Neuro and Stroke Model for the Wigan Borough. As the Committee are aware GM have mandated that from October 2019 all CCG’s will implement the mandated model within their own localities.

FURTHER ACTION REQUIRED: As above


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1 Introduction The sJCC approved the model in December 2018 and agreed to progress to full business case in order to support the enhancement of the Community Model.

1.1 This paper sets out the:

Model Investment Implementation

2 Progress November 2018 to May 2019:

2.1 A task and finish group was established in January 2019 led by the CCG, to undertake the work required to produce a full business case based on the GM model and standards, to include the financial investment required to enhance the community model. The group included all partner organisations NWBH, WWL NHS FT, WBCCG, and WBC.

2.2 A number of meetings were established within the timescale to review data, information, and to scope out the current service delivery model and how the service will be enhanced for Wigan Borough people, in line with the GM specification and standards.

2.3 A business case was developed in March 2019 and has been presented through local governance routes

Clinical Leadership Team (CLT) December 2018 Senior Leadership Team (SLT) December 2018 Joint Commissioning Committee (JCC) December 2018 Senior Leadership Team (SLT) February & April 2019 Healthier Wigan Partnership (HWP) Board – May 2019 Integrated Commissioning Committee (ICC) – June 2019

It was agreed that due to timescales and the meeting schedules, that this business case was presented to the Healthier Wigan Partnership (HWP) Board on 8 May 2019 to fully approve the Wigan community rehabilitation model and HWP Board gave permission to progress to immediate implementation in order to commence the new model in October 2019.

2.4 It is recognised that ICC needs to support the financial investment required and endorse the decisions made by the HWP Board as to not delay the implementation of the integrated community model.

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CCG investment has included the cost of implementing the enhanced model this year in Q4. Therefore the additional investment required for 2019/20 is £197,861.

The full investment cost to enhance the community service from 2020/21 is £791, 446.

2 Risks to Delivery

3.1 Workforce: The workforce requirements and availability is known at this stage, however there could be delays in implementation of the model due to recruitment of staff

3.2 Finance: The GM Model assumes that the delivery is cost neutral, however there are costs associated with delivering the service model and this has been determined via the multi-disciplinary task and finish group meetings

3.3 The risk on not approving the business case will impact on:

People of Wigan Borough – Access to Community Rehabilitation Acute providers & Rehabilitation Units-Increased length of stay Impact on the new GM Inpatient model – Delays associated

4 Benefit to Wigan Locality4.1 The business case outlines the benefits realisation which will be £319,581 based

on the following areas as outlined in the table below.

AreaGM

Calculated Saving

Rationale for inclusion/ExclusionAverage bed

day cost

Average patient

number per year

Bed days saved per

patient

Updated Saving

Current Spend

Slow stream admission avoidance

£100,123

The GM calculation uses the wrong daily price. GM calculations would mean WBCCG need to save 250 bed days. We have two patients in slow stream at present, so the GM bed days saved would mean reducing to 1 patient.

£855.3 2.7 51.9 £118,489 £532,657

Reducing post-acute LoS

£257,324

The calculation shows Wigan LoS average as 90.7, however it is actually 71. When updated, this would create a much smaller saving. The bed day rate in the calculation is also inflated from that paid in Wigan.

£385.7 26.0 2.5 £25,298

Post-acute admission avoidance

£283,696

The price rate is inaccurate (too high) as is the average LoS (being the same as that used above). The calculation suggest 7 patient admissions prevented based on Wigan population but there is no evidence to support this.

£385.7 7.0 65.1 £175,793

Total £641,143 £319,581 £2,262,832

Updated Calculation

£1,730,175

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5 Financial Investment5.1 The attached business case requires additional investment to this service.

The investment required is set out below:

Clinical Modelling – Full Financial Year

Current 2019/20 Contract value for Community Neuro & Stroke Services £958,549Additional staffing required for new model (17.94wte) £791,446Adjusted 2019/20 Contract Value for Community Neuro & Stroke Services £1,749,995

5.2 To understand what the new investment is supporting, the table below shows where the investment will be utilised. To note, this is predominantly enhancing the current workforce.

POST BandIncrease in Staff Group from Current Service to GM Spec

Administrator 2 1Administrator 3 1Therapy Assistants 3 2.57Therapy Assistant 4 2.6Occupational Therapists 5 0Occupational Therapists 6 1Occupational Therapists 7 0.67Physiotherapists 5 0Physiotherapists 6 1Physiotherapists 7 1Dietician 5 0Dietician 6 0Dietician 7 0.6Speech & Language Therapists 5 0Speech & Language Therapists 6 1Speech & Language Therapists 7 1Social Worker/Self-management Lead G9 0Neuropsychology Assistant 5 1Clinical Neuropsychology 8a 0.8Clinical Neuropsychology 8c 0.2Senior Nurse 6 0.8

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6 Feedback from HWP6.1 Following a full discussion which included challenge from the clinical team, the

business case was supported. There was a full discussion relating to the governance routes and next steps which was for the business case to be presented at ICC to approve and progress to implementation.

6.2 HWP acknowledged the risk regarding workforce and this was particularly supported by all parties including: Clinical Lead, Primary Care, WWL Medical Director and the Chief Nurse from NWBH.

7 Implementation7.1 In advance of ICC fully endorsing this business case and to support the tight

timescales, an implementation group has been established which will be taken forward by WWL FT and WWL Community Services under the responsibility of the WWL Medical Director.

7.2 The implementation group are developing a full plan to ensure that HWP deliver the new service model.

8 Summary8.1 This business case has been developed to meet GM requirements and to

support patients with neurological needs within the community. There are

Neuro CM 7 1Nurse 7 0Team Leader 8a 0.7Consultants cover n/a 0Total increase of WTE 17.94

Current WTE

Proposed WTE

Additional

Stroke 10.22 10.22 0.00Neuro 16.20 34.14 17.94Total 26.42 44.36 17.94

Additional WTE 17.94Costing at 19/20 Top of Scale Rates £791,446Costing at 19/20 Mid Point Rates £739,859

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benefits which will be delivered across the borough, the current services and to the patients and its carers. This will enhance the current service provision to reduce waiting times etc., as set out in the business case.

9 Recommendation9.1 The ICC is asked to:

Approve the business case Approve to progress to fully implement the enhanced model To support progress to monitor the implementation via HWP

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Health & Social Care Investment ProposalPlease check SharePoint via the following link for the latest version of this documentLink to be added when document is agreed as final

1. SCHEME DETAILS

Title Integrated Community Neuro and Stroke

Rehabilitation Model(ICNSR)

Log number(Finance to complete)

Owner Gill Rowlands Facilitators (names, roles, organisations and contribution)

Gill Rowlands-WBCCG- Commissioning

Helen Scott-WBCCG- Finance Peter Edwards – WBCCG-

Commissioning Lynne Savage-WBCCG-Quality Helen Mee-WWL- Therapy

Lead Dr T Gaber-WWL- Consultant

Physician Karen Lea-BCHFT Sarah Allcock-BCHFT Dr S Mullen-NWBH-Consultant

in Neuro Psychology Niamh Rigby-LA-Service

Manager Therapies

2. EXECUTIVE SUMMARY (Please indicate, if appropriate, if this scheme has been successfully implemented at any other locality and whether the scheme is mandated or not)

Neuro-rehabilitation has been identified as a service transformation priority for the Greater Manchester Theme 3 work programme, the reconfiguration and standardisation of Acute and Specialist services and how they are delivered across Greater Manchester.

The model of care that is required is that an Integrated Community Neuro-Rehabilitation Service (ICNSR-Neurology and Stroke) is commissioned in all areas of Greater Manchester (GM), to the same GM wide specification.

The ICNSR model was developed by the GM Operational Delivery Network, a collaboration of both the stroke and neuro ODNs, and was approved by the Theme 3 Board and Executive in April 2018.

Joint Commissioning Committee (JCC) approved the model in November 2018 and agreed to progress the requirement for an enhanced community model.

It has been mandated that all localities across Greater Manchester must have an Integrated Community Neuro and Stroke Model implemented by October 2019.

To date, integrated community models have been implemented in Stockport/North Manchester, East Cheshire and will be implemented in the very near future within the Salford locality. Other localities are developing their localised business cases.

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This business case has been written to underpin the mandated model and specification and to identify any key risks that would delay the implementation of this integrated service delivery model across the Wigan Locality.

Total additional funding requirement is £791,446 (£471,665 if savings are realised).

Finance, availability of workforce and understanding the true activity demand has been identified as significant challenges to localities across GM including the Wigan Borough.

3. HWP Strategic Fit

Please indicate which Healthier Wigan Design Principles the initiative will deliver? (please see list in principles in Appendix A)

It is envisaged that this integrated service for neuro and stroke will be implemented and delivered by HWP once the business case has been approved and ratified through local governance routes.

Consideration has been given to the HWP design principles as to how the ICNSR model will be delivered. The model has not just been modelled against operational principles but also equality and inclusion characteristics for all people across the Wigan Borough.

The aim of the model is to provide an equitable community based neuro and stroke rehabilitation service across the Wigan Borough that strategically fits with the Wigan Locality Plan, offering care closer to home for our residents and their carers. The community offer is also to be developed in line with NICE guidance and the Royal College of Physicians national Clinical Guideline for Stroke (2016).

In line with the HWP design principles, Integrating the neuro and stroke community team will:

Ensure that all people residing across the 7 Service Delivery Footprints (SDF) will have access to the integrated team

The model will support individuals and their families by offering care closer to home and/or within the community setting

The model will incorporate full integration of teams, with MDT and huddle working which allows teams to focus on early interventions, preventative measures to support patients to not require acute hospital services and will promote management care planning, care coordination using the asset based approach.

The model has already had a full patient engagement programme which was undertaken by the Greater Manchester Operational Delivery Network (GMODN), which allowed the model to be co-designed by patients and their carers, to showcase the real lived experience.

This integrated model has been discussed in collaboration with strategic clinical leads Dr Tarek Gaber (WWL & MFT) and Dr Stephen Mullin (NWBH) and has taken a real collaborative multi organisational steer in the form of a task and group. Wigan Borough GP Dr Mohan Kumar has also provided clinical leadership on behalf of Wigan Primary Care colleagues.

The new service will meet 2 of key commissioning strategic aims

The integration of pathways across the acute and community provision and Taking care out of the acute sector and into the community, providing care directly to the patients in their

own homes

Interdependencies – Does the project / initiative have interdependencies with any other areas of work or transformation. Please describe below

Current services for Neuro Rehab patients are delivered through Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) based at the Royal Albert Edward infirmary (RAEI) and theWWL Community Services division.

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For stroke patients care and support is provided via the Community Stroke Team who are based at WWL.

WWL Community Services supply the Speech and Language Therapy (SALT) and Occupational Therapy (OT) services within the community; this includes support to Neuro patients although there is no specific ring fenced provision for them. Physiotherapy services for Neuro patients are provided by WWL NHS FT and Psychological support is being provided by WWL Community Services division through an SLA with North West Boroughs Healthcare NHS Foundation trust (NWBH). This service is based at Leigh Infirmary and the psychological provision is reported to be considerably less than sufficient at this time.

The urgent care system is also incorporated into this area of work as people access the local accident and emergency department (A&E), walk in centre (WIC), and Primary Care appointments and systems, and is accessed by patients with stroke and neurological conditions. Activity relating to these conditions via the urgent care system has been incorporated into the baseline activity data.

Other independencies are as follows which may be accessed as needed: Greater Manchester Neurological Alliance (GMNA),Voluntary Sector, Vocational Support, Link Workers, Case Management, Exercise and Activity Sessions via Inspiring Healthy Lifestyles (IHL), Review clinics (cross organisational), Posture and Mobility Services, Spasticity Management

The ICNSR service should work in partnership with GPs, local integrated services and other primary and secondary care services to provide a holistic approach to patient care.

ICNSR service will forge relationships with other relevant statutory and non-statutory providers from across the health economy (e.g. MS society, Parkinson’s UK, Headway, Stroke Association)

Has an Equality Impact Assessment been undertaken? (Yes/No) Yes, this is in the process of being completed and finalised

3. FINANCE SUMMARY(to be completed with finance team and to cover a 5 year period where applicable, see guidance for items to be included)

A cost benefit analysis undertaken by the CCG finance team, supported by an collaborative task & finish group has identified the current spend for community Stroke and Neuro teams.

Current CCG Spend

Wigan CCG currently contract for the Community Stroke & Neuro service is as follows:

BCHFT Community stroke team £275,903BCHFT Community Neuro team £144,398WWL TherapistsWWL Consultant input

£538,248

Total £958,549

The staffing values are as at 25th April 2019.

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Additional Future Service Costs

The team has identified and costed the staffing requirement from those outlined in the GM specification. The WTE figures have been adjusted for the Wigan caseload of 1,200 patients. Operational leads have then completed a skill mix review to adjust the GM bandings to ensure service continuity, staff retention and cost efficiencies.

The calculated additional staffing requirement using the GM recommendations, adjusted for Wigan demographics, is 17.94wte across a range of disciplines and bandings. The cost of this additional workforce is £791,446. A breakdown of the additional staffing is included in the table below.

POST BandIncrease in Staff

Group from Current Service to GM Spec

Administrator 2 1Administrator 3 1Therapy Assistants 3 2.57Therapy Assistant 4 2.6Occupational Therapists 5 0Occupational Therapists 6 1Occupational Therapists 7 0.67Physiotherapists 5 0Physiotherapists 6 1Physiotherapists 7 1Dietician 5 0Dietician 6 0Dietician 7 0.6Speech & Language Therapists 5 0Speech & Language Therapists 6 1Speech & Language Therapists 7 1Social Worker/Self-management Lead G9 0Neuropsychology Assistant 5 1Clinical Neuropsychology 8a 0.8Clinical Neuropsychology 8c 0.2Senior Nurse 6 0.8Neuro CM 7 1Nurse 7 0Team Leader 8a 0.7Consultants cover n/a 0Total increase of WTE 17.94

This staffing model aligns the Wigan Neuro service to the new GM specification, with the Wigan stroke service remaining unchanged.

The adjusted contract value for the GM mandated CNSRT for a 1,200 caseload is as therefore follows:

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Current 2019/20 Contract value for Community Neuro & Stroke Services £958,549Additional staffing required for new model (17.94wte) £791,446Adjusted 2019/20 Contract Value for Community Neuro & Stroke Services £1,749,995

Benefits Realisation

Potential savings in admission avoidance and Length of stay in community rehab placements has been calculated by GM for each locality based on an average placement rate and locality population.

GM expected savings to be realised as part of the new model are as follows:

AreaGM

Calculated Saving

Description GM Calculation

Slow stream admission avoidance £100,123

These are patients in MH rehab placements i.e. at The Priory

Extrapolated wasted bed days x average cost per bed day

Reducing post-acute LoS £257,324Reduced LoS for patients in Trafford post-acute beds

Days saved by reducing LoS to GM average of 68.5 x average bed day cost

Post-acute admission avoidance £283,696 Reduced admissions to

Trafford post-acute beds

Possible admissions avoided x average LoS x average bed day cost

Total Cost of Activity £641,143 These assumptions / calculations have been scrutinised by the CCG finance team. The GM calculation utilise average prices, which are not comparable to those in Wigan. They also do not account for activity reductions already seen due to recent changes in the Neuro acute care model and the move from Taylor Unit.

A more realistic saving has been calculated by the CCG finance team and amounts to £319k, details of which are shown in the table below. Assuming we would not worsen our average Length of stay in post-acute placements, the £25k in the table below has been added back on to the £319k total.

AreaGM

Calculated Saving

Rationale for inclusion/ExclusionAverage bed

day cost

Average patient

number per year

Bed days saved per

patient

Updated Saving

Current Spend

Slow stream admission avoidance

£100,123

The GM calculation uses the wrong daily price. GM calculations would mean WBCCG need to save 250 bed days. We have two patients in slow stream at present, so the GM bed days saved would mean reducing to 1 patient.

£855.3 2.7 51.9 £118,489 £532,657

Reducing post-acute LoS

£257,324

The calculation shows Wigan LoS average as 90.7, however it is actually 71. When updated, this would create a much smaller saving. The bed day rate in the calculation is also inflated from that paid in Wigan.

£385.7 26.0 2.5 £25,298

Post-acute admission avoidance

£283,696

The price rate is inaccurate (too high) as is the average LoS (being the same as that used above). The calculation suggest 7 patient admissions prevented based on Wigan population but there is no evidence to support this.

£385.7 7.0 65.1 £175,793

Total £641,143 £319,581 £2,262,832

Updated Calculation

£1,730,175

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The total additional funding requirement for the service is £791,446 (£471,665 if savings are realised).

Benchmarking against GM Localities

Localities that have implemented this model or are in the process of developing their business cases needed financial assistance in order to meet the required GM standard.

It has been mandated that all localities across Greater Manchester must have an Integrated Community Neuro and Stroke Model implemented by October 2019.

Stockport CCG have annotated that they need £600K of new investment to ensure that they deliver a patient pathway which meets with the GM specification. Stockport has a population of 289,000 and has based this costing on a predicted caseload of 572.

