Better Care Fund planning template – Part 1
Please note, there are two parts to the template. Part 2 is in Excel and contains metrics
and finance. Both parts must be completed as part of your Better Care Fund Submission.
Plans are to be submitted to the relevant NHS England Area Team and Local
government representative, as well as copied to: [email protected]
To find your relevant Area Team and local government representative, and for additional
support, guidance and contact details, please see the Better Care Fund pages on the
NHS England or LGA websites.
1)
PLAN DETAILS
a) Summary of Plan
Local Authority
Royal Borough of Windsor and
Maidenhead (RBWM)
Clinical Commissioning Groups
Windsor, Ascot and Maidenhead CCG
(WAM CCG)
Bracknell and Ascot CCG
The Royal Borough of Windsor and
Maidenhead covers Ascot. There are
five practices in Ascot, three of these
are members of Bracknell and Ascot
CCG (population just under 24,000)and
two members of Windsor, Ascot and
Maidenhead. Bracknell and Ascot CCG
is a member of the Health and Wellbeing
Board and has signed up to the Joint
Health and Wellbeing Strategy. They
have been involved in discussions
about the BCF for the benefit of Ascot
residents. WAM CCG also includes a
small practice in Buckinghamshire and
has 12,000 local people registered in
Surrey. The CCG has received a BCF
allocation for Surrey.
Boundary Differences
Date agreed at Health and Well-Being
Board:
Interim draft plan agreed 16 January
2014 with agreement that further
changes would be made prior to 14
February submission.
Date submitted:
14.02.2014
Minimum required value of ITF pooled
N/A
budget: 2014/15
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2015/16 £8.47m
Total agreed value of pooled budget:
£3.619m
2014/15
2015/16 £8.47m
b) Authorisation and signoff
Signed on behalf of the Clinical
Commissioning Group
By
Position
Date
Windsor, Ascot and Maidenhead CCG
Dr Adrian Hayter
Clinical Chair
<date>
Signed on behalf of the Clinical
Commissioning Group
By
Position
Date
Bracknell and Ascot CCG
Dr Jackie McGlynn
Director
<date>
Signed on behalf of the Council
By
Position
Date
Cllr Burbage
Leader
<date>
Signed on behalf of the Health and
Wellbeing Board
By Chair of Health and Wellbeing Board
Date
Cllr Coppinger
<date>
c) Service provider engagement
Please describe how health and social care providers have been involved in the
development of this plan, and the extent to which they are party to it
Our plans flow from our Joint Health and Wellbeing Strategy which was widely consulted
on amongst local people and providers and sets out the outcomes we aspire to for our
residents. Health and social care providers have been engaged in the process of
developing the plan as a natural progression from our integrated engagement with them.
A range of other communication and discussion mechanisms are also in place:

A Health and Social Care Professional Leaders Group has been established
across three CCGs to engage providers and commissioners in long term strategic
planning across a wider geographical area.
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There are monthly discussions between Windsor, Ascot and Maidenhead CCG
(WAM CCG), Local Authority and Community and Mental Health Provider about
future plans for community services which have informed these plans.

The Kings Fund have been supporting the development of the integration agenda
and have undertaken interviews with NHS providers about the development of our
joint approach. These interviews have influenced our approach and engagement
with providers.

The recent development of integrated primary care teams including health and
social care have provided an excellent opportunity for co-production and
discussion.

There are a number of whole system groups which include acute trusts and the
Ambulance Trust e.g. Capacity Planning Group, inter pressures working groups, at
which these plans have been discussed.

Healthcare providers including the South Central Ambulance Service,
Heatherwood and Wexham Park NHS Foundation Trust (HWPFT), Berkshire
Healthcare NHS Foundation trust (BHFT) and Buckinghamshire Healthcare Trust
(BHT) attend monthly Urgent Care Programme Group meetings with the Councils
and CCGs.
The meetings have focussed on redesigning the urgent and
emergency care system focussing on access, patient flow through the hospital and
discharge, especially for frail elderly patients. The group have signed up to a 7 day
service innovation proposal and an Urgent and Emergency Care Recovery Plan
as part of their work. Learning and development of the system through this group
has been incorporated into discussions on the Better Care Fund (BCF).

Royal Borough of Windsor and Maidenhead (RBWM), supported by WAM CCG,
have been working on an outcome based commissioning project for home care
and this has included discussion with homecare providers about the ‘eyes and
ears’ project.

The Better Care Fund is being discussed with all NHS providers as part of contract
and commissioning intentions meetings.

Social care providers are being engaged through the Provider Forum.

