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North East
Lincolnshire
Care Trust
Plus
Geoff Lake
Lance Gardner
17 June 2010
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Where?............
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Overview of North East
Lincolnshire Care Trust Plus
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Population of 168,000
89 GPs and 34 General Practices
1,500 directly employed staff
4 Commissioning Groups
2010/2011 budget – NHS is £287 million and Adult
Social Care is £47 million
• 37 contracts for provision of health care
• 130 providers of social care
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CTP Developed in Context of…
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Male life expectancy – 75.9 years
(below national + regional average)
Female life expectancy – 80.8 years
(below national average)
49% of most deprived out of the 354
local authorities in England (2007)
24% of lower level super output areas
in North East Lincolnshire are amongst
the most deprived 10% in England
High teenage pregnancy rates
High level of smoking prevalence
Third worst area in England for alcohol
abuse
High dependency ratio
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Care Trust Plus
• Established September 2007
• Three elements:
─ Delegation of planning, purchasing and delivery of Adult Social
Care (Council to CTP)
─ Delegation of planning, purchasing and delivery of health
improvement (CTP to Council)
─ Development of Children’s Trust
─ Council as preferred provider of Community Child Health
Services
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Care Trust Plus –
Accountabilities
Adult Social Care
NHS Care Trust
Local Authority
Health Improvement
Children’s Trust
Commissioning
Board
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Characteristics of the CTP
• A health and well-being organisation
• Commissioning groups: front line integration
• An organisation rooted in its community
• Working as part of a wider care community
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CTP – Role and Functions
• Planning and purchasing of health and adult
social care - £320m
• Planning and purchasing at the level of the
individual, the locality and the population
• Contract management and procurement ie
contract consortia for main Acute Hospital
provider
• Delivery of community health and personal
care services
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CTP Current Provision
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Adult Mental Health services
Learning Disability
District Nursing and complex case management
Integrated Tier 2 services
Palliative Care and Specialist Nursing
Drug Intervention Programme
Meals on Wheels and transport services
Day Care – Older People and Physical Disability
Supported employment schemes
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Four Commissioning Groups
• Based on GP Practice populations
• Hold budgets for:
– Hospital care
– Prescribing
– Community nursing
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Care Management Teams aligned
Community nursing Teams fully aligned
Community membership scheme
Lay Boards
Integration
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Key Governance Issues
• Handling reserved matters
• Political representation
• The role of the Director of Adult Social
Services
• Communication and awareness
• Answering the difficult questions at the
start of the journey
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Joint Governance
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Legal Partnership Agreement
Three Year Strategic Agreement
Financial Risk Share Agreement
Continuing dialogue:
– Executive Officers Group
– Good Governance Group
– Performance Group
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Question 1:
what do you want us to focus
on?
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Integration as a Catalyst for
change & developing a focus on
outcomes
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The Integration Journey
Driving forces:
– Co-terminosity
– Greater and faster progress needed in delivering
better outcomes
– Long and strong history of collaboration
– Local stability within the NHS system
– High trust relationships amongst local leaders
– Strong sense of place and sound financial
performance
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The Integration Journey
Key challenges:
– View of the region and DoH
– Robust but lengthy application process
– Building local political and lay member
support
– Managing the impacts of organisational
change
– Building on belief rather than hard
evidence
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The Integration Journey
Putting in the building blocks:
– Harmonisation of terms and conditions
– Working alongside as a precursor to
integration
– Integrated management structure and
integrated support services
– Developing a new language
– Commissioning Groups at the heart of the new
organisation
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The Integration Journey
• Development of whole system thinking
• Integration driven at the strategic,
tactical and individual level
• Broader ownership and greater
influence eg Carers
• A wider set of levers deployed
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Question 2:
is integration a realistic option for
you?
• What does integration look like for you
locally and why?
• What would you need to do to become
fit for purpose?
