A vision for health and social care
services in Suffolk 2019/2020
Better Care Fund Plan
Approved – December 2014
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Better Care Fund planning template – Part 1
1)
PLAN DETAILS
a) Summary of Plan
Local Authority
Suffolk County Council
Clinical Commissioning Groups
Ipswich and East Suffolk
Great Yarmouth and Waveney
West Suffolk
Boundary Differences
Great Yarmouth and Waveney Clinical
Commissioning Group (CCG) is located
in two Health and Wellbeing Board
(HWB) areas – Suffolk and Norfolk. The
information in this template refers to the
Waveney element of the CCG geography
only, although where possible, plans are
aligned with Norfolk plans for Great
Yarmouth.
Date agreed at Health and Well-Being
Board:
27/11/2014
Date submitted:
28/11/2014
Minimum required value of BCF
£2,718,000
pooled budget: 2014/15
2015/16 £50,042,000
Total agreed value of pooled budget:
£2,718,000
2014/15
2015/16 £50,042,000
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b) Authorisation and signoff
Signed on behalf of the Clinical
Commissioning Group
By
Position
Date
Ipswich and East Suffolk
Julian Herbert
Chief Officer
27/11/2014
Signed on behalf of the Clinical
Commissioning Group
By
Position
Date
Great Yarmouth and Waveney
Andy Evans
Chief Executive
27/11/2014
Signed on behalf of the Clinical
Commissioning Group
By
Position
Date
West Suffolk
Julian Herbert
Chief Officer
27/11/2014
Signed on behalf of the Council
By
Position
Date
Suffolk County Council
Anna McCreadie
Director of Adults and Community Services
27/11/2014
Signed on behalf of the Health and
Wellbeing Board
By Chair of Health and Wellbeing Board
Date
BCF – template 1 – 28th November - FINAL
Suffolk Health and Wellbeing Board
Alan Murray
27/11/2014
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c) Related documentation
Document or
information title
A Joint Health
and Wellbeing
Strategy (JHWS)
for Suffolk
Joint Strategic
Needs
Assessment
(JSNA)
Synopsis and links
Sets out a joint vision for health and wellbeing in Suffolk. The focus of
this report is on four areas jointly agreed as priorities for the first three
years of a 10 year health and wellbeing strategy, 2012-2022. The
priorities are used to provide focus for plans across health, local
authorities and other relevant organisations ensure sure we work
together as efficiently and effectively as possible, spending public
money in a better way.
http://www.healthysuffolk.org.uk/assets/Useful-Documents/Healthand-Wellbeing-Strategy.pdf
The Suffolk JSNA is a suite of resources to inform health and care
commissioning. It is formed of a dynamic set of data presented in the
Suffolk Observatory, alongside reports, profiles and health needs
assessments produced to inform the JHWS and other commissioning
plans and strategies.
http://www.suffolkobservatory.info/JSNA.aspx
Ipswich and East
CCG Operational
Plan 2014/15 –
2015/16
West Suffolk
CCG Operational
Plan 2014/15 –
2015/16
Health and Care
Review model
Great Yarmouth
and Waveney
CCG 2 Year
Operational
Plan
(incorporating a
copy of Seven
Day Services
bid)
The Operational Plan includes the key operational metrics needed to
support the assurance of and measure performance against strategic
plans including financial and QIPP plans.
http://www.ipswichandeastsuffolkccg.nhs.uk/Portals/1/Content/Library
/Governing%20Body%20papers/25%20March%202014/Agenda%20i
tem%2008%20-%20IESCCG%201414%20Two%20Year%20Plan.pdf
The Operational Plan includes the key operational metrics needed to
support the assurance of and measure performance against strategic
plans including financial and QIPP plans.
Operational Plan 2014/15 and 2015/16 | NHS West Suffolk Clinical
Commissioning Group
See Documents 1 and 2 in Suffolk Better Care Fund Template –
Additional Related Documentation
These reports show different aspects of our integrated system and
have informed the Better Care Fund schemes in the Ipswich and East
and West Suffolk areas.
The Operational Plan for GY&W CCG. This document has a strong
focus on the development of an Integrated Care System. It also
contains a copy of the successful bid for 7 day services to the
Transformational Improvement Programme
http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/n
hsgreatyarmouthandwaveneyccgoperationalplanpublicfacingversion_
activelinks.pdf
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Suffolk County
Council Adult
and Community
Services service
plan 2014/15
The ACS service plan sets out the priorities and action for ACS over
the year 2014/15
Suffolk County
Council Cabinet
Paper 21
February 2012:
Adult and
Community
Services:
Supporting Lives
Connecting
Communities
Within Adult and Community Services (ACS) a new social work
operating model has been developed to reflect the directorate’s
Service Plan and priorities including the new way of working titled:
Supporting Lives, Connecting Communities (SLCC). SLCC relies on
a person centred approach to planning and designing care,
collaborative working between all parties around the person, keeping
people living independently at home, helping people to help
themselves, putting people in touch with what’s happening in the
community that can help them, getting people back to independence
as quickly as possible after a crisis and providing ongoing support
only for those who need it.
http://www.suffolk.gov.uk/assets/suffolk.gov.uk/Your%20Council/Plan
s%20and%20Policies/Directorate%20Plans/2014-0425%20%20Final%20Adult%20%20Community%20Services%20Direc
torate%20Plan%202014-15.pdf
http://committeeminutes.suffolkcc.gov.uk/LoadDocument.aspx?rID=0
900271180640bea&qry=c_committee%7e%7eThe+Cabinet
Great Yarmouth
and Waveney
CCG
Engagement
Strategy
This Engagement Strategy reflects the vision and goals of
HealthEast. It builds on extensive engagement completed during the
development of NHS Great Yarmouth and Waveney’s
Communications and Engagement Strategy, with focus on patient
engagement and clinical commissioning, engagement from staff,
partners, stakeholders, individuals and groups, as well as a baseline
mapping exercise.
http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/c
ommsandengagementstrategy_july2013update.pdf
Tricordant
Report: Joined
up Services for
Older People
The Tricordant pathway enables health and social care integration at
both micro and macro-levels. Tricordant was jointly commissioned to
map its person centred health and care pathway for older people in
Suffolk. It included not just partnership between health and social
care, with local authority housing, leisure and education services as
well as the police, backed by the social capital in the voluntary and
faith sectors. This work has informed the service model design,
priorities and work programmes.
The outcomes of this report were taken to the shadow Health and
Wellbeing Board on the 1st December 2011 within the Suffolk Ageing
Well – Transformation for Achievement Stage 2 Report”. Copies of
the HWB report are available from Committee Services at Suffolk
County Council (committee.services@suffolk.gov.uk)
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Terms of
Reference
GYW Integrated
Care System
Programme
Board
Sets out the remit and responsibilities of the Programme Board
Integrating health
and care
systems to
support healthy
ageing: Public
Health Suffolk
December 2013
This paper summarises the findings from an evidence review of
health system models that support healthy ageing. The review
focuses on healthy ageing policies and on the integration of health
and social care systems. Both local and international examples are
presented. Discussed at the Health and Wellbeing Board on 12 th
December 2013.
http://www.greatyarmouthandwaveneyccg.nhs.uk/_store/documents/a
genda_governing_body_part1-30january2014.pdf
Copies of the following documents are available on request from
georgina.wall@nhs.net
 GYW System Leadership Board Terms of Reference
 GYW Integrated Care System Operational Group Terms of
Reference
 GYW Better Care Fund Plan on a Page
http://committeeminutes.suffolkcc.gov.uk/LoadDocument.aspx?rID=0
900271180fc1023&qry=c_committee%7e%7eSuffolk+Health+and+W
ellbeing+Board
Age UK Suffolk –
Voice Project
Reports
Older people are interviewed individually in their own homes, two or
three times per year, on various subjects. These are agreed by a
reference group, with members from Suffolk County Council ACS,
NHS Suffolk, NHS Great Yarmouth and Waveney, Age UK Suffolk
and representatives from older people themselves.
Voice Project | Age UK Suffolk
Suffolk Family
Carers Needs
Assessment
(Draft)
See Document 3 in Suffolk Better Care Fund Template –
Additional Related Documentation
Suffolk wide assessment of carers needs scheduled for completion in
October 2014.
Report from
Healthwatch on
public
engagement
summer 2014
This report gives the public feedback on the Health and Care Review
model, and the Better Care Fund schemes.
http://www.healthwatchsuffolk.co.uk/sites/default/files/hasci_engagem
ent_report_-_v9.pdf
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2) VISION FOR HEALTH AND CARE SERVICES
a) The vision for health and social care services in Suffolk for 2019/20
The vision of Suffolk's Health and Wellbeing Board is that people in Suffolk live
healthier, happier lives. We also want to narrow the differences in healthy life
expectancy between those living in our most deprived communities and those who
are more affluent through achieving greater improvements in more disadvantaged
communities. The foreword to Suffolk's Joint Health and Wellbeing Strategy states
"Many things influence our health and wellbeing including the lifestyle we lead, the
environment we live in and the health and care services which support us". Our
vision recognises that to achieve improvements we all need to work together with a
common aim, principles and direction. Our vision has prevention at its heart and
seeks to address inequalities in Suffolk’s population
Suffolk’s existing health and care system, is not sustainable in the face of the
projected future level of need. Our population is older than the national average and
with this comes a higher than national average prevalence of long term conditions.
The demographic change anticipated in Suffolk between now and 2020 and looking
further forward 25 years is stark:
 The total population of Suffolk will grow by 3% by 2020 and 13% in 25 years
 The number of people aged 65 and over will increase by 14% by 2020 and by
almost 70% in 25 years
 The number of people aged 85 years and over in Suffolk is projected to
increase by 23% by 2020 and by 173% over 25 years (Source – ONS)
In Suffolk we spent £84m in 2013/14 on urgent care for our over 65 population. This
is likely to grow by at least £12m pa over five years due to the change in age
demographic alone. There are currently significant financial pressures within our
health and care system and these will worsen if we do not take action.
Our plans are designed to transform health and care services to meet these
challenges as follows:
 The whole system will be focused on preventing need, throughout people's
lives, whatever their age or health problems
 Health and care staff will be working in integrated teams delivering personcentred coordinated care rooted in their locality and working closely with their
communities
 There will be a focus on people (with multiple long term conditions) rather than
single disease entities
 There is a growing recognition of the importance of frailty and dementia, and of
the need to support and educate informal carers
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


Hospitals will be strong and vibrant, delivering more planned care than
emergency care and providing expertise to teams in the community
Voluntary and community sector organisations will be playing a bigger part in
supporting people with health and care needs
More services will be jointly commissioned, taking advantage of pooled
funding arrangements to deliver transformed services.
Our vision will be delivered through two transformation programmes which
recognise the different populations and structures existing in the county. The Ipswich
and East Suffolk and West Suffolk CCGs (IEWS) are working with Suffolk County
Council to deliver integrated care through the Health and Care Review. Great
Yarmouth and Waveney CCG (GYW) is working with Suffolk County Council to
deliver change for the Waveney area of Suffolk and with Norfolk County Council for
the Great Yarmouth area through their Integrated Care System.
We will achieve this change through working in partnership across all parts of the
system, putting the patient and customer at the centre of our planning and through
being relentlessly focused on the changes we have signalled through this plan. Some
changes will be brought about through commissioning differently, some through
organisational service redesign and some through strong leadership translating this
vision into action on the ground.
b) What difference will this make to patient and service user outcomes?
People have told us what they think is wrong with our current system of health and
care provision. Over the summer of 2014 the CCGs and SCC spoke face to face
with over 500 members of the public across the county about our plans for
integrated care. Comments were gathered about problems now (and also the many
positive experiences) and views on the proposed changes.
People stated that they want to be independent for longer and that they
wanted services to work more closely together to achieve this with good
communications between professionals (particularly between mental health
services and primary care)
“There didn’t appear to be a joined up approach to her care and in the end they
both pretty much gave up with it all”.
“we just need to tell the problem once”.
‘Something that the she [a family member] loved is that her GP knew both her and
her husband by name and knew their health history”
“a single point of contact or one main co-ordinator would help a great deal by
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taking away a lot of the stress in trying to manage all the services.”
A lack of services over the weekend was also highlighted as a problem to
remaining independent.
“if the GPs worked seven day weeks, then both of us wouldn’t have had to go to
A&E… this would be the same for many people across Suffolk”.
People want services closer to home
“local centres seem to be a great idea”.
“would definitely use the local centre if available”.
“the best quality of care needs to be local”.
There was an acknowledgement that being better prepared for older age (including
mental as well as physical wellbeing) whilst likely to improve people’s outcomes, is
not happening widely enough and is heavily reliant on the family and friends
network the person already has. People want service providers to work to ensure
that those who do not have these networks are also better prepared for older age
as this is where most of the public feel there is a risk. A lack of information –
particularly on availability of Voluntary Care Service support was identified as a key
reason why people are not better prepared for ageing.
Our plans foresee that by 2020 most people in Suffolk will be living as
independently as possible and where people do fall into crisis or require ongoing
support the right help will be easily accessed and promptly provided. Taking a more
preventative approach will allow more people to reach old age as healthy as
possible and delay the onset of long-term conditions. A more proactive system will
also deliver better care to the increasing number of older people living with multiple
long term conditions.
The difference we will make to people in Suffolk is:
 They will find it easy to navigate around the health and care system to find the
right information, care or services that meet their needs.
 Their physical and mental health and care needs will be identified early – in many
cases before a crisis occurs.
 They will have access to a range of mostly local services throughout the week that
focus on supporting people to self-care and supporting primary prevention.
 They will have control and choice over their care, with greater access to personal
health and care budgets so that they can manage their own health and support
costs.
 They will have a named co-ordinator when they need help who will ensure that the
system works effectively, with a single care record.
 They will have access to planned care when they need it.
 They will have the help they need to recover from an episode of ill health including
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support to getting back to the things that they enjoy doing.
Our Health and Care Review and Integrated Care System plans are targeting
improvements that will lead to improved outcomes for service users and patients:

Reduced emergency admissions to hospital: The focus of our Health and Care
Review and Integrated Care System on prevention and supporting people to live
independently will reduce the need for costly urgent and long term care. We are
targeting a reduction of 3.5% in total emergency admissions during the period Q4
2014/15 to Q3 2015/16, against a baseline of Q4 2013/14 to Q3 2014/15, which
equates to 2,241 admissions. The system recognises that this is the biggest driver
of cost that the Better Care Fund can affect and has quantified a benefit of £1.7m
as result of this reduction.
In GYW the existing Out of Hospital strategy is already leading to reduced
emergency activity. In IEWS the Integrated Neighbourhood Teams and wider
Integrated Neighbourhood Networks will provide a model of care which is more
holistic and preventative and less reliant on reactive emergency admissions.

Improved patient and service user experience: We are committed to ensuring that
people have a positive experience of care. Suffolk patients and customers have
told us repeatedly that they want to experience a joined up system. The National
Voices patient centred coordinated care overarching definition is: “Integrated care
means person centred coordinated care [where…] 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”. We already listen to
patients and service users and measure their experience through a number of
mechanisms such as the Adult Social Care Survey and the GP Patient Survey. As
we further develop integrate care on the ground we are working with user led
organisations to develop effective co-production, so that our plans deliver what
works for people alongside a greater understanding of how we track and measure
patient experience. We will be using national resources such as the Making it Real
“Making progress towards personalised community based support” markers.

Reduced rates of permanent admissions to residential care and nursing homes:
Suffolk has high rates of permanent admissions to residential care and nursing
homes for people aged 65 and over when compared with many other regions as
shown in the map below where Suffolk is outlined in red.
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Many of these admissions could be delayed or avoided through good support for
family carers. Evidence suggests that those who have no carer are more likely to
be admitted to care homes. Carer-related reasons for admission to nursing or
residential care are common, with carer stress the reason for admission in 38% of
cases and family breakdown (including loss of the carer) the reason in a further
8% of cases. Consequently, carer support services are fundamental to the new
system in enabling people to be supported in a sustainable way and to avoid
unnecessary admissions. Our plans take account of the impact that our ageing
population is likely to have on future admissions and aim to mitigate this future
pressure and target a reduction in the rate of admissions during the Better Care
Fund period.

Improved reablement outcomes so that people do not have to return to hospital:
We will help people to recover from episodes of ill-health or following injury. This
will be achieved through Integrated Neighbourhood Teams and the Out of Hospital
Service supporting people more effectively once they are back home in the
community. People at risk of readmission will have a single co-ordinated plan that
is focused on helping them to return to and sustain their independence.
We have targeted an improvement of almost 7% by 2015/16 in the proportion of
people (65 and over) who remain at home 91 days after discharge from hospital.
This means that these people will avoid being readmitted to hospital possibly as a
costly emergency admission which will contribute to our overall planned reduction
in emergency admissions.

Reductions in delayed transfers of care: Our aim is to ensure that we have an
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effective, integrated health and care system with acute, mental health and
community based care working together to ensure timely and appropriate transfer
from hospital.
We are targeting a reduction of 913 delayed days which will contribute to
commissioner savings as well as freeing up capacity within the hospital system.

Dementia diagnosis We believe that every person with dementia, who wishes it,
deserves a timely diagnosis and to allow them to access post diagnostic support
with all the benefits that can bring for them, their families and carers. It is our
ambition to increase rates of dementia diagnosis from 54% (13/14) to 67% by
2015 and to further enhance care through greater integration and alignment. Our
planned models of care include:
o Dementia diagnosis services with seamless pathways between primary and
mental health services
o Development of a comprehensive post diagnostic service model for people
with dementia and their carers. This work is being undertaken jointly with
Suffolk County Council
c) Change that will have been delivered in the pattern and configuration of services over
the next five years, and how the Better Care Fund funded work will contribute to this
The changes to our system will be delivered through our two transformation
programmes
 The Health and Care Review in the Ipswich and East Suffolk and West Suffolk
CCG area
 The Integrated Care System in the Waveney area of the Great Yarmouth and
Waveney CCG.
The scope of these programmes is significantly wider than the schemes described within
this Better Care Fund plan.
The following diagram represents the change in focus of health and care provision in
Suffolk showing a shift of activity and resource from reactive to proactive and
preventative care.
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During the next five years people in Suffolk will experience a transformed health and care
system:
 From fragmented services to integrated locally based services
 From multiple, single focused assessments to one holistic assessment
 From multiple (sometimes conflicting) care plans to one co-ordinated care plan
Whilst the vision for integrated care is common across the whole Health and Wellbeing
Board area, the concrete changes that will deliver the vision are different in each area.
Ipswich East and West Suffolk CCGs area: Health and Care Review
Changes in service delivery that will bring about our vision for the future are:

The creation of Integrated Neighbourhood Teams that bring together GPs,
community health and social care staff to work as one team. The teams will
proactively support the health and care of their local population, pulling in specialist
interventions and with access to reactive care as needed.

Organisational processes will be integrated. People receiving health and care will
have one plan, and the people working with them will use the same procedures and
processes. Integrated Neighbourhood Teams will have local data and intelligence
that helps them to tailor resources to their local population needs.
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
The following diagram gives a high level picture of the proposed integrated system:

Voluntary and community sector organisations will become key partners in care.
Working as Neighbourhood Networks with the support of a Local Area Co-ordinator
organisations within the network will be involved in delivering shared care and
support plans, particularly around issues of social isolation and lifestyle

People will have the tools to manage their health, in particular where they have long
term conditions. This will include access to training, information and advice so that
they can understand the options and choices available to them, and trigger tools so
that they know what to do if their condition deteriorates.

People at risk of deterioration and crisis will be identified and will receive a coordinated response. This will be achieved through risk stratification and care coordination, as well as the introduction of urgent care centres working along-side acute
hospitals.

The diagram below shows the model for delivering urgent and emergency care.
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Great Yarmouth and Waveney CCG area - Integrated Care System (ICS)
By 2018/19 the citizens of Great Yarmouth and Waveney will receive their health and
social care, and some district/borough services, from a cohesive integrated care system
(ICS) acting as a single provider of services. The ICS will be user focused, delivering
high quality and safe services with an orientation to innovate and develop new methods
delivering better care based on the ideas and ambitions of professionals and the
feedback of users. Because it is operating in a coordinated way, eliminating inefficiency
and waste, and striving for more effective delivery methods it will be using resources
optimally and constituent member organisations will be in financial balance and able to
invest in further improvements The ICS is a radical, ambitious and transformational
approach towards integration, working across two county councils and two district
councils.
Changes in service delivery that will bring about our vision for the future are:



Blurring of the boundaries between acute and community providers with shared
teams, in reach and out-reach services between the organisations.
Larger, stronger, better resourced teams of GPs, nurses and other professionals
working from multi-disciplinary healthy living centres in close concert with nonhealth partners such as benefits officers, community police staff and social care
professionals.
A move away from traditional bed-based models within acute and community care,
to a model that supports people remaining safely at home, wherever possible.
This will be delivered through Out of Hospital Teams (one already up and running
with a team of health and social care workers, using shared facilities, increasingly
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