A successful protected learning time session with general practices was held on
21 November 2013. This was dedicated to the integration agenda and received
excellent feedback from practices. Berkshire Healthcare Foundation Trust were
also invited to this event.

A successful event was held on 23 January 2014 with all stakeholders including
patients, local NHS and voluntary sector providers to develop the frail elderly
pathway. This was part of the Better Value Healthcare programme, led by Sir Muir,
Gray and received very positive feedback on the work we intend to develop
locally.
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d) Patient, service user and public engagement
Please describe how local people, service users and the public have been involved in the
development of this plan, and the extent to which they are party to it
There was extensive consultation with the local population in 2012/13 on the
development and final version of the Joint Health and Wellbeing Strategy, from which this
plan flows. The Joint Health and Wellbeing Strategy and Joint Strategic Needs
Assessment have informed the priorities for the BCF. Healthwatch is a member of the
Health and Wellbeing Board which signed off the Health and Wellbeing Strategy. It also
builds on previous work that had been undertaken with the public on developing
commissioning strategies and the personalisation agenda. A series of other events and
discussions have also taken place:
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The integration agenda has been discussed at the Older Persons Action Forum.

A wider engagement exercise took place at the end of January to develop our joint
commissioning strategy and BCF. This included Partnership Boards, Healthwatch
and a number of other stakeholders. Support was given for our joint vision and
people identified the benefits of our joint approach.

A successful event was held on 23 January 2014 with all stakeholders including
patients, local nhs and voluntary sector providers to develop the frail elderly
pathway. This was part of the Better Value Healthcare programme, led by Sir Muir
Gray and received very positive feedback on the work we intend to develop
locally.

Our joint vision statement has been tested out with the WAM CCG patient
experience group.

The Community Partnership Forum has membership from the three Unitary
Authorities in East Berkshire, patient representatives, Healthwatch, CCG Clinical
Chairs and Patient and Public Involvement Lay members. The meetings are open
to the public to attend and a range of issues are discussed. The Better Care Fund
has been discussed at the November and January meetings with questions and
debate about the opportunities offered.

A cross-Berkshire event took place to engage adults with learning disability and
their carers. This was an opportunity to share experience and to draw themes for
improving the patient and user experience for this group in the community whose
needs are both health and social care.

The CCGs are working with the Royal Borough of Windsor and Maidenhead to
raise awareness and engagement in our strategy and the Better Care Fund. A
campaign is being planned using the local authority newsletter that is delivered to
every household in the Borough and via the local media.
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
Plans are also being made to jointly host a public event to explain what the Better
Care Fund will do and provide an opportunity to share experience and suggestions
for improvements that could be achieved.
We believe that there is real strength in GPs and Councillors engaging with local people
as they are embedded in their communities are well placed to understand the resources
available. If this is supported by public health we can build on the Royal Borough’s
commitment to innovative approaches for Big Society projects at a local level.