North Manchester (Pennine Acute Trust) serves a population of 205,000 and has an established integrated team based in Charlestown, Manchester. The integrated model at North Manchester required £850k of new monies which was approved and funded. The model meets with the GM specification and their original costing was based on a caseload prediction of 700.This is made up of 400 neuro and 300 stroke referrals.

When comparing the additional funding requirement and populations in other localities to that in Wigan, we would expect an additional Wigan requirement to be c£791k for both the Neuro and Stroke services. The investment detailed above is therefore above that expected across GM as it relates solely to the expansion of the Neuro service

Profiling of Age Within This Patient Group

To be able to further understand the cohort of patients that this business case corresponds to, WBCCG Business Intelligence have broken hospital admissions down by treatment function and age bands, and then by treatment function, diagnosis and type of admission. This data is in relation to WBCCG patients only.

Admissions by Age of Patients and Treatment Function, February 2018 to January 2019

Treatment FunctionAge 0 to

18Age 19 to

64Age 65 to

74Age 75 &

over

Age Unrecorde

dTotal

AdmissionsNEUROLOGY 1 626 203 236 1 1067NEUROSURGERY 2 145 24 10 1 182PAEDIATRIC NEUROLOGY 24 24PAEDIATRIC NEUROSURGERY 17 17STROKE MEDICINE 2 2 4TRANSIENT ISCHAEMIC ATTACK 1 2 3Total Admissions 44 774 227 250 2 1297

Total Patients 32 361 142 227 0 762*

*There were in fact 761 patients - one patient turned 19 during the 12 month period and is counted twiceStroke and Neuro patients in this report are patients who were in the treatment functions: Neurology, Neurosurgery, Paediatric Neurology, Paediatric Neurosurgery, Stroke Medicine or Transient Ischaemic Attack. They also had an ICD10 diagnosis code between I60 and I67 (Cerebrovascular Diseases) or between G00 and G99 (Diseases of the Nervous System).

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Having an integrated community stroke and neuro model to support our patients across the Wigan Locality, will prevent some admissions to acute and post-acute (INRU) neuro-rehab units

4. IMPACT / OUTCOMES OF THE PROPOSAL

Case for Change:

How will demand on Health and Social Care Services be reduced?

The case for change is driven by the mandated Greater Manchester Model and Specification.

As community rehabilitation services for neurological patients are not standardised across the GM Conurbation, this has led to significant variation in the models of delivery offered, the services provided and the capacity available, which includes the offer to Wigan Borough people.

The ICNSR model has been developed to ensure that local services are able to:

Reduce long waiting lists for complex patients

Support timely discharge from Intermediate Neuro Rehabilitation Units (INRUs)

Reduce the length of stay (LOS)/bed days for patients admitted into the INRUs

There is early evidence from the new North Manchester Community Neuro-Rehabilitation service, showing that services commissioned and provided as per the Greater Manchester community Neuro-rehabilitation service specification, reduce the length of stay within Neuro-Rehabilitation beds. North Manchester patients have been shown to have an average length of stay in Trafford INRU which is 22 days shorter than patients from other areas of Greater Manchester within the same unit.

Reduce the wide variation in the type and intensity of rehabilitation support offered

Prevent some admissions to acute and post-acute (INRU) neuro-rehab units

Offer people a more asset based approach to their health & social care provision, via voluntary sector activity groups, with support from self – management workers

Be delivered across all 7 SDF’s providing care closer to people’s homes.

Reduce any increased workload for Primary Care

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due to the current uncoordinated service i.e. recurrent patient appointments, referrals, requests for expediting referrals/ appointments due to long patient waits.

Ensure timely discharge from acute hospital via the ICNSR team, to support people returning home quickly and prevention of unnecessary readmission to hospital or attendance within a Primary Care setting

Deliver a consistent, flexible and needs-led approach with integration not just between inpatient/community clinical and social teams, but with patients, carers, other NHS Providers and must include the voluntary sector. This would ensure an asset based approach to support and address not just the clinical aspects of the person’s journey but their wider needs are met i.e. returning to Work after rehabilitation. Wigan Borough teams including Local Authority, Health and Social Care are currently commencing on a work stream to support Health Improvement (HI) and the contribution to disease pathways. The current move to a more integrated HI offer which would include educational and leisure activities would support the ICSNR model as outlined within this business case. This would also include re-training opportunities for individuals. The teams undertaking this HI work would need to ensure that the work links into this new model of care for stroke and neuro patients and carers. Meetings are currently being diarised at present.Also to be taken into consideration are the local, GM E&S (Economy and Skills) as well as the Population Health strands, and national Department of Work & Pension programmes.

Reduce the number of inpatient beds, (117 beds in total) across the GM conurbation. £12.6m per year is spent across GM CCG’s and a further Specialised Commissioning spending of up to £5.2m.

GM ODN is working on a revised inpatient model with the potential to reduce bed numbers further over time.

List of Potential Options:

Include how Cashable Savings will be realised to fund any successful implementation, and note any potential risks.

Benefits Realisation

Undertaking an options appraisal would allow for 3 options:

1. Do nothing and continue with current provision, 2 services providing community neuro and community stroke therapy to people across the Wigan Borough. This option would not benefit Wigan Borough people as there would be the continued gaps in workforce that would be a dis-benefit in supporting the achievement of national and strategic aims. This

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service provision would not have any cost savings. Having 2 separate services works against the recommendations of GM.

2. Wigan Borough Hybrid Model - Build and develop the 2 community services (stroke and Neuro), integrating into a joint provision for people across the place, providing care closer to home and this may also support the work being undertaken by Wigan Borough Clinical Commissioning Group in redesigning of Intermediate Care provision. This integrated model would also allow for a pooled community rehabilitation budget. For patients, this integrated model will support their care by allowing for delivery by one team working under 1 overarching specification but with clear service provision as outlined in the 2 service specifications (stroke and Neuro). This model would be an asset based approach, incorporating the Wigan Deal principles to empower people of the Borough to support their own health improvements. This hybrid model would be delivered by a phased approach, concentrating on the investment needed in one service specification initially (neuro or stroke) - thus fully invest against staffing levels.The chosen service can then be measured against the service specification and resultant KPIs. Once the service is established and can be seen to be meeting KPIs , managing patients effectively through the pathways etc., the other service can be invested in - which could be at a reduced cost if first service has proved to be effective. Once both aspects of the model, neuro and stroke have been phased in and established, the next phase would be to fully integrate into the same estate facility. A phased approach to the integrated model would also support the training of staff, support recruitment, to embed the primary focus of interdisciplinary working as is specified within the specifications. CST - if CST becomes commissioned to provide 6 month service rather than current 6-8 weeks this will have a result in reducing number of referrals into Community Neuro Team - and it is the stroke patients who often require a longer period of rehab. Stopping a handover from one service to another will result in reduction of length of stay within services. Thus Community Neuro team and neuro patients will benefit from resourcing CST first as should be a reduction in waiting times for neuro patients if neuro team only needs to see neuro patients

CNRT – if CNRT invested in there will be reduction in waiting times for all ( stroke patients who require

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more than 6 -8 weeks of intervention and all other neuro patients)

To note: CNRT has greater need for investment primarily over CST due to current access waiting times ( but as alluded to above, these will reduce if not having to provide a service for stroke patients)

The Individualised Care Team (formally known as Continuing Health Care), have outlined that there could be savings in the independent sector, specifically slow stream bed usage by the consistent approach of reviewing Wigan Borough patients within 6 weeks of admission into a slow stream rehab facility. Benefits could be realised further by ensuring the appropriateness of a slow stream care facility for an individual is considered at regular intervals with alternative options explored. This would reduce spend, as slow stream rehab is expensive. Quality of care, patient and carer experience however would not be compromised.

3. Commission the GM Integrated Specification

The GM Integrated Model diagram is available at appendix 1 and both specifications for the GM Community Neuro Service and GM Stroke Service at appendix 3 & 4 respectively.

Savings could be made by the reduction of the current inpatient bed base across GM, once the ICSNR model has been embedded across the place. The reduction in inpatient beds is a priority piece of work that GM ODN are reviewing and undertaking. It has been acknowledged that Wigan Borough has utilised 6 Independent Slow Stream Inpatient Beds which could not be placed within the current NHS commissioned services. This low usage of slow stream beds has been in totality since 2015 - 2018.

There may be financial savings made in the reduction of estates and infrastructure all dependant of where the 2 teams are to be co-located. This area is being explored within the established task and finish groups.

As Wigan Borough has a Community Services (CS) model which is being embedded across the place, having an integrated Community Stroke and Neuro service allows for the opportunity to avoid duplication across other services to the people it serves with the possibility of savings due to bringing together other providers and services. It has the ability to reduce the numerous home visits by various teams and supports people in having a first contact with a practitioner, avoiding duplication in both time and number of referrals.

Quality

The provision of a combined service aimed at meeting the

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specific local need will:

Provide targeted support Improve Health & Wellbeing Ensure delivery of a high quality, safe, clinically effective

local service which will deliver long term change Offer appropriate and effective services for people living

with long term conditions Enable patients and carers easier access to the most

appropriate support and rehab Provision of a consistent approach to these areas of

rehab with a focus on sustainable change, promotion of self-management and support of a seamless transition from inpatient to community services

Deliver a more expedient and effective recovery Provide extra support for patients and their carers Support more timely discharges out of hospital

In addition the specification will include robust quality outcome measures in terms of the reduction of health inequalities and will broaden the range of support available to people with these needs.

Patient Engagement

To support the work, WBCCG Communications Team will be undertaking a patient engagement event, focussing on real life experiences of patients and carers, that are progressing on their journey of requiring neurological or stroke support services. This work will commence in May 2019 and will be supported by the Equality Impact Assessment (EIA)

Reduced LOS

The LOS for neurological conditions from an acute admission cannot be clearly identified, as studies examining the health needs for the neurologically disabled are not easily determined. Reducing the pressure on inpatient acute beds, will be supported by minimising admissions for patients with long term neurological conditions being admitted to hospital in the first place. Prompt input from ICNSR team should stabilise situations at home for the patient and their carers and prevent such admission. Naturally it could also facilitate early discharges for the patients. At this stage, an estimated reduced LOS cannot be determined.

Case Study

The case study inserted at Appendix 5, is a very recent patient journey through the Community Neuro pathway and is very powerful in its message on how a patient could benefit through investment not just in financial terms but time spent with the appropriate practitioner, medical input and to support improved outcomes for the people of the

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Potential Risks to the recommended option

Wigan Borough. The case study supports the investment needed by all stakeholders in ensuring all people receive the correct level of care with the minimum wait time.

Risks identified to date are:

1. Workforce: The current workforce would not have the capacity to deliver the GM requirements for service delivery and would require enhancing. It has been recognised at the Directors of Commissioning Meeting across GM that all localities would be recruiting at the same time, for the same staff groups which could cause delays in recruitment and the model’s implementation

2. Finance: The GM model assumes that the delivery is cost neutral, however there could be costs associated with the delivering the service. This is not going to be the case for Wigan and will need significant investment.

3. IT: Current providers within Wigan of the 2 services use different IT software which will need to be worked through as to best provide software to allow for reporting and recording of patient records. As this is a community based model of service delivery, hand held IT devices will also be required to allow for an efficient service to be delivered without the need to return to base to undertake admin related tasks for clinical practitioners.

4. Timescales: HWP are not currently involved in the work regarding the ICNSR model and are not aware at this stage that they will be required to work jointly with the Commissioners and other Team members on a joint implementation programme. HWP will require time to understand this priority piece of work which could pose a risk due to the timescales set by GM. WBCCG are presenting the model with finances at the HWP Board on 8th May 2019.

Recommendation:

Preferred OptionThis business case is recommending that option 2 is the preferred option, to commission the Wigan hybrid specification (incorporating some aspects of the GM Spec) as a phased approach at an additional cost of £791k, commencing with community neurology.

5. KEY PERFORMANCE INFORMATION(The scope of the proposal may not be fully defined at this point. Measures may only be potential and not fully defined. Some measures may be qualitative. Any assumptions should be clearly stated.)

As the activity and demand has been identified as a significant challenge, not just to the Wigan Locality but across the GM conurbation, the full scope of the model cannot be defined at this time and will continue to be monitored via activity recording by both WWL NHS FT and WWL Community Services Division until the new integrated model is implemented in October 2019.

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Measures, whether they are key performance indicators (KPIs) or outcomes, have already been defined within the GM Specification and are potential for the Wigan locality to be monitored against.

Service measures for both the neuro element and stroke have been incorporated into this business case as outlined below, however the collection of this data with is dependent on the IT infrastructure as both service providers currently use different software. This will be worked through via the Model Task & Finish Group.

The original business case was staffed to 100% of the GM spec for stroke and neuro, therefore the revised workforce model is anticipated to have an impact on the ability of the team to meet the GM outcomes and standards.

The intention of increasing workforce within CNRT to support the complexities of neuro rehab patients and maintain quality goal outcomes is to avoid attendances to A&E and possibly medical hospital admissions, and provide health and social care at the appropriate setting.

The workforce has been specified against an anticipated phased funding to deliver a fully integrated neuro and stroke community rehabilitation service that will have an interdisciplinary approach to avoid duplication of multiple, uni-disciplinary assessments. This will be monitored and evaluated against the GM Neuro Rehabilitation KPIs and Outcomes

Neuro-Rehabilitation KPIs and Outcomes

Community Neuro-Rehabilitation Service MeasuresMeasure Threshold

Source of Referral N/A

Number of re-referrals Benchmarking locally

Rehabilitation Caseload Complexity on Commencing Therapy Benchmarking locallyPercentage of patients commencing therapy within 7 day of discharge from hospital 95%

Percentage of patients triaged within 2 working days of referral 95%

Percentage of patients assessed within:- 2 working days of triage for high risk patients- 14 days of triage for moderate risk patients- 21 days of triage for low risk patients 95%

Average number of days from referral to commencing therapy Benchmarking locally

Delay in days (average) commencing therapy by uni-professional group Benchmarking locally

Percentage of goals achieved Benchmarking locally

Average length of stay in the service Benchmarking locally

Length of Stay (Range) Benchmarking locally

Percentage of patients reporting positive experience on friends and family test or patient experience survey 90%

Percentage of patients who report that their quality of life has improved as a result of CNRT intervention Benchmarking locally

Onward Referrals/Sign-postings N/APercentage of patients who have sustained change/self-management at 12 months post discharge Benchmarking locally

The core data will include: Total number of referrals per year Total number of patients admitted per year

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Disability Complexity Profile and diagnosis group Length of stay in CNRT Length of stay in inpatient neuro-rehabilitation service prior to referral to CNRT Reduction in in-patient bed days Wait times to access service and, where appropriate, any wait times along the rehabilitation pathway. Change in referrals received from GPs/other health professionals; percentage of self- referrals DNA and cancellation rates Number of and response time to dysphagia problems Total numbers of reviews completed and how many individuals have sustained change 12 months post

discharge How many are in employment and returned to employment/voluntary work on discharge Numbers of patients are discharged from acute care with a clear and agreed plan of how their

rehabilitation and care will continue in the community. Reduction in Consultant follow-up appointments per year Total amount of clinical time available/used to the service Number of referrals resulting in a reduction in care needs Quality of Life and Carer burden Referral by referral type Waits at point of referral to other specialist services e.g. provision of technology, equipment/wheelchair

& seating etc. Number of Continuing Care patients assessed Individuals’ confidence to self-manage

Expected service outcomes for Neuro-rehabilitation Patients

Disability Complexity Profile (Pre & Post) Change in person-centred goals post rehabilitation Change in Quality of Life as perceived by the patient Change in therapy objective and outcome measures

Stroke Outcomes

The Greater Manchester Stroke Operational Delivery Network has collaboratively developed a set of outcome measures for the stroke care pathway based on NICE Standards and current Sentinel Stroke National Audit Programme (SSNAP) indicators and data collection. The table below shows local defined stroke outcomes

Measure description ThresholdData

collection tool

Data collection timeline Comment

Percentage of adults having stroke rehabilitationin hospital or in the community offered at least

45 minutes of each relevant therapy for a minimum of 5 days a week for up to 6 weeks

85%SSNAP(custom fields)

During admissionto stroke unit and

to community team

NICEStandard 2

Percentage of patients reporting positive experience on friends and family test or patient

experience survey (which must include F&F test)90%

Friends and family test.

Questionnaire

Discharge fromhospital and from community team

and 6 months post index stroke

Percentage of adults who have had a stroke have their rehabilitation goals reviewed at

regular intervals (weekly)100%

SSNAP(custom fields)

During admissionto stroke unit and

referral to community team

NICEStandard 6

Percentage of patients who demonstrate positive improvement following Community Stroke Team

intervention

Benchmark locally


Admission to and discharge from

community team& 6/12 months

post index stroke

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Percentage of adults who have had a stroke whocan be referred to a clinical psychologist with expertise in stroke rehabilitation who is part of the core multidisciplinary stroke rehabilitation

team


Discharge from hospital

NICEStandard 3

Percentage of adults who have had a stroke areoffered active management to return to work and

advice on driving if they wish to do so80%


During admissionto hospital and to community team

NICEStandard 5 (RTW only)

Percentage of patients who were screened onadmission to the Community Stroke Team for mood disturbance and cognitive impairment


During admissionto community

team

PreviousNICE

StandardPercentage of patients referred seen within 72hours for an assessment by Community

Stroke Team


Within 3 days ofreferral to

community team

PreviousNICE

Standard

Activity Measures 2017-2018 Wigan Borough

To enable the measure of the proposed activity for the ICNSR team, activity for the first year has been identified by using validated data from year 2017/18.