sharing data and with streamlined management)
An increase in preventative activity
A Community hub will be developed in each of four areas across the CCG (two in
Suffolk) to support local communities and care closer to home across a range of
services including primary care, community health, social care, district/borough
councils and the 3rd sector.
A change in the way in which we use capacity and provide community based care.
We will work with our acute provider to maximise reductions in length of stay and
reduce the need for inpatient care. Our proposed change in community bed
capacity involves commissioning care home bed days based close to local
communities, together with providing higher acuity community beds as necessary.
Closing capacity will prevent beds freed up by reduced emergency demand being
filled, and we also anticipate that our proposed scheme to have a strong GP
practice base at the ‘front door’ of JPUH will also reduce emergency demand
within JPUH.
Pathway design around one stop services, and providing interventions in reduced
activity settings e.g. increased day case activity and moving some day case
activity to outpatient settings.
These changes will be experienced by everyone who accesses care and health services.
However they will be most felt by those with complex (often multiple) long term
conditions, the frail elderly and people with disabilities. Their experience will be of a
single system supporting them 7 days a week, regardless of the provider or which
organisation has commissioned the service.
All partners are signed up to the vision of integrated care. The Better Care Fund will be
an enabler for delivery of the change, and specific elements of the funding will be spent
on our Better Care Fund schemes as detailed in Template 2. Through pooling funding
and developing a joint plan at this level of detail the Better Care Fund deepens and
extends our understanding of how the mechanisms to deliver integrated care, particularly
the funding, might work. It is likely that without the Better Care Fund progress in these
areas would be limited and would shift at a slower pace.
The Better Care Fund will be used to part fund all of the schemes described in this plan.
IEWS Schemes
The service models which are being designed as part of the Health and Care Review
feature the following which have been captured as Better Care Fund schemes.
Scheme 1 - IEWS: Integrated Neighbourhood Teams
Multi agency, multi professional teams who proactively work to support people with
health and care needs and in particular those who are risk of hospital admission or
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deterioration in order to shift activity and resource from reactive to proactive and in so
doing reduce emergency admissions.
Scheme 2 - IEWS: Access to specialist services and support
Linking specialist services eg continence services and specialist dementia teams to
Integrated Neighbourhood Teams to support people with particular health and care
needs.
Scheme 3 (a) - IEWS: Admission prevention
Implementation of risk stratification and personalised care plans designed to get
upstream of a crisis in order to reduce the number of people who are admitted to hospital
during a crisis.
Scheme 3 (b) - IEWS : Admission prevention - crisis response.
Whilst our plans are targeting a shift in unplanned care to planned care, there will be
times when a crisis response is needed which will be achieved through partnership
working across the system.
Scheme 3 (c) - IEWS : Admission prevention - reablement and rehabilitation
Patients will have a single outcome focused reablement and rehabilitation plan which will
be coordinated by a named care coordinator in the Integrated Neighbourhood Team.
GYW Schemes
We believe that the development of an Integrated Care System across GY&W can help
tackle the issues faced by health and social care (highlighted above) and that our Better
Care Fund schemes listed below will provide a catalyst towards this.
Scheme 4 - GYW: Supporting independence by provision of community based support delivered closer to people’s homes, 7 days per week. This will help people
maintain/regain their independence
Scheme 5 - GYW: Integrated Community Health and Social Care Teams including Out of
Hospital Team and Palliative Care Service – to deliver timely joined up quality care and
support to people in the community
Scheme 6 - GYW: Urgent Care Programme - The delivery of integrated community care
services that reduce admissions and expedite faster appropriate discharge thereby
reducing delayed transfers of care
Scheme 7 - GYW: Support for People with Dementia and Mental Health problems People with dementia and their carers receive specialist support which will avoid/delay
admissions to hospital/residential care and provide assessment of on-going care needs.
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3) CASE FOR CHANGE
Our plans are based on an assessment of need and opportunity derived from an analysis
of our population using risk stratification and segmentation.
Summary
 Life expectancy in Suffolk is good. In 2007-11 life expectancy at birth was 83.7
years for females and 79.9 years for males, however
 The population of Suffolk is generally older than that of the East of England and
England as a whole.
 The prevalence of most long term conditions is higher than average for England.
 Emergency admission rates are slightly lower than the national average, however,
as a consequence of the projected growth in older residents there is a high risk
that emergency admissions will increase if no change is made. There is also
variation in admission rates across CCG areas in Suffolk.
 The relative rurality of Suffolk is an important factor which has been taken into
account in the system redesign.
 The health and care system in Suffolk will experience increasing financial pressure
as a result of these challenges.
 Importantly people tell us that they want a better health and care system whilst people are generally happy with health and care services they state very
clearly that there are aspects of the care they receive that should be improved
(see section 2 b) on page 8). This is an important factor in our case for change
alongside the demographic and financial challenges in Suffolk.
Population segmentation by age
Suffolk is a rural county with a resident population of over 730,000. The chart below
depicts the distribution of the Suffolk population by broad age-band compared with
England population and shows the projected change in the population profile between
2012 and 2037.
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By 2037, Suffolk will have a further 94,900 people overall. There will be 103,900 more
over 65s and 37,400 more over 85s. About 31% of the population of Suffolk will be over
65 compared with 24.0% in England as a whole.
We have made an initial assessment of the cost impact of our older population focussing
on urgent care using 2013/14 as our baseline. The following analysis shows that 48% of
all emergency admissions were aged over 65 attracting 63% of spend. With a projected
increase of 14% in over 65s by 2019/20 it is apparent that this age group will continue to
consume an increasingly disproportionate level of care which drives significant cost
across the system.
Age band
0-18
19-64
65+
Total
2013/14
A&E
attendances
% of
total
Emergency
admissions
(@full tariff)
% of
total
Activity
Spend £m
Activity
Spend £m
Activity
Spend £m
41,459
4.0
90,247
9.6
41,987
5.0
24%
21%
52%
52%
24%
27%
10,697
10.1
22,237
36.0
30,361
79.3
17%
8%
35%
29%
48%
63%
Activity
Spend £m
173,693
18.6
100%
100%
63,295
125.4
100%
100%
Total
Projected
Total spend A&E/EA increase in
£m
spend per population
capita £ by 2019/20
Projected
spend in
2019/20 £m
Increase
£m
14.1
84
1%
14.2
0.2
45.7
111
0%
45.7
0.1
84.3
519
14%
95.8
11.5
144.0
195
3%
155.7
11.7
Cost analysis of emergency admissions per age band to 2019/20
Population segmentation by relevant long term condition
As people get older they develop more long-term conditions e.g. dementia, osteoporosis,
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diabetes and chronic obstructive pulmonary disease (COPD). Evidence suggests that
majority of over-65s have 2 or more long-term conditions and that majority of over-75s
have 3 or more long-term conditions. Overall, there are more people living with 2 or more
long-term conditions than those with only 1.
The most common long term conditions experienced by the Suffolk population include
high blood pressure (13.7%), depression (13.4%), asthma (6.5%), diabetes (5%) and
coronary heart disease (3.7%). By 2020 the number of people living with diabetes,
chronic obstructive pulmonary disease (COPD) and coronary heart disease is expected
to increase by 21,000.
The following chart shows disease prevalence by CCG as covered by QOF in 2010/11.
This shows a higher prevalence compared to the average for England for most long term
conditions in each CCG area with the Great Yarmouth and Waveney CCG higher in all
but one area.
Prevalence of conditions covered in QOF
disease register 2010/11
Coronary Heart Disease
Stroke or Transient Ischaemic Attacks (TIA)
Hypertension
Chronic Obstructive Pulmonary Disease
Hypothyroidism
Cancer
Mental Health
Asthma
Heart Failure
Heart Failure due to LVD
Palliative Care
Dementia
Atrial Fibrillation
Cardiovascular Disease Primary Prevention
Diabestes Melitus (17+)
Epilepsy (18+)
Depression (18+)
Chronic Kidney Disease (18+)
Obesity (16+)
Learning disability (18+)
Ipswich and
East Suffolk
CCG
West Suffolk
CCG
Waveney area
of GYW CCG
14,660 3.8%
7,342 1.9%
53,211 13.9%
5,705 1.5%
12,854 3.4%
6,572 1.7%
2,755 0.7%
24,631 6.4%
3,249 0.8%
1,684 0.4%
595 0.2%
2,220 0.6%
6,481 1.7%
4,620 1.2%
15,868 5.1%
2,418 0.8%
42,027 1.4%
14,290 4.7%
35,230 11.2%
1,094 0.4%
8,226 3.5%
4,185 1.8%
33,319 14.2%
4,066 1.7%
8,315 3.6%
4,723 2.0%
1,710 0.7%
15,693 6.7%
2,027 0.9%
1,043 0.4%
408 0.2%
1,232 0.5%
3,824 1.6%
3,079 1.3%
10,014 5.2%
1,388 0.7%
25,975 13.8%
6,542 3.5%
20,555 10.6%
792 0.4%
5,149
2,587
20,063
2,837
5,538
2,487
1,032
8,072
1,230
675
332
903
2,292
2,196
6,242
868
14,600
5,811
13,155
489
Total
Suffolk
4.2% 28,035
2.1% 14,114
16.4% 106,593
2.3% 12,608
4.5% 26,707
2.0% 13,782
0.8%
5,497
6.6% 48,396
0.1%
6,506
0.6%
3,402
0.3%
1,335
0.7%
4,355
1.9% 12,597
1.8%
9,895
6.2% 32,124
0.9%
4,674
14.8% 82,602
5.9% 26,643
12.9% 68,940
0.5%
2,375
Lower than the England average
Close to the England average
Higher than the England average
It is recognised that QOF data tends to underestimate the true prevalence of long term
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conditions as it relies on the disease registers being complete and only indicates the
number of people known to services. For instance, the number of people with learning
disabilities not known to health or social care services is estimated to be considerably
larger than that of those in contact with services. Based on national estimates, there
could be as many as 20-25,000 people in Suffolk with a diagnosed or undiagnosed
learning disability. The population of Suffolk (over 14 years) is projected to increase to
around 644,000 by 2021. This increase in population size, added to improved survival
rates for pre-term birth babies and changes to diagnostic practice could see increases in
both the proportion of the population and the total number for people diagnosed with a
learning disability. Future social care need and spend is therefore likely to be
significantly higher in this group.
Emergency Admissions
Non-elective admission rates are lower than the national average and lower than the
comparable ONS clusters. This means that reducing emergency admission rates will be
more challenging in Suffolk compared to CCG which have been underperforming. In
Suffolk, the average change in non-elective activity from 2009/10 to 2013/14 was an
increase of 1% which is in line with the national median increase of 0.7%. However, as a
consequence of the fact that Suffolk’s population is growing older at a higher rate than
the national average there is a significant risk that the non-elective admission rate is
likely to increase. This is consistent with the primary objective of this Better Care Fund
plan which is to reduce emergency admissions.
Rurality
The map below shows population density in Suffolk at the 2011 Census. The map shows
a concentration of population in the towns in the county but it is also clear that urban
areas form only a small part of the geographical area of Suffolk.
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People over 75 are more likely to experience isolation, ill health and mental illness
including depression than any other section of the population. As high users of
healthcare this has implications for access to Urgent Care services. The limited
availability of public transport outside of normal working hours and travel times to
community health services is therefore being taken into account in our design of
Integrated Neighbourhood Teams and Networks.
Risk stratification in practice
We have defined as high risk the top 2% of our adult population who are at risk of
emergency admission in the following year. In Suffolk, this equates to an estimated
11,700 adults. This cohort is being identified through our risk stratification tools.
These people at high risk will have a named care coordinator, who will help them to
develop a shared outcome focused plan which will assess risk and plan care. This lead
professional will be the most appropriate based on the needs of the customer.
In IEWS the RAIDR risk stratification tool will be used to identify patients at risk. These
patients will be included in a Proactive Case Management Register and will be the focus
of prevention opportunities (Every Contact Counts).
 Adults 18 + years old
o Vulnerable adults
o High risk patients
o End of Life Care
 0-17 year olds
o Complex physical or mental conditions
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In GYW, we recognise that establishing sustainable year-round delivery requires demand
and capacity analysis to be ongoing and robust, which then informs the planning and
delivery of services based on evidence. The rigorous and ongoing analytical review of the
drivers of system pressures has now been agreed by all partners in the Great Yarmouth
and Waveney system. This should help us develop plans to mitigate these pressures
using a collaborative approach. The project is well underway and we are in a position to
agree a baseline for the current activity pressures across the acute, community, mental
health, out of hours and ambulance trusts. This data will be updated monthly and
benchmarked against the system capacity. This will enable the whole system to move
away from a reactive approach to managing operational problems, calculating the
amount and type of capacity that will be required in the future, and towards a proactive
system of year round operational resilience.
The following theory of change diagram represents both health and care integration
programmes. The Better Care Fund will impact generally across both programmes, but
more specifically to deliver certain outcomes.
Health and care integration – theory of change
Main interventions that support BCF metrics including reduced
emergency admissions
To help people to be healthy and more independent for
longer, whenever possible
Reduce costs of health
and social care
Higher cost interventions
are replaced with lower
cost interventions
(consideration of whole
system costs)
People at risk of
deterioration and
crisis are identified
and receive a coordinated response
Communities are easy
and supportive places
to live with a health or
care need
Health and care system
is co-ordinated and
effective
Organisational
processes are
integrated
Health and
care staff work
together in an
integrated
system
Create a system that is
rewarding to work in
People manage their
own health and social
care
People have
the tools to
manage their
LTC
Information and
advice is readily
available to people
Voluntary and Community sector organisations are key partners in care
Better Care Fund Schemes
Key
Primary objective
Secondary objectives
Overarching outcomes
Immediate outcomes
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4) PLAN OF ACTION
The key milestones for delivery of the Better Care Fund Plan are on the plan below:
1 - IEWS
Integrated Neighbourhood Teams
Nic Roper
Gillian Montague
Dawn Barrick-Cook
Methodologies agreed for
INTs and specialist services
Shared guidance for integrated working
produced
Nic Roper
Gillian Montague
Dawn Barrick-Cook
G
3(a) IEWS
Admission prevention - risk
Nic Roper
stratification, personalised care plans, a Gillian Montague
reponsive health and care system
Dawn Barrick-Cook
G
3(b) IEWS
Admission prevention - crisis response
G
3 (c)IEWS
Gillian Clarke
Admission prevention - reablement and
Mark Cook
rehabilitation
Dawn Barrick-Cook
G
4 - GYW
Supporting Independence by provision
of Community based support
interventions
Geoff Empson
G
Review current services and agree future models of service provision
4- GYW
Supporting Independence by provision
of Community based support
interventions
(Integrated Home Care)
Geoff Empson
G
Finalise proposals and obtain relevant authorisation (from Norfolk County Counisl, Suffolk County Council
and Great Yarmouth and Waveney CCG) to proceed
5 - GYW
Integrated Community Health and Social
Jane Hackett and
Care Teams including Out Of Hospital
Maggie Parsons
team and Palliative Care
G
6 - GYW
Urgent Care Programme
Geoff Empson
(Integrated Home Care and Reablement)
G
6 -GYW
Urgent Care Programme
G
7 - GYW
Support for people with dementia and
older people with functional mental
Kim Arber
health problems living in the community
Access to specialist services and
support
Mark Lim
Jane Hackett
G
System model agreed for using reablement and rehabilitation services across health, social care and the
voluntary sector
Finalise models
Finalise proposals and obtain relevant authorisation (from Norfolk County Counisl, Suffolk County Council
and Great Yarmouth and Waveney CCG) to proceed
Finalise model
Finalise proposals, following NSFT
consultation, and produce report for
GYW Governing Body
Define structure of teams including skills mix and staff numbers
Comms, propoerty and workforce development plans all in place and operational
Delivery plan agreed, including workforce development plan
Oct-15
Sep-15
Aug-15
Jul-15
w/c 29 June
w/c 22 June
w/c 15 June
w/c 8 June
w/c 1 June
Jun-15
w/c 25 May
w/c 18 May
w/c 11 May
w/c 4 May
May-15
w/c 27 Apr
w/c 20 Apr
w/c 13 Apr
w/c 6 Apr
Apr-15
w/c 30 Mar
w/c 23 Mar
w/c 16 Mar
w/c 9 Mar
Mar-15
w/c 2 Mar
w/c 16
w/c 9
w/c 2
w/c 26
w/c 19
w/c 12
w/c 5
Feb-15
G
Finalise service model
Set up delivery team
2 - IEWS
w/c 29 Dec
Jan-15
w/c 22 Dec
w/c 15 Dec
w/c 8 Dec
w/c 1
Dec-14
w/c 24
w/c 17
w/c 10
w/c 3
Nov-14
w/c 27
w/c 20
w/c 13
w/c 6
w/c 29
Oct-14
w/c 22
w/c 8
w/c 1
Sep-14
w/c 25
RAG
w/c 18
Leads
w/c 11
Aug-14
w/c 4
Scheme
Key tasks and milestones
Reference
w/c 15
Great Yarmouth and Waveney Scheme Milestones
Community Services
reprocured
INTs and specialist
services working to new
structure
Capacity matched to
demand
Core and specialist
integrated reablement
service in operation
Recommission and implement agreed models of service
provision
Finalise service model, procurement model and
relevant documentation
Procure integrated home care
Recruit/commission
Implement models
Finalise service model, procurement model and
relevant documentation
Procure integrated home care
Recruit/commission
Transition to
new
integrated
home care
Transition to
new
integrated
home care
Implement model
Implement recommendations agreed at September GYW Governing Body
Key
Milestone Planned
Milestone Achieved
Milestone Delayed
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th
Key interdependencies:
 Contracts: Suffolk Community Healthcare, 111 and the Out of Hours contracts
terminate in 2015/16. The remodelling of the services currently provided by these
contracts is key to the delivery of our vision for integrated care. The health aspects
of the IEWS Better Care Fund schemes are likely to be largely delivered through
these contracts and their successors. As a consequence of the timing of the
contract renewals and the ongoing engagement process with patients and system
partners the service specifications are not yet at a stage where final costings are
known. As a result expenditure estimates included in Part 2 of the template are
based on the existing cost envelope and will be updated during the coming
months.
 Transformation programmes in Suffolk County Council are key
interdependencies for this plan. They are:
o Supporting Lives Connecting Communities – changing adult social care
so that it promotes independence and recovery, local solutions in
supportive communities, working in partnership, building on people’s
capacity and strengths and looking for tailored support to individuals
tailored to their situation.
o Making Every Intervention Count - Re-shaping Children and Young
People’s Services so they remain effective into the future and provide the
best possible outcomes for children and families within available resources.
o Local response - Suffolk’s public services are designed and delivered in a
way that reflects and responds to the varying needs, priorities and
opportunities within our communities and in different places.
 7 day working pilot in Great Yarmouth and Waveney – one of the DH pilots to
deliver and test 7 day working.
 The CCGs have had considerable success in recent years in making significant
QIPP savings year on year, but ongoing savings are becoming increasingly harder
to achieve. This has led to three main conclusions and ongoing pieces of work, as
set out briefly below.
o The need to reshape the system so that we have modern, community
based, services to enable services closer to people’s homes. This will
entail some changes to facilities going forward, and may necessitate a
degree of public consultation.
o Linked to the point above, modelling of the impact on capacity, activity and
cost within the system as IEWS and Great Yarmouth and Waveney
proceed with their integrated care system implementation. This modelling is
being undertaken in conjunction with refreshing the CCG’s Five Year
Strategy.
o A realisation, that with the financial pressures on the health and social care
systems, that there is an imperative to review health and social care spend
together, in order to identify further efficiencies which can benefit the pooled
fund within the Better Care Fund.
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Resilience Plans
 Ipswich and East Suffolk CCG is able to evidence system-wide resilience by the
delivery of several complex redesign programmes of work which will deliver
sustainable system-wide integrated care. These programmes are aligned with the
BCF schemes and include:
o Development of pathways for ambulatory care conditions, falls
(multifactorial assessments and interventions) admission avoidance
(including community IV therapy clinics), alcohol and substance misuse.
o Integrated Neighbourhood Teams are being developed across the area to
increase collaborative working.
o A care home improvement programme.
o Integrated winter planning schemes developed in partnership with social
care, primary care, community services, the acute hospital and voluntary
sector.
o QIPP schemes and resilience schemes are interrelated and interdependent
and are all designed to reduce unnecessary A&E attendances, acute
hospital admissions, ambulance call-out and conveyance and to promote
self-care.
 West Suffolk CCG has developed a local operational resilience plan for urgent
care in collaboration with the membership of our local System Resilience Group
and reflects the principles of good practice outlined in the national guidance. This
plan which was recently rated as ‘assured’ by the Area Team builds on the work
already underway in West Suffolk which aims to reduce urgent care demand on
the system through delivery of evidence based good operational practice, system
wide working and proactive case finding and care planning for people who are
most at risk of presenting to the urgent care system.
 GYW is a resilient system, as demonstrated by good A&E performance, reducing
non elective admissions and reasonable referral to treatment performance. We
have made sure that our plans around the Better Care Fund schemes are
complementary to other schemes funded non recurrently out of operational
resilience monies during 2014/15. These include ambulatory care pathways and
an urgent care centre co-located with A&E, both of which should help to further
reduce pressure on A&E attendances and non-elective admissions, and thus help
with developing a sound platform for the delivery of the Better Care Fund.
b) Please articulate the overarching governance arrangements for integrated care locally
Our programmes are under the oversight of the Suffolk Health and Wellbeing Board
supported by the two System Leaders Partnerships. The Health and Wellbeing Board will
oversee the integrated plans and also enable strategic influence and encourage and
support integrated working across our whole system.
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Suffolk Joint Working
Suffolk HWB
Ipswich &
E Suffolk and
W Suffolk SLP
Norfolk HWB
Suffolk
Commissioners
Group
Gt Yarmouth &
Waveney SLP
Norfolk
Joint
Commissioning
Groups
The Systems Leaders Partnerships hold oversight of the progress on the Health and
Care Review in the Ipswich and East and West Suffolk areas, and the Integrated Care
System programme in the Waveney area. They are able to unblock problem areas
escalated to them by SLP members or identified by the Health and Wellbeing Board.
They can also identify further areas where integration would benefit the system and
commission the work to take these forward.
The delivery structures below the SLPs are as follows:
Ipswich and East and West Suffolk
IEWS SLP
Ipswich and East
Integrated Care
Board
Operational Delivery
Group
West Suffolk Integrated
Care Board
Operational Delivery
Group
The Integrated Care Boards are monthly multi-agency meetings with senior
representation. Their remit is to:
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-
Ensure clear local plans are in place to deliver the agreed Health and Care
Review service model (which incorporates the Better Care Fund schemes)
To ensure adequate resources and leadership are in place to deliver the plans
with joint roles established as appropriate
To identify local issues and concerns and ensure these are addressed
To build local system working with all parties.
Members of the SLP take responsibility for clearing decisions through their own
organisational governance arrangements.
Joint working in the IEWS area is supported through:
- Regular joint meetings at all levels to progress projects and unblock barriers
- Co-location of staff in West Suffolk House
- Joint leads for programme work streams and Better Care Fund schemes
- Joint Health and Social Care Integration (HASCI) Resource Hub
- Workforce Planning and Development Forum
- Suffolk Informatics Partnership
Great Yarmouth and Waveney
GYW SLP
CCG Governing Body
ICS Programme
Board
Integration Committee
ICS Operational
Delivery Group
The ICS Programme Board is a monthly multi-agency meeting with senior representation.
Their remit is to:
- work closely in partnership with all local organisations responsible for health,
county and district council services to ensure whole system engagement,
commitment and implementation of ICS principles through aligned activities,
sharing of budgets and pragmatic integrated projects.
- Manage the relationships between implementation groups to ensure effective
coherence to deliver desired outcomes in the real world rather than a whole
project approach delivering a product.
- Ensure projects and integration activities are built from the bottom up and support
the emergent ICS; they will be concerned with action and delivery as a priority.
- Explore how resources can be shared and work to achieving their use optimised at
an ICS level.
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Members of the SLP take responsibility for clearing decisions through their own
organisational governance arrangements.
Joint working is supported in Waveney through:
- Regular joint meetings at all levels to progress projects and unblock barriers
- Collocation of front line staff
- Workforce Planning and Development Forum
- Suffolk Informatics Partnership
Suffolk’s health and care system is keen to use innovative estates management to
facilitate fundamental change, help improve efficiency, move activity out of hospitals and
exploit new technologies.
 We are taking every opportunity to co-locate our services with appropriate partner
organisations through our Single Public Sector Estate programme and seek to go
further and develop new ways for delivering integrated public services in our
communities.
 This programme aims to work with Public Sector Partners to efficiently use their
estate, to improve customer access and improve service benefits by sharing
buildings and services. The initial vision was to create a ‘one front door’ where
customers can visit one place to access services they need, while saving money
for organisations.
The project was launched in Suffolk in 2010 and has since opened new shared spaces in
Bury St Edmunds (West Suffolk House), Ipswich, (Endeavour House) and the current
project in Lowestoft (Riverside Road) in addition to significant sharing across the whole of
Suffolk.
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c) Management and oversight of the delivery of the Better Care Fund plan
The management and oversight of the delivery of the Better Care Fund Plan will be
through the governance arrangements described above.
The reporting and monitoring arrangements will be as follows:
Health and Wellbeing
Board
System Leaders
Partnership
Integrated Care
Boards/ICS
Programme Board
Will receive
Quarterly performance updates
Quarterly highlight BCF report
Monthly programme updates
Quarterly BCF expenditure reports
Monthly/quarterly (dependent on
availability of metric measures)
performance updates
- Emergency admissions
- Residential care home
admissions
- DTOCs
- Effectiveness of reablement
- Patient and service user
satisfaction
- Dementia diagnosis rates
Requests from the SLP for remedial
action where plans are off track
Monthly project updates from
projects delivering BCF schemes
Quarterly BCF expenditure reports
Monthly / quarterly (dependent on
availability of metric measures)
performance updates
Monthly performance updates
- Emergency admissions
- Residential care home
admissions
- DTOCs
- Effectiveness of reablement
- Patient and service user
satisfaction
- Dementia diagnosis rates
Will produce
Quarterly Signed off
performance updates
and BCF report for the
HWB
Monthly requests for
remedial action where
plans are off track
Monthly performance
updates for the SLP
on progress with
delivering BCF plans
Reports outlining
remedial actions
where plans are off
track
Requests to delivery
projects for remedial
action where plans
are off track
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d) List of planned BCF schemes
Please see Annex 1 for Detailed Scheme Description for each of these schemes.
Ref no.
1
2
3 (a)
3 (b)
3 (c)
4
5
6
7
Scheme
IEWS - Integrated Neighbourhood Teams
IEWS - Access to specialist services and support
IEWS - Admission prevention - risk stratification, personalised care plans, a
responsive health and care system
IEWS - Admission prevention - crisis response
IEWS - Admission prevention - reablement and rehabilitation
GYW - Supporting independence by provision of community based support
interventions
GYW - Integrated Community Health and Social Care Teams including Out
of Hospital teams and Palliative Care
GYW - Urgent Care Programme
GYW - Supporting people with dementia and older people with functional
mental health problems living in the community
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5) RISKS AND CONTINGENCY
a) Risk log
The following risk log has been jointly developed in accordance with acknowledged risk management good practice that identifies the
risk, its likelihood and impact and offers a risk rating that has an associated mitigation plan.
There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
1. There is a
system wide risk
that resources
available to us
are unable to
reduce forecast
demand growth
and manage the
impact of
reductions in
central
government
resources for
health and care.
4
5
20
Our target reduction in nonHigh
elective admissions will result in a
cost saving of £1.7m. In the event
that this saving is not realised the
cost of this activity will be
compensated by the CCGs.
We recognise that this is a risk that we
need to manage together across the
health and care system. All partners
are involved, as the impact of this risk
affects all our organisations. We have
committed to managing this risk
together as system leaders,
dynamically and collaboratively. We
will ensure effective joint working to
implement the schemes, timely
monitoring and evaluation of the
impact when schemes are
implemented and joint governance, risk
sharing and financial
monitoring/planning
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There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
Owner – System Leaders Partnerships
Timeline – monthly programme and
performance reports – see performance and
monitoring arrangements on page 30
(please see governance section p 27 onwards)
2. This plan is not
rigorously or
coherently
delivered due to
an organisational
inability to coordinate and
manage change
leading to
inefficient service
models.
3
3
9
Medium
Senior leadership directly involved,
with strong programme governance
arrangements and robust delivery
plans, including a collaborative
workforce development plan.
CCG and County Council design leads
are working closely together and with
key partners (eg, VCS, providers,
service users/patients).
Plans are being tested against the best
available evidence and jointly modelled
to assess local impact.
Plans implemented through a “learning
through doing” approach that allows
development to flex to build on what
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th
There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
works and stop what is not working.
Owner – System Leaders Partnerships
Integrated Care Boards/ICS Programme Board
meet monthly and have direct responsibility for
ensuring that there is a coherent change
programme in place.
Timeline – monthly programme and
performance reports - see performance and
monitoring arrangements on page 30
3. Operational
pressures will
restrict the ability
of our workforce
to deliver the
required
investment and
associated
projects that will
make the vision
of care outlined
in our Better
Care Fund
submission a
4
5
20
High
A performance dashboard is being
developed as part of the year one
activity.
This information will identify system
stress and where schemes are not
delivering. By using clear metrics
success can be accelerated and
unsuccessful interventions reviewed.
As a result, timely intervention by the
appropriate part of the local system’s
governance will be undertaken.
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There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
Owner – Integrated Care Boards/ICS
Programme Board
Timeline – monthly finance and performance
reports – see performance and monitoring
arrangements on page 30
Performance dashboard will be ready and
operational by April 2015
reality.
This risk has been
particularly raised
during public
engagement.
4. Improvements in
the quality of
care and in
preventative
services will fail
to translate into
the required
reductions in
acute and
nursing/care
home activity by
2015/16,
impacting on the
overall funding
available to
support core
4
5
20
High
Action plans for our transformation
programmes set out high impact
changes. We will monitor delivery of
our action plans against anticipated
outcomes. This information will be
embedded in the governance system
and monitored regularly. This will
enable the right part of the local
system to take appropriate remedial
action
Owner – Integrated Care Boards/ICS
Programme Board for system oversight, and
commissioners and provider organisations for
remedial action.
Timeline – monthly performance reports – see
performance and monitoring arrangements on
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There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
page 30
services and
future schemes.
5. Social care
services fail to be
protected as a
consequence of
financial
agreements
reached in the
development of
the Better Care
Fund plan, with a
subsequent
impact on the
ability to reduce
non-elective
emergency
admissions.
3
5
A minimum amount of £16.748m
has been committed to protecting
social care, A further £5.4m has
been committed upon realisation
of additional savings through joint
working.
Moderate
15
.
The Section 75 agreement will set out
how funding the protection of social
care will be paid across to Suffolk
County Council. This will include
schedules showing agreed savings
plans, and how savings are allocated
initially to SCC and then on a risk
sharing basis.
The plan will be reviewed through the
Suffolk Commissioners Group as part
of their overview of system health
Owner – System Leaders Partnership for joint
performance and Section 75 agreement.
SCC and CCGs for savings plans (as
schedules to the S75)
Timeline –Section 75 agreement and savings
schedules will be in place by the end of
February 2015
performance and monitoring arrangements on
page 30.
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There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
Section 75 agreement and savings schedules
will be reviewed monthly.
6. The introduction
of the Care Act
will result in a
significant
increase in the
cost of care
provision from
April 2016
onwards that is
not fully