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The Model of Delivery
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Integrated Care Model
NHS funding
and regulation
Interventions
General population
Regeneration
Citizenship
Neighbourhood
Information access
Lifestyle
Practical support
Prevention
Personalised
Housing
Low to moderate needs
Children's Trust
Extended primary care
Intermediate care
Early intervention
Transport
Substantial needs
Enablement
Community support
Institutional avoidance
Acute
Complex needs
Specialised
Shifts in
investment
Timely discharge
Outcomes
(Financial sustainability, user experience, quality)
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Increasing numbers
Increasing cost
Whole System Partnership
Escalating complexity related to
fees, related in turn to
competency of workforce
Public bodies, accessibility and
citizenship
Emerging tiered
approach
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Community Clinical Activity
Tier
Health Duties
Social Care Duties
Health Professional
Social Care
Market / Provision
Eye Drops
Bloods
Clexane – PGD
Insulin – PGD
Hygiene
Nutrition
Shopping
Cleaning
Health Support (Band 3) 2
in each CG but centrally
supervised by Band 5
Nurse
Basic care any Lay carer
could reasonably perform
Home Care Worker
(Bands 2 & 3)
Night Sitting
Day Services
Meals on Wheels
Maintenance of Activities
and Daily Living
Community Nurse (Band 5)
Health Support (Band 3)
Providing
health
maintenance
and
prevention services
Home Care Worker
(Bands 3 & 4)
Assistant Practitioner
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Continence Assessments
Stoma Care
Bowel Care
Basic Leg Dressings
Nutrition
Ear Syringing
Health Advice Promotion
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Long Term Conditions
Complex Leg Dressings
Palliation
Drains
PEG’s
Invasive Procedures
Intensive Home Support
Bathing
Nutrition
Passive Therapies
Case Manager (Band 6)
Tier 3 becomes transitional
tier with people moving
from
maintenance
to
increased need, and from
complex
care
to
maintenance
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Multiple Long Term
Conditions
Complex Palliation
Dementia
Severe Disability
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Complex
Case
Management (Band 7)
Part
of
the
broader
Complex
Care
Management Team
3 Band 7’s in each CG
Advanced Practitioner
Social Care
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Emerging Achievements
Reshaped Intermediate Tier
- Re-ablement
- Integrated menu of choice
- Rapid Response
- Workforce profile
Long Term Care
- Improvement in standards
- Placement policy
- Responsiveness and partnership
- Range of support
- End of Life
- Dementia mapping
- Infection control
- Targeted improvements
A3 Single Hub:
- multi-function (Sept.) 00 Hours
- Solution not service
- Keeping individuals out of the labyrinth
- No door is the wrong door
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• Complex Case Management
- Kaiser principles
- ASC; the axis of ‘three’
- 5% + 20%
- Single resource
• Dementia
- Social model of disability
- De-medicalise
- Systemic
- Memory service not clinic
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CTP: Emerging Benefits
• Significant increase in quality ratings of
Care Homes
• No direct admissions to Care Homes
from hospital
• Redesign of Tier 2 services – reduction
in hospital admission
• Doubling the number of people helped
to live at home
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CTP: Emerging Benefits
• Use of co-production models for health and
personal care
• Philosophy of normalisation developing within
front line teams
• Broader set of PIs and standards in contracts
reflecting total care issues
• Cost shunting ie NHS continuing care,
transitions
• NHS funding of care substitution
• Management of winter pressures/incidents
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CTP: Emerging Benefits
• 35% reduction in formal social care
referrals
• Greater focus on prevention and
re-enablement driving redistribution of
resources
• Use of integrated care to reduce costs and
improve quality for those with the most
complex needs
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Reflections
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MEANS AND BENEFITS
(i) Integrated Commissioning
Single resource
• Single outcome framework
- qualitative
- quantitative
• Market shaping: whole system
- broader methodology
- personalisation
• Availability and Responsiveness
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ENABLERS
• Breeding leaders and believers
- confidence
- breaking the rules
- doing it differently
- devolving responsibility
• Visible and sustained communications
• Individual not ideology
• Single workforce
- competencies
- pay
- supervision
• Shared care record
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• Doing the ‘knitting’ consciously
- Long-term care
- Support at home
- Neighbourhood
- Tiers
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A Parallel Journey
Adaptive and flexible ‘means to an end
not an end’
‘Care’ not health, not social care
Managers out of their comfort zone
Separation and evolution
- Social Enterprise
- Integrated Commissioning
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ADULT SOCIAL CARE: some messages
• Insistent and Assertive
• Establish credibility
- internal
- external
• Strategic interpretation for the NHS
• Single outcome framework (make the
pool work)
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• Performance
- ASC:
• New leaders and managers
• New practitioner philosophy
• Branding
• Saying goodbye to some
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Key Messages
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Key Messages
Make outcomes the goal and all else
the servant
Combine entrepreneur behaviour with
business modelling
Integrated Commissioning driving
integrated delivery
Identify, sustain, encourage new
leaders: model the value systems
required
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Current Barriers to Personalisation
• The regulatory system
• Political see-saw
• Cultural indoctrination
• Eligibility
• Traditional ‘workforce’ practices
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Financial Approach
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Managing Resources
Clear and explicit documentation for each
budget that sets out:
─ Which partner is accountable
─ Which partner is responsible
─ Who funds the risks that arise in-year
and the approach to recurrent resolution
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Establishing Partnership Budgets
• Use 3 year costs and trends to inform
partnership budgets
• Formally agree how the budgets will be
negotiated going forward (cost
pressures, inflation, savings, investment
priorities)
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Moving to Pooled Budgets
• Understanding each partner contribution
but loss of identity on spend
• Need to have built sufficient trust
• Able to demonstrate accountability and
delivery to everyone’s satisfaction
• The services really need it
• Start small
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Language and Culture
• Need a common language and process/
approach for:
– Assessing and demonstrating VFM
– Reshaping the use of resources to support
delivery of priorities and outcomes
• Transparency and trust need to be in place
between the DOFs
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Language and Culture
• DOFs need to meet regularly and take a
lead in strategic financial management,
setting the tone of the overall financial
relationship and unblocking problems
• Expect to learn from each other and be
open to this
• Sharing teams and TUPE of back office
staff really does help
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Use of Shared Services
• Reduces costs eg Council could reclaim VAT
on community equipment purchases but the
NHS couldn’t
• Make best use of existing expertise/systems
- debt collection
• Can add assurance: use of LA internal audit
service for Adult Social Care services
• Reduce residual costs: £800k of back office
services bought from the Council
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Leadership is the
capacity to translate
vision into reality
Warren G Bennis
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