In the financial year 2017/18, the Community Stroke Team (CST) received 510 referrals and the Community Neuro Team (CNT) received 942 respectively, from this figure, the team removed any duplicate and rejected referrals, therefore 560 referrals were accepted.

In totality, in 2017/18, 1200 patients accessed the Community teams for Neuro and Stroke

Patients having a Stroke equates to approximately 800 per year. WWL have reported that some of these stroke patients may not be recorded as requiring input from CST as they were recorded via the hyper acute pathway data. To note: Sentinel Stroke National Audit Programme (SSNAP), does not record all strokes therefore was not used in activity planning for this business case.

Incorporated within the activity are approximately 100 patients that are referred onto the Neuro Psychologist.

A description of the current model and pathways of service delivery for both stroke and neuro can be found at appendix 2.

6. PARTNER AGREEMENT / SUPPORT(Embedded e-mail or signature required. This is to ensure agreement from partner organisation(s) on the impacts to them; or the support that they have agreed to provide.)

Partner Impact (£) Agreement Confirmation

BCHFT

WWL NHS FT

WIGAN LOCAL AUTHORITYWBCCG

Has the appropriate scrutiny and authorisation been received from internal subject matter experts?

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(Yes / No)(see ‘authorisation’ section of Appendix A below)

7. INVESTMENT PROPOSAL REVIEW DETAILS(I.e. date and forum this document has been reviewed and documentation of the decision.)

Forum Date Comment

8. POST IMPLEMENTATION REVIEW(I.e. date and forum that the evaluation of any agreed proposal will be reported detailing any specific reporting expectations.)

Forum Date Comment

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Appendix 1 - GM Service Specification

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Appendix 2 - Current Models of Care within Wigan Borough

Model of Stroke Rehabilitation

There are four pathways of support to meet the needs of the identified levels of dependency, these are as follows:

1. High Functioning – Home with Community Stroke Team only (CST) up to six to eight weeks rehabilitation with a six months review

2. Lower Functioning – Home with CST and domiciliary rehab support for up to six to eight weeks with a six months review

3. Non Manageable at home – Residential intermediate care/Acute bed with CST daily input until person reached level 2 dependency. The CST has access to the inpatient beds as these are based in the Community at Alexandra Court Care Home which is based in Wigan.

4. Residential Care – CST visit to ensure correct management and rehabilitation programme if needed

To note: the above model is delivered across the Wigan Borough however the CST pathway is also embedded into the GM Centralisation of Acute Stroke Care Pathway which was mandated in 2015.

Model of Neurological Rehabilitation

There are three levels of clinical need offered to Wigan Borough patients who require community neurological support.

Referrals are made into the team, based at Leigh Infirmary, and are triaged by a band 7 clinician. The referral is then categorised and the patient will be seen in order of priority.

1. Urgent – patient will be seen within 2 weeks2. Priority – patient will be seen within 6 weeks3. Routine – patient will be seen within 18 weeks

A full needs assessment is carried out by a practitioner within the community setting for all levels of need.

Therapy commences almost immediately once a need assessment has been completed.

Therapy delivered is patient and goal centred.

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Appendix 3

Greater-Manchester-Community-Neuro-Rehabilitation-Service-Specification-V1.2-16.1.18.pdf

Appendix 4

Greater Manchester integrated community stroke rehabilitation service specification v1.3 Nov 17.docx

Appendix 5

case study.docx

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REPORT TITLE: Wigan Council and CCG Financial Outturn 2018/19

REPORT AUTHOR:Paul McKevitt, Director - Resources and Contracts (Deputy Chief Executive) Wigan Council and Chief Finance Officer, Wigan Borough CCG

PRESENTED BY:Craig Hall - Director of Transformation & Sustainability / Deputy Chief Finance Officer, Wigan Borough CCG


Receive

EXECUTIVE SUMMARY:

The committee is asked to note the summary report attached.



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ICC Committee

1. Wigan Council’s and CCG’s Outturn positions 2018/19

This report updates the Committee on the Council and CCG’s final financial position in 2018/19. Both organisations have been preparing their statement of Accounts. The CCGs accounts were approved by the Audit Committee on 24th May, whilst the draft statement of Accounts was produced by Wigan Council on the 31st May 2019.

The Committee have received detailed reports of the financial position of each organisation during the year, so this report provides a summary of the draft/ final position for each budget.

2. Final Outturn of Wigan Borough CCG

The CCG achieved statutory financial balance after receiving financial support of around circa £12.4m through the Section 75 agreement. This arrangement has now largely been reversed.

The CCG accounts have been audited and submitted to NHS England by the deadline of the 29th May. There were no material issues picked up in the audit and the accounts were approved with an unqualified opinion.

3. Draft Outturn of Wigan Council Revenue Budget

The provisional outturn for 2018/19 shows a small surplus of £0.303m when compared against the budget agreed by Council in March 2018. This means that the savings requirement of £12m has been delivered. Whilst it is comforting that the savings targets have been achieved there remain risks related to the delivery of the transformation of Childrens Services. Additional time is required for the full impact of the large scale transformation of childrens social care to come to fruition, progress will be closely monitored throughout 2019/20.

The Council also manages a capital programme. For 2018/19 expenditure of £82m. The capital programme is fully funded from a mixture of capital receipts, grants, contributions and prudential borrowing. The current programme is fully financed with no additional revenue support being required.

4. Draft Housing Revenue Account 2018/19

The Housing Revenue Account (HRA) income ofoverall revenue position shows an underspend against budget of £1.562m, this despite a budgeted position which expected to drawdown reserves of £4.8m.

The gross dwelling rent was reduced by £380k which was made in respect of a historical reduction in the number of bedrooms across approximately 257 properties across the HRA estate which required the housing benefit to be repaid.

No HRA debt was written off during the year which increased the arrears position for the HRA.

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Supervision & managements cost increased due to ERVR costs of £1.3m funded by the HRA as the Council continues to restructure staffing following on from the transfer of WALH staff back in to the Council.

The Council was able to draw down HCA grant of £4.4m to fund capital programme and this meant that it did not need to fund £5.4m of capital spend through revenue as expected.

The bad debt provision was reduced as the arrears position did not worsen dramatically as expected in respect of the roll out of Universal Credit, though the medium-term Forecast continues to take a pessimistic view.

The number of Council House sales which has risen steadily from 111 in 2014/15 to 233 in 2017/18, did fall slightly with 178 Council Houses sold in 2018/19. The total value of sales fell from £9.3m in 2017/18 to £7.6m in 2018/19.

5. Recommendation

The Committee are asked to note the financial outturn of each organisation.

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REPORT TITLE: Better Care Fund (BCF) Position 2018/19

REPORT AUTHOR: Mark Rotheram, Strategic Financial ManagerResources and Contracts

PRESENTED BY: Mark Rotheram


For the Integrated Commissioning Committee to note the 2018/19 year-end BCF position

EXECUTIVE SUMMARY

The BCF Quarter 4 return was submitted on time to NHS England.

The locality is still awaiting details of the 2019/20 BCF allocations and Planning Requirements.

In 2018/19 there was a small underspend (£0.312m) on the capital element of the BCF which will be rolled forward into 2019/20 to be utilised in line with the grant conditions to support individuals to remain independent in their own homes.

In 2018/19 performance was generally good against the key BCF metrics and Wigan’s performance was comparatively strong on a local and a national level. However in the light of the year on year increase in non-elective admissions and permanent admissions to residential care these performance measures will be closely monitored going forward.

FURTHER ACTION REQUIRED:For the 2019/20 BCF plan to be presented to the ICC for consideration once the Planning Requirements and Allocations are confirmed.


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Integrated Commissioning CommitteeWednesday 19th June 2019

Better Care Fund (BCF) and improved Better Care Fund 2018/19 Financial and Performance Report

1.0 Introduction

1.1 The Wigan locality submitted the BCF Quarter 4 return on the 18th April 2019 to NHS England in line with the nationally prescribed deadline. This report summarises the key year-end finance and performance data from the return.

1.2 As it currently stands we are still awaiting details of the Better Care Fund Planning

Requirements and allocations for 2019/20. Dependant on the timing of this release the proposed BCF plan for 2019/20 may need to be presented to the Wigan Health and Wellbeing Board for final sign off on the 07/08/2019. The 2019/20 Allocations have been confirmed for the improved Better Care Fund (IBCF - £14.678m), Disabled Facilities Grant (DFG - £4.014m) and the Adults Social Care Winter Pressures Grant (£1.592m). The iBCF, DFG and Winter Pressures grant monies are paid directly to local authorities under Section 31 of the Local Government Act 2003, with specific grant conditions, including a requirement that the funding is pooled in the BCF. Given the delay with the BCF planning guidance the National Better Care Team has confirmed that there will be no Quarter 1 reporting required for 2019/20.

1.3 In June 2018 Central Government announced a review of the current functioning and structure of the Better Care Fund to ensure that it supports the integration of health and social care. This review will report later in this financial year.

2.0 Finance

2.1 As detailed in Appendix 1 an under spend of £0.312m has been reported at year-end against the 2018/19 allocation. This underspend relates to the Disabled Facilities Grant (DFG) and even though the DFG has been transferred into the BCF there are still specific grant conditions attached to how this money has to be spent. As such this underspend along with the £0.682m rolled forward from previous years will be available for utilisation alongside the 2019/20 allocation of £4.014m. The DFG allocation has been increasing steadily over the last few years with the 19/20 allocation being an increase of £0.892m (28.6%) on the 2016/17 allocation. Further work is now being undertaken to ensure that the allocation can be utilised as widely as permissible to support people to remain independent in their own homes thus avoiding more costly health and social care interventions.

2.2 The increasing demand and acuity of care has increased the level of expenditure required to be covered by the Section 75 Agreement. Wigan Council agreed to increase its’ in-year contribution by £16m to facilitate the delivery of the Wigan Locality Plan and balance the year-end position. This will be balanced out by a variance of future contributions going forward.

2.3 Appendix 2 breaks down the cumulative position by individual scheme. Given that 2018/19 is Year 2 of a two year plan approved by Wigan Health & Wellbeing Board on the 23/08/2017 it is inevitable that there will be a fair degree of variation between planned and actual spend on an individual scheme basis. For example the additional adaptations resource available to the locality generated an underspend on this scheme which has effectively offset the additional

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resource required to fund the programme capacity and support required to help facilitate the necessary health and social care integration in the locality.

3.0 Performance

3.1 As detailed in Appendix 3 the performance on non-elective admissions for 2018/19 shows an adverse variation against target of 8.4% and an adverse variation of 5.6% against the 2017/18 position. The adverse variation reported is due to the increased demand and acuity across all areas of Urgent Care. However it is encouraging to note that the 18/19 performance compared with 17/18 steadily improved throughout the year with overall improvements in Quarter 3 (2.5%) and Quarter 4 (5%) compared with the last financial year. Coupled with the fact that actual non-electives in March 2018 showed an improvement against target of 1.2% offers hope that this trend can continue into 2019/20.

3.2With regard to the Delayed Transfers of Care (DTOC), performance for 2018/19 shows a favourable variance both against target and the 2017/18 position of 18.5%. This strong level of performance is also evidenced nationally. The May 2019 edition of the North West Association of Directors of Adults Social Services (NWADASS) monthly Delayed Transfers of Care update placed Wigan 32nd best nationally based on the sum of delayed bed days per head of population as at March 2019. This places Wigan top of the 23 North West Authorities. This is illustrated in the extract of the NWADASS Dashboard included as Appendix 4.

3.3 In terms of the rate of permanent admissions to residential care performance for 2018/19 shows an adverse variance against plan of 7% and against the 17/18 position of 6.5%. As detailed in Appendix 3 the main reason for this adverse variation is the Quarter 1 performance which was a legacy of the previous winter pressures. Subsequent to this Quarters 2,3 & 4 show a favourable variance against plan. However this overall increase is resulting in significant financial pressure on the locality and as a result further work is being undertaken to better understand this year on year increase in permanent admissions. This will consider bed capacity issues and any connection with the continued strong DTOC performance.

3.4With regard to the proportion of older people who ere still at home 91 days after discharge from hospital into reablement / rehabilitation services performance for 2018/19 shows a favourable variance against target of 7.9% and an adverse variance against the 2017/18 position of 3.1%. This is based on the fact that for reporting purposes performance is based on a snapshot in time which ties in with the Quarter 4 performance. The year on year adverse variation is as a result of extending the reablement service to a more complex cohort of individuals who previously would not have had access to the service.

3.5The Department of Health & Social Care (DHSC) and the Ministry of Housing, Communities & Local Government (MHCLG) have worked with stakeholders to develop a performance dashboard to indicate how health and social care partners in every Local Authority area in England are performing at the interface between health and social care. The dashboard identifies the following 6 key indicators of performance:

a) Emergency Admissions (65+) per 100,000 65+ population

b) 90th percentile of length of stay for emergency admissions (65+)

c) Total delayed days per day per 100,000 18+ population

d) Percentage of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services

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e) Percentage of older people (65 and over) who are discharged from hospital who receive reablement / rehabilitation services

f) Percentage of discharges (following emergency admissions) which occur at the weekend

The NHS Social Care Interface Dashboard published in September 2018 placed Wigan as the 4th best out of the 150 local Authority areas

4 Summary

4.1The key messages from the 2018/19 financial and performance report are:

a) At the end of the 2018/19 financial year there was an underspend on the BCF capital allocation of £0.312m, in line with the grant conditions attached to this, it is proposed to roll this forward into 2019/20 as part of an overall resource of circa £5m to support people to remain independent in their own homes.

b) With regard to non-elective admissions, an increased demand and acuity across all areas of Urgent Care resulted in an adverse variation against the 18/19 target of 8.4% and an adverse variation of 5.6% against the 2017/18 position. However a steadily improving performance throughout the year offers encouragement that this trend will continue into 2019/20.

c) With regard to DTOC performance for 2018/19 shows a favourable variance both against target and the 2017/18 position of 18.5%. For March 2019 Wigan’s DTOC performance ranked the best of all 23 North West Authorities.

d) Work is underway to better understand the year on year increase in permanent admissions to residential care homes which in the main was a legacy of 2017/18 winter pressures.

e) Whilst there was a year on year adverse variation on the reablement indicator this was as a result of the service being extended to a more complex cohort of individuals who previously would not have had access to the service.

f) On the national measure to assess the interface between health and social care published in September 2018 Wigan was ranked 4th best out of 150 Local Authority areas.

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Appendix 1 - Section 75 - Partnership Arrangement under the NHS Act (2006)

Pooled Budget Arrangement for the Better Care Fund

Partners to the Agreement : - Wigan Borough Council & NHS Wigan Borough Clinical Commissioning GroupPOOLED FUND MEMORANDUM ACCOUNT for the year-ending 31st March 2019

CCG Wigan Council Pool £000 £000 £000Income Revenue 23,337 27,719 51,056Capital Grant 3,720 3,720

Total Income 23,337 31,439 54,776Expenditure Revenue expenditure 20,564 30,492 51,056Capital expenditure 3,408 3,408 Total Expenditure 20,564 33,900 54,464 Total Underspend on 2018/19 Resource -312Carry Forward of Capital Expenditure into 2018/19 -682Revenue Underspend / Overspend 0Capital Underspend to be carried forward into 2019/20 -994

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Appendix 2 - Income and Expenditure Detail

Original BCF Schemes

Original value as per Submission (£)

Quarter 4 (April to March) Actual Spend (£)

Quarter 4 (April to March) Variance (£)

RAID Psychiatry Liaison 1,130,000 1,130,000 0

Primary Care - Extended Integrated Neighbourhood Teams Programme 2,948,760 2,948,760 0

NHS Funding to Support Social Care 2,879,961 2,879,961 0

Assistive Technology 720,882 759,182 38,300

Community Equipment & Adaptations 622,344 554,761 -67,583

Occupational Therapy 1,247,613 1,288,395 40,782

Hospital Discharge 924,368 915,165 -9,203

Community Early Prevention 461,046 497,753 36,707

Reablement 2,215,397 2,298,987 83,590

Carers 870,244 773,112 -97,132

Mental Health services 1,102,795 1,123,378 20,583

Older Persons & Intermediate Care Services 220,551 163,286 -57,265

Continuing Care / Funded Nursing Care 65,138 80,567 15,429

Care Bill Reform New Burdens 950,112 956,844 6,732

Protecting Social Care Services 2,783,423 2,783,423 0

Reablement Care Model 829,792 791,629 -38,163

Hospital & Community Based Social Work Teams (7 day Working) 518,620 513,785 -4,835

Community Support 326,756 331,610 4,854

Housing with Care Developments / Major Adaptations Programme 1,082,413 1,115,598 33,185

IT Development 31,117 25,136 -5,981

Transformed Home Care Model 622,344 622,344 0

Development of High Quality Dementia Services 705,323 705,323 0

Disabled Facilities Grant Capital 3,719,802 3,408,149 -311,653

BCF Total 26,978,801 26,667,148 -311,653

Improved BCF Schemes Budget (£)2018/19 Outturn (£) Variance (£)