quantifiable
currently and will
impact on the
sustainability of
current social
care funding and
plans.
4
5
20
High
Suffolk adult social care has
undertaken an initial assessment of the
effects of the Care Act and the
additional costs associated with its
introduction. The initial amount
allocated for implementation is
reflected in the Better Care Fund
finance table. This will continue to
need significant focus as our integrated
plans develop.
Owner – Adults and Community Services
Transformation Board
Timeline – the ACS Transformation Board will
receive monthly programme reports
Key milestones for the Care Act are April 2015
and April 2016. Ongoing monitoring will identify
where financial pressure building because of
Care Act requirements, and this will be
escalated to the Systems Leaders
Partnerships as part of the regular reporting
and monitoring processes.
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There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
7. Having a Suffolk
overview of
performance fails
to recognise
changes in
performance in
constituent
planning unit
areas.
4
8. Sharing data at a
system level is
not possible due
to restrictions on
NHS
organisational
use of local
patient
information.
5
5
20
High
Performance dashboard will include
overview of performance on
constituent planning unit areas.
Owner – Health and Wellbeing Board
Timeline – quarterly review – see performance
and monitoring arrangements on page 30.
4
20
High
Plans to implement the NHS number
are well advanced; however, the
statutory restrictions on data sharing
reduce the ability to plan in an
integrated way. It also undermines the
local system’s ability to fully
understand an individual’s journey
through the system.
Owner – Suffolk Informatics Group
Timeline – dependent on national policy
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There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
changes
9. Public confidence 4
is not maintained
during the
development and
implementation
of our plans.
5
20
High
We have clear communication,
consultation and coproduction
strategies and aligned messages so
that people in Suffolk have a coherent
story of change, know what we are
doing and why.
Where appropriate we will carry out
formal consultation exercises.
We have a strong ethos of coproduction in our transformation
programmes which will involve people
in changes to the health and care
system.
The Health and Wellbeing Board takes
an active role in overseeing the Suffolk
wide shift to integrated working.
We have representatives from service
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There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
user groups, including Healthwatch at
all levels of our system governance.
Owner – Health and Wellbeing Board
Timeline – Initial Communication, Consultation
and Co-production report published December
2014.
Phase 2 strategy will be coproduced with user
led organisations and refreshed by April 2015.
10. 7 day services
are not effective
due to
affordability with
some parts of the
system not able
to deliver 7 day
services or there
is a delay in
implementation
11. The anticipated
impact of closer
working with the
Voluntary and
4
4
16
High
Integrated Care governance
arrangements and the Workforce
Development and Planning Forum will
be asked to develop mitigating actions
to manage this risk.
Owner – Integrated Care Boards/ICS
Programme Board
Timeline – ongoing – see Plan of Action
2
4
8
Medium
Early engagement through established
joint forums such as the Working
Together Forum and Suffolk Congress.
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th
There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
Community
Sector is not
realised.
Building on the Supporting Lives
Connecting Communities approach
which has delivered significant demand
reduction in adult social care.
Locality work with our early adopter
sites between statutory and VCS
partners to deliver change on the
ground.
VCS are key partners in the work we
are doing to deliver early adopter sites
and initiatives. Early adopter sites have
specific VCS workstreams.
Owner – Integrated Care Boards/ICS
Programme Board
Timeline – Engagement with the VCS –
building on an event in October 2014, further
events planned. Will be reported as part of the
monthly programme reports. .
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There is a risk that:
How
likely is
the risk
to
materiali
se?
Potential impact
Please rate on a scale of 1-5 with 1 being a
relatively small impact and 5 being a major impact
And if there is some financial impact please
specify in £000s, also specify who the impact of
the risk falls on)
Overall
risk factor
Mitigating Actions
(likelihood
*potential
impact)
Please rate on
a scale of 1-5
with 1 being
very unlikely
and 5 being
very likely
12. Contracting
3
timescales slow
down
implementation
of transformation
plans : IEWS and
WSCCG 111,
OOH and
community health
services original
contract expiry
dates fall within
2015/16.
4
12
(moderate)
IEWS and WSCCG have agreed the
process for extension / reprocurement
of existing services during 2015/16.
Robust transitional plans will be
developed as appropriate to ensure
that service transformation (ie the BCF
schemes) can be implemented to
agreed timescales.
Owner –CCG Governing Bodies Timeline –
Procurement to be complete by 31/3/2015.
Escalation through to Suffolk Commissioners
Group as part of regular reporting.
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Risks have been assessed using the following risk matrix, which takes into account
likelihood and impact. Each is given each a score from 1 to 5. The overall risk score is
the product of the two.
Almost certain
(5)
Likely
(4)
Moderate
(3)
Unlikely
(2)
Rare
(1)
5
10
15
20
25
4
8
12
16
20
3
6
9
12
15
2
4
6
8
10
1
2
3
4
5
Insignificant
(1)
Minor
(2)
Moderate
(3)
Major
(4)
Extreme
(5)
b) Contingency plan and risk sharing
Our integration plans are overseen by the HWB supported by the two System Leaders
Partnerships. The delivery of the BCF will be managed through the IEWS Integrated
Care Boards and the GYW ICS Programme Board as described in section 4b) of this
Plan. These Boards are multi-agency with senior representation and meet on a monthly
basis.
The financial impacts of the agreed funding for the Better Care Fund are embedded in
the CCG two year Operational Plans and Five Year Plans and in SCC’s financial plans.
Financial balance for the CCGs and SCC are predicated on challenging QIPP targets
and savings plans which are tightly monitored through the appropriate governance
arrangements. For CCGs these targets include reductions to emergency admissions.
The principal risks to the CCGs are those associated with failure to achieve the
savings associated with the delivery of the Better Care Fund target outcomes and in
particular the failure to reduce non elective activity in the acute sector.
The CCGs are considering a variety of contracting methods with providers in the future
which will assist in increasing wider ownership of the Better Care Fund plans and
distribution of risk to the system., These reviews are in their early stages and will take
time to develop, the current expectation is that these changes will start to be
implemented from October 2015.
From an acute provider perspective, it is unlikely that the BCF presents a risk to them as
they tell us that they make a loss on non-elective activity. At two of our acute providers,
activity above the 2008/09 threshold (or adjusted) is paid at 30% as per National Tariff
arrangements. Acute providers will continue to be paid as per the contractual agreement
on activity performance. In the event that the Better Care Fund is successful in reducing
emergency admissions, there is a risk to that there will be some ‘stranded costs’,
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primarily fixed costs that the trusts may not be able to take out of the system
immediately. However, our providers advise us that reductions will ease the considerable
pressure on clinical resources and that they are planning to reduce capacity in line with
reductions as they materialise.
£1.7m has been identified as the Payment for Performance element of the Better Care
Fund. This sum will be available to the Fund in the event emergency admissions are
reduced by 3.5% from the baseline. In the event that the target for emergency
admissions is not met, there will be a commitment to pay acute providers, in accordance
with contractual arrangements, for the activity which has not been avoided. In IEWS, an
amount equivalent to the planned benefit from reducing emergency admissions (£1.1m)
is identified as a Contingency in the BCF pooled fund (see Expenditure Summary in
Template 2). The GYW share of the Payment for Performance amount of £0.6m is
embedded within their schemes – see Template 2.
The nature of our agreement means that SCC have certainty over £16.7m allocated to
protect social care. A further amount of £5.4m is conditional on additional savings
achieved through joint working, both from the Better Care Fund schemes and through
joint commissioning, procurement activity and reductions in non-elective activity. This
provides a strong incentive for all parts of the system to work together to achieve savings
albeit that there remains a risk to social care from the funding settlement as outlined in
the risk log and in Section 7 below. The CCGs and SCC are committed to working
collaboratively to identify opportunities for additional savings and have identified finance
and staff resources to move this on at pace.
A detailed risk sharing agreement will be agreed as part of the s.75 agreements (one for
each of the CCGs) and a comprehensive risk register will be in place to manage or
mitigate known and emerging risks associated with the development and implementation
of the Better Care Fund Plan. High level principles for the s.75 have been agreed.
Detailed drafting is to be finalised by end December with a view to approval at CCG
Governing Body meetings and SCC Cabinet in January with final sign off by the HWB in
March.
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6) ALIGNMENT
a) Alignment with other initiatives related to care and support underway in Suffolk
Suffolk is ambitious in accelerating collaborative working. The Better Care Fund is a
catalyst but only a small part of our wider ambitions for integrated working across
Suffolk’s public sector along with VCS and private sector partners. Our approach to
transformation, based on a drive towards more efficient services through cost
reductions and demand management is threaded through all our transformation in
Suffolk, creating synergy and opportunities that complement our ambitions for
integrated health and care.
There is a strong foundation of joint working in Suffolk and there are a number of
work streams focussing on better integrated working across health and care. These
are also embedded in the Suffolk system governance that means relevant partners
can take appropriate action to ensure the work delivers the desired impacts. The
work is focussed at different levels from strategic to operational and locally based,
which reflects local partners’ commitment to work more efficiently together but not
impose top down action and focus on what is most appropriate to the specific
issue/need being addressed.
Leaders of NHS Great Yarmouth and Waveney Clinical Commissioning Group and
local government partners were presented with the top prize in the ‘improved
partnerships between health and local government’ category at a prestigious Health
Service Journal award ceremony in London on 19th November 2014.
The national award comes in recognition of the work being undertaken in developing
an integrated care system. This has seen NHS Great Yarmouth and Waveney CCG,
Suffolk, and Norfolk County Councils, Great Yarmouth Borough and Waveney
District Councils and local health providers work more closely together to improve
services for local people. The judges said “The strategic vision and commitment
required to achieve this project across a range of councils, providers and CCG is
truly outstanding.
The above endorses the commitment to work together and recognises the progress
that has already been made.
Other initiatives that align to and support integrated working in Suffolk are listed
below.
Through the DCLG community budget pilot in Haverhill and asset based
community development projects in some local market towns, partners have begun
to better understand local need and communities’ capacity to become more selfsustaining.
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Our schemes emphasise the need to develop health and care services on a local
basis so that services deliver against local priorities, but also so that local assets and
opportunities are maximised to support people to stay and remain healthy and
independent. In particular the development of Integrated Neighbourhood Teams
(Scheme 1) and community based support interventions (Scheme 4) will benefit from
work already carried out to strengthen communities. Specific benefits will include the
use of buildings and the ability to develop strong relationships between the voluntary
and community sectors and the local health and care teams.
A Transformation Challenge Award (TCA) bid has been submitted by the public
sector in Suffolk under the steer of its Public Sector Leaders group. This has been
developed from the collaboration principles agreed by Suffolk’s Public Sector
Leaders in 2013, and commits to collaboration as a way of working but which
respects organisational sovereignty and is focussed at strategic or operational level
according to where the greatest impact is made. As a result, the bid seeks to build
capacity at strategic and operational levels through skills development and
infrastructure investment to improve collaborative working (for example, IT that
enables more effective information sharing and co-location). Economic growth and
wellbeing, health and social care will be the areas of focus for the bid. To avoid
duplication, the wellbeing focus will use the JHWS as a framework.
If Suffolk is successful with the TCA bid there will be a major boost to the health and
care integration programme. Depending on the size of any award and the decisions
made locally as to priorities for spend it is anticipated that funding will support
schemes to grow community based support, develop integrated locality working and
support for people with dementia living in the community. Benefits are likely to
include funding for community development, support for the costs of colocation and
general funding that helps us to make faster progress with our plans.
In implementing Suffolk’s Joint Health and Wellbeing Strategy (JHWS), the Health
and Wellbeing Board acknowledged that additional help would be valuable in
tackling its priority that “people in Suffolk have the opportunity to improve their
mental health and wellbeing”. As a result it successfully bid for Local Vision support.
Their support programme expanded from focus on mental health crisis to prevention
and recovery. Consequently, a joint commissioning strategy for mental health is
being developed (supported by a new partnership board reporting into the System
Leaders Partnership) in order to deliver the multi-agency strategy for mental health
promotion and early intervention. The strategy will be in line with the integration
programmes in Waveney and in IEWS. These outputs have been incorporated into
the Board’s JHWS delivery plan.
The connections and integration with mental health services is a key issue for our
schemes as it is widely agreed that the different elements of our services are
disjointed – leading to inefficiencies in the system and a poor service for people.
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The Local Vision support will provide a clear way forward which will help all our
schemes to deliver on their ambition to provide integrated care in a holistic and
person centred way.
The Health and Wellbeing Board is also in the process of consulting on a Suffolk
Health and Housing Charter since housing is acknowledged as underpinning its
JHWS’s strategic outcomes. The Charter (due for agreement at the November
Board) sets out a shared vision and commitments designed to improve the overall
health and wellbeing of Suffolk’s residents. As such, encouraging sustainable
supplies of age appropriate housing within Suffolk’s localities is likely to be part of
Suffolk’s TCA. In addition to the potential additional resource, this provides a shared
priority between the Board and wider public sector governance in Suffolk.
The development of the Housing Charter will ensure that local integrated teams can
work with district and borough councils to access appropriate housing support for
people they are working with. Whilst this will not provide immediate financial benefit
to our work, it is an important element of the prevention and early intervention
agenda and will support people to stay well and out of crisis, thus reducing demand
on emergency and other services.
Suffolk County Council, as well as Ipswich and West Suffolk Hospitals, each with the
support of the CCGs have bid to the NHS England Technology Fund to ensure that
their IT systems are compatible and can interface at a customer level. If success the
projects funded will support faster and more effective transfer of information, shared
care plans and risk stratification. If successful this initiative will be of financial benefit
to all our schemes through the introduction of technology that supports our vision for
integrated care.
b) Alignment with existing 2 year operating and 5 year strategic plans and local
government planning documents
The Better Care Fund plan of action is embedded within the County Council’s medium
term financial plans that are updated on an annual basis as part of its annual budget
setting process. In 2014 a set of corporate transformation programmes were agreed in
order to deliver the radical changes required to meet the savings required from 2015-18.
These programmes include health and social care integration along with the
implementation of re-design delivery models for adult and children and young people’s
social care.
For IEWS, the BCF plan is viewed as an opportunity to drive forward delivery of
integrated services through the Health and Care Review. Integration, system-wide
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working and partnership are key themes underpinning the two CCG two year Operational
Plans and the Suffolk 5 year Strategic Plan. The detailed activity and financial impacts
will be incorporated in the refreshes of these plans post finalisation of this BCF plan.
The Better Care Fund plan is embedded within the Great Yarmouth and Waveney two
year Operational plan and five year strategic plan and will be used as a catalyst to
achieve Great Yarmouth and Waveney’s ambition to create an integrated care system
(virtual at first) encompassing the activities of all of the local organisations responsible for
health, social care and District Council services.
Examples of the relationship between the Better Care Fund and the 5 year strategy
include:
Out of Hospital Care: Impact on System:- reduced A&E attendances and emergency
admissions. Reduced residential nursing home admissions, reduced DTOCs. Major
contributors are scheme one, two and four. Supported by Urgent Care Centre pilot
(funded through Operational Resilience monies)
Shift from acute inpatient (elective and non-elective) to less intensive forms of
support (including social care): Impact on system:- Permits change acute capacity and
facilitates availability of capacity to support repatriation of activity from other acute
hospitals. Major contributors are schemes one, three and four. Supported by
development of in-reach/outreach resources shared between our providers
Combining budgets, streamlined management, co-location within an Integrated
Care System: Impact on system:- fewer handoffs for patients, increased purchasing and
financial efficiencies, reduced use of expensive facilities. Public consultation regarding
services and facilities to start late 2014.
c) Alignment with plans for primary co-commissioning
Ipswich and East and West Suffolk CCGs submitted expressions of interest to cocommission primary care on 20th June 2014 and received a green rating from NHS
England as ‘ready to co-commission now’ with ‘delegated responsibility transferred with
clear accountability to Area Team’.
Progressing to the next stage requires clarity of governance and implementation
arrangements with NHS England, which will then inform a final decision by the CCGs’
member practices in line with their Constitution. The CCGs were clear in their
submissions that final agreement to proceed is inextricably linked with the outcome of the
PMS Review and the retention of viable, PMS contracts with current minimum levels of
premium funding which enable meaningful co-commissioning for our patients. The
submissions were approved in principle by the Suffolk Health and Wellbeing Board.
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Co-commissioning has the potential to enable delivery of the Health and Social Care
Review and emerging Primary Care Strategy, both of which have involved member
practices systematically in their development. All member practices were engaged in the
initial scoping of the urgent care redesign programme in December 2013 and received
the model for comment in July 2014. The GP members of the CCG Clinical Executives
have been involved at each key point in the model’s development and preparation of
individual service specifications for the out of hours, community service and 111
services. A core group of GPs from both CCGs have engaged in weekly meetings with
Suffolk County Council, Healthwatch and other partners in detailed review of evidence
and design options.
Primary care is integral to the current and new model of health and independence and
urgent care most specifically, the principle that people in Suffolk will be served by an
integrated model with an overall responsibility for urgent care across the population –
primary, community, mental health, social care, secondary care, the voluntary sector and
other organisations working as part of an integrated system with common objectives.
The CCGs’ primary care strategies will enable delivery of this model. The first draft of the
strategy will be completed by the end of September 2014. It will include a vision for
primary care, building on its current strengths in delivery of high quality services and
integrated working as demonstrated through Multi-Disciplinary Teams. The strategy and
its subsequent action plan will set out models of delivery at multiple scales and practical
action to respond to associated collaboration, workforce, property, IT challenges.
Great Yarmouth and Waveney CCG has submitted an expression of interest to the east
of England area team to become involved in their work developing co-commissioning
with CCGs. At present we are waiting further news regarding how the area team intend to
take this initiative forward but we anticipate that further details will emerge over the next
3-6 months. GYWCCG welcome the opportunities that co-commissioning will offer in
terms of developing an integrated healthcare system for all the patients in East Norfolk.
As soon as the direction of travel is clarified we will take prompt action to ensure timely
implementation
GP practices in Great Yarmouth and Waveney are all Members of NHS GY&W CCG and
member practices are closely involved in decision making. There is strong GP and
practice manager representation on the Clinical Executive Committee and on the CCG’s
Governing Body which ensures clinical input into all areas of our work. Alongside this
there are regular GYW Clinical Leads Forum, where a representative from every practice
attends, and our monthly PTL (Protected Time for Learning) sessions, plus our practice
manager meetings and a range of regular informal practice visits.
Each practice sends a GP to the clinical leads meetings and in addition there is a lead
practice manager from both of the main geographical areas at each meeting, i.e. Great
Yarmouth and Waveney. These groups guide strategic development, prioritisation, and
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practical implementation.
There are also ten retained GPs and two retained Nurses working in NHSGYWCCG who
provide a valuable resource to help with commissioning decision making, they inform this
process through the programme boards and specific work areas.
Meetings are held with all Clinical Leads across GYW to identify and agree our
commissioning priorities and intentions for 2014/15 and beyond. The clinical leads
groups have been involved in shaping and approving our overall strategic plans at both a
health system and Programme Board level.
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7) NATIONAL CONDITIONS
a) Protecting social care services
i)
Agreed local definition of protecting adult social care services
Our definition of protecting social care in Suffolk is that the criteria for adult social care
will remain at substantial and critical and that the provisions of the Care Act will be fully
implemented. This means that people in need of care and support will continue to receive
the appropriate services they need in an integrated and preventative health and social
care system. Our approach is founded on a whole system approach to health and care
services.
The Health and Wellbeing Board understands the vital importance of robust social care
provision in Suffolk as part of a whole system approach to health and social care.
We recognise that the way we allocate resources within adult social care may change
because of our shared transformation programmes, but what we are interested in is
delivering the better outcomes for individuals.
In Suffolk we know that the social care demands from our population are increasing year
on year in part because of the rising numbers of older people in our communities. At
present approximately 10% of Suffolk’s population is aged over 75 and this is set to rise
by 72% by 2031. Between 2012 and 2017 there is a predicted 15% increase in people
with high and very high care needs and the number of people with dementia will double
between 2013 and 2030. The cumulative effect of demographic changes will place
additional demands on adult social care, which translates into ongoing financial
pressures of around £5 million each year.
Meeting these challenges requires transformation of the health and social care system
and we recognise that the best way of protecting adult social services is to do this
together. This means developing integrated services together, commissioning jointly and
differently and working to ensure that different elements of the health and care system
interact in an effective, efficient way in the interests of the service user.
ii) How local schemes and spending plans will support the commitment to protect social
care
Delivery of the Better Care Fund schemes and the national conditions will enable the
services and supports provided by social care to be delivered alongside health provision,
leading to efficiencies in delivery and outcomes, a better experience for customers, and
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eventually to transformed services.
The focus of our schemes on prevention and getting upstream of crisis and long term
care (the “shift left” approach) will reinforce the role that social care plays within an
integrated system. In the short term, an integrated approach to care in a crisis and to
reablement will stop people from needing to go to hospital and into more intensive longer
term care. In the longer term it will delay the onset of long term conditions and frailty that
lead to health and care needs.
Suffolk County Council and the CCGs have agreed how Better Care Fund spending will
support the commitment to protect social care.
iii)
The total amount from the BCF that has been allocated for the protection of
adult social care services.
The amount of the Better Care Fund that has been allocated for the protection of social
care services is a minimum of £16.748m. This is made up of:
- £1.8m for implementation of the Care Act responsibilities.
- £14.948m – previously referred to as S256
In order to better protect social care our agreement is to rigorously identify additional
savings, targeting a further £5.4m through joint working, both from the Better Care Fund
schemes and through joint commissioning, procurement activity and reduction in
emergency admissions and demand. The CCGs and Suffolk County Council have
identified finance and staff resources to move this on at pace.
- In IEWS it has been agreed that £3.4m achieved through this process will be
passed across to the County Council for the protection of social care.
- In Waveney £2m will be transferred to SCC at the beginning of 2015/16, with a
50/50 risk share agreement if savings are not achieved up the value of £2m.
In both IEWS and Waveney savings over and above this amount in 15/16 will be split
equitably between the County Council and the CCGs in accordance with a risk sharing
agreement, to be developed.
iv) How the new duties resulting from care and support reform set out in the Care Act
2014 will be met
The requirement to provide universal information, advice and guidance to the citizens
of Suffolk in their geographical or common interest communities gives us the opportunity
to jointly commission the voluntary and community sector, who will work alongside the
integrated health and care system to deliver information, advice and guidance within their
locality or to their community of interest. This activity is already underway through our
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transformation programme, Supporting Lives Connecting Communities, which focuses on
the least intrusive interventions in order for people to maximise their independence.
We are also refining our Information and Digital Strategy to address the aspects relating
to self-funders and financial capping and new assessment and eligibility responsibilities.
We are piloting new data sharing protocols between Health and Social Care and county
wide Information Standards. Current arrangements with Independent Financial
Advisors will be expanded to be Care Act compliant.
The development of Neighbourhood Networks with Local Area co-ordination to support
the effectiveness of Integrated Neighbourhood Teams is underway and will be further
refined through co-production with User Lead Organisations in Suffolk (such as the
Suffolk Coalition of Disabled People) and evolving user and carer led monitoring and
evaluation processes. Supported self-assessment, robust risk stratification and shared
care planning are integral to these changes.
New policy and guidance and resource allocation systems are being developed for carers
assessments and personal budgets and will be used by the new Integrated
Neighbourhood Teams and partners in the Neighbourhood Networks if this function is
delegated. This will promote parity of access to assessments and support for carers
with their cared-for across Suffolk.
An Integrated Carers Commissioning Group has been established to oversee carers
developments when the Care Act comes in in April 15. This group has been endorsed
through governance of all three CCGs in Suffolk and through Suffolk County Council’s
Adult and Community Services and Children and Young People Directorates.
These changes are wholly in line with our integrated care transformation programmes in
both IEWS and in Waveney and are within the main programme. They will be overseen
by the relevant programme boards within these two systems. These programme boards
will be accountable for delivery against the plans.
iv)
Level of resource that will be dedicated to carer-specific support
The total spend on carers by Suffolk County Council is £2,425,961:
- Provided to carers as a personal budget - £1,594,052
- Funding to commission services for carers - £831,909
The resources identified through the Better Care Fund totals £1.724m and is made up
of:
- Ipswich and East and West Suffolk CCGs carers breaks funding - £1,406m
- Waveney element of the Great Yarmouth and Waveney CCG carers breaks
funding - £0.318m
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The intention in Suffolk is to pool this funding (apart from that provided to carers as a
personal budget) in order to jointly commission carer support. An Integrated Carers
Commissioning Officers Group has been established to take a strategic view about
responding to the needs of carers. Carers needs in Suffolk have been identified though
our recent stakeholder engagement and within the recent Suffolk Family Carers Needs
Assessment. Engagement events have identified the need for training for carers, both in
safe moving and handling and “Carers with Confidence” type courses, as well as a
“mumsnet” type website to promote opportunity for sharing of information and support.
The principle of carer-led commissioning and evaluation of services is integral to the work
of the Integrated Carers Commissioners Officer Group. By working together we can
prioritise those schemes which work on a risk stratification approach to carer support,
targeting interventions with those carers most at risk of leaving education, employment or
training and those where the caring role is at risk of breaking down due to lack of
information, advice and support. The Integrated Carers Commissioning Officers Group
will also be responsible for building business cases for new carer’s services, for making
sure that services are equitable across Suffolk, and for ensuring that new Care Act duties
are implemented.
A number of pilot schemes have been running in Suffolk and our integration programmes
will facilitate roll out of the things that we know work well and will address shared
outcomes in critical areas, for example delayed transfers of care (supporting carers as
experts in discharge planning – West Suffolk and Ipswich Hospitals), and preventing
avoidable admissions to hospital and residential care caused by carer breakdown.
Our schemes will support carers in their role as a key partner in care. Integrated delivery
arrangements (such as Integrated Neighbourhood Teams and the Out of Hospital Team)
will support carers to access the help available through current services such as:
-
-
-
Supporting Carers at hospital discharge – this is a service available at the
hospitals which provides information and support when people are discharged
from hospital
Suffolk Family Carers GP workers – based in GP practices and delivering 1-2-1
support for carers.
Respite on Prescription initiative which enables GPs to “prescribe” information,
breaks and bespoke support from voluntary and statutory sector partners.
Strategic Partnership funding for Suffolk Family Carers – countywide and covers
generic carer support and information and advice, together with community
development, training and awareness raising. Suffolk Family Carers in addition
has a jointly funded Mental Health Team.
Carers budgets – iCARE and Enhanced Carers Budgets offered to carers who
have received a carers assessment.
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vi) Extent to which Suffolk County Council’s budget been affected against what was
originally forecast with the original BCF plan
Provisional agreement was reached in May that in addition to the £16.748m for
implementation of the Care Act and s256, an additional amount of £4m would be
transferred unconditionally to Suffolk County Council for the protection of adult social
care.
This amount has risen to £5.4m as described in (iii) above. This amount is conditional on
achievement of savings through joint commissioning and contracting. Plans are well
developed, with savings opportunities being scoped and identified and staffing resources
in the recruitment pipeline.
The risks associated with the protection of social care are incorporated within the BCF
risk log in Section 5 (particularly risks 1 and 5). Ownership for these risks is with the
Systems Leaders Partnerships and they will receive regular monitoring reports to support
them to manage the mitigations required as the Plan moves forward.
The extent to which the County Council’s budget plan has been affected by the new
agreement for the protection of social care: The BCF Section 75 agreement and savings
plans sit alongside other County Council savings plans. If these savings are delivered in
full there will be sufficient funding to meet the needs of eligible adult social care
customers, based on current demand projections.
b) 7 day services to support discharge
In Suffolk, the three CCGs and social care are already committed through our System
Leadership Partnerships to providing person centred health and social care services
seven days a week. Delivering effective 7 day services are a core part of our system
wide plans for integrated services. Progress will be monitored through our Integrated
Care Boards in IEWS and the ICS Programme Board in Waveney.
All three CCGs in Suffolk have CQUIN initiatives with provider organisations that
incorporate the 10 clinical standards, and require 7 day services to support discharge
and admission prevention within agreed timeframes.
In IEWS areas there are already existing services operating and available 7 days a week
in Suffolk, but a more effective and integrated response is being developed through our
integration delivery plans by both the CCGs and Suffolk County Council. New service
models will ensure that health and care services work together to support discharge and
admission prevention both in-hours and out of hours with scalable health and social care
capacity to match demand. This will be tested in practice as we role our pilot sites for
integrated working across East and West Suffolk. This will mean:
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