Investment in the continued innovation and sustainability of the Residential & Nursing Market 2,527,000 2,527,000 0

Investment in community based care and support to ensure the ongoing sustainability of provision including ethical home care and supported living 2,817,000 2,817,000 0

Delivery of change capacity around an asset based approach to social care delivery 325,000 416,000 91,000

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Improved BCF Schemes Budget (£)2018/19 Outturn (£) Variance (£)

People powered technology and digital reform to upscale emerging technology within care settings and people's own homes 196,000 195,000 -1,000Implementation of Community Book 50,000 35,000 -15,000

Capacity building in community and voluntary sector for health and social care benefit

610,000 624,000 14,000

Reform and expansion of Early Intervention services including community and bed based reablement 1,332,000 1,250,000 -82,000

Design and implementation of a Home Safe model & Additional Care Costs of Discharge to Assess facility 100,000 112,000 12,000

Increase flu vaccination uptake across social care providers 30,000 13,000 -17,000

Upscaling of health support to care homes alongside strengthened quality oversight 130,000 130,000 0

Enhanced investment and prioritisation of property adaptations 500,000 0 -500,000

Additional investment in Community Social Work and Safeguarding Capacity to assist with demand reduction and enhanced 7 day working 875,000 875,000 0

Investment in mental health support to help delayed discharges and enable people to be supported within the community 487,000 487,000 0

Design and implementation of Home Care Wellbeing model 0 13,000 13,000Reformed Model of Supported Employment 257,000 291,000 34,000

Contribution to demographic and demand led pressures within Social Care 1,213,000 1,213,000 0

Programme Capacity and support to help facilitate health and social care integration 270,000 721,000 451,000

IBCF Total 11,719,000 11,719,000 0

BCF and IBCF Total 38,697,801 38,386,148 -311,653

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Appendix 3 - Wigan Better Care Fund Performance Dashboard

Performance Indicators

Total non-elective admissions to hospital (general & acute) all age per 100,000 population

Quarter 1 April to June

Quarter 2 July to September

Quarter 3 October to December

Quarter 4 January to March

Cumulative Position April to March

2017/18 Actual 8,449 8,993 9,898 9,863 37,2032018/19 Plan 9,171 8,605 9,390 9,055 36,2212018/19 Actual 10,460 9,801 9,646 9,367 39,2742018/19 Actual : Plan 14.1% 13.9% 2.7% 3.4% 8.4%2018/19 Actual : 2017/18 Actual 23.8% 9.0% -2.5% -5.0% 5.6%

Delayed transfers of care (delayed days) from hospital per 100,000 population (aged 18+)






2017/18 Actual 1,086 1,600 1,385 1,462 5,5332018/19 Plan 1,344 1,260 1,379 1,550 5,5332018/19 Actual 983 1,015 1,134 1,380 4,5122018/19 Actual : Plan -26.9% -19.4% -17.8% -11.0% -18.5%2018/19 Actual : 2017/18 Actual -9.5% -36.6% -18.1% -5.6% -18.5%

Rate of permanent admissions to residential care per 100,000 population (aged 65+)






2017/18 Actual 99.0 98.0 75.0 131.0 403.02018/19 Plan 100.3 100.3 100.3 100.3 401.02018/19 Actual 145.0 90.0 96.0 98.0 429.02018/19 Actual : Plan 44.6% -10.2% -4.2% -2.2% 7.0%2018/19 Actual : 2017/18 Actual 46.5% -8.2% 28.0% -25.2% 6.5%






2017/18 Actual 91.1% 91.3% 92.0% 90.8% 90.8%2018/19 Plan 81.6% 81.6% 81.6% 81.6% 81.6%2018/19 Actual 90.2% 90.4% 89.0% 88.0% 88.0%2018/19 Actual : Plan 10.5% 10.8% 9.0% 7.9% 7.9%2018/19 Actual : 2017/18 Actual -1.0% -1.0% -3.3% -3.1% -3.1%

Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services

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Appendix 4

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REPORT TITLE: Developing a ‘Single Quality System’ for Health and Care Briefing Paper

REPORT AUTHOR:Lynn Mitchell Senior Assistant Director Nursing & Quality Wigan Borough CCG

PRESENTED BY:Lynn Mitchell Senior Assistant Director Nursing & Quality On behalf of Sally Forshaw (Executive Director Nursing & Quality; Wigan Borough CCG


Approve

EXECUTIVE SUMMARY:

The briefing paper seeks to outline the :

Background and origins of the brief to develop a Single System for Quality - ‘Quality the Wigan Way.’

Vision and concept for quality oversight defined as a whole systems approach via the integrated commissioner and provider alliance through the auspices of the HWP.

Progress made by the Quality Task and Finish Group regards the development of a ‘Single Quality System’.

Proposed ‘Strategic Framework’ for the ‘Wigan System for Quality’.

FURTHER ACTION REQUIRED: As detailed within the body of the briefing paper.


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Developing a ‘Single Quality System’ for Health and Care Briefing Paper

1. Background

1.1 The Wigan Place Based Strategic Commissioning Function Operating Model described the elements of integrated commissioning for the ‘place’. The model also envisaged how a ‘whole system singular approach’ to quality assurance and improvement could be delivered, without dismantling the robust and tested systems and processes in place. However; in doing so there must be a clear recognition that the system must maintain the ability to provide assurance to both internal and external bodies to be able to meet its statutory obligations and duties.

1.2 In order to understand how we could develop a ‘Single Quality System’ for Health and Care

the ‘Quality the Wigan Way’ Workshop Event was held on 3 October 2018. The intention of the event was to enable us to set out the vision of a ‘Whole System Approach’ for the Borough, with the added opportunity to pool quality improvement expertise and knowledge to achieve maximum benefit. The overall aim being to; create a common architecture and collaborative approach to quality assurance and improvement capability and capacity.

2 The Vision 2.1 The vision is to create a joined up health and care system that is fully integrated to best meet the needs of the people living in the Wigan Borough. 2.2 Through the Healthier Wigan Partnership (HWP) local commissioners and providers are working together and have made a commitment to:

Join up health and social care services where people live; Help people to be physically and mentally well; Help people to live a full, active life doing what they like to do; Offer easy to access services; Provide people with the right treatment at the right time; Offer the best possible care in the most affordable way; Design services with people to meet their needs; Support people to take care of themselves and manage their own care, and to Build on the strengths of people & communities through an asset based approach.

3 The Concept

3.1 The Wigan Borough alliance of providers and commissioners through the HWP will set out how the partners will develop and agree on, a ‘single shared view of quality’, that also demonstrates how the right of commissioners to step outside the collaboration to take action, as and when required will be reserved.

3.2 The concept is that quality assurance and improvement activity were ever it is reasonably

practicable to do so will be captured at the Service Delivery Footprint (SDF) level. To do this all partners will need to develop and agree on a set of locally agreed quality priorities with clear and measurable outcomes that can be delivered by the whole system.

3.3 It is recognised that the development of the Primary Care Networks (PNC’s) will be a key enabler in capturing the contributions of primary care services to this process.

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3.4 Mandated national outcomes and data sets for example; CQUINs; NICE Compliance, Audits and National Experience Surveys will be a given. The evidence/data submitted by HWP partner organisations will then be collated, and post analysis will provide a position on the overall achievement against the system wide outcomes. The level of assurance on compliance should then be reported via the HWP Quality Dashboard.

3.5 Ultimately understanding and gaining assurance on Quality must be a high priority for the HWP Board and must be evidenced through a robust internal organisational framework for Clinical Governance.

4 Summary - Position to Date

4.1 The Wigan Place Based Strategic Commissioning Function Operating Model is currently being refreshed to ensure currency and relevancy and importantly to reflect the developments in relation to the integrated commissioning functions. 4.2 The Quality Task and Finish Group has been reformed as was agreed and is meeting on a bi-monthly basis. The Group consists of providers; commissioners and other local bodies; such as Healthwatch. The Terms of Reference for the group have been approved by the Wigan Borough Locality Plan Portfolio Group (on 19 March 2019). 4.3 A Strategy on a Page (inclusive of the identified potential risks to delivery) and a supporting Quality Delivery Plan have been developed by the group. The Delivery Plan remains on track, the next steps as agreed by group are as follows:

Public Engagement: The content and format of the information that will support the

public engagements are in draft inclusive of an easy read version. This will enable us to capture the public views on what quality ‘looks and feels’ like. The aim is to use the public’s views to influence the HWP quality priorities for the Borough. The public engagement activity is to be completed by the end of August (2019).

Quality Task and Finish Group - Workshop: It was felt that to progress at a pace that a ‘sub group workshop’ would provide an opportunity for quality leads to identify a defined set of quality outcomes that all partner organisations within the HWP alliance could contribute to and deliver improvement against. The workshop event was held on 15 May (2019) further details on this activity are included within the following section.

5 Quality Task and Finish Working Group (15 May 2019)

5.1 The Group was asked to consider the current ‘National, Regulator Quality Assurance and

Improvement Model’ and to describe as a whole system how we could build onto the existing duties and obligations to ensure that we define and agree a ‘Single System Model for Quality across Health and Care’.

5.2 The system should not only satisfy the national drivers and regulatory activity, but importantly will encompass and drive the local quality improvement and innovation agendas. The following key questions were posed to the group:

(The presentation used to promote the group discussion has been included at appendix 1 for reference) 5.3 Following the group activity and discussion the following actions were agreed by the group members:

What would an Integrated Provider ‘Single Quality Framework’ potentially look like? What would an Integrated Provider ‘Quality Dashboard’ consist of?

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Integrated Commissioning Committee (ICC) Outcomes Framework - Quality

The Quality Task and Finish Working Group agreed that rather than draft a Borough wide Quality Outcomes Framework; that Quality should be an integral component within the draft of the ‘ICC Outcomes Framework’.

The ICC Outcomes Framework current data collection is wholly performance data, the group agreed that qualitative outcomes could be identified and included. This would address the quality assurance/improvement gap, avoid duplication and add a further level of assurance to the overall framework ensuring it is more robust. The draft ICC Outcomes Framework - high level objectives have been summarised below.

The Quality leads have all agreed to provide details of the quality measures that their organisation routinely collates i.e. incidents, complaints, clinical audit, NHS Friends and Family Test, Peer Reviews, patient and staff surveys, quality improvement visits etc. This will be shared with the HWP Business Intelligence (BI) who will then populate the ICC Outcomes Framework to capture the quality outcome measures.

6 Public Engagement & ‘I’ Statements: 6.1 The intention is to use the feedback gained from the public engagement activity to influence the Quality Priorities for the Borough. The narrative captured from the public engagement activity will assist the Quality Task and Finish Group to form a number of individual ‘I’ Statements. 6.2 The intention is that the ‘I’ Statements will capture the things that people who use health and care services and their carers would be able to say if their care was truly high quality; person centred and coordinated. These can often be summed up by one overarching statement for example: “’I’ can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.” 6.3 The engagement activity as previously noted in the above section of this paper is due to be completed by the end of August (2019). Following the review and analysis of the feedback the individual ’I’ Statements will be drafted and shared. 7 Care Quality Commission (CQC) System Wide Reviews 7.1 Given the transitional arrangements and the related quality agendas it was felt that it would be beneficial to have an insight into the outcomes and learning from the system wide reviews. A brief insight into the nature of the reviews has been outlined below.

Obj. 1

Young People - All children and young people will be treated equally, feel safe and care about their education, health and future employment

Obj. 2

Enable physical and emotional wellbeing, increase independence and reduce reliance on health and social care services

Obj. 3

Resources are orientated towards early intervention and people have access to timely and responsive services in the right place at the right time

Obj. 4

To deliver more coordinated, integrated and informed personalised care, in the most appropriate community setting

Obj. 5

Increase the number of years that people are healthy and reduce the difference in life expectancy between communities

Obj. 6

Resident experience of health and social care in Wigan is one that demonstrates a good experience of care and enhanced quality of life

Obj. 7 To reduce the need for institutionalised care and avoid re-admittance

Obj. 8 To provide Financially Sustainable Services

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7.2 The CQC have been approached and have agreed to support a local event, this is planned to be delivered in late autumn/early winter. Commissioners; and providers within the HWP alliance will all be invited. 8 Proposed Governance Framework for the Wigan System 8.1 We should first recognise that the Boards (or similar bodies) of the partner organisations within the HWP should have robust quality systems in place, and be clear about who is ultimately responsible for making the system work effectively. This should include fair processes for staff and the people who use the services. The Leaders within those organisations should ensure they personally inform themselves about the standards being achieved and have governance arrangements in place that include clarity about the levels of accountability within their organisations. 8.2 All those with Leadership Responsibility at locality level should:

Champion the importance of good quality services;

Champion the importance of providing channels for people to feed back about their experience, and listening to their views and embed co-production as a principle when designing services;

Promote a culture of openness and continuous learning, amongst all the partner organisations within HWP;

Challenge provider organisations about their internal quality assurance processes and ensure they are accountable to the public,

Challenge commissioning organisations about how they are monitoring quality, and ensure they are accountable to the public.

8.3 Health and Wellbeing Boards (HWBs) should:

Make themselves aware of how quality is being monitored locally, and of the priority issues and concerns in the locality;

Where necessary, ensure action is taken and reported on those priority issues; Ensure a joined up approach, and good information-sharing, between HWP partners;

Be aware of the work of the quality oversight activities for the locality which coordinates quality assurance activity for health and social care,

Identify the priorities for fuller scrutiny (e.g. Overview and Scrutiny Committee; CQC; NHS England/ NHS Improvement).

8.4 To enable the locality to ensure the above will require a robust Integrated Governance Framework. The diagrams included at appendix 2 set out the proposed views on the single system for quality oversight. The diagram at Figure 1 details the HWP Whole System Governance for the delivery of out of hospital care. Figure 2 provides a proposed high level ‘Strategic View’ for the Wigan ‘Single Quality System’.

The CQC has completed a programme of targeted local system reviews in 20 Local Authority areas to assess how well services are working together to care for and support people aged 65 and over. The result report, Beyond barriers: how older people move between health and social care in England, summaries CQC’s findings from the reviews. During the reviews the CQC sought feedback from a range of people involved in shaping and leading the system, those responsible for directly delivering care, as well as people who use services, their families and carers. In brief the aim is that each local area review highlights: What is working well Opportunities for improving how the system works for people using services

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https://www.cqc.org.uk/sites/default/files/20180702_beyond_barriers.pdf

https://www.cqc.org.uk/sites/default/files/20180702_beyond_barriers.pdf

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9 Developing a ‘Single Quality System’ for Health and Care - Delivery Plan - Next Steps 9.1 The planned activities for the Quality Task and Finish Group have been summarised within the paper. The group fully recognises that whilst the activities to date have gone to plan we will need to clearly define the future activities and the timeframes for bring this work to a conclusion by 2020/21 as initially identified. The immediate steps are.

10 Activity Beyond 2020/21 10.1

11 Reporting 11.1 The Integrated Commissioning Committee is requested to review and comment on the

paper provided by the Quality Task and Finish Group, outlining the progress to date and future actions in seeking to establish a ‘Single System for Quality.

1 Propose a Strategic Framework for the Wigan System for Quality

2 Undertake the planned Patient Engagement Activities (July/August 2019)

3 Formulate and approve the ‘I’ Statements

4 Provider organisations represented on the Quality Task and Finish Group to identify and agree a common set of outcome indicators and metrics for quality that can be consistently provided to the HWP to demonstrate a level of compliance against the ICC Outcomes Framework

5 Review the quality delivery plan following the outcomes from the quality workshop (15 May, 2019) and the public engagement activities. This should include the timeframes for the delivery of any remaining actions/activities

Paper prepared by: L Mitchell, Senior Assistant Director Nursing & Quality (NHS Wigan Borough CCG) Date: 4 June 2019 Receiving Committee: Integrated Commissioning Committee Date: 19 June 2019

Wigan Borough Strategy for Quality Once the system has an approved ‘Single Quality Framework’ in place and the HWP is providing assurance on the agreed outcome measures, and the reporting systems are fully functional, the intention going forward is to develop and agree a Wigan Borough wide ‘Strategy for Quality’ that the whole system can sign up to.

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Appendix 1

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8

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Appendix 2

Figure 1: HWP Governance Framework for the Wigan System - Delivery of Out of Hospital Care

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Figure 2:

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REPORT TITLE: Integrated Performance Framework

REPORT AUTHOR: Steph Hancock/SWOG

PRESENTED BY: Rachel Robinson/Gemma Bathurst -Whittle


The committee are asked to consider and comment onthe proposals for a significant change in business intelligence support for the Whole System Governance.

EXECUTIVE SUMMARY

This paper sets out a system wide proposal and ambition to succeed with a truly integrated business intelligence model for Wigan borough. It describes how and when the Whole System Governance structure requires support from business intelligence and outlines how a significant shift to outcome-based analysis will take place.

The paper is split into 2 parts:Section 1 describes the integration of business intelligence to support whole system governance

Section 2 describes the Population Health journey through Investments and their impact 2019-2021 – a shift change from performance reporting to case study and strategic analysis.

In addition, the ICC is provided with an update on current system performance, with detail against a number of key partnership measures and performance against Greater Manchester Transformation metrics.

The paper finalises by seeking approval from the ICC that the change in business intelligence support is endorsed and proposes the delivery of a future business case to request support to implement the described changes.

FURTHER ACTION REQUIRED: Business case


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Business Intelligence System for Commissioning

Section 1: Integration of Business Intelligence to support Whole System Governance - what to expect from integrated business intelligence

Section 2: Describing the Population Health Journey through Investments and their Impact 2019-2021 – shift change from performance reporting to case study and strategic analysis.

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1. Integration of Business Intelligence to Support Whole System Governance

1.1 We have a fantastic opportunity in the borough to harness the strengths of our partnership working by creating an integrated business intelligence model that will offer consistency in performance and outcome measurement, robust strategic and tactical analysis, and provide a strong evidence base to support effective place-based commissioning and transformation.

1.2 In response to a request from the ICC, this paper sets out a system wide proposal and ambition to succeed with a truly integrated business intelligence model for Wigan borough. It describes how and when the Whole System Governance structure requires support from business intelligence, uses the different strengths and capabilities from across the system in a joined-up way and supports a system where there is a strong culture of robust analysis, a focus on outcomes and a strong evidence base supporting effective decision making and investment.

1.3 This shift change to outcome based analysis will require significant cultural, mind set and technical changes. It is integral that the ICC receives accurate evidence-based analysis to ensure that the committee can support system providers in delivery against agreed system wide outcomes and quality assurance for the borough.

1.4 As the ICC has responsibility for addressing performance and quality issues within the health and social care system as well as the right to take corrective action as required, the decision making requires significant support from integrated partnership business intelligence.

1.5 Based upon the new governance arrangements described in a previous report to the Integrated Commissioning Committee (ICC), it has been agreed that the Healthier Wigan Partnership Strategic Leadership Team will operate as the design authority for the system to ensure that transformation proposals are led and managed through Healthier Wigan Partnership Board on behalf of the ICC. This will require business intelligence reporting to operate in a way that provides the right level of detail regarding system and population health in the right way at the right time/point. Not only will this ensure that business intelligence is drawing from a single version of information, but it is also consistent message to ensure a whole system response to include population health and the wider determinants that drive service demand.

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1.6 Using the Whole System Governance structure as the foundation to establish the integrated business intelligence model, the below diagram highlights the detail potentially required at each level.

Figure 1: Whole System Governance Supported by Business Intelligence

1.7 Building on the diagram, the following explains the detail proposed for each board/group:

Health and Wellbeing Board – Strategic Business IntelligenceRequiring an update on business intelligence to support decision makers to drive policy and set strategy for the system. This will include research on ‘what works’ locally and nationally and ensuring that the Health and Wellbeing Board is at the forefront of key policy changes as well as leading the way in terms of innovative and ground- breaking approaches, placing our residents at the centre of decision making and giving it assurance that our programmes and services are delivering against local needs.

ICC – Strategic Business IntelligenceWill turn the policy and strategy into commissioning intentions. This group will therefore require cross system intelligence, including an update on how the partnership is performing against the Greater Manchester transformation measures, see Appendix 1 (note this is an example of the current GM Tableau Dashboard and there are currently queries regarding the figures contained therein, local monitoring

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will be developed) as well as the boroughs own plans and priorities in the context of The Deal 2030, Locality Plan and agreed population outcome measures. The information provided to the ICC will enable decision makers to assess if funding decisions have been successful, whether they are delivering an impact, evidencing a value for money and how the investment is having an impact on improving outcomes for our residents, and the performance of our system. The main detail that will be presented to the ICC will be in the form of case study analysis to show the impact on outcomes as opposed to performance. See section 2: Describing the Population Health Journey through Investments and their Impact 2019-2021

Healthier Wigan Partnership Board – Strategic Business Intelligence Will monitor the movement against the 8 systemwide outcome measures and agreed targets. See Appendix 2 for detail of outcomes. The role of this board from a business intelligence point of view is to be able to understand the health of the system and identify gaps in delivery v’s demand. This will include reporting against key transformation activity as defined by the board. To be successful in this process, the analysis will require substantial input and support from the tactical performance and analysis occurring within the Healthier Wigan Strategic Leadership Team and Delivery Boards that sit beneath.

Healthier Wigan Partnership Strategic Leadership Team and Delivery Boards – Tactical Business IntelligenceThis section of the governance structure will be where the ‘every day business’, tactical analysis and performance dashboards will be supported. At this level, there will be much more in-depth monitoring of trends and data that is linked to outcomes and investment. The performance and analysis at this level in the business intelligence process will be much more granular and led wholly by the delivery board, supported by business intelligence. These boards are the engine rooms of the data and analysis that will be fed up through the appropriate channels as and when required. Examples may include when there is need for further investment, to scale up, when there may be strategic issues that need unblocking or when the strategic boards need to be made aware of a significant shift in performance and/or outcome change. Information drawn from these groups will support the ICC to develop and understand commissioning intentions for the borough. Each group will have a dedicated business intelligence lead who will coordinate the asks of the group back to the System Wide Outcome Group (SWOG). See Appendix 3 for collection of current system key pressures.

1.8 The boroughs Service Delivery Footprints (SDF’s) are integral to the integrated business intelligence and all performance and analysis completed will reflect this.

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1.9 Examples of where we are starting to explore integrated business intelligence to support the whole system governance: Mental Health - The Mental Health Board requested a dashboard of activity to be completed to understand current system pressures. Business Intelligence leads have come together to support the board and are now working with the group to commission and complete a Mental Health Needs Assessment for the borough. it has been agreed with members of the menta health board that to complete this analysis accurately and ensure a full partnership input it will take 6 months to complete. Expectations have been managed to support the process, moving away

SDF Leadership Teams – Each SDF Team has been provided with an initial evidence base of the ‘population health in the SDF’, this is a sound baseline from which business intelligence colleagues can update and work through with the SDF Leadership Board to develop achievable and realistic recommendations. It would be anticipated that these recommendations should then form part of a business delivery plan which the board will work through. Any issues, blockages, requests for investment will then be highlighted to the SLT and fed through the governance structure as appropriate.

The above 2 recent examples illustrate where we are starting to explore integrated business intelligence to support the whole system governance, providing analysis in addition to performance reporting. Within our partnership we have excellent business intelligence support but often constraints of performance reporting requirements does not allow the time for in depth analysis, recent examples are building on these strengths however the new system governance structure allows an opportunity to expand and formalise an integrated business intelligence response.

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2. Describing the Population Health Journey through Investments and their Impact 2019-2021

2.1 This section describes and shows an example of outcome driven analysis. This form of analysis requires a shift change in current thinking and expectation of receiving primarily performance information and allows business intelligence to explore and understand in more detail the impact that our transformation programmes and investments are having on our population. Performance analysis will continue to meet statutory reporting requirements and to support and underpin outcome analysis rather than drive business.

2.2 Currently within the borough there is a tendency to rely upon performance measures that are not necessarily wholly reflective of local delivery or help evidence the impact of our activity. This is a methodology that is replicated across other boroughs throughout the country. Building on this we have an opportunity via case study analysis to work with our services to implement a different way of reporting impact. An example of questions we will explore include:

What is the transformation story – what is the programme or activity trying to achieve?

How is the programme doing this? And why? How does this translate into investment v’s impact? How has the frontline offer changed? Feedback from staff and from residents? – impact on workforce of changes. What has changed from a data intelligence collection perspective? Do we need to change the way in which information is collated to evidence

impact? Are system changes needed to support the required information collection? What are the gaps in the system around intelligence? What are the opportunities and challenges?

2.3 To answer these questions business intelligence colleagues will need to work closely with services and transformation programmes to understand the data collated and where necessary work with staff to ensure appropriate and useful intelligence is being collated at the right time in the right place.

2.4 Figure 2 details an example of an early case study, using information that is readily available at the current point in time. Once the model has matured the case study will also include reference to the above questions. This is purely illustrative at this point to indicate to the ICC the potential direction of travel.

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Comprehensive assessments completed and adaptions and support provided

Figure 2: Example Case Study Analysis – Margaret

Community Services

Photo of Jodie?

+

- Concern from neighbour Police

Contact x2

Agree to CRT referral

Short stay in step up bed

Returned home 3 days later with wrap around support

Stable and safe at home. Margaret remained on CRT ‘watch List’ and MDT and DR updated. Referral to Age Concern arranged to alleviate social isolation

NWAS

Neighbour

nts

Friends

nts

GP

nts

Police

MargaretCindy (Dog)

Family & Friends

nts

Services

nts

For 101 years she has remained healthy and

resilient at home and was determined not to go into

long term care

Privileged to work as a team with the patient to enable her to remain at

home safely with ongoing support

With the support of CRT we helped her achieve her goal to not going into long term care!

GP Visit – denies any problem

NWAS Call x2

CRT

Age Concern

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3. Interim Performance Update

3.1 The above describes a proposed integrated business intelligence model that will support the whole system governance structure. This is a future model which will take time to develop and embed however the governance structure still needs to understand system health and challenges. To ensure this is available, business intelligence will continue to provide the ICC with:

Greater Manchester Transformation Metrics (see Appendix 1) An overview of Systemwide Measures (see Appendix 3)

4. Next Steps

4.1 The process detailed above requires a significant shift in analytical thinking where business intelligence will be moving towards richer evidence led and outcome analysis. To fully embed and ensure sustainability there will be a need to coordinate and support services and staff. A review of current system capacity and capability to support the BI transformation will take place however it is envisaged that additional strategic analytical partnership support will be required and it is therefore proposed that a business case, requesting additional capacity will be submitted to the next ICC for consideration.

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Appendix 1: Greater Manchester Transformation Metrics (See PDF)

Appendix 2: Outcomes

Appendix 3: Systemwide Measures (See PowerPoint)

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IndicatorUpdateFrequency

LatestDate

Previous ValueLatest Value Direction ofTravel

YTD Value YTD Plan YTD % Var toPlan

Category

Activity

First Outpatient Attendances Monthly Feb-19

Follow Up Outpatient Attendances Monthly Feb-19

Elective Admissions Monthly Feb-19

Day Case Admissions Monthly Feb-19

% Zero Day Length of Stay - ElectiveAdmissions

Monthly Feb-19

% One Day Length of Stay - Elective Admissions Monthly Feb-19

% Two Days Plus Length of Stay - ElectiveAdmissions

Monthly Feb-19

Non Elective Admissions - Zero Day Length ofStay

Monthly Feb-19

Non Elective Admissions - One Day Plus Lengthof Stay

Monthly Feb-19

Non-Elective Readmissions (30 Days) Monthly Feb-19

Emergency Admissions Aged 65 and Over Monthly Feb-19

Bed Days Aged 65 and Over Monthly Feb-19

Total Bed Days per 1,000 Weighted Population Monthly Feb-19

Non-Elective 1+Days LOS per 1,000 (Weighted) Monthly Feb-19

A&E Attendances Monthly Feb-19

Stranded Patients Monthly Feb-19

Super-Stranded Patients Monthly Feb-19

System Management

% Child Non-Elective Admssions with Zero LOS Monthly Feb-19

Admissions for asthma, diabetes and epilepsy(Under 19's)

Monthly(Rolling 1..

Feb-19

DTOC per 100,000 Monthly Feb-19

% Aged 65+ Discharged to Residential Care Monthly Feb-19

CQC - % of Beds in Residential Homes Rated'Outstanding' or 'Good'

Monthly Apr-19

CQC - % of Beds in Nursing Homes Rated'Outstanding' or 'Good'

Monthly Apr-19

CQC - % GP Practices Rated 'Outstanding' or'Good'

Monthly Apr-19

Prescribing: Cost Per ASTRO-PU Monthly Feb-19

Deaths Occurring at Usual Residence Quarterly Dec-18

86,458

169,906

34,195

29,953

90.1%

5.0%

4.9%

11,837

20,850

2,725

11,618

100,475

48.4

6.4

105,496

2,848

1,282

46.2%

2,910

9.9

4.3%

74.0%

52.9%

87.1%

3.71

42.5%

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

78,715

152,817

32,419

28,001

88.6%

5.2%

6.2%

10,915

19,243

2,116

10,491

95,813

46.8

5.9

97,907

3,139

1,469

44.7%

2,927

12.3

4.0%

73.5%

56.2%

87.9%

3.33

42.3%

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

▼▼▼▼▼▲▲▼▼▼▼▼▼▼▼▲▲▼▲▲▼▼▲▲▼▼

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

908,404

1,765,375

361,142

310,019

125,675

218,315

1,124,990

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

931,129

1,849,745

363,695

315,603

116,339

210,165

1,100,340

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

-2.4%

-4.6%

0.7%

-1.8%

8.0%

3.9%

2.2%

Choose LocalityGreater Manchester

Key:Above Plan

Below Plan

N/A

Transformation Investment AgreementDashboard for Greater Manchester

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Outcome

1. Young People All children and young people will be treated equally, feel safe and

care about their education, health and future employment.2. Wellbeing

Enable physical and emotional wellbeing, increase independence and reduce reliance on health and social care services.

3. ResourcesOrientated towards Early intervention, with access to

timely/responsive services.4. Delivery

To deliver more coordinated, integrated and informed personalised care, in the most appropriate community setting.

5. Life ExpectancyIncrease the number of years that people are healthy and reduce

the difference in life expectancy between communities.6. Quality

A good experience of care and enhanced quality of life.7. Care

To reduce the need for institutionalised care/avoiding re-admittance.8. Finance

To provide Financially Sustainable Services

Appendix 2: Systemwide Outcomes – already agreed by the ICC (JCC at the time)

Page 109

Integrated Care Communities: June 2018/19 Aspirations and strategy outcome measures

Repeat Incidents of Domestic Abuse (Jan – March ‘19)

609 Repeats Oct – Dec 18

6% Reduced 5 percentage points on Q3 18/19 figures (Q3 = 11%)

Remaining referrals met by information and advice or supported by the third sector

Healthy Life Expectancy Males / Females 2009 – 2017

75.576

76.577

77.578

78.579

79.580

2 0 0 9 - 1 1 2 0 1 0 - 1 2 2 0 1 1 - 1 3 2 0 1 2 - 1 4 2 0 1 3 - 1 5 2 0 1 4 - 1 6 2 0 1 5 - 1 7

Wigan North West England

79.5

80

80.5

81

81.5

82

82.5

83

83.5

2 0 0 9 - 1 1 2 0 1 0 - 1 2 2 0 1 1 - 1 3 2 0 1 2 - 1 4 2 0 1 3 - 1 5 2 0 1 4 - 1 6 2 0 1 5 - 1 7


MALES FEMALES Wigan North West England Wigan North West England

2009-2011 77 77.3 78.8 80.8 81.4 82.7 2010-2012 77.3 77.6 79.1 80.8 81.6 82.9 2011-2013 77.6 77.9 79.3 80.9 81.7 83 2012-2014 77.6 78 79.4 81.3 81.8 83.1 2013-2015 77.7 78.1 79.5 81.2 81.8 83.1 2014-2016 77.8 78.2 79.5 81.2 81.7 83.1 2015-2017 77.8 78.2 79.6 80.9 81.8 83.1

Healthy Life Expectancy Males / Females Comparison with CIPFA Stat Neighbour Group

MALES: Wigan ranked 10th best of 16

Stat Neighbours Value (Male) Stat Neighbours Value (Female)

England 79.6 England 83.1 Bolton 77.8 Calderdale 82.1

Kirklees 78.6 Bury 81.2 Doncaster 77.9 Wigan 80.9 Calderdale 78.6 Telford and Wrekin 81.9

Telford and Wrekin 78.5 Doncaster 81.7 Wigan 77.8 Barnsley 81.9 Bury 78.5 Dudley 82.9

Barnsley 78.1 Stockton-on-Tees 81.4 Dudley 78.9 Rochdale 80.6 Halton 77.4 Bolton 81.6

Rotherham 77.8 Kirklees 82.5 Wakefield 78 St. Helens 80.9 Tameside 77.5 Halton 80.7 St. Helens 77.5 Tameside 80.8 Rochdale 77.2 Rotherham 81.7

Stockton-on-Tees 78.1 Wakefield 81.8

FEMALES: Wigan ranked 12th best of 16

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Integrated Care Communities: Aspirations and strategy outcome measures

74.7

77.1

75.4

76.3

74.6

Jan 2014-Dec2014

Jan 2015-Dec2015

Jan 2016-Dec2016

Jan 2017-Dec2017

January 2018- December

2018

Employment rate

74.6% Although in the last few years there has been a slight downward trend in employment rate, Wigan’s labour market outperforms its statistical neighbours and the national average. However, quality of jobs remains an issue

72.6% Stat neighbours Employment Rate (17/18)

Patient experiences of GP services

Percentage of people reporting a 'very good' or 'fairly good' experience of GP services, weighted for design and non-response, 95% Confidence Intervals (CI)

87.8 87.7

88.0

86.9

87.5

88.4

88.7

January2018 toMarch2018

January2017 toMarch2017

July 2015to March

2016

July 2014to March

2015

July 2013to March

2014

July 2012to March

2013

July 2011to March

2012

269 285 249

301 303 277 302

300 303

292 260

308

269

296 304 262

260 252

206

254

325

246

304

265 292

284

0

50

100

150

200

250

300

350

First Contacts Seen - F2F Subsequent Contacts Seen - F2F

RAID face to face contacts April 2018 – April 2019

3718 Total number of First Contacts Seen as at April 2019 up from 2589 on December 2018 figures.

3550 Total number of Subsequent Contacts Seen as at April 2019 up from 2405 on December 2018 figures.

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261 266

280 285 282

265 265

292 286

294

281

266

275 280

293 293

308

High Intensity User Trend Jan 18 Dec 18 Total number of High Intensity Users as at March 2019 up from 280 on December 2018 figures.