Scoping out the demand and options for delivering 7 day services that support
discharge, in line with our integrated service model – Nov 2014 - March 2015
Ensuring our commissioning activity is aligned to deliver the services and support
needed eg Out of Hours GP services, Care Line crisis support, step down and
rehab bed capacity – Nov 2014 - March 2015
Ensuring assessment and delivery capacity is available 7 days a week so that
decisions can be made at the appropriate time, and people can flow through the
system in a timely and effective way. Managing crisis with the effect of reducing
emergency admissions, and securing timely, safe hospital discharge, thereby
reducing delayed transfers of care and associated costs. We will test this through
our early adopter pilots in IEWS which are aiming to be active from April 2015 and
then roll out once confident of the delivery model (target June 2015)
o Acute hospitals are working to a similar timeframe for sustainable
improvements in workforce, flow and communications. This includes
additional consultant, therapy and critical care outreach capacity.
o Community Health CQUIN will have put elements of 7 day working in place
by April 2015.
Monitoring and performance review arrangements implemented – April 2015
Other activity that will take place within our transformation programme will support 7 day
services:



Aligning core hours in Integrated Neighbourhood Teams for health and care
professionals
Alignment between our out of hours provision, and between out of hours and in
hours.
Reviewing workforce needs and building the flexibility to deliver 7 day services into
core contracts.
Gt Yarmouth and Waveney CCG and partners, including social care, have successfully
bid to be an early adopter for the Seven Day Services Transformational Improvement
Programme. This work is supported by a strategic ambition to include all public sector
partners in an integrated system, and will deliver initiatives such as 7 day working
through one part of the patient pathway at a time. Learning from Gt Yarmouth and
Waveney’s early adopter work is being shared across the County through the
governance and programme arrangements.
There is Great Yarmouth and Waveney system recognition that we cannot implement 7
day services across the board all at once, therefore we aim to seek agreement that we
concentrate our resources on the areas that can have the best benefits in terms of
addressing variation in urgent and emergency services.
The proposed 7 day service focus areas therefore are around admissions avoidance,
diagnostics and discharge which are all interdependent and need staff from all parts of
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the system to work together across organisational and professional boundaries for the
good of the person in order for the whole system to be successful in achieving the above
outcomes.
Work is well underway to deliver 7 day services in Waveney due to being part of the
Seven Day Services Transformational Improvement Programme. Future milestones for
the 7 day services programme in Waveney are:
 Improve communications regarding Out of Hospital Team and their services with
James Paget University Hospital (JPUH) – December 2014
 Enhance multidisciplinary team working in JPUH – April 2015
 Enhance clinical recording systems in JPUH in relation to access to a consultant
within seven hours – April 2015
 Develop Out of Hospital model across Waveney – April 2015
The risks associated with 7 day services are:
 Financial implications of delivering 7 day services, in terms of affordability.
 All providers need to provide 7 day services for the process to work as they are all
independent. Un-willingness or capacity to deliver from some providers including
private and 3rd sector could hinder progress.
 Workforce issues: Not only capacity to deliver across 7 days but potential changes
of contract for staff and consultants could require consultation / negotiation,
resulting in potential time lags in delivery.
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c) Data sharing
i) Suffolk plans for using the NHS Number as the primary identifier for
correspondence across all health and care services
NHS partners in Suffolk and Suffolk County Council are committed to using the NHS
number as the primary identifier for correspondence. This is a key enabler for integrated
working. The NHS is already using the NHS number as the primary identifier for
correspondence across all health and social care services.
The NHS number is a key field in all social care records within the core social care
system in Suffolk, and is currently populated in around 55% of these records. A project
has been put in place that will achieve 100% coverage and allow for information sharing
at customer and population levels; this project is underway and aims to have the batch
processing update mechanism fully in place by December 2014 and will be run on a
regular basis (anticipated to be monthly). It is expected that the first run of this will
identify some data mismatches so achieving full coverage is likely to take some months
to achieve. In addition, a further system related to our Home First activity, being
implemented with planned go live in early 2015, includes a core requirement for NHS
number to be a primary identifier.
It is also planned that the NHS number will be a key enabler to sharing of data for
secondary use, particularly between commissioners across the CCGs and Local
Authority. However, this has only been made possible to pioneer sites through a Section
251 exemption and will not be possible in Suffolk until the national legal framework is in
place to enable sharing at this level.
Our service redesign plans will ensure that as a default health and care staff will be using
a shared care plan. This will use the NHS number as the common identifier.
ii)
The Suffolk approach for adopting systems that are based upon Open APIs
(Application Programming Interface) and Open Standards (i.e. secure email
standards, interoperability standards (ITK))
Suffolk County Council and the three CCGs in Suffolk are committed to Open APIs and
Open Standards. We wish to ensure that that they are secure for information and data in
all cases.
We will ensure procurement, implementation and upgrade of systems factors in Open
APIs and Open Standards throughout the health and care system; this has been evident
in our most recent NHS England Technology Fund Application.
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iii)
The Suffolk approach for ensuring that the appropriate IG Controls will be in
place.
We are committed to ensuring all appropriate IG controls are in place. The Suffolk
Partnership Agreement, signed off by the Health and Wellbeing Board, is a general
protocol already in use across our system.
Other data sharing arrangements are in place between NHS organisations and with
Suffolk County Council in order to share customer data. Specific agreements are in place
to facilitate the Multi Agency Safeguarding Hub which was set up earlier in 2014.
SCC is compliant with the NHS Information Governance Toolkit and has undertaken
internal audits to improve ratings in this area. The County Council has a Caldicott
Guardian who advises on data exchanges, beaches, sharing of data keeping customer
data information safe. All ACS Staff have received Data Protection Training.
CCGs - Information Governance is taken seriously with robust arrangements in place to
ensure compliance with the Data Protection Act, Common law duty of confidentiality and
other relevant legislation. All Suffolk CCGs have attained as a minimum level 2 on the
information Governance Toolkit providing assurance to organisations who wish to share
data with CCGs. In addition the Suffolk CCGs also have Accredited Safe Haven (ASH)
status, which enables the CCGs to receive, monitor and analyse certain data flows to
support its role as a commissioner. The IG Toolkit is audited on an annual basis. All
CCG staff undergo annual mandatory training in respect of IG and IT security.
The CCGs work collaboratively with social care and are in the process of finalising
Information Sharing Protocols with Suffolk County Council. Data sharing agreements are
used to provide detail for more specific sharing arrangements and the controls that are in
place. These documents are signed by the CCG appropriately. SIRO and Caldicott
Guardian roles are I place within CCG’s. These roles actively monitor IG & IT security
controls & Patient confidential data flows.
Any introduction of significant new systems, services or products involves the use of ICO
recommended Privacy Impact Assessments. Thus allowing the CCGs to identify any
privacy concerns and reduce the risks of harm to individual’s personal information.
Where there is a duty to share or legal basis in place the CCGs will share information for
the direct patient care or if there is a significant risk of harm to an individual or individuals.
j) Joint assessment and accountable lead professional for high risk populations
i) Proportion of the adult population identified as at high risk of hospital admission, and
approach to risk stratification used to identify them
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Risk stratification - We have identified predicted top 2% of our adult population who are
at risk of emergency admission in the following year. This cohort is identified through our
risk stratification tools. The total number of adults in Suffolk that this gives us as high risk
is 11,700.
Risk stratification tools have also been used to identify the top 2% of high risk customers
for case management intervention and support. The list is reviewed monthly. People at
high risk will have a named care coordinator, who will help them to develop a shared
outcome focused plan which will assess risk and plan care. This lead professional will be
the most appropriate based on the needs of the customer. In IEWS the RAIDR tool,
which is based on the combined predictive model is in the process of being rolled out. It
takes into account a variety of factors, including primary care and hospital admissions
data and identifies a risk level for every patient. In Waveney GPs and other professionals
have signed up to the Eclipse tool which can identify patients at high risk of hospital
admission.
Multi-disciplinary team (MDT) meetings in GP surgeries are used to identify adults at
high risk of hospital admission or of needing long term care. MDTs are attended by GPs,
Community Health staff and social care staff. This practice provides the foundation for
the Integrated Neighbourhood Teams across Ipswich and East and West Suffolk CCG
areas – described in Scheme 1 and the Integrated Community Health and Social Care
Teams – described in Scheme 8. Currently these meetings take place on a monthly
basis, but it is intended that the identification of high risk patients will become more
frequent as integrated neighbourhood working develops and with the implementation of
the new risk stratification tool.
Will also be identifying the cohort of people who are not yet frequent users of services or
at risk of hospital admission but who are developing LTCs and therefore who potentially
could fall in the high risk group. Our new service models will define the support offer for
people in these groups in order to reduce or mitigate the risks and help people to sustain
independent living.
ii) Joint processes in place to assess risk, plan care and allocate a lead professional for
this population
Suffolk County Council and NHS organisations in Suffolk are committed to ensuring that
there is joint assessment, an accountable lead professional and care co-ordination for
people at high risk of hospital admission.
The key tools for achieving this are:
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Multi-disciplinary teams - to undertake joint assessments with the lead case
management role being taken by the person that makes most sense for the individual
across the whole of the area. This will often be the lead social care professional
undertaking the lead on-going care management role but sometimes by others, for
example the Occupational Therapist who has had the most involvement or the nurse
case manager. Whoever it is will be working on behalf of the whole team, always linking
back to the team, and thus a seamless service can be provided without the individual
having to be referred multiple times and handed off at each point. All Better Care Fund
schemes will link into the delivery of this key tool.
Care coordination to provide the lead professional role, co-ordinated care and to ensure
that joint assessment is carried out. The case manager is determined based on which
professional has the most appropriate skill-set at the time, and in some cases will be the
persons GP. The Care Coordinator will be the patient’s main contact for issues around
their care plan. They will liaise with other health and care professionals to ensure that the
right clinical and professional inputs are in place for patients. This will include specialist
teams and resources, including mental health and learning disabilities teams. (Scheme 2
develops this link between locality resources and specialist resources).
Joint assessment that will be based around a core assessment covering a standardised
set of questions and fields. Specialist assessment will build on the core assessment to
provide a comprehensive assessment across health and social care. In some cases this
will be carried out in specialist teams, for example for those people with a mental illness
or people with dementia. In Children’s services the Common Assessment Framework
(CAF) and Single (Statutory) Assessment provides the framework for multiagency
assessment and planning and allocation of a lead professional to oversee the
implementation of the care plan. The Better Care Fund schemes 1,3(a) and 7 will work
to overcome the barriers in achieving joint assessment and shared care planning.
Shared care planning is being developed across health and social care so that people
have a single outcome focused plan that co-ordinates all their immediate physical and
mental health and care needs. The plan will be developed collaboratively with a patient
and their carer (if applicable) and be jointly owned by the patent, carer, and named
accountable GP and/or care coordinator. If the patient consents, the personalised care
plan will be shared with the multi-disciplinary team and other relevant providers. All Better
Care Fund schemes will link into the delivery of this tool.
Workforce development will define roles within new teams, build the culture to support
joint working and embed working practices so that joint working becomes the norm for
health and care staff.
Accountable professional role will be delivered through the Reducing Unplanned
Admissions Enhanced Service specification which requires all GPs to provide the
accountable professional role for people who are elderly, with complex needs or who are
needing end-of-life care, particularly those who are at risk of admission to hospital. This
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is particularly relevant for Better Care Fund schemes 1, 5 and 7.
iii)
The proportion of individuals at high risk already have a joint care plan in place
Our understanding of how many individuals at high risk have a joint care plan is currently
under development. At this stage there are no firm figures at CCG level for the proportion
of individuals identified as being high risk who already have a joint care plan in place.
However, there are established multi- disciplinary teams working within the CCG area
and individuals identified at high risk supported through these MDTs have a joint care
plan.
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8) ENGAGEMENT
a) Patient, service user and public engagement
Our Plan is based on what people have told us is important to them over a number of
years. Suffolk Healthwatch has helped us engage with the public, patients and services
users over the summer. Evidence from this work has helped focus the schemes to
support people’s needs as effectively as possible. We know, from previous Suffolk
consultation events, the Voice Project and involvement forums that people are not
interested in structures – seamless service provision seems obvious to them. They are
more concerned about their own care and independence, and that any support should be
tailored to their needs, provide them with choices and control, be delivered with dignity
and respect and for their care to be planned with them, so that it will support their
aspirations of living well. This feedback forms the guiding principles for the design of our
schemes: integrated, timely and responsive and enabling independence as much as
possible. The final report of this work is listed in Section 1 c) Related Documents.
Across the area there is active patient, carers, service user and public engagement
where views are regularly sought to inform the development of integration and future
commissioning intentions. In developing our integrated health and social care plans we
have also been able to build on pre-existing partnership work and plans, which have had
active public, service user, patient and family carer involvement. In Waveney
Commissioning Programme Boards include representation from patients, family carers,
service users and the public.
In IEWS for the Health and Care Review, stakeholder events were held prior to the
Urgent Care work stream starting to inform the work programme, for example Town Talk
Village Voices where lead GPs and officers went to ten locations across East Suffolk,
such as Felixstowe’s Morrisons supermarket and Ipswich Crown Pools, asking for the
public’s opinion on the NHS 111 service and what would they would like the NHS to do
differently if they were taken suddenly ill. In addition, we are building on existing public
consultations, working alongside patient groups in GP Practices, and the Council’s
connecting communities work in localities, working with Healthwatch and Health Scrutiny
Committees.
Great Yarmouth & Waveney partners have listened to what patients and service users
have said and included their views in strategic and operational planning including the
overall approach to the Better Care Fund. The CCG also has a patient representative on
the Board and the Better Care Fund has been fully discussed and debated in this forum
with key focus on patient experience and outcomes. Patients and customers have said
clearly that they want to experience a joined up system.
In order to continue engagement with our patients and public about the design of our
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services going forward a programme of events such as public participation forum, our
Patient and Public Experience Group meeting and our Patient, Carer and Community
events have been put in place. Alongside this we will continue our dialogue with other
representative organisations such as the Older Peoples Network.
The Suffolk System Leaders Partnership agreed an Engagement and Communication
Plan in February 2014 to
 Ensure that engagement starts with co-production with people who use our
services.
 Include statutory and voluntary stakeholders, with service users as equal partners.
 Recognise the need for engagement with staff.
 Ensure engagement and communications are planned and co-ordinated.
 Build a long term engagement partnership across organisations in Suffolk.
The Engagement and Communications Plan enables the SLP to ensure that key
messages and questions are developed and that there is a timetable for engaging with
key partners not already involved with the Health and Care Review. Healthwatch and
other voluntary sector partners have agreed to lead on co-production and engagement
with service users and to bring insights and experience into the debate.
We have a track record of co-production, for example in developing our integrated plans
for dementia services, in integrated health and care service delivery for children in our
Suffolk Family Focus (troubled families) programme, in Lowestoft Rising (testing place
based models of service delivery) and in the development of the new operating model for
adult social care: Supporting Lives Connecting Communities and children’s services:
Making Every Intervention Count.
Two mental health workshops (April 2014) have been co-produced by service users and
commissioners focussing on early intervention and prevention, crisis response and
recovery. The workshops will support the development of the Suffolk Needs Assessment
for Mental Health, shape the 5 year Joint (CCG’s and County Council) Commissioning
Strategy for Mental Health and clarify how to continue to engage with service users and
mental health organisations alike.
Evidence from engagement and co-production activity has been used in the development
of the Better Care Fund schemes outlined in annex 1.
The following diagram shows the Suffolk Health and Wellbeing Board organisational
engagement map.

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This diagram shows the connections from the Suffolk Health and Wellbeing Board and
the two System Leaders Partnerships in Suffolk (which include a wide range of
commissioner and provider organisations).
b) Service provider engagement
i) NHS Foundation Trusts and NHS Trusts
The main service providers in Suffolk listed in the following table which also shows in
which areas they operate.
Provider
Waveney area
Ipswich Hospital
West Suffolk Hospital

IEWS area


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James Paget Hospital

Norfolk and Suffolk
Foundation Trust (mental
health)

Health East

Suffolk Community
Healthcare
Primary Care providers
Care providers – both
home care and
residential care
Voluntary and
Community sector
organisations
District and Borough
Councils










All service providers have been involved in developing the two integrated services
programmes in Suffolk through the governance and delivery arrangements.
The Suffolk Better Care Fund Plan (the Plan) has been developed by working groups of
the Suffolk Health and Wellbeing Board. The accountability for the development work is
the two System Leaders Partnerships which include Chairs of the three Suffolk CCGs,
the Chief Officers of the CCGs, the Director of Public Health, the Director of Adult Social
Care and Director of Children’s Service, Chief Executive of the Norfolk and Suffolk
Foundation Trust, Chief Executives of Ipswich, West Suffolk and James Paget Hospitals,
the Chief Executive of Suffolk Community Healthcare, the Chief Executive of East Coast
Community Healthcare, Healthwatch, Community Action Suffolk/Suffolk Congress
representing the voluntary and community sector, the Cabinet Lead for Health and Adult
Care and District and Borough representatives.
The acute providers have now become regular invited members of the Health and
Wellbeing Board.
In the IEWS area:
- Two initial workshops to build the vision for integrated care were attended by provider
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-
-
organisations in November/December 2013. During these workshops they played a
critical role in shaping the vision going forward, and the work streams that are
developing the proposed changes.
All providers have been core members of the Systems Leaders Partnership and the
programmes making up the Health and Care Review. They have also been involved
in workshops and other meetings to develop the integrated model for the area. At the
SLP meeting in May the acute providers and the mental health trust were invited to
present their future vision for their organisation.
There has been extensive provider engagement in a number of work stream groups,
and forums where practical plans for integration have been developed, for instance
around urgent and integrated care. Their involvement has led to a greater
understanding of the risks and opportunities of developing safe and effective care..
In the Great Yarmouth and Waveney area:
- A Great Yarmouth and Waveney integrated care system event in December 2013,
attended by all public sector commissioners and providers from the area including
health and social care. At this event the development of an Integrated Care System
was fully debated including the opportunities presented by the Better Care Fund. Key
principles were agreed and issues discussed in greater detail to inform the plan
including seven day working, cohesive pathways, combining budgets and impacts on
the workforce.
- All three Waveney providers are core members of the Great Yarmouth and Waveney
System Leadership Partnership and the Integrated Care System Operational Delivery
Group. In addition there are a number of specific multi-agency groups that these
organisations are involved in, such as Programme Boards and Seven Day Services
where specific Better Care Fund schemes are discussed.
- All provider organisations were consulted on focussed areas for the schemes and
have continued to be actively involved in both the design and the implementation
phases to ensure alignment of operational planning.
- The James Paget Hospital is already aligned with the CCG in terms of forecast
reductions in emergency activity and acute capacity. This is due to increasing
integration of pathways, and the hospital playing an important role around
increasingly offering outreach services into the community and primary care.
All provider organisations have incorporated integration and the Better Care Fund in their
2 year operational plans and 5 year Strategic Plans.
ii) Primary care providers
Seeking member practices views – All Suffolk GP practices are members of one of the
three CCGs. We’re focused on member practices being closely involved in decision
making and have published our Practice Charter and Constitution documents, which are
our ‘rules for engagement’ laying out what practices can expect from the Governing
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Bodies, and the Governing Bodies from practices, and how practices interact as a unified
body.
We have strong GP and practice manager representation on our Clinical Executive
Committees and on the CCG Governing Bodies which ensures clinical input into all areas
of our work.
The CCGs variously have regular Clinical Leads Forums and Locality meetings with
representation from all practices, along with monthly PTL (Protected Time for Learning)
and Education and Training sessions, plus practice manager meetings and a range of
regular informal practice visits.
We have a number of retained GPs and retained Nurses working with the CCGs. This is
a tremendously valuable resource to help us with commissioning decision making, and
being clear on our commissioning intentions going forward.
CCG members are involved in quality priority setting in Plans – Each CCG met with
clinical leads to identify and agree commissioning priorities and intentions for 2014/15
and beyond. We recognise the need to engage with member practices to help them
understand the quality challenge in both primary and secondary care to develop an
appropriate response for our population and our area, and to translate that into real
action and real quality improvement.
Member practices involved in decision making processes - Our clinical leads
meetings are fully representative with GPs and practice managers in attendance. These
groups guide strategic development prioritisation, and practical implementation of
pathway redesign, and meeting the QIPP challenge via system transformation. Retained
GPs inform this process through the programme boards, and workstreams. The Clinical
Executive Committees are the delegated authority for decision making from Governing
Bodies. Thus clinical leadership is not only accountable at Governing Body level, but
involved at executive level in all spending decisions, monitoring delivery of the QIPP
challenge and priority setting for each commissioning year. The CCG Governing Bodies
include member practice representation at clinical and managerial level and lead
strategic planning for the CCGs, with extensive clinical involvement in decision making.
Member practices understand at a high level our local plan and priorities - Our
clinical leads have been involved in shaping and approving our overall strategic plans at
both a health system and Programme Board and workstream level. Specifically, the
Health and Independence and Urgent Care models (IEWS) and Urgent Care Strategy
and Frail Elderly Strategy (GYW) have been discussed in detail with clinical leads and
amended in the light of feedback prior to their presentation to the Clinical Executive
Committees.
Effective and transformational Integrated Care Network System Forum and Clinical
Workstreams (IEWS) and Programme Boards (GYW) have extensive clinical
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engagement from a wide range of providers and are actively influencing commissioning
intentions.
One example of CCGs supporting GP practices is in transforming the care for patients
over 75 years old by providing funding to practices to commission additional local
services that will improve the quality of care for older people and reduce avoidable
emergency admissions. This funding is an enabler to the CCGs’ integrated care
programmes in supporting people with complex needs. The CCGs are supporting primary
care to develop plans that underpin the principles of the plans relating to case finding,
comprehensive assessment and proactive case management with shared care planning.
The plans being developed by primary care aim to further develop the accountable GP
and case management approach to managing people with complex care needs with a
focus on prevention and admission reduction.
iii) Social care and providers from the voluntary and community sector
The Health and Wellbeing Board includes social care and voluntary and community
sector (VCS) representation. There is a voluntary sector subgroup that meets regularly in
between HWB meetings to ensure engagement of the wider sector in the work of the
Board.
The VCS are also represented on the two System Leaders Partnerships, and on the
programme boards designing and implementing integrated systems in Suffolk.
The key organisations involved are:
- Healthwatch
- Community Action Suffolk (which is the umbrella body for the VCS in Suffolk)
Other involvement includes:
- Suffolk Coalition of Disabled People are a core member of the Health and Care
Review Engagement Group and have been supporting the development of focus
groups to explore the implications of the changes proposed, particularly with hard to
reach communities.
- A large number of organisations have been involved in developing the community
facing aspects of the Health and Care Review:
o Hospices
o Support services for people with personal budgets
o Community development groups
o Groups working with people with drug and alcohol problems.
The wider VCS have been involved through established forums like the Working
Together Forum. In May an event was held by Ipswich and East Suffolk CCG with
Community Action Suffolk which involved around 100 VCS organisations with an
opportunity to feed into the Health and Care Review and therefore the design of the
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Better Care Fund plan.
Social care providers have been engaged through Market shaping events and provider
forums run by Suffolk County Council which have involved our private sector partners in
redesigning the home care market for a more integrated system.
c) Implications for acute providers
NHS commissioners will be working closely with partners towards the savings quantified
in Everybody Counts, namely reductions in emergency non-elective activity
and efficiency savings in planned care.
The three acute hospitals in Suffolk are committed to playing a full part in the
development of an integrated system and are key participants in the design and
implementation work. In order to plan services effectively we must develop clarity around
which services we will need in the future and which will no longer be provided, either in a
particular setting or none at all.
An integral part of our financial plans is to achieve a reduction in hospital activity. What
must be delivered, in collaboration with our partners, is a radical transformation of the
way services are provided which will enable public funds to be used more cost
effectively, across all sectors.
In IEWS we are working with our acute providers to support their sustainability.
Both Ipswich and West Suffolk Hospitals are reporting underlying financial deficit
positions and are rated as high risk according to TDA and Monitor risk ratings. We are
targeting reductions in emergency non-elective activity through our Health and Care
Review and local QIPP Plans. The BCF is expected to accelerate the progress of these
plans. Reductions in non-elective activity will provide the opportunity for the acute trusts
to reduce costs or release capacity to accommodate other commissioned activity. The
Marginal Rate paid for non-elective activity above threshold levels creates a cost
pressure for trusts which will be avoided by reducing this activity. Both hospitals agree
that a reduction in non-elective admissions will ease the considerable pressure on the
Trusts’ clinical resources but note that there is a risk in planning for delivery of changes
which do not occur.
Both hospitals are engaged in the system-wide Health and Care Review which is
developing the Urgent Care and Health and Independence service models. The elements
of these services which fall within the scope of these BCF plans (Schemes 1-3) are
targeting reductions in emergency admissions of 979 (Ipswich Hospital) and 640 (West
Suffolk Hospital) in 2015/16. It is our intention that when agreed, the output of the
detailed modelling will be incorporated in the refresh of the 2015/16 CCG and provider
plans.
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Ipswich Hospital has stated in its 5 year Plan: “Our commissioners are clear in their
desire to deliver integrated care and the importance of an Integrated Care Model. The
vision of integrated care is one wholly supported by the Board of IHT. It requires
organisations to work effectively across boundaries recognising the value and
contribution of all sectors of the health and social care community.”
West Suffolk Hospital stated in its 5 year Plan that it “is working in collaboration with
partners to deliver transformational programmes and maintain our excellent record for
delivering high levels of quality and operational performance. WSFT believes it will
remain clinically viable and deliver high quality services for the life of the plan, however at
this point we are unable to make a declaration of financial sustainability, although this
position is likely to improve over the five years if emergency activity is reduced in line with
national requirements.”
In addition, we are developing a number of schemes which will benefit providers such as:
 Rapid Assessment Interface and Discharge (RAID) psychiatric liaison service: a
high profile mental health team at the hospital front door providing a range of
mental health specialities within one multidisciplinary team. This is comprised of
mental health liaison practitioners specialising in general psychiatry, deliberate
self-harm, substance misuse and old age psychiatry. This means patients can be
assessed, treated, signposted or referred appropriately. By working closely with
hospital clinicians and managers, the professionals ensure that the mental and
physical health needs of people are considered and treated together.