A & E High Intensity Users (High intensity = 10+ attendances in a 12 month period)

308

A&E attendances monthly / quarterly performance (excluding planned)

2,200

4,200

6,200

8,200

10,200

12,200

14,200

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2018/19 2017/18 2016/17

Attendances Year-On-Year Variance

Quarter 2016/17 2017/18 2018/19 2017/18 2018/19 Q1 36,904 36,059 37,623 (2.29%) 4.34% Q2 36,606 35,678 36,495 (2.54%) 2.29% Q3 35,090 35,855 36,296 2.18% 1.23%) Q4 33,696 34,433 37,450 2.19% 8.76%

Non-elective admissions Includes Ambulatory Care

0.9% Increase in non-elective admissions comparing April – March 2018 (28,905) with April – March 2019 (29,841)

3,196

3,797

3,470 3,457 3,310

3,039

3,172 3,290

3,189

3,193

2,963 3,200

1,500

2,000

2,500

3,000

3,500

4,000

Apr MayJun Jul AugSep Oct NovDec Jan Feb Mar

2015/162017/182018/19

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0.9% Increase in non-elective admissions comparing April – March 2018 (28,905) with April – March 2019 (29,841)

Includes Ambulatory Care

A & E High Intensity Users (High intensity = 10+ attendances in a 12 month period)


A&E attendances monthly / quarterly performance (excluding planned)

308 Total number of High Intensity Users as at March 2019 up from 280 on December 2018 figures.

Mortality rate from causes considered preventable

Reduced 2 value points on 2013-15 figures (2013-15 = 184.5)

Below North West average however continuously remains significantly higher than England average

220.4 222.8 220.8 224.9 223 220.4

184.5 182.8 181.5

2013 - 15 2014 - 16 2015 - 17


301

395

497

429

210 200

181 194 203 212

261 200

240

0

100

200

300

400

500

600

Repeat in 12 months

Domestic Abuse

Repeat Incidents of Domestic Abuse (Jan – March ‘19)

609 Repeats Oct – Dec 18

701 Repeats Jan – Mar 19

65 65.5

68.9

63.2

JULY 2014 TO MARCH 2015

JULY 2015 TO MARCH 2016

JANUARY 2017 TO MARCH 2017

JANUARY 2018 TO MARCH 2018

People feeling supported to manage LTC

63.2 Total number of people feeling supported to manage their Long Term Condition 68.9 Previous year March 2017

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70.50%

71.70%

72.70%

72.00%

Q1 Q2 Q3 Q4

2018/19

Adult social care users by year and quarter

Proportion of Adult Social Care Users in receipt of a community based service

England 70.3% Stat Neighbours 70.8% North-West 72.1%

9%

8%

10%

8%

10%

7% 7%

9%

6%

10%

9%

10%

8%

11%

10%

9% 9%

9% 7% 8%

11%

9%

7% 6%

0%

2%

4%

6%

8%

10%

12%

14%

% of Contact and Assessment Referrals requiring long-term support

6% Reduced 5 percentage points on Q3 18/19 figures (Q3 = 11%)

Remaining referrals met by information and advice or supported by the third sector

155.8 167.4 165.7

124.2

240.3

149.1 149

Q1 Q2 Q3 Q4

17/18 18/19

Permanent admissions of older people 65+ to res/nursing per 100,000 population 2017/18

Wigan 734.1 England 585.6 Stat Neighbours 682.0 North-West 737.8

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Permanent admissions of older people 65+ to res/nursing per 100,000 population 2017/18 – 2018/19

Awaiting Q4 information for 2018/19

22.6% 23.6%

26.5% 26.0%

27.9%

24.53%

22.04%

24.30%

Q1 Q2 Q3 Q4

2015/16 2016/17 2017/18 2018/19

% of Children’s Social Care re- referrals

24.30% A 2.26% increase in comparing Q4 17/18 to Q4 18/19 England 21.9% Stat Neighbours 21.7% North-West 22.3%

60 60 60 60 62

64

79 81

82 82

86

91

73

74 72

65.8

70.6

66.3

2013 2014 2015 2016 2017 2018

England North West WiganLooked after children Rates per 10,000 children aged under 18 years

66.3 Children per 10,000 population 4.3% Decrease in the looked after children rate from 2017 to 2018

Statistical Neighbours 2018:

98.2 looked after children per 10,000 population aged <18

37.70

55.40

63.80

67.00

69.30

68.60

49.74

56.18

63.36

66.70

68.73

69.85

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00

2013

2014

2015

2016

2017

2018

Statistical Neighbours Wigan

School Readiness Good level of development at age 5: children defined as having reached a good level of development at the end of the Early Years Foundation Stage (EYFS) as a percentage of all eligible children

68.6% A 0.7% decrease on 2017 figures. Wigan has been overtaken by North West and statistical neighbours as they demonstrate a better rate of school readiness.

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REPORT TITLE: Drug and Alcohol Update

REPORT AUTHOR: Professor Kate Ardern MBChB, MSc, FFPH – Director of Public Health

PRESENTED BY: Lisa Ball, Business Manager – Alcohol, Drugs, Health and Reducing Reoffending


Receive

EXECUTIVE SUMMARY:

This report is to outline the outcome of the Care Quality Commission inspection of local drug and alcohol services provided by Addaction.

FURTHER ACTION REQUIRED: Service Delivery Action Plans to be implemented


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1.0 Purpose

This report is to outline the outcome of the Care Quality Commission inspection of local drug and alcohol services provided by Addaction.

2.0 Background

Wigan Council is recognised as having a strong partnership approach to drugs and alcohol. In terms of commissioned services, the council is often regarded to be at the forefront of innovative practice whilst simultaneously delivering strong performance results on core business activity. The current adult drug and alcohol service contract commenced in April 2018 with an all age service delivered by Addaction.

The approach for the drug and alcohol services from April 2018 built on the existing recovery-oriented approach, and work to achieve the local vision and outcomes outlined in the Deal for The Future, Deal for Health and Wellness, Deal for Adult Health and Social Care, Deal for Children and Young People, and Deal for Communities. The model strongly supports the delivery of the Wigan Locality Plan, the Transforming Population Health Plan and actively support the Greater Manchester devolution work including the common standards and vision outlined for drug and alcohol services under the Greater Manchester Drug and Alcohol Strategy. The priorities reflect the broad areas outlined in the National Drug Strategy which was published in July 2017, but the GM Strategy goes further in documenting specific regional priorities and demonstrating how these will be achieved.

The drug and alcohol service model has several key elements to it. The model provides a much greater emphasis on prevention, early help and building self-reliance than any previous commissioned model. This is achieved through better understanding communities, by working with communities, and through connecting to community assets and service providers in a place. The service also pursues a stronger approach to understanding an individual through utilising family and friend networks.

At the heart of the model is an asset-based conversation and approach which ensures that the service provides a bespoke response to each individual that appropriately reflects the level of support needed. This is delivered at the right time and in the right place to maximise the chances of success.

The key components of the model are as follows:

1. An integrated adult and young people service2. A service for alcohol and all other drugs3. A service embedded in the community4. A service that is part of a wider system and complimentary to wider commissioned

services

3.0 Care Quality Commission Service Inspections – Community-based Services

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The Care Quality Commission inspect all community-based services that provide, care, treatment and support in the community for people with substance misuse issues. This may also include people who have dual diagnosis or co-occurring disorders where the person is experiencing a mental health concern as well as substance misuse.

The inspection took place on the 19th March, just as Addaction were completing the implementation of the first full year of operation of the new model. In addition, this is the first year that the Care Quality Commission have rated substance misuse services which follow a three-year inspection cycle.

The inspection team assess across five key rating domains, we are delighted to report that Addaction received an overall rating of ‘Good’ across each of the domains, with two areas of outstanding practice.

To fully understand the experience of people who use services, the inspection team ask the following five questions of every service and provider:

Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led?

Before the inspection visit, the inspection team reviewed information that they held about the location including the provider information return that the registered manager had submitted.

During the inspection visit, the inspection team:

visited both prescribing centres Coops and Kennedy House, looked at the quality of the environment and observed how staff interacted with clients

spoke with five clients who were using the service spoke with the registered manager and operational managers for the service spoke with 11 other staff members; including a doctor, nurses and recovery co-

ordinators, and a volunteer attended and observed two flash meetings (daily team meetings) looked at 12 care and treatment records of clients, and 8 records for prescribing looked at a range of policies, procedures and other documents relating to the running

of the service.

Addaction Wigan and Leigh were rated as good because:

The service provided safe care. The premises where clients were seen were safe and clean. The service did not have waiting lists and clients who required urgent support were given priority and seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding

Staff levels and skill mix were planned, implemented and reviewed to keep clients safe at all times. Any staff shortages had been responded to quickly and adequately. There were daily flash meetings, effective risk management and multidisciplinary team meetings held to ensure staff could manage risks to clients

Clients’ care and treatment was planned and delivered in line with current evidence-based guidance and outcome measures were in place to check consistency of practice. Clients’ individual needs and preferences were central to the planning and delivery of tailored services. Clients had comprehensive assessments of their care needs which considered physical, mental and emotional health

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Staff treated clients with compassion and kindness and understood the individual needs of clients. They actively involved clients and families and carers in care decisions. Clients were supported to take responsibility for their own recovery and staff supported them in a non-judgemental way to achieve this

There was a proactive approach to understanding the needs of diverse groups of clients and to deliver care in a way that met their needs and promoted equality. The service had a community-based approach ensuring clients could receive care within their community

The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

Addaction were also commended for two areas of outstanding practice:

1. The community rehab at Greenslate Farm including delivery of therapeutic recovery interventions and NVQ Mental Health and Health and Social Care qualifications. The inspection team commented on the effective partnership that had been developed with the community organisation to collectively support clients in recovery

2. Provision of a specialist midwife embedded within the core team who provided midwifery leadership and co-ordinated maternity care for pregnant women who had either recently used or were currently using illicit substances and/or alcohol or were under the care of the recovery service in Wigan or Leigh. This was a dedicated service provision for women who misused substances in or immediately prior to pregnancy.

4.0 Feedback from CQC Relationship Manager and next steps

The Care Quality Commission Relationship Manager wanted to express that the service was a really strong ‘good’ and were close to outstanding in caring, responsive and well-led.

He commented that the reason why the service didn’t quite hit outstanding was that we had good plans in place, but we hadn’t been operating for long enough yet to evidence the plans coming to fruition. He advised on a few points where we can gather evidence over the next couple of years to move us up the scale which we have included in our service delivery action plans for the next 12 months:

1. Formalising our relationships with external agencies. They said our current relationships particularly with the police, NPS, CRC and PSR were already much more robust, advanced and evidencing positive results and positive relationships than other services he had inspected. If we could provide more evidence of how we had formalised these relationships and how we were influential in directing joint working like we do with the midwife arrangement this would move us to outstanding in well-led. He acknowledged that we had started plans in these areas, but these plans were still in the infancy stages.

2. Use of audit information to support service improvements. They were impressed with how audit information was used to support service improvements e.g. where staff who were under performing by being supported on performance improvement plans but needed to evidence regular audits.

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3. Supporting staff. In caring, they discussed how we supported our staff that had a substance misuse history themselves (staff had self-reported this), if this was evidenced it would improve the rating.

4. Outreach and work in the community. They loved the outreach elements and working in the community especially things like the community rehab at Greenslate Farm, but also appointments being offered in libraries, community centres, GP surgeries etc and felt that over the next couple of years as this grew this could provide an outstanding rating in the responsive domain

5. Quality of Care Records. They commented that the amount of detail in patient records varied and had been highlighted in an audit carried out by Addaction. Three staff had been identified and performance improvement processes had been initiated to improve the quality of their care records.

We are incredibly proud of the rating Addaction has achieved and the positive feedback about the direction of travel of the service, but the most significant part was captured in the section ‘What people who use the service say’:

“Clients we spoke with said that staff treated them with kindness and respect. They stated that staff understood their needs and always had time for them. They felt inspired, supported and motivated to recover and had progressed through their treatment. Clients described the service as life-changing”.

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REPORT TITLE: 100 Day Commissioning Review and GM Commissioning Review

REPORT AUTHOR: Rebecca MurphyHealthier Wigan Partnership Director

PRESENTED BY: Dr DaltonChair WBCCG


Receive and note progress and expectations of Commissioners

EXECUTIVE SUMMARY:

This item includes the final 100 Day Commissioning Review & Review of GM Commissioning Report, which was presented to the GM Partnership Executive Board. This is presented to ICC for information. The report outlines how the wider GM system needs to offer more explicit support to the development of new models of integrated commissioning and provision in each place, and if successful should lead to ICC and HWP being able to draw more explicitly on expertise, advise and support from a more mature GM wide system and JCB.

From the perspective of the ICC there are some key principles and suggested approaches that should help support the developing maturity of local arrangements for SCFs and LCOs.

In relation to SCFS and LCOSs and place1) Support the breadth, depth and ambition of the ICC as the focal point for decision making on

commissioning decisions in the place, reducing reliance on uni-organisational processes (but nevertheless recognising the statutory accountability of each). Wigan has been more ambitious than some in his area but there is more work to do to embed the centrality of the ICC as the focal point for place based commissioning.

2) Progress the related working on the transition of some CCG and Council capacity into the remit of the Integrated Care Organisations

3) More explicitly connect, from both a commissioning and provider perspective, the alignment of SDF/ neighbourhood-based health and care reform with the connection to wider public services reform

4) Build joint and shared approach to working with/commissioning VCSE, and recognise the importance of “communities of interest” (e.g. veterans) as well as place

5) Challenge GM programmes/recommendations when they are reflective of an individual sectoral or programme approach and they don’t describe how the implementation is framed by place-based working – e.g. at the level of SDF or borough considering the different needs of different places

Cont./

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In relation to acute commissioning

1) Participate in the necessary review of lead commissioner arrangements in a way that allows confidence and trust in the emergent model of lead commissioner working across the JCB

2) Understand more explicitly the proportion of acute commissioning activity that would nominally be in scope of the work of the LCO in time.

In relation to Population

1) Ensure that the work of the ICC is connected to the wider population health perspective. (In Wigan this is more clearly understood – for example the work with the Kings Fund and the Kings fund recommendations on the characteristics of a population health system.

2) Receive the GM wide population health strategy implementation plan and test and refine local priorities accordingly

In relation to the operation of the JCB1) Ensuring representation into the JCB and its emerging sub structure (e.g. Commissioning Leadership

Group, and a group with the characteristics of a Directors of Integrated Commissioning Group)that is mandated, informed and representative of the place and the ICC

In relation to the establishment of the Joint Commissioning Team

1) Positively support and constructively challenge the development of the JCT.

FURTHER ACTION REQUIRED: To note the summary and recommendations in the final report


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1

100 Day Commissioning Review

& Review of GM Commissioning

Final Report for Partnership Executive Board

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Report Contents

1. Transformational Ambition in Greater Manchester

2. Context

3. Commitments, Learning Points and Recommendations for;

a. Commissioning for Place Based Integrated Servicesb. Commissioning for Acute Service Reformc. Commissioning for Population Health Gaind. Future Role and Function of GM Joint Commissioning Board e. Future Role and function of GM Commissioning Hub

4. Summary of Recommendations and Implementation Plan

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1. Transformational Ambition in Greater Manchester

‘Taking Charge’ (2016) signalled an ambitious programme to transform the operation of the health and care system in Greater Manchester, focusing on improving population health, improving outcomes, and securing clinically and financially sustainable services.

The Greater Manchester Health and Social Care Partnership, comprising 34 statutory organisations including commissioners and providers of services, came together through the GM Health and Care Board to meet these objectives, and supported by a Chief Officer (and team) with responsibilities for duties, powers and resources delegated from NHS England, including commissioning functions.

An important part of the partnership arrangements is the conversion of strategic intent into prioritised and affordable commissioning action. An independent review in 2017 prompted new integrated commissioning arrangements between CCGs and local authorities at the level of each of the 10 localities (Strategic Commissioning Functions (SCF)), and at a Greater Manchester level through the creation of the Joint Commissioning Board (JCB) consisting of mandated clinical, political and managerial representation from each of the 10 localities. At a time elsewhere in the country where CCGs are aggregating together to address challenges of administrative cost reduction, Greater Manchester is pursuing a different model through integrated commissioning at locality level, and creating opportunity to secure the necessary economies of scale and governance for commissioning arrangements requiring a conurbation wide perspective. GM will however need to demonstrate that the different model of commissioning arrangements is at least as effective as the alternative.

At an SCF level the arrangements are maturing rapidly – the 1st of April 2019 for example represents a step change in the formality, depth and breadth of many of the SCF arrangements. The work is driven by a belief that integrated commissioning arrangements are more likely to create the conditions for development of models of community based care with a relentless co-ordinated and multi-agency focused on prevention, early intervention, and joined up working across health and care and indeed wider public and voluntary services - substantially the work of Locality Care Organisations. In this the role of political and clinical leadership working together in each of 10 places, and across GM as a whole to secure improved services and outcomes is central.

Inherent to both local and GM wide commissioning arrangements are the significant opportunities to influence and co-design the work of partners in securing population health and wellbeing gain. The work at a GM level on (for example) employment, transport, and air quality, is supplemented by important local effort in delivering public health interventions and building working relationships at the front line with key partners like GMP, housing providers, DWP, schools and others.

GM has therefore created for itself the potential through new commissioning arrangements to exploit economies of scale at a GM level where required, and a step change on our focus on prevention, early intervention, integrated provision, and demand reduction at a local level.

This report on the review of commissioning arrangements in GM is intended to ensure the way we commission in future makes a full contribution to the transformational ambition of the GM Health and Social Care Partnership

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2. Context

Since 2016 the GM Health and Care Partnership (GMHCP) has made significant progress in implementing Taking Charge – key strategic frameworks developed, key indicators measuring GM Health and Care System improvement, and the construction of the GM Health and Care Partnership system architecture for the transformation required – for example in the role of the Joint Commissioning Board, (JCB), the Provider Federation Board (PFB), the Primary Care Board (PCB), and at a local level.

This commissioning review recognises the positive progress made at a GM and local level, but suggests that as we enter the final 2 years of the scope of ‘Taking Charge’, and nearly two years after a 2017 review of commissioning in GM, the commissioning system needs to inclusively and developmentally quicken its implementation of the agreed strategy of the GM Health and Care Partnership in order to secure the benefit to residents and patients in Greater Manchester intended.

Further context is provided by the launch of the NHS Long Term Plan and the national GP contract proposals, where much of both are supportive of the direction of travel described in Taking Charge.

Three years into the GM Health and Care Partnership Arrangements and the implementation of ‘Taking Charge’, the system is developing a greater level of maturity of working. This also reflects evolving national expectations of Integrated Care Systems. In this context, and as part of the development of the Target Operating Model, the role of the GM HSC team will also change and evolve. In supporting the stewardship of the Greater Manchester system is likely to carry out a smaller number of core functions itself, those that are most important to the devolved model of governance, including retaining the authority for functions delegated to GM from NHS England. This will be matched by an expectation of more dispersed leadership of functions and programmes by different parts of the GM health and care system, working together. The increasing maturity of the GM Health and Care Partnership, the national context provided by the NHS Long Term Plan, the challenge of CCG administrative cost reduction, the challenging financial environment for many systems, and the evolution of the role of the GMHSCP Team, provides important context for the contribution of commissioning arrangements at a local (SCF) and GM level (JCB) to the objectives of the GM Health and Care Partnership.

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3. Commitments, Review Learning, and Recommendations.

Five key priorities have been identified from this review;

a. Commissioning for Place Based Integration,b. Commissioning for Acute Service Reform,c. Commissioning for Population Health Gain,d. Future role and Function of JCB,e. Future role and function of GM Commissioning Hub.

For each of them this summary provides a ‘Commitment Statement’, ‘Key Learning Points from the Review’, and ‘Recommendations’. There are eleven recommendations in total, and they are summarised in Chapter 3.

The commitment statements and recommendations are limited to the terms of reference for the reviews. The commitment of all partners in GM to, for example, core NHS constitutional standards, or national policy frameworks is strong and consistent and is implicit in this review of commissioning arrangements.

3.1 Commissioning Arrangements for Place Based Integrated Services

Commitment StatementWe recommit to the development of place (locality) based integrated commissioning arrangements, particularly in using commissioning levers to create the conditions for community based integrated health and care provision predicated on clustered primary care at a 30-50k population spatial level (as part of Local Care Organisations). We also commit to the developing opportunity to engage with and influence the commissioning of wider public service and VCSE capacity in each place in order to address determinants of demand for health and care services, and to secure an improvement in population health and well-being.

Learning Points from the ReviewWhile some progress has been made in developing SCF and Local Care Organisations the review has highlighted that further work is required at a pace commensurate with the scale of the health, well-being and financial challenge. In particular;

Integrated Commissioning Arrangements at a local level are at very different levels of maturity. Some areas have made significant progress in developing integrated teams between council and CCG of enabling capacity to support joint commissioning, but others have made less progress and the use of the terms ‘tactical’ and ‘strategic’ commissioning has sometimes been seen as unhelpful. This review is an opportunity to support and address some of the cultural and operational barriers to genuinely integrated approach to commissioning (through SCFs) in creating conditions for LCOs.

Nevertheless at an SCF level the arrangements are maturing rapidly – the 1st of April 2019 for example represented for many a step change in the formality of ‘Joint Committee’ arrangements, the depth (for example in the size of the pooled budget and commitment to joint sight of ‘aligned’ and ‘in view’ budget) and breadth (all age) of many of the SCF arrangements.

Further work is required to clarify connection for some GM wide commissioning arrangements such as primary care and directly commissioned services with SCFs, LCOs and JCB. Such work

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needs to recognise the formal accountability of the Chief Officer who holds delegated authority on behalf of NHS England, and the opportunity to align to new models of place based working

A key task for the SCFs is to help create the conditions for the new LCO arrangements to thrive. There is variable progress on the development of the LCO arrangements in localities, manifested in variable progress in shifting organisational capacity (from CCGs, Local Authorities, and providers) to be collectively deployed through integrated management arrangements from the LCO leadership team.

Good work has been undertaken through the LCO network but the GM system could do more to prioritise the importance of LCO development, for example in creating a place in GM wide partnership arrangements or governance for LCO leadership, and for ensuring the understanding of LCOs as a vehicle for delivery of transformation when presenting transformational programmes.

The notion of 30-50k populations (neighbourhoods) as a “currency of integration” for health and care through LCOs is well understood, and it is also recognised as the same spatial level described in the GM white paper on Public Service reform (which the February JCB Executive recognised as an important over-arching framework). The NHS Long Term Plan, the GM White Paper, and the national GP contract proposals (particularly) around primary care networks all create an opportunity for the partnership in GM to go further than currently in building essentially population health systems locally

Good progress has been made in building more structured commissioning relationships with the VCSE at both GM and local level, but the extent to which the Voluntary, Community and Social Enterprise sector is recognised as a key partner to developing LCO arrangements is variable. The VCSE sector bring a unique level of capacity, versatility and expertise without which there is a consequent risk of missed opportunities to enhance the development of collaborative approaches to work with and engage citizens and communities in support of agreed place-based priorities. Further work is required on the commissioning framework for sustainability of the third sector across GM.

The focus on fully exploiting the opportunity of place-based integration of services is necessary and transformational but the SCFs and also the JCB should also recognise the importance of communities of interest in terms of commissioning, co-design and service delivery.

In summary while there are some excellent examples of place-based commissioning arrangements creating the conditions for LCOs predicated on neighbourhoods working we have the experience to go further, faster and support those neighbourhoods and localities to progress to mature and sustainable place based arrangements.

Recommendations relating to Place Based Integration Recommendation 1. – Commissioning arrangements supporting and aligned to SCFs.

There should be a timeline agreed by JCB and PEB to bring forward recommendations from a number of existing programmes of work that have the potential to strengthen place based working through new commissioning arrangements. Each of these programmes are different in the extent to which they relate to aggregation or delegation of aspects of commissioning responsibility but they will all need to provide assurance on accountability and governance. The programmes of work include

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Primary care commissioning arrangements including GP services, Dentistry, Optometry and Community Pharmacy,

Commissioning of Public Health “Section 7a” services, notably screening and immunisation, with an early opportunity to consider the locality input to the immunisation work,

Commissioning from the VCSE sector across GM, including development of a VCSE Commissioning Framework to support JCB and SCF commissioning arrangements,

Commissioning implications at a local and GM level of key transformation programmes, including Adult Social Care, Urgent & Emergency Care and Planned Care Reform

Local Authority public health commissioning responsibilities Development of more integrated commissioning arrangements at a local and Greater

Manchester level for children’s services (driven by Directors of Children’s Services working with Children health services commissioning leads, and others), building out of the work on standards of the Children’s Health and Well Being Board and the DCS transformation programme and reflecting the ambition for an “all age” commissioning perspective.

Recommendation 2 – developing the maturity of SCFs and LCOs

PEB should review the maturity of LCOs and JCB should commit to fully participating to understand the role of commissioning arrangements at a JCB and SCF level to further create the conditions for their success. This programme should be undertaken in the spirit of collaborative improvement rather than assurance – it should be peer led and the commissioning contribution to the review could include a focus on improvement capacity and support and sharing best practice. It should include;

the maturity of the SCF arrangements to share learning and best practice and identify opportunities for support and further development,

the maturity of LCO arrangements in GM, (sponsored by PEB and drawing on the PFB (Provider Federation Board, PCB (Primary Care Board), and JCB to share learning and best practice and identify opportunities for support and further development (and connected to the alignment of wider public services),

Recommendation 3. – Delivering place based integration of public service including LCOs

The JCB should fully participate in work undertaken through the PEB (including PFB and PCB) and with GM Reform Board to ensure a common understanding of the way in which GMHSCP and GMCA will develop consistent guidance and support and advocacy for place based working at borough and neighbourhood level and the necessary commissioning arrangements required. This will include;

a single paper by May 2019 describing as far as possible the 67 x 30-50k population spatial neighbourhoods used as their currency of community based health and care and public service integration, and commit that future service proposals including commissioning arrangements must explicitly describe their contribution to the model where appropriate,

a single report focusing on the extension of SCF and LCO arrangements to include wider public services and the outcome of the VCSE-LCO development guide currently under development.

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3.2 Commissioning For Acute Services Reform

Commitment Statement We commit to using the opportunity of local Strategic Commissioning Functions and the GM Joint Commissioning Board to work with NHS provider organisations in the GM Health and Care Partnership to secure better outcomes from hospital services through improved commissioning arrangements.

Learning Points from the ReviewThere is good progress being made in many aspects of commissioning and redesign of acute hospital services – for example in the development of models of care for “improving specialist services” (formerly known as ‘theme 3’) and of the understanding by wider leadership of those models, and the governance process through JCB of receiving and considering associated options.

However, there are a number of opportunities for further development of the arrangements.

There is an ambition to ensure ‘improving specialist services’ (theme 3) activity is considered in the context of the opportunities to reduce demand and cost through prevention and early intervention - a whole pathway perspective. There is also a recognition that the 8 Models of Care fall within a wide spectrum from (e.g.) acute neuro-rehab where standards and outcomes commissioned once makes sense, to (e.g.) respiratory which more neatly falls into local integrated commissioning and provision arrangements. Consequently, there are differences of opinion on the best spatial level of commissioning decisions about ‘improving specialist services’ (theme 3) (particularly in relation to GM or sector level working).

The understanding of the current and most importantly, the potential future role of ‘lead commissioner’ varies, spanning elements from ‘relationship management’ through to procurement. Early work should take place to agree an approach to identifying where lead commissioner arrangements are required and then setting out potential models, including consideration of decision-making, budgetary and accountability approaches.

Work on clarifying lead commissioners should progress where possible and it is not necessary to conclude and clarify all arrangements before being able to progress with some. However there should always be scope to review the success or otherwise and refine over time.

There is felt to be more work to do at a local level on the role of acute services in the development of local care organisations, and the connection to GM wide acute sector commissioning decisions. There is a potential tension between the vision of an outcomes based, population health and care system commissioned through the SCF via an LCO and the development of a GM system based on segments (e.g. mental health) or services (e.g. theme three) and potential to disconnect these from local systems.

‘Improving specialist services’ (Theme 3) has been dominant in the work of the JCB to date and JCB members wish to consider their contribution to the wider transformation programme. It is recognised that the programme is important to deliver clinically sustainable services, and that JCB is in part specifically convened as a joint committee to be able to take decisions on the models under development. However, there are important other aspects to the commissioning of acute services in GM that need consideration at the JCB, including for example the mandated collaboratively commissioned specialist services (Tier 1,2,3) commissioned at a GM or supra GM level, and the provision of core DGH services at a local level connected to the developing maturity of LCOs.

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Recommendations relating to Acute Commissioning Recommendation 4. - Relating to Theme 3 Commissioning

The GM JCB, working with PFB and GMHSCP team through the ‘improving specialist care’ (Theme 3) Board should finalise the appropriate spatial level for commissioning of all aspects of the ‘improving specialist care’ (theme 3) programme, and report to PEB. This should take into account the need for clarity in decision-making and contractual arrangements, and the importance of retaining a whole pathway perspective to influence future demand.

Recommendation 5. - Relating to JCB sight of the breadth of acute service commissioning

The GMJCB needs to assure itself of the progress on the breadth of commissioning of acute services outside of the relatively narrow definition of ‘improving specialist care services’ (theme 3), including; the portfolio of specialist commissioning services and in particular, explicitly describing the

opportunities of SCFs and LCOs to take actions to reduce demand for these services via interventions focused on prevention and early intervention. This may include Joint Contract Review meetings with specialised commissioning providers for specific services/pathways, where appropriate,

The outcomes of clinical pathway thematic improvement functionality. The JCB should work through the PEB with the PFB, PCB, GMHSCP team and the Strategic Clinical Networks to understand how best to maximise the opportunities presented by the clinical leadership connections established, particularly in relation to maintaining a whole pathway perspective – from prevention to tertiary service provision,

The scope and breadth of the local acute services in scope of the LCO and ensure the SCF is the focal point for the further connection of these services to integrated community models of care.

Recommendation 6. – Relating to clarifying lead commissioner arrangements for acute Services

GM JCB should establish a task and finish group out of the Joint DoCs/DoFs meeting and with wider commissioners and the PCB as appropriate to determine (for the JCB to approve) which services should be commissioned once across GM (in addition to the outcome of the recommendation relating to ‘improving specialist care’ (theme 3) commissioning arrangements). This work will require finalisation of the criteria to be used to determine which services fall within this category, the definition of lead commissioner (is it solely standard setting, developing specifications, monitoring performance and outcomes, leading on contract negotiations or all?), the potential inclusion of non-NHS Providers, and the role of sector based commissioning. The outputs of the work should not await full completion for all services and should be adopted by service/pathway when ready and subject to subsequent evaluation and review.

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3.3. Commissioning for Population Health Gain

Commitment Statement We commit to realising the benefits of devolution in Greater Manchester to population health gain and reformed health and care and wider public service delivery through the GM Health and Care Partnership and the Greater Manchester Combined Authority.

Learning Points from the ReviewThe overarching objective of Taking Charge is to deliver a transformational improvement in population health and well-being. Some of this can be supported through the commissioning of new models of health and care provision at a GM, and locality level. However, it is recognised further work is required to capitalize on the opportunity of the GM arrangements to improve population health and reduce health inequalities. It is recognised that this commissioning review coincides with development of the Implementation Plan for the Population Health System endorsed at the Partnership Executive in December 2018. It also coincides with an emerging proposition about a Marmot review of progress in GM on addressing health inequality and the extent to which we are deploying the connections to things like the industrial strategy, prosperity review, air quality and so forth.

In the meantime, the following opportunities for development of the arrangements are highlighted. To move towards a better and more coherent population health system, requires us to develop a

consensus view on the population health policy and interventions that should be driven by SCFs and LCOs and which is fully aligned with our emerging population health framework, connecting wider determinants, lifestyles and behaviours, wider community engagement and our new models of integrated public service delivery. In this context, there is large variation across GM in the extent to which ‘population health policy and interventions’ are regarded as core to the business of the SCFs/LCOs.

Alongside the small group of PH professionals there is the opportunity to develop a much wider advocates for the improvement in health outcomes across clinical, managerial and community spheres. Aligned to this will be repurposing the specialist population/public health capacity in the system to maximise our existing resources across the new system at GM and locality levels.

There is an under-recognised opportunity to engage the wider health and care sector as major employers with key GMCA priorities such as housing/spatial planning, transport, air quality, and the Industrial Strategy.

Many members of the JCB have expressed their view that population health gain, and addressing health inequality, is their highest priority, and that the JCB should ensure its commissioning policy and decisions is aligned to these goals.

Recommendations relating to Population health gain and health inequality.

Recommendation 7.

Partnership Executive Board will receive and approve the detailed implementation plan for the Population Health System paper and following this the JCB will need to consider the commissioning implications and recommendations identified.

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3.4 Future Role and Function of GM JCB

Commitment StatementWe commit to rapidly take all necessary steps to develop the maturity and effectiveness of the Greater Manchester Joint Commissioning Board, so that it can play a leading role in GM Health and Care Partnership arrangements and support the objectives of Taking Charge and the wider Greater Manchester Strategy.

Learning Points from the ReviewThe establishment and early work of the JCB is regarded as a very positive achievement. Clinical, political and managerial leadership mandated by each of the SCFs working together at a GM level to secure the scale and pace of transformation required is a positive and unique collaboration. There is a recognition that it is a relatively new construct and the membership has not had the opportunity to build the relationships required to make it as effective as possible. In this context, there are a number of opportunities for further development of the JCB.

The JCB needs to clarify its relationship to the PEB. Broadly, the JCB is a core partner to the GMHSCP arrangements that together co-designs, develops and implement strategy with, PFB, PCB etc. JCB role is in part to translate that into a commissioning work plan through a prioritisation process including judgements on affordability.