Clinical Forums: A Commissioning for Quality and Innovation (CQUIN) scheme
has been developed to support clinically led transformation of selected specialties
to meet the QIPP challenge. This is the vehicle for achieving high quality with
significant saving required for financial sustainability. The role of clinical forums is
to combine experts and patients to transform the care we deliver in distinct areas
across the system for true integration of primary, community, secondary and even
tertiary care.

In Ipswich and West Suffolk Hospitals the psychiatric liaison service is being
embedded and further expanded to include services for young people aged 13 to
18 to address long term conditions. There will be a full evaluation in quarter two of
2014/15 which will inform the commissioning model going forward into 2015/16
and beyond.

During 2014/15 post diagnostic service model will be developed for people with
dementia and their carers for procurement in 2015/16 in order to remodel
pathways of care for people with dementia to eliminate gaps in service and
support people and their carers to live well with dementia in their own homes for
as long as possible. This work is being undertaken jointly by West Suffolk CCG
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and Suffolk County Council.

The 2014 mental health needs assessment will include a specific focus on
perinatal mental health. Ahead of its publication: we are working with Norfolk and
Suffolk NHS Foundation Trust to ensure that the services offered by the Suffolk
Wellbeing Service are accessible and available to pregnant women and new
mothers. We will support Norfolk and Suffolk NHS Foundation Trust to develop
more effective relationships with the Ipswich Hospital Midwifery Service so that
there is a better understanding of what the Wellbeing service offers and to
establish clear referral pathways. These pathways will help contribute to the 15
per cent treatment rate for IAPT during 2014/15. We are also participating in the
Strategic Clinical Network Pilot to develop the Integrated Delivery Commissioning
Toolkit for perinatal and post natal mental health care.

A mental health practitioner has been commissioned to work alongside a Police
Emergency Response vehicle to support people with mental health care needs in
crisis.
In Great Yarmouth and Waveney the key implications are:

An innovative scheme being considered with practices in the Gorleston area which
would collocate on the James Paget University Hospital (JPUH) site, providing
integrated front line care to patients from the whole area attending as
emergencies, diverting demand from traditional A&E services and reducing
cost. There will also be provision of services by East Coast Community
Healthcare (ECCH) within JPUH and provision of services by JPUH staff outside
the confines of the hospital buildings to move forward towards a fully integrated
provision model.

Commissioners are working with providers in acute and community health to foster
a strategic alliance between JPUH and ECCH. It is intended that JPUH will retain
its provision of a full service District General Hospital, but drawing on the
opportunities for a networked approach with the Norwich and Norfolk University
Hospital wherever appropriate, in order to ensure highest standards of clinical
safety, but also ensure sustainability of services. It remains very clear that the
relative isolation of some Waveney residents means we need strong local
services.

We will need to manage capacity effectively within the system to maintain a
balanced financial position over the next five years. Capacity will be supported by
an innovative out of hospital team, supported as necessary by additional care
home capacity locally. Emergency admissions have reduced compared to
2012/13 and the intention is to build on the evidence that the increasingly
integrated working between health and social care is starting to manage down
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demand.
We are also working through the consequences of non-achievement of the targeted
savings and associated contingency plans.
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ANNEX 1 – Detailed Schemes Description
Scheme ref no.
Scheme 1 - IEWS
Scheme name
Integrated Neighbourhood Teams
What is the strategic objective of this scheme?
We will create multi agency multi professional teams which will pro-actively work to
support people with health and care needs and in particular those who are at risk of
hospital admission or deterioration in order to turn unplanned care into planned care.
Overview of the scheme












Community health staff, social care staff, mental health staff, practice based staff
and GPs, co-located where possible.
A core team of key multi-disciplinary staff and a wider team of other professionals,
with strong links to staff within specialist services.
Strong local focus with interface with the local voluntary and community sector,
district council, police partners and others.
Shared holistic assessment and a single plan to co-ordinate care and support with
individuals holding their own plan and playing a key part in designing it.
Self-care and prevention advice underpinning all service delivery and developed
within NICE guidelines, including the development of a Green/Amber/Red trigger
tool that supports people to identify what their own self care plan is and when to
contact services
Build on existing work in Suffolk, but with accelerated progress through
commissioning, joint workforce development and the development of joint
operational policies and infrastructure.
Aligned core in hours/out of hours.
Appropriate 7 day coverage and clinical standards.
Improved standards and responsiveness of services across community based,
specialist and mental health services.
Shared workforce development plan that supports person centred culture and
practice within the Integrated Neighbourhood Team through shared planning
systems.
The Integrated Neighbourhood Team will be working with all ages. However
particular focus within the team will be on the frail elderly, those with a Long Term
Condition and those at risk of higher future health and care needs, including on
hospital discharge
The Integrated Neighbourhood Teams will work closely with the local voluntary
and community sector (Neighbourhood Network) to support people’s care.
The delivery chain
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The delivery of Integrated Neighbourhood Teams will be through partnership working
across Ipswich and East Suffolk CCG, West Suffolk CCG, Suffolk County Council’s
Adults and Community Services (ACS), Suffolk Community Healthcare, Norfolk and
Suffolk Foundation Trust and others.
Commissioning activity (eg the re-commissioning of community health, 111 and the Out
of Hours Services is aligned to deliver the new model.
ACS transformation programmes are delivering a transformed social care workforce.
All commissioners are working with community health providers to deliver change within
contract, prior to the termination of existing contracts.
In order to test out the transformation on the ground a number of early adopter sites
(including the Sudbury Alliance) have been agreed. Establishing a locality alliance will
give an opportunity to understand how the service model will operate in practice in a
number of sites. It will give a test of concept, and the ability to develop the model further.
It will provide a blueprint for further role out of the model, whilst building confidence in the
new ways of working. The early adopter sites will include involvement from the local
community health team, local GPs, the social care team, the acute hospital trust, the
local voluntary and community sector, the District Council and others.
The evidence base
Integrated Teams - Evaluating integrated and community-based care – the Nuffield
Trust review of national integrated care pilots and virtual wards1 showed reductions in
planned admissions and in outpatient attendances for some interventions that involved
case management using multidisciplinary teams and those using virtual wards, but no
evidence of a general reduction in emergency admissions.
King’s Fund analysis of the evidence2 suggests that joint commissioning between health
and social care that results in a multi-component approach is likely to achieve better
results than those that rely on a single or limited set of strategies.
The Torbay integrated care model has reduced the use of hospital beds by a third from
750 in 1998/1999 to 502 in 2009/2010. Emergency bed day use for people aged 75 and
over fell by 24% between 2003 and 2008 and by 32% for people aged 85 and over.3 4
The Institute of Public Care at Oxford Brookes University reports that joint health and
social care investment in dental care, podiatry services, incontinence, dehydration
1
Evaluating integrated and community-based care – a review of national integrated care pilots and virtual wards
http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/evaluation_summary_final.pdf
2 Goodwin et al, 2012, Integrated care for patients and populations: Improving outcomes by working together – The King’s Fund:
http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together
3 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-studykingsfund13.pdf
4 Thistlethwaite, P. (2011) "Integrating health and social care in Torbay: improving care for Mr Smith" The King's Fund, London:
http://www.kingsfund.org.uk/sites/files/kf/field/field_document/PARR-combined-predictive-model-final-report-dec06.pdf
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monitoring (liquid intake), falls prevention and stroke recovery services has a positive
impact on admissions to residential care.5
Structured Discharge Planning by multi-disciplinary teams - A Cochrane database
systematic review of hospital discharge planning provides robust evidence that a
discharge plan tailored to the individual patient probably brings about reductions in
hospital length of stay and readmission rates for older people admitted to hospital with a
medical condition. The impact of discharge planning on mortality, health outcomes and
cost remains uncertain. The review assessed randomised controlled trials (RCTs) that
compared an individualised discharge plan with routine discharge care that was not
tailored to the individual patient. Participants were hospital inpatients.6
A Cochrane systematic review of randomised controlled trials recruiting stroke patients in
hospital assessed the difference between those receiving conventional care with those
with early discharge with rehabilitation at home (early supported discharge). 7 Results
showed that early supportive discharge significantly reduced the length of hospital stay
equivalent to approximately seven days. Early Supported Discharge can reduce longterm mortality and institutionalisation rates for up to 50% of patients, as well as lower
overall costs.
7-day Service - Where hospitals, primary and community care providers and social
services have reduced services at weekends it becomes more difficult to transfer or
discharge patients at a rate that is consistent with weekdays. A recent report from the
National Audit Office found that 0.83 million acute bed days were lost due to delayed
discharges in 2012/13. A lack of availability of specialist community and primary care
services, resulting in more patients on an end of life care pathway dying in hospital.8
Optimal lengths of stay can only be achieved if all health and social care services are
provided seven days a week. More than one trust referred to patient audits which found
that a third or more of patients in hospital at weekends could actually be cared for outside
hospital; but this is hard to achieve when there is only a limited service from primary and
social care at weekends.9
There is a growing body of evidence that case mix-adjusted mortality rates are higher for
patients admitted electively or as emergencies to hospital ‘out-of-hours’, with most
research focussing on weekends. The size of the weekend effect lies between 0.2% and
1% absolute increase in crude mortality over all admissions. Factors contributing to
5
CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive
services: a structured approach to service transformation and delivering better outcomes for older people
6
Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane
Database of Systematic Reviews 2013, Issue 1.
7 Fearon P, Langhorne P Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev.
2012 Sep 12;9:CD000443.
8 National Audit Office (2013) Emergency admissions to hospital: managing the demand.
9 Healthcare Financial Management Association (2013). Costing seven day services. The financial implications of seven day
services for acute emergency and urgent services and supporting diagnostics. NHS Services, Seven Days a Week Forum.
http://www.england.nhs.uk/wp-content/uploads/2013/12/costing-7-day.pdf
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increased mortality may include inadequate numbers of skilled staff, healthcare error and
adverse events, lack of organisation and structure for care delivery, and reduced access
to specific interventions. [Freemantle 2012, Mohammed 2012, Cram 2004, Cavallazzi
2010, Aylin 2010, Kruse 2011, Buckley 2012, MaGaughey 2007, James 2010, Worni
2012, De Cordova 2012, Deshmukh 2012, Kane 2007, Cho 2008, Needleman 2002,
Pronovost 2002, Wallace 2012, Kim 2010, Aiken 2002, Penoyer 2010].10 11
In a major study, retrospective statistical analysis of routinely collected acute hospital
admissions in England, involving all patient discharges from all acute hospitals in
England over a year (April 2008-March 2009), showed that weekend admission appears
to be an independent risk factor for dying in hospital and this risk is more pronounced in
the elective setting.12
Further evidence of this “weekend effect” was reported in an analysis of NHS inpatient
data from 2009/10 by Freemantle et al. The analysis concluded that being admitted at the
weekend is associated with an increased risk of mortality within 30 days of admission
compared to weekdays. This ranged from an 11% increase on Saturday to a 16%
increase on Sunday when compared to patients admitted on a Wednesday. 13
Studies have shown an association between seven day physiotherapy services and a
reduction in overall length of stay for patients.14 15
The report by the Centre for Mental Health cites a wide body of evidence suggesting a
reduction in length of stay of 2-5 days per patient is achievable. An evaluation of the
RAID (Rapid Assessment, Interface and Discharge) service in Birmingham identified
reduction of 14,500 hospital bed-days (equivalent to £3.55m) in the first full year of
implementation.16
Suissa et al showed that patients hospitalised for COPD or pneumonia are at increased
risk of death when staying over on a Friday or a weekend. The additional 40-56 deaths
per 100,000 patients staying in hospital on those days are most likely due to reduced
access to healthcare at that time.17
10
Academy of Medical Royal Colleges (2012). Seven day consultant present care. Academy of Medical Royal Colleges.
http://www.aomrc.org.uk/doc_view/9532-seven-day-consultant-present-care
11 NHS Improvement. (2012) Equality for all: Delivering safe care – seven days a week.
http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx
12 Mohammed et al (2012). Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency
setting: a retrospective database study of national health service hospitals in England. BMC Health Services Research 2012, 12:87.
http://www.biomedcentral.com/1472-6963/12/87
13 Freemantle, N. Et al (2012) Weekend hospitalization and additional risk of death: An analysis of inpatient data. J R Soc Med
105(2):74-84, http://jrs.sagepub.com/content/105/2/74.full
14 Cardiff and Vale University Health Board (2009). Extended day and seven-day physiotherapy service in acute medicine.
15 Rapoport J and Judd-Van Eerd M (1989) Impact of Physical Therapy Weekend Coverage on Length of Stay in an Acute Care
Community Hospital. Journal of the American Physical Therapy Association. 69: 32-37.
16 NHS Services, Seven Days a Week Forum (2013). Evidence base and clinical standards for the care and onward transfer of acute
inpatients. http://www.england.nhs.uk/wp-content/uploads/2013/12/evidence-base.pdf
17 Suissa S, Dell'Aniello S, Suissa D, Ernst P (2014). Friday and weekend hospital stays: effects on mortality. Eur Respir J. pii:
erj00077-2014.
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Study from Scotland showed that patients admitted as emergencies to medicine on
public holidays had significantly higher mortality at 7 and 30 days compared with patients
admitted on other days of the week.18
Another Scottish study also showed that despite a general reduction in mortality over the
last 11 years, there is still a significant excess mortality associated with weekend
emergency admissions.19
Investment requirements
£12,570,000
Impact of scheme
This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
In conjunction with schemes 2, 3(a), 3(b) and 3(c) this scheme will generate a total
saving of £1,094,620
Feedback loop
The schemes will be overseen by current Integrated Care partnership arrangements: the
System Forum in West Suffolk and the Integrated Care Board in Ipswich and East
Suffolk. As part of maintaining the success of the early adopter site a suite of local
metrics will be developed. These will include consideration of the Better Care Fund
metrics, patient and user satisfaction, the costs of delivery and the impacts against the
Suffolk Theory of Change described above.
What are the key success factors for implementation of this scheme?
Higher cost interventions are replaced with lower cost interventions
a) Reduced emergency admissions
b) Effectiveness of reablement
Health and care system is co-ordinated and effective
a) Numbers of people identified through local risk stratification
b) Numbers of people with a named care co-ordinator and care plan
c) Patient satisfaction
18
Smith S, Allan A, Greenlaw N, Finlay S, Isles C (2014). Emergency medical admissions, deaths at weekends and the public
holiday effect. Emerg Med J.;31(1):30-4. doi: 10.1136/emermed-2012-201881.
19 Handel AE, Patel SV, Skingsley A, Bramley K, Sobieski R, Ramagopalan SV (2012). Weekend admissions as an independent
predictor of mortality: an analysis of Scottish hospital admissions. BMJ Open. 6;2(6). pii: e001789. doi: 10.1136/bmjopen-2012001789.
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Scheme ref no.
Scheme 2 - IEWS
Scheme name
Access to specialist services and supports
What is the strategic objective of this scheme?
This scheme links specialist services (for example continence services and specialist
dementia teams) to our Integrated Neighbourhood Teams to support people with
particular health and care needs.
Overview of the scheme
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Clear revised service specifications for specialist services, jointly commissioned
where appropriate.
Clear pathways in and out of specialist services (for example the post diagnostic
dementia pathway).
Working practices that support the Integrated Neighbourhood Teams and the
Neighbourhood Networks (local voluntary, community and other services) to pull
the expertise for use with their customers and to enhance skills across the system.
Inclusion of services addressing both mental and physical health.
Consistency of access to specialist services, including by Neighbourhood
Networks.
Patient pathways are those where specialist input is needed, eg those with
complex co-morbidities and where the Integrated Neighbourhood Team does not
have the appropriate clinical or other skill to provide effective care.
Established strong links into the Integrated Neighbourhood Teams
The delivery chain
The delivery of specialist services will be through partnership working across Ipswich and
East Suffolk CCG, West Suffolk CCG, Suffolk County Council’s Adults and Community
Services, Suffolk Community Healthcare, Norfolk and Suffolk Foundation Trust and
others.
Commissioning activity (eg the recommissioning of community health, 111 and the Out of
Hours Services) is aligned to deliver the new model.
ACS transformation programmes are delivering a transformed social care workforce.
All commissioners are working with community health providers to deliver change within
contract, prior to the contracts for services changing.
The evidence base
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Specialist Services for Continence Care - Urinary incontinence significantly increases
the risk of hospitalisation and admission to nursing homes.20 An intervention involving
behavioural and lifestyle counselling provided by specialised nurses led to reduced
incontinent events and incontinence pad use.21 This may mean that the costs of
professional time are offset by reductions in pad costs.22
Specialist Services for Dementia Care - In a systematic review of randomised
controlled trails, four out of six good quality studies found that case management of
dementia patients was associated with delayed or reduced institutionalisation, although in
one study this was only significant in one of three countries studied. However, none of
the good quality studies found evidence for savings in healthcare expenditure or reduced
hospitalisation rate/emergency visits. NHS investment in early assessment services for
people with dementia can produce significant savings for social care, particularly in
relation to residential care (National Dementia Strategy – Impact Assessment – economic
case for early assessment and memory services).23
Investment requirements
£1,445,000
Impact of scheme
This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
In conjunction with schemes 1, 3(a), 3(b) and 3(c) this scheme will generate a total
saving of £1,094,620
Feedback loop
The schemes will be overseen by current Integrated Care partnership arrangements: the
System Forum in West Suffolk and the Integrated Care Board in Ipswich and East
Suffolk. As part of the early adopter site a suite of local metrics will be developed. These
will include consideration of the Better Care Fund metrics, the costs of delivery and the
impacts against the Suffolk Theory of Change described above.
20
Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and
mortality. Age and Ageing 26(5):367-374.
Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence:
a randomized controlled trial. CMAJ. 14;166(10):1267–1273
22 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A
guide for commissioners written by continence care professionals.
21
http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf
23 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf
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What are the key success factors for implementation of this scheme?
Higher cost interventions are replaced with lower cost interventions
a) Reduced emergency admissions
b) Effectiveness of reablement
Health and care system is co-ordinated and effective
a) Specialist services have supported the Integrated Neighbourhood Teams to
deliver personalised, outcome focused care
b) Organisational processes are integrated – across multiple providers
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Scheme ref no.
Scheme 3(a) - IEWS
Scheme name
Admission prevention
What is the strategic objective of this scheme?
Our approach to admission prevention is designed to get upstream of crisis in order to
reduce the number of people who are admitted to hospital during a crisis.
Overview of the scheme