There is a lack of clarity on the sub structure to support the JCB – groups like chief officers, DoCs, connection to heads of commissioning etc. could be more effective if there was less variability in the local roles and a clearer flow of activity between the groups.

The work of JCB to date has been dominated by ‘improving specialist care’ (theme 3) and in fact the JCB needs to consider how best it can deploy its unique position and role across the breadth of Taking Charge (for example in relation to any single commissioning decisions for non-NHS services)

The JCB needs to develop a stronger connection to the Provider Federation Board (PFB) and develop a more mature system relationship in the context of the wide GMHSCP arrangements, particularly where for example partnership arrangements are jointly chaired on behalf of both (e.g. Cancer Board)

JCB needs to develop a stronger relationship to the Primary Care Board (previously Primary care Advisory Group), ensuring senior level primary care leadership advice into its work and by extension the work of the PFB and the GMCA.

The JCB needs to undertake its work in the context of the knowledge of the performance of the system – financial, quality, activity etc. This is not to duplicate performance oversight arrangements (for example in the Performance and Delivery Board or Urgent Care Board) but to ensure JCB prioritisation is rooted to system arrangements and performance.

Commissioning could be improved if there was a realistic number of priorities, which are jointly recognised by the GMHSCP. This would then enable support functions (Strategic Clinical Networks, and Health Innovation Manchester etc.) to have focussed work plans to support implementation of agreed priorities. JCB should be able to prioritise its work and will need constructive dialogue with PEB if it cannot take on PEB agreed priorities (for example for reasons for capacity, timeliness or affordability).

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The GM JCB will need to consider how it ensures the co-design and co-production of commissioning frameworks and plans with residents and the health and care system workforce. In part it will be through its relationship to its constituent bodies and its accountability to the Partnership, but there is also the need for adherence to agreed principles that ensure inclusive system leadership

The JCB should recognise the role of the VCSE sector at both a local level and also as a contributor to conurbation wide working and leadership in developing commissioning arrangements.

Recommendations relating to the role and function of the JCB Recommendation 8.

The JCB should form a task and finish group to develop a programme of ‘organisational development’, particularly focused on a) the formality of the working arrangements of the meeting and b) the rapid development of trust building between all partners to the group, recognising the JCB is a relatively new cohort of senior leadership. This should include the following Finalise and embed a process for agreeing commissioning priorities/work programme for the JCB.

This should include the process by which JCB will translate strategic priorities agreed across the partnership, and a dialogue with PEB as required on prioritisation and affordability.

Develop and implement a robust performance and finance monitoring system for the JCB to ensure JCB priorities are effectively tracked and managed.

Work with GMHSP team to ensure that there are effective arrangements in place to ensure the JCB is aware of system-wide performance issues so that the JCB can ensure that commissioning priorities are developed in this context.

Finalise the operational protocol between the PEB and the JCB for the translation of GMHSCP strategic intent into commissioning work plan, and on an going dialogue on prioritisation and affordability as required

The arrangements to secure resident and workforce engagement in commissioning plans and frameworks.

Recommendation 9.

The JCB needs to co-ordinate a review of the “sub structure” to the JCB to ensure the JCB can progress its decision-making and prioritisation with confidence, and this review should recognise the developing partnership arrangements across the GMHSCP. These arrangements should continue to harness the expertise of commissioning leaders and managers across the system, but reflect the establishment of formal Integrated Commissioning arrangements in localities. This needs to include: Reviewing the role of the current CO meeting and potentially replacing it with a group comprised

of senior leaderships from each locality with authority from local SCFs across the breadth of commissioning in each locality. This group should also operate as the board/steering group for the GM Joint Commissioning Team , and would also need to include representation from other commissioners in GM (e.g. GMHSCP team and GMCA) such that the meeting was reflective of the constituencies of the JCB

Finalising the membership and authority of a meeting that has the characteristics of a ‘GM Directors of Integrated Commissioning’ and clarifying its relationships with DASS, DCS, and LA Heads of Commissioning to deliver joint agendas. In so doing, Directors of Integrated Commissioning with mandated authority from their SCFs, to develop sub-structure arrangements to support delivery of its extensive agenda.

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Ensuring appropriate representation from GMCA and NHSE in the sub structural arrangements of the JCB

Recommendation 10

The PEB, including reps from JCB, will meet to develop a framework of joint working to clarify the role of improvement collaborative functionality and an improvement model that embeds clinical advice and leadership in a different way in GM and the reporting to all parts of the GM Partnership arrangements. This will need to include NHSI and NHS England for those Strategic Clinical Networks funded nationally and GM will also need to consider the relationship with other ICS in the NW.

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3.5 The Future Role of the GM Commissioning HubCommitment StatementWe recognise that the work of the SCFs and the JCB, and wider GM Public Service Reform Board needs to draw on GM level capacity and expertise, and such capacity should be timely, efficient, of good quality, and felt to be owned by the system.

Learning Points from Review A more detailed report on the potential role and function of the GM Commissioning Hub is

available but in summary, feedback from the system has been positive about many aspects of the emerging GM Commissioning Hub and its potential:

• The support to the development of the JCB, • The potential to commission ‘once’ at a GM level, providing economies of scale,

streamlining processes and supporting more cost effective commissioning• Potential to integrate commissioning across the wider public sector reform agenda• The role of the Interim MD in making connections across the system, and ‘connecting’ the

work of the JCB with the PRB, GMPSRB, PCB etc.

However there are opportunities for further development identified including; Lack of connection across the system in terms of priorities, potentially leading to an

‘eclectic mix’ of priorities for the emerging Commissioning Hub, Disconnected governance, lack of clarity about decision making, authority over resources, A need to find an effective governance solution to connect the GMHSCP Direct

Commissioning function to the JCB and GM Commissioning Hub, How to effectively embed GMSS within Commissioning Hub arrangements.

During the review there was a consistent support for the operation of a GM Commissioning function which is able to:

Support the JCB, ensuring effective governance and delivery, Co-ordinate and connect the commissioning system, Support LCOs/SCFs by providing commissioning support functions, Connect a range of lead commissioner arrangements, including that of the GMHSCP team

as an 11th Commissioner Support the system to continually review the best level for commissioning arrangements, Potentially to provide and co-ordinate improvement support for commissioning through

facilitating the agreement of standards for improvement, sharing best practice, Undertake a prioritised stock take of current GM standards, maintain single register, and

develop a methodology for ongoing maintenance.

Recommendation in relation to the future role of the GM Joint Commissioning Hub

Recommendation 11 – The development of the GM Joint Commissioning Team

The GM JCB should receive an initial proposal by June 2019 on the role, function, size and positioning of a GM Commissioning Team (as a development of the Hub), Ensure effective leadership of the Joint Commissioning Team, and develop and implement an

appropriate structure within available resources. It should be framed according to four key blocks of work; Commissioning and contracting support,

Improvement and Delivery, Commissioning Strategy, System Secretariat It should be positioned as GM Joint Commissioning Team supporting the JCB, GMHSCP team and

GMCA.

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4. Summary of Recommendations and Implementation Plan

(Lead Officer names and timelines to be confirmed following consideration at GM JCB)

No. Topic Recommendation Senior Lead Lead officers Provisional Milestone(to be confirmed by JCB)

1. Commissioning arrangements supporting and aligned to SCFs.

There should be a timeline agreed by JCB and PEB to bring forward recommendations from a number of existing programmes of work that have the potential to strengthen place-based working through new commissioning arrangements. Each of these programmes are different in the extent to which they relate to aggregation or delegation of aspects of commissioning responsibility, but they will all need to provide assurance on accountability and governance. The programmes of work include

Sarah Price

1.1 Primary care commissioning arrangements including GP services, Dentistry, Optometry and Community Pharmacy,

Sarah Price/Tracey Vell

Sara Roscoe, Laura Browse

July 2019

1.2 Commissioning of Public Health “Section 7a” services, notably screening and immunisation, with an early opportunity to consider the locality input to the immunisation work,

Sarah Price Sara Roscoe and Jane Pilkington

July 2019

1.3 Commissioning from the VCSE sector across GM, including development of a VCSE Commissioning Framework to support JCB and SCF commissioning arrangements,

Rob Bellingham Warren Escadale/ Stewart Lucas with Rob Bellingham

September 2019

1.4 Commissioning implications at a local and GM level of the Partnership based Adult Social Care Transformation programme,

Stuart Cowley Jo Chilton July 2019

1.5 Local Authority public health commissioning responsibilities Lesley Jones/Sarah Price

GM DPH Group September 2019

1.6 Development of more integrated commissioning arrangements at a local and Greater Manchester level for children’s services (driven by Directors of Children’s Services working with Children health services commissioning leads, and others), building out of the work on standards of the Children’s Health and Well Being Board and the DCS transformation programme and reflecting the ambition for an “all age” commissioning perspective.

Charlotte Ramsden

Melissa Maguinness September 2019

2 Developing the The JCB to request that PEB review the maturity of LCOs and commit to fully PEB to confirm

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maturity of SCFs and LCOs

participating to understand the role of commissioning arrangements at a JCB and SCF level to further create the conditions for their success. This programme should be undertaken in the spirit of collaborative improvement rather than assurance – it should be peer led and the commissioning contribution to the review could include a focus on improvement capacity and support and sharing best practice. It should include;

2.1 the maturity of the SCF arrangements to share learning and best practice and identify opportunities for support and further development,

PEB to co-ordinate Task and Finish Group establishment

October 2019

2.2 the maturity of LCO arrangements in GM, (sponsored by PEB and drawing on the PFB (Provider Federation Board, PCB (Primary Care Board), and JCB to share learning and best practice and identify opportunities for support and further development (and connected to the alignment of wider public services),

Warren Heppolette October 2019

3 Delivering place-based integration of public service including LCOs

The JCB should fully participate in work undertaken through the PEB (including PFB and Primary Care Board) and with GM Reform Board to ensure a common understanding of the way in which GMHSCP and GMCA will develop consistent guidance and support and advocacy for place-based working at borough and neighbourhood level and the necessary commissioning arrangements required. This will include;

JCB with PEB to confirm

JCB to confirm, Warren Heppolette, Andrew Lightfoot

3.1 a single paper by May 2019 describing as far as possible the 67 x 30-50k population spatial neighbourhoods used as their currency of community-based health and care and public service integration, and commit that future service proposals including commissioning arrangements must explicitly describe their contribution to the model where appropriate

May 2019

3.2 a single report focusing on the extension of SCF and LCO arrangements to include wider public services and the outcome of the VCSE-LCO development guide currently under development.

June 2019

4 Relating to Theme 3 Commissioning

The GM JCB, working with PFB and GMHSCP team through the ‘improving specialist care’ (Theme 3) Board should finalise the appropriate spatial level for commissioning of all aspects of the ‘improving specialist care’ (theme 3) programme, and report to PEB. This should take into account the need for clarity in decision-making and contractual arrangements, and the importance of retaining a

Sarah Price & Anthony Hassall

Improving Specialist Care Board

July 2019

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whole pathway perspective to influence future demand.

5 Relating to JCB sight of the breadth of acute service commissioning

The GMJCB needs to assure itself of the progress on the breadth of commissioning of acute services outside of the relatively narrow definition of ‘improving specialist care services’ (theme 3), including;

JCB with PFB July 2019

5.1 the portfolio of specialised commissioning services and in particular, explicitly describing the opportunities of SCFs and LCOs to take actions to reduce demand for these services via interventions focused on prevention and early intervention. This may include Joint Contract Review meetings with specialised commissioning providers for specific services/pathways, where appropriate,

JCB to confirm Via SCOG group and Louise Sinnott

September 2019

5.2 The outcomes of clinical pathway thematic improvement functionality. The JCB should work through the PEB with the PFB, PCB, GMHSCP team and the Strategic Clinical Networks to understand how best to maximise the opportunities presented by the clinical leadership connections established, particularly in relation to maintaining a whole pathway perspective – from prevention to tertiary service provision,

PEB to confirm PEB to confirm

5.3 The scope and breadth of the local acute services in scope of the LCO and ensure the SCF is the focal point for the further connection of these services to integrated community models of care.

JCB to confirm October 2019

6 Relating to clarifying lead commissioner arrangements for acute Services

GM JCB should establish a task and finish group out of the Joint DoCs/DoFs meeting and with wider commissioners and the PCB as appropriate to determine (for the JCB to approve) which services should be commissioned once across GM (in addition to the outcome of the recommendation relating to ‘improving specialist care’ (theme 3) commissioning arrangements). This work will require finalisation of the criteria to be used to determine which services fall within this category, the definition of lead commissioner (is it solely standard setting, developing specifications, monitoring performance and outcomes, leading on contract negotiations or all?), the potential inclusion of non-NHS Providers, and the role of sector based commissioning. The outputs of the work should not await full completion for all services and should be adopted by service/pathway when ready and subject to subsequent evaluation and review.

JCB Ian Williamson, Anthony Hassall, Steve Dixon (DoFs) and Margaret O Dwyer (DoCs)

July 2019

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7 Population health gain and health inequality.

Partnership Executive Board will receive and approve the detailed implementation plan for the Population Health System paper and following this the JCB will need to consider the commissioning implications and recommendations identified.

PEB and then JCB to frame commissioning response

Sarah Price, and JCB to confirm

June 2019

8 Role and function of JCB

The JCB should form a task and finish group to develop a programme of ‘organisational development’, particularly focused on a) the formality of the working arrangements of the meeting and b) the rapid development of trust building between all partners to the group, recognising the JCB is a relatively new cohort of senior leadership. This should include the following

JCB

8.1 Finalise and embed a process for agreeing commissioning priorities/work programme for the JCB. This should include the process by which JCB will translate strategic priorities agreed across the partnership, and a dialogue with PEB as required on prioritisation and affordability.

JCB with GM Commissioning Team – Rob Bellingham

May 2019

8.2 Develop and implement a robust performance and finance monitoring system for the JCB to ensure JCB priorities are effectively tracked and managed.

GM Commissioning Team – Rob Bellingham

September 2019

8.3 Work with GMHSP team to ensure that there are effective arrangements in place to ensure the JCB is aware of system-wide performance issues so that the JCB can ensure that commissioning priorities are developed in this context

GMHSCP Team and PEB

September 2019

8.4 Finalise the operational protocol between the PEB and the JCB for the translation of GMHSCP strategic intent into commissioning work plan, and on an going dialogue on prioritisation and affordability as required

JCB and PEB to confirm

GMHSCP Team and PEB

September 2019

8.5 The arrangements to secure resident and workforce engagement in commissioning plans and frameworks.

JCB and PEB October 2019

9 JCB Sub Structure

The JCB needs to co-ordinate a review of the “sub structure” to the JCB to ensure the JCB can progress its decision-making and prioritisation with confidence, and this review should recognise the developing partnership arrangements across the GMHSCP. These arrangements should continue to harness the expertise of commissioning leaders and managers across the system,but reflect the establishment of formal Integrated Commissioning arrangements in localities. This needs to include:

JCB with GMHSCP Team

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9.1 Reviewing the role of the current CO meeting and potentially replacing it with a group comprised of senior leaderships from each locality with authority from local SCFs across the breadth of commissioning in each locality and would also need to include representation from other commissioners in GM (e.g., GMHSCP team and GMCA) such that the meeting was reflective of the constituencies of the JCB. This group should also operate as the board/steering group for the GM Joint Commissioning Team

Task and Finish Group established by JCB to include GMHSCP Team, Ian Williamson

May 2019

9.2 Finalising the membership and authority of a meeting that has the characteristics of a ‘GM Directors of Integrated Commissioning’ and clarifying its relationships with DASS, DCS, and LA Heads of Commissioning to deliver joint agendas. In so doing, Directors of Integrated Commissioning, with mandated authority from their SCFs, to develop sub-structure arrangements to support delivery of its extensive agenda

Task and Finish Group established by JCB to include GMHSCP Team

July 2019

9.3 Ensuring appropriate representation from GMCA and NHSE in the sub structural arrangements of the JCB

Task and Finish Group established by JCB to include GMHSCP Team

On going

10 JCB and PFB Joint Working

The PEB, including reps from JCB, will meet to develop a framework of joint working to clarify the role of improvement collaborative functionality and an improvement model that embeds clinical advice and leadership in a different way in GM and the reporting to all parts of the GM Partnership arrangements. This will need to include NHSI and NHS England for those Strategic Clinical Networks funded nationally and GM will also need to consider the relationship with other ICS in the NW.

GMHSCP through PEB

PEB to confirm

11 GM Commissioning Team Development

The GM JCB should receive an initial proposal by June 2019 on the role, function, size and positioning of a GM Commissioning Team (as a development of the Hub),

JCB with GMHSCP Team and GMCA JCB, Ian Williamson

June 2019

11.1 Ensure effective leadership of the Joint Commissioning Team, and develop and implement an appropriate structure within available resources.

JCB June 2019

11.2 It should be framed according to four key blocks of work; Commissioning and contracting support, Improvement and Delivery, Commissioning Strategy, System Secretariat

JCB with GMHSCP Team and GMC

June 2019

11.3 It should be positioned as GM Joint Commissioning Team supporting the JCB, JCB June 2019

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GMHSCP team and GMCA.

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