Risk stratification as well as local knowledge to identify and support those at risk of
admission.
An enhanced reactive responsive within the local health and care system which
will provide community based services to support people at risk of crisis, including
step up and step down beds and rapid access to diagnostics and treatment for
minor injuries. Staff trained to work with the urgent care centres to prevent
admission and support people to return to their own homes.
Personalised health and care plans, and holistic assessment (including for family
carers) which support people to get information, advice and support in a timely
way, which more generally will reduce unplanned admissions to hospital.
Ensure that Emergency Care Plans are developed to prevent future crisis due to
carer breakdown.
The delivery chain
The delivery of admission prevention will be through partnership working across Ipswich
and East Suffolk CCG, West Suffolk CCG, Suffolk County Council’s Adults and
Community Services, Suffolk Community Healthcare, Norfolk and Suffolk Foundation
Trust and others.
Commissioning activity (eg the re-commissioning of community health, 111 and the Out
of Hours Services) is aligned to deliver the new model.
ACS transformation programmes are delivering a transformed social care workforce.
All commissioners are working with community health providers to deliver change within
contract, prior to the contracts for services changing.
The evidence base
Risk stratification or predictive modelling - Statistical models can be used to identify
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or predict individuals who are at high risk of future hospital admissions in order to target
care to prevent emergency admissions. The evaluation of predictive modelling options24
suggests including GP data in predictive modelling is particularly important, and including
all patients in an area rather than just those with prior hospital use was found to improve
case-finding. It also suggests25 using an ‘impactability model’ to identify high risk patients
who are most likely to benefit from preventive care.
Intensive Case Management - A Kings Fund Paper in 201026 on the research evidence
around avoiding hospital admissions recommended that commissioners and providers
should consider implementing intensive and/or assertive case management for people
with mental health illnesses. This is most effective when focused on patients with
frequent hospital use and assertive case management by multidisciplinary teams may
reduce mental health admissions.
A Cochrane review of ‘Intensive case management for severe mental illness’ (2011) 27
found that Intensive case management is of value at least to people with severe mental
illnesses who are in the sub-group of those with high level hospitalisation (about 4 days a
month in past 2 years) and the intervention should be performed close to the original
model.
Falls Prevention - There have been a series of Cochrane reviews relating to falls
prevention.28 29 The most recent - a Cochrane review of 159 randomised controlled trials
of falls prevention interventions revealed that group and home-based exercise
programmes and home safety interventions significantly reduce rate of falls and risk of
falling, multifactorial assessment and intervention programmes significantly reduce the
rate of falls but not the risk of falling, and Tai Chi significantly reduces the risk of falling
but not the rate of falls.
The Cochrane reviews provide additional evidence on the following interventions:
a) Exercise for preventing falls
 Group and home-based exercise programmes, and home safety interventions
reduce rate of falls and risk of falling.
 Tai Chi reduces risk of falling.
b) Exercise for improving balance and physical functioning in older people
 Progressive Resistance Strength Training is an effective intervention for
improving physical functioning in older people, including improving strength
24
Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013).
Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR
Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf
25 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund
26 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010.
27 Intensive case management for severe mental illness (Review). Dieterich M, Irving CB, Park B, Marshall M. Wiley 2010.
28 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in
older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI:
10.1002/14651858.CD007146.pub3
29 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review) 2010 The Cochrane
Collaboration.
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and the performance of some simple and complex activities. However, some
caution is needed with transferring these exercises for use with clinical
populations because adverse events are not adequately reported.30
 There is some evidence that some types of exercise (gait, balance, coordination and functional tasks; strengthening exercise; 3D exercise and
multiple exercise types) are moderately effective, immediately post
intervention, in improving clinical balance outcomes in older people.
c) Medications and medical devices
 Gradual withdrawal of psychotropic medication reduced the rate of, but not risk
of falling. A prescribing modification programme for primary care physicians
significantly reduced risk of falling.31
 The effectiveness of the provision of hip protectors in reducing the incidence of
hip fracture in older people is still not clearly established. Poor acceptance and
adherence by older people offered hip protectors have been key factors
contributing to the continuing uncertainty.32
A Department of Health economic evaluation of fracture prevention services has
modelled that each hip fracture avoided will save on average over £12,000 for the NHS
and £3,879 for social care over two years, and an avoided fracture of the humerus, spine
or forearm will avoid over £5,000 for the NHS and over £200 for social care. Over a five
year period, the NHS and local authority social care save over £290,000, against an
additional £234,181 revenue costs, which nationally equates to a saving of £8.5 million
over five years. The model anticipates 797 fractures of the hip, humerus, spine or
forearm from a population of 320,000.33
Interventions for preventing falls in older people living in the community found potential
cost-savings when delivering falls prevention interventions to subgroups of people at high
risk of falling. The Otago Exercise Programme, involving people aged over 80, resulted in
fewer hospital admissions and therefore cost-savings.34 Salkeld et al found cost-savings
when delivering a home safety programme to participants with a previous fall35 and Rizzo
et al found cost-savings when delivering a multifactorial intervention of people with four or
more of eight risk factors.36
30
The Cochrane Library. Falls Prevention and Balance in Older People. Available at:
2011.http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html.
31 Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem Drugs
Aging. 2012 Jan 1;29(1):15-30.
32 Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database of
Systematic Reviews 2010, Issue 10.
33 Department of Health (2009) Fracture Prevention Services: an economic evaluation.
http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fra
ctures.pdf
34 Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise
programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697-701.
35 Salkeld G, et al, 2000:The cost effectiveness of a home hazard reduction program to reduce falls among older persons. Aust N Z
J Public Health. 2000 Jun;24(3):265-71.
36 Rizzo JA et al 1996: The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly
persons. Med Care. 1996 Sep;34(9):954-69.
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Education and Self-Management For People with Asthma and COPD - Patient selfmanagement seems to be beneficial for patients with COPD and asthma.37 38 39 The
Cochrane reviews concluded that education with self-management reduced unplanned
hospital admissions in adults with asthma, and in chronic obstructive pulmonary disease
COPD patients but not in children with asthma. There is weak evidence for the role of
education in reducing unplanned hospital admissions in heart failure patients.40
Joint Health and Social Care Investment in Primary Prevention - The Institute of
Public Care at Oxford Brookes University reports that joint health and social care
investment in dental care, podiatry services, incontinence, dehydration monitoring (liquid
intake), falls prevention and stroke recovery services has a positive impact on
admissions to residential care.41
Investment requirements
£4,833,000 (note that this investment requirement is for schemes 3(a) and 3(b))
Impact of scheme
This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
In conjunction with schemes 1, 2, 3(b) and 3(c) this scheme will generate a total saving of
£1,094,620
Feedback loop
The schemes will be overseen by current Integrated Care partnership arrangements: the
System Forum in West Suffolk and the Integrated Care Network in Ipswich and East
Suffolk. As part of the early adopter site a suite of local metrics will be developed. These
will include consideration of the Better Care Fund metrics, the costs of delivery and the
impacts against the Suffolk Theory of Change described above.
37
Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010
http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf
38 Effing T, Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev.
2007 Oct 17;(4):CD002990.
39 Tapp S, Lasserson T, Rowe B (2007). ‘Education interventions for adults who attend the emergency room for acute asthma
(Cochrane Review)’. Cochrane Database of Systematic
Reviews, issue 3, article CD003000. DOI: 10.1002/14651858.CD003000.pub2.
40 Kirsty J. Boyd; Living with advanced heart failure: a prospective, community based study of patients and their carers The
European Journal of Heart Failure 6 (2004) 585– 591.
41 CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive
services: a structured approach to service transformation and delivering better outcomes for older people.
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What are the key success factors for implementation of this scheme?
Higher cost interventions are replaced with lower cost interventions
a) People at risk of crisis are identified and receive a co-ordinated response
b) Reduction in emergency admissions
People manage their own health and social care
a) People have the tools to manage their Long Term Conditions
b) Information and advice is readily available to people
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Scheme ref no.
Scheme 3(b) - IEWS
Scheme name
Admission prevention – Crisis response
What is the strategic objective of this scheme?
Whilst our transformation plans are working to shift unplanned care into planned care we
recognise that there are times when a crisis response is needed, including when people
have a mental health crisis.
Overview of the scheme
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
Our default response is to treat people at home, or as close to home as is possible
People get the right response in a timely way wherever they access the system
including those with a mental health crisis, which returns them to a stable situation
and enables them to retain their home life for longer, whether they contact through
111, out of hours arrangements, through their GP receptionist or through social
care contact arrangements.
This enables a timely and skilled response to avoid unnecessary ambulance
conveyances to hospital.
We work closely with the Police Emergency Response service to support people
with a mental health need in times of crisis.
There is effective transfer back into the non-urgent systems where appropriate,
including from the acute trusts so that scarce A&E resources are protected from
dealing with primary care problems. This is effected through urgent care centres
locally at acute trusts with speciality input for example 136 suites, psychiatric
liaison, diagnosis and minor injuries.
Support following a crisis is available for patients and their family carers through
our Integrated Neighbourhood Teams working with their local Neighbourhood
Network and with specialist services, including mental health services.
The delivery chain
The delivery of services in a crisis will be through partnership working across Ipswich and
East Suffolk CCG, West Suffolk CCG, Suffolk County Council’s Adults and Community
Services, Suffolk Community Healthcare, Norfolk and Suffolk Foundation Trust and
others.
Commissioning activity (eg the recommissioning of community health, 111 and the Out of
Hours Services) is aligned to deliver the new model.
ACS transformation programmes are delivering a transformed social care workforce.
The evidence base
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Integrated Crisis and Rapid Response Service - There is a lack of robust evidence to
evaluate the effectiveness of crisis response services. However some case studies
provide positive results.42 There are recommendations from The ‘Silver Book’43 – a
guidance document for care for frail older people during the first 24 hours of an urgent
care episode.
The national evaluation of the Department of Health Partnerships for Older People
Projects pilots (POPPs) found economic benefits from targeted intensive interventions to
prevent crisis (e.g. falls services) or at a time of crisis (e.g. rapid response hospital
admissions avoidance services) or post-crisis reablement services. For every £1 spent
on such services to support older people, hospitals were found to save £1.20 in spending
on emergency beds.44
Information from ‘A vision for social care’ 45 the Care Services Efficiency Delivery
Programme suggests that an integrated crisis or rapid response service, that responds to
people who have a crisis within a four hour period could save an average of £2 million
per PCT and £0.5 million per local authority by reducing ambulance call-outs,
unnecessary admissions to hospital and unplanned entry to long term nursing or
residential care.46
Crisis Resolution and Home Treatment (CRHT) services have been shown to decrease
unplanned hospital admissions and length of stay. 47 48
The National Audit Office suggests that the NHS could save £12-50 million annually by
increasing the number of patients taking part in CRHT programmes.49 Integration of
CRHT or other community teams with inpatient staff can lead to reductions in bed use,
and this approach in Norfolk has led to annual savings of approximately £1 million.50
Investment requirements
42
Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010.
Quality care for older people with urgent and emergency care needs
http://www.bgs.org.uk/campaigns/silverb/silver_book_complete.pdf
44 Karen Windle et al, 2009: National Evaluation of Partnerships for Older People Projects: Final Report Dept of Health
45 A Vision for Adult Social Care – 2010. Dept of Health: http://www.cpa.org.uk/cpa_documents/vision_for_social_care2010.pdf
46 Humphries, 2011 Social care funding and the NHS An impending crisis? The King’s Fund:
http://www.kingsfund.org.uk/sites/files/kf/Social-care-funding-and-the-NHS-crisis-Kings-Fund-March-2011.pdf
47 National Audit Offi ce (2007a). Helping People Through Mental Health Crisis: The role of Crisis Resolution and Home
Treatment services. London: The Stationery Office. www.nao.org.uk/publications/0708/helping_people_through_mental.aspx
48 Chiles JA, Lambert MJ, Hatch AL (1999). ‘The impact of psychological interventions on medical cost offset: A meta-analytic
review’. Clinical Psychology: Science and Practice, vol 6, no 2, pp 204–20.
49 Howard C, Dupont S, Haselden B, Lynch J, Wills P (2010). ‘The effectiveness of a group cognitive-behavioural breathlessness
intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease’.
Psychology, Health and Medicine, vol 15, no 4, pp 371–85.
50
Department of Health (2009) partnerships for Older people projects final report. London. Department of Health.
43
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£4,833,000 (note that this investment requirement is for schemes 3(a) and 3(b))
Impact of scheme
This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
In conjunction with schemes 1, 2, 3(a) and 3(c) this scheme will generate a total saving of
£1,094,620
Feedback loop
The schemes will be overseen by current Integrated Care partnership arrangements: the
System Forum in West Suffolk and the Integrated Care Network in Ipswich and East
Suffolk. As part of the early adopter site a suite of local metrics will be developed. These
will include consideration of the Better Care Fund metrics, the costs of delivery and the
impacts against the Suffolk Theory of Change described above.
What are the key success factors for implementation of this scheme?
Higher cost interventions are replaced with lower cost interventions
a) People at risk of crisis are identified and receive a co-ordinated response
b) Reduction in emergency admissions
People manage their own health and social care
a) People have the tools to manage their Long Term Conditions
b) Information and advice is readily available to people
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Scheme ref no.
Scheme 3(c) - IEWS
Scheme name
Admission prevention – Integrated Reablement & Rehabilitation (IRR) Model
What is the strategic objective of this scheme?
Reablement and rehabilitation is not a particular service, it is a journey that everyone
should have access to and be supported through in order to maximise their effective
recovery and independence outcomes. Reablement and rehabilitation services then
become one way that people can achieve certain short term outcomes that will prepare
them for longer term well-being and independence.
Integrating the reablement and rehabilitation services and offers across organisational,
and statutory and voluntary boundaries will allow the reablement journey to commence
earlier and to continue beyond the traditional cut-off points. This will deliver a more
personalised service and lead to sustainable outcomes,
The integrated reablement and rehabilitation pathway is a core element of our integrated
design. The right resource will be used at the right time in a person’s journey and without
delay or duplication, and will be targeted at specific outcomes to maximise their
reablement opportunity and reduction in demand for longer term services.
Overview of the scheme









A greater focus on prevention and self-management and timely intervention to
avoid admissions and maximise longer term independence and well-being.
A single outcome focused reablement and rehabilitation plan.
Delivery of a rapid response so that reablement and rehabilitation outcomes can
be maximised
Family carers supported to play an active part in the reablement and rehabilitation
plan
A greater use of assistive technology to support the achievement of greater
independence
Market development to ensure that all services are delivered using an enablement
ethos and approach, for example the Home Care Market.
Continuous stretch for providers to improve reablement rates, including from
mental health and inpatient units.
Review of step up and step down bed provision as part of the retendering of NHS
community services in 2015.
Community Equipment Store re-commissioning in 2015 to underpin new
integrated service model with timely access to equipment, that aligns to the
personalisation and prevention agenda by making equipment solutions available
as part of the approach to reducing or preventing increases in dependency in Long
Term Conditions.
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
Links with Neighbourhood Networks (voluntary, community and other services) so
that people can get back to doing the things that they enjoy.
The delivery chain
The delivery of the integrated reablement and rehabilitation model will be through
partnership working across Ipswich and East Suffolk CCG, West Suffolk CCG, Suffolk
County Council’s Adults and Community Services, Suffolk Community Healthcare,
Norfolk and Suffolk Foundation Trust and others within the voluntary sector.
Commissioning activity (eg the recommissioning of community health, 111 and the Out of
Hours Services, the Support to Live at Home Service) is aligned to deliver the new
model.
ACS transformation programmes are delivering a transformed social care workforce.
All commissioners are working with community health providers to deliver change within
contract, prior to the contracts for services changing.
The evidence base
Reablement Services - The evidence base for reablement services is limited by a lack
of robust studies. However, there is evidence that reablement can reduce on-going
homecare costs to social care.51 The results showed a reduced use of home care
services over time associated with median cost savings per person of approximately AU
$12,500 over nearly 5 years when compared with individuals who had received a
conventional home care service.
Glendinning et al (2010) showed that there is a 60% reduction in social care costs for
those receiving reablement.52
Physical Rehabilitation for Long-Term Care Residents - A Cochrane review of 67
trials, involving 6300 participants showed that physical rehabilitation for long-term care
residents may be effective, reducing disability with few adverse events, but effects
appear quite small and may not be applicable to all residents. There is insufficient
evidence to reach conclusions about improvement sustainability, cost-effectiveness, or
which interventions are most appropriate.53
Assistive Technology – Tele Health - Tele health is effective in reducing hospital
admissions in people with chronic heart failure (meta-analysis of 11 randomised
51
Lewin GF et al 2013 - Evidence for the long term cost effectiveness of home care reablement programs. Clin Interv Aging.
2013;8:1273-81.
52 Glendinning et al (2010) Home Care Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal
study) SPRU/PSSRU report http://socialwelfare.bl.uk/subject-areas/services-activity/social-work-careservices/spru/135160Reablement10.pdf
53 Crocker T Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013 Feb 28;2:CD004294.
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controlled trials showed a significant 21% reduction in hospital admissions in this group
of patients.54
In addition, the results of a meta-analysis study support the use of telephone-delivered
CBT as a tool for improving health in people with chronic illness.55
Assistive Technology – Tele Care - Tele care and Falls prevention: There is some
evidence from a longitudinal prospective cohort study that a light path plus teleassistance reduced falls and significantly reduced post-fall hospitalisation.56
Tele care and Dementia Care: The British psychological Society (2007) recommends that
dementia care plans should include environmental modifications to aid independent
functioning.57
Two case studies are highlighted below that show the effectiveness of tele care. This is
low quality evidence and must be interpreted with caution. Evidence from evaluation of
tele care provision in Essex and impact for social care found that for every £1 spent on
tele care, £3.82 was saved in traditional care.58 Tele care in North Yorkshire project
evaluation estimates one year savings in care packages of £1 million.59
Investment requirements
£14,291,000
Impact of scheme
This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
 Increased effectiveness of reablement
In conjunction with schemes 1, 2, 3(a), 3(b) this scheme will generate a total saving of
£1,094,620 + an additional anticipated saving of £46,610
54
Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF (2010). 'Structured telephone support or
telemonitoring programmes for patients with chronic heart failure (Cochrane Review)'. Cochrane Database of Systematic
Reviews, issue 8, article CD007228.
55 Muller I, Telephone-delivered cognitive behavioural therapy: a systematic review and meta-analysis. J Telemed Telecare.
2011;17(4):177-84.
56
E.A. Tchalla, et al The effect of fall prevention and management technologies Gerontechnology 2012; 11(2):347
57The British Psychological Society (2007) Dementia – available at:
http://www.nice.org.uk/nicemedia/pdf/CG42Dementiafinal.pdf
58 Evaluating telecare and telehealth interventionsWSDAN briefing paper: http://www.kingsfund.org.uk/sites/files/kf/Evaluatingtelecare-telehealth-interventions-Feb2011.pdf
59 Department of Health (2009) ‘Use of resources in adult social care A guide for local authorities’
http://www.thinklocalactpersonal.org.uk/_library/Resources/Personalisation/Personalisation_advice/298683_Uses_of_Resources.p
df
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Feedback loop
The schemes will be overseen by current Integrated Care partnership arrangements: the
System Forum in West Suffolk and the Integrated Care Network in Ipswich and East
Suffolk. As part of the early adopter site a suite of local metrics will be developed. These
will include consideration of the Better Care Fund metrics, the costs of delivery and the
impacts against the Suffolk Theory of Change described above.
What are the key success factors for implementation of this scheme?
Higher cost interventions are replaced with lower cost interventions
a) Effectiveness of reablement
b) Fewer people being admitted to permanent residential/nursing care
c) Reduced emergency admissions
d) Reduced use of social care support packages
e) Service user identified increase in independence and well-being
Health and care system is co-ordinated and effective
a) Numbers of people identified through local risk stratification
b) Numbers of people with a named care co-ordinator and plan
c) Numbers of people achieving personalised reablement / rehabilitation
outcomes
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Scheme ref no.
Scheme 4 - GYW
Scheme name
Supporting independence by provision of community based support interventions
What is the strategic objective of this scheme?
To deliver community based support interventions, closer to people’s homes, 7 days per
week that maintains / regains independence, including the use of Personal Health
Budgets to help prevent people’s needs escalating
Overview of the scheme
Fast track End of Life CHC / CHC Domiciliary Care - An increasing number of people
are receiving end of life care through NHS Continuing Healthcare funding; many of whom
are receiving this care in their own homes.
The delivery chain
Commissioners – NHS GYW CCG, SCC, NCC
Providers – ECCH, JPUH, NRS, NCC, Voluntary Sector, Social Care, Housing, private
care agencies, Charitable Organisations
The evidence base
Community based support interventions, Self-care & self-management - Patient
self-management seems to be beneficial for patients with COPD and asthma.60 61 62 The
Cochrane reviews concluded that education with self-management reduced unplanned
hospital admissions in adults with asthma, and in chronic obstructive pulmonary disease
COPD patients but not in children with asthma. There is evidence for the role of
education in reducing unplanned hospital admissions in heart failure patients.63
There is some evidence that demonstrates that investment in learning for older people
can reduce the costs of medical and social care and improve the quality of life for older
people, their families and communities, NIACE, 2010.64
60
Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010
http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf
61 Effing T, Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev.
2007 Oct 17;(4):CD002990.
62 Tapp S, Lasserson T, Rowe B (2007). ‘Education interventions for adults who attend the emergency room for acute asthma
(Cochrane Review)’. Cochrane Database of Systematic
Reviews, issue 3, article CD003000. DOI: 10.1002/14651858.CD003000.pub2.
63 Kirsty J. Boyd; Living with advanced heart failure: a prospective, community based study of patients and their carers The
European Journal of Heart Failure 6 (2004) 585– 591.
64 NIACE: Lifelong Learning: Contributing to wellbeing and prosperity http://www.niace.org.uk/sites/default/files/2010-SpendingReview.pdf
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Reablement Services - The evidence base for reablement services is limited by a lack
of robust studies. However, there is evidence that reablement can reduce on-going
homecare costs to social care.65 The results showed a reduced use of home care
services over time associated with median cost savings per person of approximately AU
$12,500 over nearly 5 years when compared with individuals who had received a
conventional home care service.
Glendinning et al (2010) showed that there is a 60% reduction in social care costs for
those receiving reablement.66
Physical Rehabilitation - A Cochrane review of 67 trials, involving 6300 participants
showed that physical rehabilitation for long-term care residents may be effective,
reducing disability with few adverse events, but effects appear quite small and may not
be applicable to all residents. There is insufficient evidence to reach conclusions about
improvement sustainability, cost-effectiveness, or which interventions are most
appropriate.67
Risk Stratification - Statistical models can be used to identify or predict individuals who
are at high risk of future hospital admissions in order to target care to prevent emergency
admissions. The evaluation of predictive modelling options68 suggests including GP data
in predictive modelling is particularly important, and including all patients in an area
rather than just those with prior hospital use was found to improve case-finding. It also
suggests69 using an ‘impactability model’ to identify high risk patients who are most likely
to benefit from preventive care.
Carer Support Services - A systematic review and meta-analysis of cognitive re-framing
for carers of people with dementia showed beneficial effects over usual care for carer
mental health.70
A report assessing the effectiveness and cost-effectiveness of support and services to
informal carers of older people by the audit commission in 200471 showed that Day care,
Home/help care and Institutional respite care (but not in all cases) may lead to delayed
65
Lewin GF et al 2013 - Evidence for the long term cost effectiveness of home care reablement programs. Clin Interv Aging.
2013;8:1273-81.
66 Glendinning et al (2010) Home Care Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal
study) SPRU/PSSRU report http://socialwelfare.bl.uk/subject-areas/services-activity/social-work-careservices/spru/135160Reablement10.pdf
67 Crocker T Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013 Feb 28;2:CD004294.
68 Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013).
Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR
Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf
69 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund
70 Vernooij-Dansen, M., Draskovic, I., McCleery, J., & Downs, M. (2011). Cognitive reframing for carers of people with dementia.
The Cochrane Collaboration(11).
71 The effectiveness and cost-effectiveness of support and services to informal carers of older people
http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/Lit
Review02final.pdf
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admissions to institutional care (and may be cost-effective).
Respite Care - A report for the Princess Royal Trust for Carers and Crossroads Care
(2011)72 states that investing in respite care results in savings resulting from reduced
costs to health and social care: spending more on breaks, training, information, advice
and emotional support for carers reduces overall spending on care by more than £1bn
per annum, as a result of reductions in unwanted (re)admissions, delayed discharges
and residential care stays.
A focused review of the UK literature by the Audit commission looked at the effectiveness
and cost effectiveness of respite care of older adults (60+ or 65+) and included cost
effectiveness studies from the US literature.73 Day care, home help/care, institutional
respite care and social work/counselling were found to be effective and/or cost-effective
for carers in terms of one or more of the outcomes in improving carer welfare and
delaying admission to institutional care.
Assistive Technology – Tele Health - Tele health is effective in reducing hospital
admissions in people with chronic heart failure (meta-analysis of 11 randomised
controlled trials showed a significant 21% reduction in hospital admissions in this group
of patients.74
In addition, the results of a meta-analysis study support the use of telephone-delivered
CBT as a tool for improving health in people with chronic illness.75
Assistive Technology – Tele Care - Tele care and Falls prevention: There is some
evidence from a longitudinal prospective cohort study that a light path plus teleassistance reduced falls and significantly reduced post-fall hospitalisation.76
Tele care and Dementia Care: The British psychological Society (2007) recommends that
dementia care plans should include environmental modifications to aid independent
functioning.77
Two case studies are highlighted below that show the effectiveness of tele care. This is
low quality evidence and must be interpreted with caution. Evidence from evaluation of
72
The Princess Royal Trust for Carersand Crossroads Care. (2011). Supporting Carers: The case for change.
Pickard, L. (2004). The effectiveness and cost-effectiveness of support and services to informal carers of older people. A review
of the literature prepared for the audit commission. Audit Commission.
74 Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF (2010). 'Structured telephone support or
telemonitoring programmes for patients with chronic heart failure (Cochrane Review)'. Cochrane Database of Systematic
Reviews, issue 8, article CD007228.
75 Muller I, Telephone-delivered cognitive behavioural therapy: a systematic review and meta-analysis. J Telemed Telecare.
2011;17(4):177-84.
76
E.A. Tchalla, et al The effect of fall prevention and management technologies Gerontechnology 2012; 11(2):347
77The British Psychological Society (2007) Dementia. http://www.nice.org.uk/nicemedia/pdf/CG42Dementiafinal.pdf
73
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tele care provision in Essex and impact for social care found that for every £1 spent on
tele care, £3.82 was saved in traditional care.78 Tele care in North Yorkshire project
evaluation estimates one year savings in care packages of £1 million.79
Supported and Sheltered Housing - There is some evidence from a variety of case
studies that local authorities are able to reduce their spend on residential care and
increase the level of support for people to live in their own homes by facilitating
supported housing; 80 for people with learning disabilities; and for older people
(sometimes referred to as extra-care housing, very-sheltered housing or assisted living).
The results from the case studies provide growing evidence that even people with
medium–high care needs can be supported in their own homes with the right staffing,
technology, aids and adaptations. This is recognised in the Government’s national
housing strategy for an ageing society, Lifetime Homes, Lifetime Neighbourhoods, and in
More Choice, Greater Voice.81
Research into the financial benefits of the Supporting People programme found that for
most groups, packages of housing-related support services avoid costs elsewhere and
as well as promoting independence produce a net financial benefit. The cost to savings
ratio for older people’s housing support was particularly favourable: £327.9m to
£1,398.3m.82
Home Improvement Interventions - There is a range of evidence demonstrating the
resultant cost benefits of home repairs, adaptations and hospital discharge housing
related help in the Fit for Living Network. This showed that for every £1 spent on
handyperson services (which provide fast, low cost help with adaptations and repairs),
£1.70 was saved, the majority to social services, health and the police; hospital discharge
schemes offering housing help to speed up patient release save local government social
care budgets at least £120 a day.
An analysis by Care and Repair Cymru of the outcomes of their Rapid Response
Adaptations programmes identified that every £1 spent generated £7.50 cost savings to
the NHS. These savings were associated with speeded up hospital discharge, prevention
of people going into hospital and prevention of accidents and falls in the home providing
an adaptation in a timely fashion can reduce social care costs by up to £4,000 a year.
78
Evaluating telecare and telehealth interventionsWSDAN briefing paper: http://www.kingsfund.org.uk/sites/files/kf/Evaluatingtelecare-telehealth-interventions-Feb2011.pdf
79 Department of Health (2009) ‘Use of resources in adult social care A guide for local authorities’
http://www.thinklocalactpersonal.org.uk/_library/Resources/Personalisation/Personalisation_advice/298683_Uses_of_Resource
s.pdf
80 The Business Case for Extra Care Housing in Adult Social Care: An Evaluation of Extra Care Housing schemes in East Sussex
http://www.housinglin.org.uk/Topics/type/resource/?cid=8988&msg=0
81 Lifetime Homes, Lifetime Neighbourhoods, and in More Choice, Greater Voice – A publication by communities and local
government - 2008: http://www.cpa.org.uk/cpa/lifetimehomes.pdf
82 Communities and Local Government (July 2009) ‘Research into the financial benefits of the supporting people programme’
http://tiny.cc/k5czx
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The cost effectiveness of Home adaptations – a report by The University of Bristol based
on a review of case studies revealed: 83
 Adaptations to the home can reduce the need for Homecare daily visits. In the
cases reviewed – between £1,200 and £29,000 saved per year
 Savings in home care costs by home adaptations mainly found in younger
disabled people. In older people adaptations are found through prevention of
accidents or deferring admission to residential care and improved quality of life
 Home adaptations can reduce the need for residential care in disabled people
 Findings on the impact of adaptations include 70% increased feelings of safety
and an increase of 6.2 points on the SF 36 scores for mental health
 Home adaptations that improve the environment for visually impaired people leads
to savings through prevention of falls.
 The provision of adaptations and equipment can save money by speeding hospital
discharge and preventing hospital admission
 Audit commission stresses effectiveness and value of investment in equipment
and adaptation to prevent unnecessary and wasteful health costs
 Adaptations give support to carers and avoid health care costs for strain and injury
Investment requirements
£4,010,000
Impact of scheme
This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
 Increased effectiveness of reablement
In conjunction with schemes 5, 6 and 7 this scheme will generate a total saving of
£556,010 + an additional anticipated saving of £25,330
Fast track End of Life CHC / CHC Domiciliary Care - At present this care is delivered
by a range of private care agencies, with varying levels of quality and costs. The nature
of the commissioning of these services from a significant number of providers is that it is
very difficult to incorporate and manage quality monitoring of the services delivered to our
patients. The providers do not have the infrastructure in place to enable the monitoring
that we would require and doing so would likely significantly increase the cost. The cost
variation between providers and packages is also questionable and this indicates that a
83
The cost effectiveness of Home adaptations: Report - Better Outcomes, lower costs – University of Bristol Office for Disability
Issues (Heywood and Turner, 2007) http://odi.dwp.gov.uk/docs/res/il/better-outcomes-report.pdf
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provider model is needed to be able to address the quality requirements and finance
control.
Therefore a new model is being developed; this being the commissioning of NHS CHC
fast track domiciliary care from a single provider within Great Yarmouth & Waveney. The
ambition for this model is:
 A block contract would be issued to the preferred single provider (following the
appropriate procurement process).
 The block contract will include comprehensive quality requirements, information
requirements and delivery requirements.
 A single provider would have the infrastructure in place to ensure robust quality
monitoring and reporting within the contract with the CCG
 The preferred provider will have a level of guaranteed activity and as such could
allow improved recruitment/employment for the care giving workforce
 This approach will enable financial stability and in year cost control for the CCG
 Depending on the preferred provider, if this is an organisation within which there is
an established clinical infrastructure (or links to organisations with and established
clinical infrastructure) then the service provided to the patients will be enhanced; in
particular they will have an improved access to services such as occupational
therapy e.g. to meet equipment needs, Hospice at Home services, District Nursing
services, amongst others.
Feedback loop
This will be undertaken through the contract monitoring process.
Measures and metrics will be developed but will include measures of patient and family
experience/satisfaction, patient safety, workforce training and development,
recruitment/workforce metrics. Other evaluation of outcomes will include cost/value for
money to ensure that the budget is allowing the CCG to fund the best quality and
accessible service for our patients in receipt of NHS fast track CHC funding.
What are the key success factors for implementation of this scheme?
A project management approach is being developed for this programme development. In
2013/14 the CCG spent £718,454 on domiciliary fast track care with an anticipated year
on year increase in line with improving awareness of the benefits of dying within the
place of choice, which invariably is a person’s own home. Key factors will include the
ability of the provider to be able to be responsive to a person’s end of life care needs and
be able to implement the care packages within a rapid timeframe.
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Scheme ref no.
Scheme 5 - GYW
Scheme name
Integrated Community Health and Social Care Teams including Out of Hospital Team &
Palliative Care
What is the strategic objective of this scheme?
Continue to develop integrated community out of hospital team and an integrated
palliative care service, delivering timely, joined up quality care.
Integrated Community Health and Social Care Team - Out of Hospital Team
Lowestoft - To Provide care at home whenever it is safe, sensible and affordable to do
so. The care will be organised around the patient, focusing on individual need and
empowering independence.
Thus enabling GYW CCG to achieve its strategic objectives of:
- Care closer to home
- Integrated service provision
- Reduction in emergency admissions to acute beds
The Out of Hospital Team (OHT) is an inter disciplinary team of health and social care
professionals for whom the objective of its service is to provide care at home whenever it
is safe, sensible and affordable to do so. The care the team provides is organised
around the patient, focusing on individual need and empowering independence. The
team offers intensive, short term care, reducing as the patient regains health and
independence. Care is holistic, co-ordinated, and responsive and goal focused, using a
case management approach.
The OHT is made up of key health and social care professionals supported by workers
able to perform many types of basic nursing, therapeutic and personal care tasks. The
shared values and aims underpinning care delivered by the entire OHT include:





Patient centred care; staff will involve patients and their family and, or carers in the
care planning approach
Staff will be sensitive to the needs of family and carers
Care will be provided in patients’ usual places of residence but only if it is safe and
sensible to do so
The OHT will be easily accessible to patients and their families and, or carers
The OHT will focus on proactive delivery of care and if a patient is in crises will
react rapidly to keep that patient safe in their usual place of residence.
Overview of the scheme
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Model of Care and Support
The OHT operates 24 hours a day, seven days a week. For all urgent referrals initial
assessment by the OHT is undertaken within two hours of receipt of the referral. Initial
assessment of all other referrals takes place within 1 working day. The response time is
determined by the triage process. Through Multi-Disciplinary Team Meetings and regular
patient review, care packages are kept relevant to the patients’ needs and personal aims.
Following assessment and on the same day as the assessment, the OHT organises
appropriate care provision for the patient in their place of usual residence or, if
necessary, in a bed with care.
The OHT ensures that, with immediate effect, provision is put in place to keep the patient
safe at home until the full care package can be implemented. The full care package is
always implemented within 12 hours of the initial assessment being made.
The OHT is made up of key health and social care professionals supported by workers
able to perform many types of basic nursing, therapeutic and personal care tasks.
The Senior Professionals
The range of Senior Health and Social care professionals comprising the Lowestoft OHT
include as a minimum:
 Independent Nurse Prescribers
 Community Nurses
 Physiotherapists
 Occupational Therapists
 Mental Health Workers; Dementia Intensive Support Workers and Complexity in Later
Life Workers
 Social Workers
 Social Care Assessors
The responsibilities of these Senior Health and Social Care professionals include as a
minimum:
 To undertake combined health and social care assessments of patients referred into
the service, to determine their suitability for care at home
 To agree with the patient an individual management plan to optimise recovery,
independence and wellbeing at home
 To ensure patients and their family and, or carers are fully included in the care
planning process
 To prescribe appropriate medication when necessary and support patients and their
family and, or carers to safely manage and comply with their medication regimes
 To oversee implementation of patients’ management plans by appropriate Assistant
Practitioners and care workers within the Lowestoft OHT
 To undertake regular review of patients’ needs to ensure the care package remains
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
relevant and patients are progressing towards their optimum levels of independence
and health
To work closely with community and acute providers to facilitate timely and safe
discharges to patients’ usual places of residence, if necessary it is expected that
assessors will visit patients in hospital to review their discharge requirements
The Support Staff
Within the Lowestoft OHT are included as a minimum, the following Support Staff:
 Assistant Practitioners
 Reablement Practitioners
 Generic Workers
 Home Care Workers
 Community Phlebotomists
The responsibilities of these staff are to actively support patients in achieving their
individualised care plans and personal goals. Practitioners must be trained in a wide
range of therapy and nursing competencies to enable in one visit, for example, a
dressing to be changed, an exercise programme to be completed and activities of daily
living to be developed.
Care Workers will also be trained in a range of health and social care competencies
enabling them to carry out multiple tasks when visiting a patient, for example, taking
bloods, assessing for a repose cushion and helping with activities of daily living.
Support staff also carry out welfare checks on patients.
Beds with Care
If, during the combined assessment process, it is determined that a patient is not
appropriate to remain at home and they require a short admission to a bed with care, this
admission is managed by the OHT. All admissions to beds with care, for Lowestoft
patients, will be through the OHT following assessment by them.
Where a patient is admitted to a bed with care the OHT monitors progress of that patient
and agrees an expected date of discharge with the Care Home. The Lowestoft OHT
provides in-reach therapy support to the Care Home. This support includes but will not be
limited to:
 Specialist therapy advice
 Advice on transfer and mobilisation of patients
 Programmes for rehabilitation and reablement
 Advice about equipment
The OHT attends MDTs at the Care Home and ensures all care plans are in place to
support discharge back to patients’ place of usual residence.
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Triage
The Lowestoft OHT operates a combined triage team made up of both health and social
care professionals including but not limited to:
 Day Co-ordinators (Health)
 Duty Workers (Social)
 Allocation Co-ordinators
 Administrators
The responsibilities of the triage team include as a minimum:
 Receiving referrals
 Contacting various others for further information
 Triaging referrals
 Allocating assessments
 Imparting necessary information to the assessor
 Daily contact with acute and community bed providers to ascertain details of patients
who will require supported discharge
 Daily contact with acute and community bed providers for updates on patients’
expected dates of discharge and any changes to patients circumstances and, or care
needs
General
All members of the Lowestoft OHT are responsible for:
 Assessing for and delivering equipment to patients in their places of usual residence
 Providing support, instruction, advice and sign posting to family and, or carers
 Ensuring patients and their family and, or carers are fully included in the care planning
process
 Attending MDTs as necessary
Where & When It Will Be Delivered
The Lowestoft OHT is located at Kirkley Rise and operates 24 hours a day, 7 days a
week.
Patient Cohorts being Targeted
Referrals to the Lowestoft OHT will be accepted for patients registered with a Lowestoft
GP. Referrals can be made by any health or social care worker. Patients referred to the
service must be 18 years of age and over.
Referrals are only accepted for housebound patients or those who are only able to leave
their place of usual residence with substantial support; irrespective of whether the
patient, when medically fit, is normally ambulant. Referrals for ambulant, self-caring
patients with capacity will not be accepted by the Lowestoft OHT.
Urgent referrals are made by phone. Non-urgent referrals can be made by fax.
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Referrals are made to the Lowestoft OHT through East Coast Community Health’s Single
Point of Access. Some referrals are expected to come through Suffolk County Council’s
Single Point of Access. These referrals are immediately and automatically directed to the
Lowestoft Out of Hospital integrated Triage Team.
Referrals must be for Lowestoft patients for whom it is considered input from the OHT will
be of benefit.
Referrals could, for example, include:
 Patients experiencing an acute exacerbation of their Long Term Condition
 Patients experiencing acute symptoms due to chest infection or urinary tract infection
 Patients whose mobilisation has suddenly reduced or is rapidly deteriorating
 Patients for whom the current care package is no longer robust enough and urgent
review and amendment is required to prevent a breakdown of carer support
 Patients requiring a supported hospital discharge to their usual place of residence
 Patients presenting at Accident and Emergency who do not require an emergency
admission but do require additional short term support to enable them to return home
 Patients who require a short term placement in a bed with care
 Palliative and End of Life patients requiring short term input for example following a
fall or an infection
Projected volume of activity: 2 referrals daily for crises intervention resulting in a daily
reduction of emergency admissions to the acute provider of 2.
This figure to increase to 3 after the first 8 months of service delivery.
Integrated EOL / Palliative Care - The aim of the integrated palliative and end of life
care service will be to provide high quality and consistent palliative care in the patient’s
preferred place of care
via: assessment of patient/carer needs, provision of 24/7, 7/7 palliative care advice and
information and sign posting to other services, co-ordination of a range of flexible
health and or social care packages to support further patients to die in the home care
setting, offer a timely and co-ordinated response to crises and ensure effective
information sharing with partner organisations, patients and carers.
The planned objectives of the service redesign are to:
• Increase the number of patients able if preferred to die in their home care setting
• Provide palliative care as defined in the national EOL Quality Standard (2012).
• Improve co-ordination and consistency of care packages thereby reducing care
package breakdown in the last weeks/days of life.
• Support informed choices through the proactive provision of information about local
services and support for patients/carers.
• Improve continuity and consistency via effective information sharing with partner
organisations.
• Audit care needs to promote improvement of service provided (e.g. the type of care
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•
required, the number of hours of care provided, the number of patients seen, the
number of patients who achieve their preferred place of care/death, and the number
of potential admissions to acute care and care package breakdowns avoided in the
last weeks/days of life).
Carry out regular patient/carer surveys to ensure a responsive and high quality
service is being provided e.g. via “VOICES” or “I Want Great Care”.
The delivery chain
Integrated Community Health and Social Care Team - Out of Hospital Team
Lowestoft - The Commissioners are NHS Great Yarmouth and Waveney CCG and
Suffolk County Council (Adult Social Care)
The Providers are East Coast Community Health and Suffolk County Council (Adult
Social Care)
Integrated EOL / Palliative Care




Local Health and Social Care commissioners: NHS GYW, Norfolk County Council,
Suffolk County Council
Local providers: East Coast Community Health, James Paget University Hospital,
Great Yarmouth and Waveney Continuing Health Care Palliative Care Fast Track
Service, Marie Curie Nursing Service, Big C Charity, St Elizabeth’s Hospice, All
Hallows Independent Community Hospital, Cruse and Crossroads Care
Service user group: Together Against Cancer
Other stakeholders (which link to the project through a Programme Board): Macmillan
Cancer Support, East Coast Hospice, Norfolk & Suffolk Palliative Care Academy,
Transforming Community Cancer Care pilot sites, EOE Strategic Clinical Network for
Cancer.
The evidence base
Integrated community health and social care teams - Evaluating integrated and
community-based care – the Nuffield Trust review of national integrated care pilots and
virtual wards84 showed reductions in planned admissions and in outpatient attendances
for some interventions that involved case management using multidisciplinary teams and
those using virtual wards, but no evidence of a general reduction in emergency
admissions.
King’s Fund analysis of the evidence85 suggests that joint commissioning between health
and social care that results in a multi-component approach is likely to achieve better
results than those that rely on a single or limited set of strategies.
84
Evaluating integrated and community-based care – a review of national integrated care pilots and virtual wards
http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/evaluation_summary_final.pdf
85 Goodwin et al, 2012, Integrated care for patients and populations: Improving outcomes by working together – The King’s Fund:
http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together
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The Torbay integrated care model has reduced the use of hospital beds by a third from
750 in 1998/1999 to 502 in 2009/2010. Emergency bed day use for people aged 75 and
over fell by 24% between 2003 and 2008 and by 32% for people aged 85 and over. 86 87
The Institute of Public Care at Oxford Brookes University reports that joint health and
social care investment in dental care, podiatry services, incontinence, dehydration
monitoring (liquid intake), falls prevention and stroke recovery services has a positive
impact on admissions to residential care.88
Structured Discharge Planning by multi-disciplinary teams - A Cochrane database
systematic review of hospital discharge planning provides robust evidence that a
discharge plan tailored to the individual patient probably brings about reductions in
hospital length of stay and readmission rates for older people admitted to hospital with a
medical condition. The impact of discharge planning on mortality, health outcomes and
cost remains uncertain. The review assessed randomised controlled trials (RCTs) that
compared an individualised discharge plan with routine discharge care that was not
tailored to the individual patient. Participants were hospital inpatients.89
A Cochrane systematic review of randomised controlled trials recruiting stroke patients in
hospital assessed the difference between those receiving conventional care with those
with early discharge with rehabilitation at home (early supported discharge). 90 Results
showed that early supportive discharge significantly reduced the length of hospital stay
equivalent to approximately seven days. Early Supported Discharge can reduce longterm mortality and institutionalisation rates for up to 50% of patients, as well as lower
overall costs.
Specialist team for Continence Care - Urinary incontinence significantly increases the
risk of hospitalisation and admission to nursing homes.91 An intervention involving
behavioural and lifestyle counselling provided by specialised nurses led to reduced
incontinent events and incontinence pad use.92 This may mean that the costs of
professional time are offset by reductions in pad costs.93
86
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-studykingsfund13.pdf
87 Thistlethwaite, P. (2011) "Integrating health and social care in Torbay: improving care for Mr Smith" The King's Fund, London:
http://www.kingsfund.org.uk/sites/files/kf/field/field_document/PARR-combined-predictive-model-final-report-dec06.pdf
88 CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive
services: a structured approach to service transformation and delivering better outcomes for older people
89
Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane
Database of Systematic Reviews 2013, Issue 1.
90 Fearon P, Langhorne P Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev.
2012 Sep 12;9:CD000443.
91 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and
mortality. Age and Ageing 26(5):367-374.
Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence:
a randomized controlled trial. CMAJ. 14;166(10):1267–1273
92
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Local evidence
• Public health mapping: In July 2013 Public Health Norfolk published the following
findings re the palliative care needs of the population of Great Yarmouth and
Waveney:
• The number of expected deaths per annum in Great Yarmouth and Waveney is
approximately 2,000 patients per annum (Marie Curie EOL Atlas 2010/11), so
over 2 years the commissioners (the CCG, and Norfolk and Suffolk County
councils) would expect that approximately 80% of these 4,000 patients and their
carers would need support from health and social care services.
• Some of the wards in Great Yarmouth and Waveney are amongst the most
deprived in England with 27% of the population of Great Yarmouth living in the
most deprived postcode areas in the country. This leads to a significant incidence
of life limiting illnesses associated with lifestyle issues e.g. cancer, chronic
respiratory disease and heart disease. Dementia as a co-morbidity is also an
issue in relation to an increasing need for palliative and end of life care services
to 2025. This work also shows that 54% of local patients die in hospital, despite
their preference being for receiving care in their home care setting (62% EOE
wide).
• The development of services in or closer to home will in particular support the
needs of the elderly population who are more likely to experience rural isolation
and difficulty in accessing services.
•
•
•
Palliative Care Skills Audit (Norfolk & Suffolk Palliative Care Academy and UEA
2013): The Academy carried out a skills audit with the UEA in 2013 which showed
that 63% of staff asked were providing palliative care but had not received any
training in the last 3 years to do so.
Marie Curie Delivering Choice Programme: The Marie Curie Delivering Choice
Programme showed a significant variation in the quality of end of life care and also
showed a need to improve the education and training for generalist staff providing
palliative and end of life care (Marie Curie Delivering Choice Phase 3 report 2011).
How We Manage Death and Dying in Norfolk (Norfolk County Council and Norfolk
and Waveney Cancer Network 2005): Showed a significant variation in the quality of
local palliative care services.
Investment requirements
£1,505,000
Impact of scheme
Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A
guide for commissioners written by continence care professionals.
93
http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf
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This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
In conjunction with schemes 4, 6 and 7 this scheme will generate a total saving of
£556,010
Integrated Community Health and Social Care Team - Out of Hospital Team
Lowestoft
Benefits to Lowestoft Patients
The benefits to Lowestoft patients from this approach to care will be many. As a minimum
the benefits to patients are expected to include:
 Improved patient experience; the patient will be seen by the right professional at the
right time and will have a key worker they, or their relatives/carers, can contact for
advice
 Improved dignity and reduced exposure to communal acquired infections
 Patients will retain their independence for longer and will be able to remain in their
place of usual residence for longer
 Patients will recover faster and more fully in their place of usual residence;
 Patients and their families/cares will be involved in decision making around care
choices
Benefits to the Lowestoft Health and Social Care System
The benefits to the local system, from this type of care approach, will be many. As a
minimum the benefits to the system are expected to include:
 Reduced numbers of emergency admissions to acute and community beds
 Reduced length of stay in acute and community beds
 Reduced reliance on long term placements in residential and nursing homes
 Elimination of overlaps across service provision within the Lowestoft system
Projected volume of activity: 2 referrals daily for crises intervention resulting in a daily
reduction of emergency admissions to the acute provider of 2.
This figure to increase to 3 after the first 8 months of service delivery.
Integrated EOL / Palliative Care - This new integrated service will deliver an adapted
form of the Macmillan Cancer Support patient/carer outcomes (2013) for people
affected by life limiting illnesses in Great Yarmouth and Waveney by aiming for
people in GYWCCG who have reached the end of their life to be able to state:
• I was diagnosed early
• I understand and am involved, so I make good decisions
• I get the treatment and care which are best for my illness and my life
• Those around me are well supported to care for me at home if this is where I want
to be and it is safe to do so.
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•
•
•
•
•
I am treated with dignity and respect
I know what I can do to help myself and who else can help me
I can enjoy life
I feel part of a community and feel inspired to give something back
I want to die well and to be offered choice about my place of care/death
Feedback loop
Integrated Community Health and Social Care Team - Out of Hospital Team
Lowestoft - KPIs:
A set of KPIs has been developed to reassure the commissioner that the Lowestoft OHT
is providing care timely and that the workforce capacity and skill mix within the team is
therefore appropriate:
-
-
Service User Experience - % of patients issued with a service user
Service User Experience – Provision of an action plan to address issues raised via
the service user questionnaires returned
% of patients urgently referred that are assessed within 2 hours
% of patients referred non-urgently that are assess within one working day
% of patients urgently referred receiving provision of Care within 1 hour of
assessment.
% of patients receiving care package within 12 hours of assessment
(Implementation of Provision of Care to Keep Patient Safe until Full care package
is implemented)
% of patients receiving care package within 12 hours of assessment where the
referral was non-urgent
% of Beds with Care MDT meetings where Out of Hospital team member attends
Participation in clinical audit in partnership with NHS Great Yarmouth & Waveney
CCG
Monthly Minimum Data Set (MDS):
Data is recorded on SystemOne by the Out of Hours Team resulting in a monthly
minimum data set:
-
Date and time of referral
Referral source
Registered GP
Reason for referral
For all urgent referrals; wait time for initial assessment
For all other referrals; wait time for initial assessment
For all urgent referrals; wait time for care package commencement
For all other referrals; wait time for care package
The data from the MDS enables the commissioner to identify trends in for example,
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referral numbers, reasons for referral, use of the service by different parts of the system.
In order to measure the impact on emergency admissions, data from the acute provider
is analysed to:
- Compare emergency admission rates from the Lowestoft area for current and
previous months / years
- Compare emergency admission rates from the Lowestoft area to the rest of Great
Yarmouth and Waveney
Finally, clinical audit of patients under the care of the OHT but who have also presented
as an emergency admission is undertaken to understand what triggered the admission
and whether the OHT could have behaved differently in the patients pathway of care.
Integrated EOL / Palliative Care - Outcomes will be measured through the monitoring
of:
• %of patients/carers reporting a positive experience of their care
• % of patients with a recorded preferred place of care/death
• % of patients achieving this preference
• A reduction in the number of inappropriate admissions in the last year of life due to
care package breakdown
• % of palliative patients with a key worker in both community and acute care
settings
• Minimum standards for timeliness of response to care package breakdown and
information sharing with generalist providers
• Provision of NICE compliant specialist palliative care services
• Evidence of the competence and confidence of generalist staff to provide safe and
effective palliative care.
What are the key success factors for implementation of this scheme?
Integrated Community Health and Social Care Team - Out of Hospital Team
Lowestoft - The following are identified as key success factors for implementation of the
Lowestoft OHT and action is in place to ensure these factors are robustly built into the
implementation and delivery of the scheme
Workforce Development:
- Generic workers with an extensive competency base to ensure an holistic
approach to care – there is a generic worker programme lead by our community
provider
- Skill mix within the OHT
- Moving to 7 day and 24/7 contracts of employment - underway
- Cultural shift to integrated working – there is ongoing organisational development
work within both East Coast Community Health and Suffolk County Council Adult
Social Care
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Access to the OHT:
- Easy to access service – single point of access in place
- Ability of service to respond quickly and appropriately – skill mix and capacity is
planned
- System knows how and when to access the service and understands what the
service can offer – the CCG and the providers have invested significant time in
introducing the scheme to the system
- That the service is available 24/7
Sharing Information:
- Co-location of the staff which make up the OHT – based at Kikley Mill, Lowestoft
- MDTs with general practice in the Lowestoft area – these take place
- Handovers between shifts and across the team – these take place
- Shared IT - adult social care within the OHT will have access to SystemOne
Integrated EOL / Palliative Care - The number of expected deaths per annum in GYW
is approximately 2,000 patients per annum (Marie Curie EOL Atlas 2010/11), so over
2 years we would aim to meet 80% of these 4,000 patients and their carers under the
new model of care.
Successful delivery of this model of care will also improve performance vs. the nationally
defined proxy measures associated with the QIPP challenge:
• The % of patients with an advance care plan
• The % of patients able to die in the care setting of their choice
• Improved patient/carer experience of care
• Reduction of the number of inappropriate admissions to acute care settings in the
last year of life.
Scheme ref no.
Scheme 6 - GYW
Scheme name
Urgent Care Programme
What is the strategic objective of this scheme?
Admission Prevention Service - To deliver integrated community care services that
reduce admissions and expedite faster appropriate discharge and reduce delayed
transfers of care
Thus enabling GYW CCG to achieve its strategic objectives of:
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-
Care closer to home
Reduction in emergency admissions to acute beds
The Admission Prevention Services will encompass Admission Prevention and Falls, and
will provide a community-based service to Service Users to enable them to live
independently and prevent admission to hospital.
The purpose of the service is to :
 Prevent admissions into hospital.
 Facilitate early discharge from acute and community hospitals enabling a prompt
supported recovery at home.
 Reduce admission to residential care.
 Reduce need for long term care package.
 Carry out aspects of a multifactorial falls assessment for people at high risk of falls
and injury
Admission Prevention will support Service Users at home and promote independence,
and will work with Norfolk and Suffolk Social Services to reduce avoidable admissions
into hospital beds (acute or community), and to facilitate early discharges, enabling
Service Users to make a prompt recovery at home.
Overview of the scheme
Model of care and support
The Service
Admission Prevention Services will provide a “one-stop shop” approach to service
provision, encompassing, but not limited to:
 A multidisciplinary team who will provide rapid assessment/planning and
reablement;
 Same day social care assessment;
 Same day equipment provision;
 Carer support; and
 Facilitating early discharge.
 Home Hazard/environmental intervention to reduce the risk of falls;
 Strength and balance training;
 Coping strategies and confidence building;
 Improving Service Users’, and their Carers’, confidence in their functional ability
and reduction in the fear of falling;
 Reducing the risk of Service Users being left for long periods incapacitated and
unattended following a fall (a “long lie”) (by, for example, encouraging the Service
User to utilise pendant alarm systems, or by teaching them techniques to get up
off the floor);
 Encouraging participation of older people in falls prevention programmes within
the community and through the exercise referral programme; and
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
Using a multi-agency, collaborative approach to falls management.
Care Planning/Co-ordination/Management
The Provider will plan, co-ordinate and manage care to:
 Develop, manage and review documented individually structured management
plans;
 Ensure access to a comprehensive range of services;
 Ensure the co-ordination of care across all agencies involved with the Service
User;
 Ensure that there is continuity of care and that Service Users are followed
throughout their contact with the treatment system;
 Maximise Service User retention within the treatment system and minimise the risk
of Service Users losing contact with the treatment and care services;
 Encourage Service Users who have dropped out of the treatment system to reengage and offer appropriate referral and sign-posting to services;
 Avoid duplication of assessment and interventions; and
 Apply best efforts to prevent Service Users “falling between services”.
Review of Care Plan
The Provider will review the individually structured management plan regularly and will
also review the Individually Structured Management Plans at the request of a healthcare
practitioner, the Service User or their Carer. The date of the next review meeting will be
set and recorded at each meeting. In any review of the individually structured
management plan, the Provider will consider:
 The relevance of the individually structured management plan;
 The effectiveness of the individually structured management plans/outcomes;
 Any unmet needs;
 Service User satisfaction with care;
 Treatment/Rehabilitation/Intensive support – Modality/Frequency of support/Team
Support;
 Activities of daily living / Social Care Support;
 Medication – how monitored/reviewed;
 Relapse prevention plans; and
 Risk assessment procedures and crisis/urgent response
The service is available across Great Yarmouth and Waveney 8am – 8pm, 7 days a
week. The service is delivered by 2 teams; one for the Great Yarmouth area and one for
the Waveney area. Both teams are co-located with other community staffing colleagues
and with colleagues from social care.
Staffing:
The service is led by qualified Occupational Therapists and Physiotherapists and
supported by generic Rehabilitation Support Workers.
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The Patient Cohort being targeted:
Persons referred to the service must:
 Be medically stable - an acute medical problem must have been assessed by a
GP or Community Matron in the previous 24 hours and a treatment plan
established.
 Give informed consent.
 Be an adult permanently residing and registered with a General Practitioner in the
Great Yarmouth and Waveney area.
 Have a need for a multidisciplinary team for crisis intervention, which can be met
within the community setting.
The Day Co-ordinator will contact you within an hour and request the relevant information
as highlighted within the referral guide.
On receiving a referral a member of the service will contact or visit the Service User
within 2 hours and carry out an assessment. They will liaise with the Service User and
relevant others to set up an action plan
Referrals will be accepted from any Health or Social Care Professional.
The service is not suitable for
 End of life care → consider Hospice at Home 01493 809977
 People unwell requiring hospitalisation for medical intervention
Eligibility Criteria for Facilitating Early Discharge
 Person must be medically fit for discharge.
 Person must be motivated and consent to the referral. The Service User must
have realistic aims about returning home and would benefit from active
intervention in one or more of the above areas.
If Service User is waiting for a long term care package a date must be identified, that is
no longer than 7–10 days wait.
The delivery chain
Commissioners – NHS Great Yarmouth and Waveney
Providers – East Coast Community Health
The evidence base
Urgent Care Programme - The Keogh report on the Urgent and Emergency Care
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Review sets out proposals for the future of urgent and emergency care services in
England.94 95 There are five key elements, all of which must be taken forward to ensure
success. The report suggests that we must –
 Provide better support for people to self- care.
 Help people with urgent care needs to get the right advice in the right place, first
time.
 Provide highly responsive urgent care services outside of hospital so people no
longer choose to queue in A&E.
 Ensure that those people with more serious or life threatening emergency care
needs receive treatment in centres with the right facilities and expertise in order to
maximise chances of survival and a good recovery.
 Connect all urgent and emergency care services together so the overall system
becomes more than just the sum of its parts.
The evidence base for change identified a number of areas for improvement within the
current system of urgent and emergency care in England.96 97 In summary:
 More people are using the urgent and emergency care system to access
healthcare, leading to mounting costs and increased pressure on resources.
 Overall fragmentation of the system means that many patients may not be able to
access the most appropriate urgent or emergency care service to suit their needs,
leading to unnecessary attendances and resource use.
 Poor access to social care being responsible for both emergency admissions and
poorly managed discharge resulting in re-admission or delayed transfers of care.
Accident and Emergency departments have seen a significant number of patients that
could be managed in other settings, adding to those with life-threatening conditions.98
One interpretation of this is that the new services are meeting a previously unmet need.
Alternatively, it could be that the increased provision has led to supply induced demand
and therefore increased uptake, or demand caused by a failure to intervene earlier in the
urgent and emergency care pathway or system.
Rising costs across urgent and emergency care services can be associated with
94
NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care
services in England - Urgent and Emergency Care Review, End of Phase 1 Report (2013).
http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf
95 NHS England (2013). Transforming urgent and emergency care services in England - Update on the Urgent and Emergency Care
Review (2014).
http://www.nhs.uk/NHSEngland/keogh-review/Documents/uecreviewupdate.FV.pdf
96 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care
services in England - Urgent and Emergency Care Review, End of Phase 1 Report, Appendix I – Revised Evidence Base from the
Urgent and Emergency Care Review.
http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV.pdf
97 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care
services in England - Urgent and Emergency Care Review End of Phase 1 Report, Appendix 3 – Summary of Engagement
Responses.
http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%203.Engage.Results.FV.pdf
98 Coleman, P et al (2011) Why do patients with minor or moderate conditions that could be managed in other settings attend the
emergency department?; Emergency Medicine Journal; 29: 487-491
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fragmentation of the current system of urgent and emergency care. This fragmentation
leads to confusion among patients about how and where to access the care they need,99
and many people are unable to navigate to the level of care appropriate to their condition,
leading to multiple calls or attendances and unnecessary use of A&E or ambulance
services.100 It is estimated that around three-quarters of A&E attendances relate to
serious or life-threatening conditions and about one quarter could have been treated
elsewhere.101 102 103 However there is variation between different A&E departments, with
deprived urban areas having the highest proportion of patients who did not require
hospital treatment.
Evidence suggests that patients’ experience of GP services, particularly when related to
ease of access, affects uptake and interaction with primary care. This affects the way in
which patients choose to access health care because patients that are not satisfied with
their GP practice are more likely either to resort to using urgent and emergency care
services for primary care needs; or only seek help when they become acutely ill,
increasing the risk of emergency admission.104
Urgent care services are highly fragmented and difficult to navigate causing many
patients to experience difficulty choosing the service most appropriate to their needs. 105
106 Variations in opening hours, clinical expertise, access to diagnostics and
nomenclature can lead to confusion and referrals to a number of urgent care services
within the same episode of care. This increases cost, delay and clinical risk and leads to
poor patient experience.107
The evidence base for improving urgent and emergency care in England indicates that
there is variation in access to primary care services across England leading to many
patients accessing urgent and emergency care services for conditions that could be
treated in primary care.108
99
NHS Alliance (2012) A practical way forward for clinical commissioners; NHS Alliance on behalf of NHS Clinical Commissioners
and sponsored by NHSCB (Now NHS England)
100 Bickerton, J. et al (2012) Streaming primary urgent care: a prospective approach; Primary Health Care Research &
Development; 13(2): 142-152.
101 Cooperative Pharmacy (2011) Reducing needless A&E visits could save NHS millions
102 NHS Networks (2011) New Choose Well Campaign
103 Self Care Forum (2012) Over 2 million unnecessary A&E visits “wasted”; http://www.selfcareforum.org/2012/10/30/over-2million-unnecessary-ae-visits-wasted/
104 The King’s Fund (2012) Data briefing: improving GP services in England: exploring the association between quality of care and
experience of patients
105 The King’s Fund (2011) Managing urgent activity – urgent care
106 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decisionmaking process; Emergency Medicine Journal
107 Primary Care Foundation (2011) Breaking the mould without breaking the system. Primary Care Foundation
108 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decisionmaking process; Emergency Medicine Journal
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There is a clear need to adopt a whole-system approach to commissioning more
accessible, integrated and consistent urgent and emergency care services to meet
patients unscheduled care needs.109
Falls Prevention - There have been a series of Cochrane reviews relating to falls
prevention.110 111 The most recent - a Cochrane review of 159 randomised controlled
trials of falls prevention interventions revealed that group and home-based exercise
programmes and home safety interventions significantly reduce rate of falls and risk of
falling, multifactorial assessment and intervention programmes significantly reduce the
rate of falls but not the risk of falling, and Tai Chi significantly reduces the risk of falling
but not the rate of falls.
The Cochrane reviews provide additional evidence on the following interventions:
a) Exercise for preventing falls
 Group and home-based exercise programmes, and home safety interventions
reduce rate of falls and risk of falling.
 Tai Chi reduces risk of falling.
b) Exercise for improving balance and physical functioning in older people
 Progressive Resistance Strength Training is an effective intervention for
improving physical functioning in older people, including improving strength
and the performance of some simple and complex activities. However, some
caution is needed with transferring these exercises for use with clinical
populations because adverse events are not adequately reported.112
 There is some evidence that some types of exercise (gait, balance, coordination and functional tasks; strengthening exercise; 3D exercise and
multiple exercise types) are moderately effective, immediately post
intervention, in improving clinical balance outcomes in older people.
c) Medications and medical devices
 Gradual withdrawal of psychotropic medication reduced the rate of, but not risk
of falling. A prescribing modification programme for primary care physicians
significantly reduced risk of falling.113
109
NHS England (2013). Transforming urgent and emergency care services in England. http://www.nhs.uk/NHSEngland/keoghreview/Pages/urgent-and-emergency-care-review.aspx
110 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls
in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI:
10.1002/14651858.CD007146.pub3
111 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review) 2010 The Cochrane
Collaboration.
112 The Cochrane Library. Falls Prevention and Balance in Older People. Available at:
2011.http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html.
113 Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem
Drugs Aging. 2012 Jan 1;29(1):15-30.
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
The effectiveness of the provision of hip protectors in reducing the incidence of
hip fracture in older people is still not clearly established. Poor acceptance and
adherence by older people offered hip protectors have been key factors
contributing to the continuing uncertainty.114
A Department of Health economic evaluation of fracture prevention services has
modelled that each hip fracture avoided will save on average over £12,000 for the NHS
and £3,879 for social care over two years, and an avoided fracture of the humerus, spine
or forearm will avoid over £5,000 for the NHS and over £200 for social care. Over a five
year period, the NHS and local authority social care save over £290,000, against an
additional £234,181 revenue costs, which nationally equates to a saving of £8.5 million
over five years. The model anticipates 797 fractures of the hip, humerus, spine or
forearm from a population of 320,000.115
Interventions for preventing falls in older people living in the community found potential
cost-savings when delivering falls prevention interventions to subgroups of people at high
risk of falling. The Otago Exercise Programme, involving people aged over 80, resulted in
fewer hospital admissions and therefore cost-savings.116 Salkeld et al found cost-savings
when delivering a home safety programme to participants with a previous fall117 and
Rizzo et al found cost-savings when delivering a multifactorial intervention of people with
four or more of eight risk factors.118
Desktop Research
The commissioners (both health and social) have thoroughly explored models in other
parts of the UK, which demonstrate successful working resulting in reduced emergency
admissions. Lessons learnt and best practice has been built into the Admission
Prevention Services model.
The commissioners (both health and social) have thoroughly explored models in other
parts of the UK, which demonstrate successful working resulting in reduced falls and falls
related admissions. Lessons learnt and best practice has been built into the Admission
Prevention Services model.
The CCG has undertaken extensive clinical audits, led by local GPs, of existing key
114
Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database of
Systematic Reviews 2010, Issue 10.
115 Department of Health (2009) Fracture Prevention Services: an economic evaluation.
http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fra
ctures.pdf
116 Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home
exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697-701
117 Salkeld G, et al, 2000:The cost effectiveness of a home hazard reduction program to reduce falls among older persons. Aust N Z
J Public Health. 2000 Jun;24(3):265-71.
118 Rizzo JA et al 1996: The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly
persons. Med Care. 1996 Sep;34(9):954-69.
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community services (community hospital beds, Community Matron Services and District
Nursing Services) to fully understand what works well, where challenges and barriers to
better care lay and to better understand the therapeutic and personal care inputs
required to empower patients to remain at home and be safe from risk of falling. This
detail informed the skill mix and competency base the admission prevention team.
Investment requirements
£1,569,000
Impact of scheme
This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
In conjunction with schemes 4, 5 and 7 this scheme will generate a total saving of
£556,010
The Admission Prevention Services will:
 Reduce length of stay in hospital;
 Reduce the risk of falls amongst Service Users;
 Reduce the number of fracture neck of femur, especially in female Service Users;
 Increase or maintain Service User’s independence in place of usual resident; and
 Service Users will be involved in decision making
Feedback loop
KPI:
LOC-011: % of referrals assessed within standard (APS). STANDARD: Assessed ≤ 7
working days from referral.
In order to measure the impact on emergency admissions, data from the acute provider
is analysed to:
- Compare emergency admission rates for current and previous months / years
Clinical audit of patients under the care of the admission prevention team but who have
also presented as an emergency admission is undertaken to understand what triggered
the admission and whether the admission prevention team could have behaved
differently in the patients pathway of care.
What are the key success factors for implementation of this scheme?
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The following are identified as key success factors for implementation of the Lowestoft
OHT and action is in place to ensure these factors are robustly built into the
implementation and delivery of the scheme
Workforce Development:
- Generic workers with an extensive competency base to ensure an holistic
approach to care – there is a generic worker programme lead by our community
provider
- Moving to 7 contracts of employment - underway
Access to the OHT:
- Easy to access service – single point of access in place
- Ability of service to respond quickly and appropriately – skill mix and capacity is
planned
- System knows how and when to access the service and understands what the
service can offer – the CCG and the providers have invested significant time in
introducing the scheme to the system
Sharing Information:
- Attendance at MDTs with general practices across great Yarmouth and Waveney
– these take place
- Handovers between shifts and across the team – these take place
- Joined up working with colleagues in social care and mental health – the APS
teams are co-located with colleagues from social care
Use of evidence based care for falls prevention
Scheme ref no.
Scheme 7 - GYW
Scheme name
Support for people with dementia and older people with functional mental health
problems living in the community
What is the strategic objective of this scheme?
To deliver specialist support to people with dementia and their cares to avoid / delay
admissions to hospital / care and provide assessment of on-going care needs.
Overview of the scheme
Dementia and complexity in later life community (DCLL) - A Community Mental
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Health Team for people with dementia and complexity in later life, offering specialist
assessment, diagnosis, treatment and care specifically to older adults with mental health
problems in their own homes and the community. They may provide a whole range of
community-based services themselves, or be complemented by one or more teams
providing specific functions. For example memory assessment.
The services provide a community focused resource for the residents of Great Yarmouth
& Waveney.
These are full multidisciplinary teams comprising nursing, medical, occupational
therapy/technical instructor & psychology staffing.
Interventions offered:
 Assessment and diagnosis of mental health problems including dementia
 Initiation and stabilisation of dementia treatment in accord with the shared care
protocol with primary care.
 Monitoring of mental health difficulties and agreed treatment plans
 Therapeutic interventions including; individual, family and group work
 Specialist psychology input
 Consultation to external agencies around mental health issues and the
management of challenging behaviour
 Diagnosis and treatment of other mental health issues other than dementia in the
CLL pathway
Referral and access to services is via Access and Assessment Team (AAT).
Service is provided 9am to 5pm, Monday to Friday.
Dementia Intensive Support Team - Dementia Intensive Support Teams (DIST) will
provide services in the community and in-reach into to acute hospitals to aid safe and
early discharge.
Service provided daily (7 days per week) 08:00 to 21:00
Service User Group covered
Adults with age related needs (usually, but not exclusively people over the age of 65
years) suffering from acute, severe and enduring mental health problems including
anxiety, depression, confusion (clusters 4 to 17) and adults of any age with dementia and
related behavioural problems (clusters 18 to 21).
Service users seen by the DCLL service will have complex age-related needs such as
physical frailty, multi-system pathology, and very poor mobility.
Geographical area covered
Service is provided across Great Yarmouth and Waveney CCG.
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The delivery chain
Commissioners – NHS GYW CCG
Providers – Norfolk and Suffolk NHS Foundation Trust, Norfolk County Council and
Suffolk County Council
Services can be accessed in the following settings:
Patients home; GP surgeries; Local Hospitals; Community Venues
The evidence base
Dementia Care - In a systematic review of RCTs, four out of six good quality studies
found that case management of dementia patients was associated with delayed or
reduced institutionalisation, although in one study this was only significant in one of three
countries studied. However, none of the good quality studies found evidence for savings
in healthcare expenditure or reduced hospitalisation rate/emergency visits. NHS
investment in early assessment services for people with dementia can produce
significant savings for social care, particularly in relation to residential care (National
Dementia Strategy – Impact Assessment – economic case for early assessment and
memory services).119
Intensive Case Management for Mental Health patients - A Kings Fund Paper in
2010120 on the research evidence around avoiding hospital admissions recommended
that commissioners and providers should consider implementing intensive and/or
assertive case management for people with mental health illnesses. This is most
effective when focused on patients with frequent hospital use and assertive case
management by multidisciplinary teams may reduce mental health admissions.
A Cochrane review of ‘Intensive case management for severe mental illness’ (2011)121
found that ICM is of value at least to people with severe mental illnesses who are in the
sub-group of those with high level hospitalisation (about 4 days a month in past 2 years)
and the intervention should be performed close to the original model.
Integrating Mental Health into Chronic Disease Management - There is a growing
evidence base that suggests that more integrated ways of working with collaboration
between mental health and other professionals offers the best chance of improving
outcomes for both mental health and physical conditions. There is also evidence that the
costs of including psychological or mental health initiatives within disease management
or rehabilitation programmes can be more than outweighed by the savings arising from
improved physical health and decreased service use.122
119
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf
Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010.
121 Intensive case management for severe mental illness (Review). Dieterich M, Irving CB, Park B, Marshall M. Wiley 2010.
122 The Kings Fund and Centre for Mental Health : Long-term conditions and mental health, Naylor et al 2012
120
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Integrated Care Pathways for Mental Health - An Evidence briefing (2011)123 produced
by the Centre for Reviews and Disseminations found that there is some evidence
suggesting that ICPs can reduce mental health hospital costs, most studies were not
conducted in the UK NHS.
Mental health promotion through early intervention in psychosis is thought to be costsaving for the NHS.124 This involves a multidisciplinary team with emphasis on an
assertive approach to maintaining contact with the patient and encouraging a return to
normal vocational pursuits. UK evidence shows it can reduce relapse and readmission to
hospital and improve quality of life.
Early intervention in psychosis (modelled on a target group of people aged 15-35 years)
is thought to save the NHS over £5 for every £1 spent within one year.
Crisis Resolution and Home Treatment for Mental Health patients (CRHT) - Crisis
Resolution and Home Treatment (CRHT) services for mental health patients have been
shown to decrease unplanned hospital admissions and length of stay. 125 126
The National Audit Office suggests that the NHS could save £12-50 million annually by
increasing the number of patients taking part in CRHT programmes.127 Integration of
CRHT or other community teams with inpatient staff can lead to reductions in bed use,
and this approach in Norfolk has led to annual savings of approximately £1 million.128
The clinical interventions are based upon NICE Guidelines.
The National Dementia Strategy (NDS) was supported by a full economic impact
assessment and it contains 17 objectives. Those objectives that are relevant to mental
health services have formed the basis of the service proposal’s objectives.
In the area covered by NHS Norfolk and Waveney there are over 15,000 people with
dementia but less than half of them are in receipt of a diagnosis. In other words more
than half of the people with dementia locally have no diagnosis and therefore no access
to treatment that can prolong their quality of life and independence, delay expensive
institutionalisation, and help prevent expensive episodes of unplanned care.
123
Evidence briefing on integrated care pathways in mental health settings. National Institute for health research. Sept 2011.
Knapp M, McDaid D, Parsonage M (eds) (2011). Mental Health Promotion and Mental Illness Prevention: The economic case.
London: Department of Health.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf
125 National Audit Offi ce (2007a). Helping People Through Mental Health Crisis: The role of Crisis Resolution and Home Treatment
services. London: The Stationery Office. Available at: www.nao.org.uk/publications/0708/helping_people_through_mental.aspx
126 Chiles JA, Lambert MJ, Hatch AL (1999). ‘The impact of psychological interventions on medical cost offset: A meta-analytic
review’. Clinical Psychology: Science and Practice, vol 6, no 2, pp 204–20
127 Howard C, Dupont S, Haselden B, Lynch J, Wills P (2010). ‘The effectiveness of a group cognitive-behavioural breathlessness
intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease’.
Psychology, Health and Medicine, vol 15, no 4, pp 371–85.
128 Department of Health (2009) partnerships for Older people projects final report. London. Department of Health.
124
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Investment requirements
£665,000
Impact of scheme
This scheme will impact on:
 Reduction in non-elective emergency admission
 Reduction in delayed transfers of care
In conjunction with schemes 4, 5 and 7 this scheme will generate a total saving of
£556,010
The key objectives will be met as a result of:
 Maintenance of functioning, independence and quality of life of people with dementia
for as long as possible
 Prevention of inappropriate admissions to acute and mental health care hospitals
 Prevention of or delaying admission to care homes, where appropriate.
 Early identification of people who might have dementia
 Early assessment and diagnosis.
 Early treatment and access to care.
 Support, information and advice for people with dementia and their carers
 Routine advanced care planning
 Appropriate review of patients and their carers
 Timely and appropriate support for carers
 Enhanced support for patients and their carers who are in crisis, at risk of admission
or who are already admitted to an acute hospital.
 To work with partners and wider services to ensure clear pathways and access to
wider support services, with the aim of improving patient outcomes and care.
 To work with AAT ensuring effective pathways from AAT to DCLL are done so in a
timely manner
 To discharge back to primary care as appropriate
Feedback loop
CQUIN goals
 Friends and Family Test
 Communication with GP
 DIST
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We have started to analysis the DIST data submitted by NSFT for the period April 2013 –
June 2014
What are the key success factors for implementation of this scheme?
With the recent public consultation on Dementia and Complexity in Later Life there
maybe changes to how the DIST and the older people’s services function. The final
decision on the recommendations and proposals will not be made until end of September
2014.
There are social workers within this service who are employed by Norfolk County Council
and Suffolk Council, so there is an element of integration and co-location. However, there
needs to be a move towards becoming part of the Out of Hospital Teams to ensure that a
more holistic and system wide approach is in place to support these complex
patients/service users.
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Annex 2 – Ipswich Hospital NHS Trust Commentary
(note text in boxes amended but unable to show highlighted as inserted as a pdf)
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Annex 2 - West Suffolk NHS Foundation Trust Commentary
Name of Health & Wellbeing
Board
Name of Provider organisation
Name of Provider CEO
Suffolk
West Suffolk NHS Foundation Trust
Dr Stephen Dunn
Signature (electronic or typed)
For HWB to populate:
Total number of
2013/14 Outturn
non-elective
2014/15 Plan
FFCEs in general
2015/16 Plan
& acute
14/15 Change compared to 13/14
outturn
15/16 Change compared to planned
14/15 outturn
How many non-elective admissions
is the BCF planned to prevent in 1415?
How many non-elective admissions
is the BCF planned to prevent in 1516?
19,944
17,630
16,386
2,313(-11.6%)
1,244(-7.1%)
0
640
For Provider to populate:
Question
Do you agree with the data
above relating to the impact of
the BCF in terms of a reduction
1. in non-elective (general and
acute) admissions in 15/16
compared to planned 14/15
outturn?
Response
The Trust supports the planned reductions of
non-elective admissions targeted through the
BCF, integrated in a wider programme of
pathway change aimed to keep people out of
hospital.
If you answered 'no' to Q.2
above, please explain why you
2. do not agree with the projected
impact?
n/a
Can you confirm that you have
considered the resultant
implications on services
3. provided by your organisation?
Yes – our current plan is predicated on a more
conservative reduction in non-elective demand
however we are supportive of the planned
reductions, are exploring further how we can
contribute to their achievement, and will reduce
our capacity in line with the reductions as they
materialise.
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Annex 2 - James Paget University Hospital Foundation Trust
Commentary
Name of Health & Wellbeing
Board
Name of Provider organisation
Name of Provider CEO
Suffolk
James Paget University Hospital Foundation Trust
Christine Allen
Signature (electronic or typed)
For HWB to populate:
Total number of
2013/14 Outturn
non-elective
2014/15 Plan
FFCEs in general
2015/16 Plan
& acute
14/15 Change compared to 13/14
outturn
15/16 Change compared to planned
14/15 outturn
How many non-elective admissions
is the BCF planned to prevent in 1415?
How many non-elective admissions
is the BCF planned to prevent in 1516?
9306
9329
9006
+23/ +0.2%
-323/ -3.5%
81
380
For Provider to populate:
Question
Do you agree with the data
above relating to the impact of
the BCF in terms of a reduction
in non-elective (general and
acute) admissions in 15/16
compared to planned 14/15
1.
outturn?
If you answered 'no' to Q.2
above, please explain why you
2. do not agree with the projected
impact?
Can you confirm that you have
3. considered the resultant
implications on services
Response
The Trust supports the planned reductions of
non-elective admissions targeted through the
BCF, integrated in a wider programme of
pathway change aimed to keep people out of
hospital.
The 3.5% reduction should result from the BCF
schemes. These have been designed to have
an impact across the whole system. We are
also anticipating additional system benefits
through internal transformational change within
JPUH.
n/a
Yes – however further analysis will be
completed across the system to quantify the
impact as schemes are further developed.
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provided by your organisation?
Our plan is predicated on a more prudent
reduction in non-elective demand.
This may enable planned reductions in capacity
as whole scale system change starts to take
effect, aided by the BCF schemes.
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