Engagement on the Call to Action is in progress and will include specific focus
groups for people with long term conditions and their carers. The CCGs and
Royal Borough are developing a joint communications and engagement
campaign, led by local Councillors and GPs.
e) Related documentation
Please include information/links to any related documents such as the full project plan for
the scheme, and documents related to each national condition.
Document or information title
Synopsis and links
Prevention strategy
The strategy describes our local approach to
the prevention agenda and joint action that
will be taken as a result of this. We have
already jointly commissioned a prevention
service as a result of this. This is a draft
strategy and will be signed off in March 2014
by both organisations
Falls strategy
This is a draft strategy and will be signed off
in March 2014 by both organisations. It
describes our local approach to fall
prevention.
We have already jointly
commissioned a joint falls service in
conjunction with the prevention service.
Integrated Primary Care Team project
documentation
During 2013/14 we set up integrated primary
care teams which include health, social care
professionals and GPs to have case
conferences for those most at risk of hospital
admission. These documents demonstrate
the progress of this joint venture.
Care homes project documentation
This is a joint project to improve the quality
and experience in care homes.
These
documents demonstrate the progress of this
joint venture.
Dementia Challenge Fund
Dementia challenge fund and capital
documentation
RBWM has been awarded £847,000 from the
Department of Health’s Dementia-Friendly
Environments Capital Investment Fund, to be
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used in the 17 care homes registered with the
Care Quality Commission for dementia. The
aim is to give a high standard of care across
the Royal Borough by improving three main
areas:
signage,
interaction
with
the
environment and bathrooms & toilets. A best
practice assessment toolkit issued by the
Kings Fund has been used to identify the
work to be carried out, and the project
includes innovative use of Rempods (portable
reminiscence environments) and My Life
Software.
Joint Strategic Needs Assessment
The JSNA includes a range of quantitative
and qualitative evidence looking at specific
groups, like hard to reach groups, as well as
wider issues that affect health such as crime,
community safety, education, skills and
planning. The Joint Strategic Needs
Assessment (JSNA) is the means by which
we assess the current and future health
healthcare and wellbeing needs of the local
population in Windsor, Maidenhead and
Ascot. It is an assessment of local, current
and future health and social care needs that
could be met by local authorities, Clinical
Commissioning Groups (CCGs), the NHS and
other partners. It will inform Windsor and
Maidenhead's Joint Health and Wellbeing
Board, which has a duty and responsibility to
identify key priorities to improve the Health
and Wellbeing for people living in Windsor,
Maidenhead and Ascot. The Health and
Wellbeing Board produces a health and
wellbeing strategy which is based on the
needs identified within a JSNA.
Health and Wellbeing Strategy
The Joint Health and Wellbeing Strategy
(JHWS) has been co-produced by all partners
and with local people. It sets out our three
overarching priority themes and the actions
by which we will deliver specific outcomes for
local people to improve health and wellbeing.
We will operate in partnership under the
agreed shared principles contained in the
document
http://www.rbwm.gov.uk/web/jhws.htm
This document describes our whole system
approach to dealing with the winter
pressures.
A joint strategy between health and social
Winter plan
Draft Carers Strategy
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care is being scoped and consulted on in
preparation for 2014. This will ensure that
carers are supported to receive services that
enable them to keep caring
7 Day working pilot documentation
Pioneer bid
Intermediate care review
This sets out our bid to pilot seven day
working
Both organisations were keen to gain Pioneer
status. This document sets out our proposal
for this.
This review has not yet been signed off but
will be by the end of February 2014.
Better Home Care Commissioning
RBWM have developed a new model for
homecare that focuses on commissioning
outcomes for people and increasing their
independence and continuing with a
reablement focus, rather than focusing on a
traditional time and task model. This model
has health integration as part of the model
that prevents health conditions deteriorating
with an eyes and ears approach from the
homecare service.
Bid for funding to Thames Valley
Health Education
This document sets out a joint bid for
workforce development focussing on the
integration agenda.
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2)
VISION AND SCHEMES
a) Vision for health and care services
Please describe the vision for health and social care services for this community for
2018/19.
 What changes will have been delivered in the pattern and configuration of services
over the next five years?
 What difference will this make to patient and service user outcomes?
Our Vision
We have built our integrated vision on the bedrock of the Health and Well Being Strategy
and supported the leadership for this vision through a series of workshop events
facilitated by the Kings Fund.
In Windsor, Ascot and Maidenhead you will be supported to remain active in a safe
and caring community allowing you to live a fulfilled life as independently at home
for as long as possible. When you need care you will only have to tell your story
once to access the support you need. You will have access to information and
services that guide you to make the right choices for you about services.
The changes being planned will result in the following:
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Care being led by the person and involving their family and carers. Conversations
should always start with ‘what is important to you’ and services will come to
people.
Older people continuing to feel part of a community and providing them with
opportunities to ‘give back’ their time and skills, thus promoting mental wellbeing
and enabling them to live a full life
Socially isolated people will be encouraged to become more active by the
community reaching out to them
Promoting understanding and the development of a caring community through
cross generational activities
One point of contact and information sharing between organisations so that people
do not have to tell their story more than once and can access information about
the right services for them
Promote the use of technology to support families, carers and care professionals
to work together effectively
One person who will work with people to understand their choices
Supporting older people to remain active, age well and remain fitter for longer
through the use of leisure facilities and community events and networks
Having a comprehensive and responsive spectrum of care available which does
not rely on institutional care
Recognise everyone desires to be as independent as possible and we will do all
we can to support that wherever you live.
What Phyllis wants
We will use the story of Phyllis to describe the changes that seek to make:
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Phyllis is 85 years old and her husband died two years ago. She suffers from arthritis,
chronic obstructive pulmonary disease and ischaemic heart disease. She sits in her
sitting room, with the television on in the background at high volume with the tv remote
control at her side. She has magazines and papers all around her and pictures of
grandchildren who live elsewhere in the country. She also has a notepad beside her
phone in large writing with lots of telephone numbers on it. This is her world.
It seems that she is isolated, vulnerable, confused and possibly has dementia. She tries
to cook for herself. She regards herself as very independent. But is she on the verge of
deteriorating and falling into institutional care.
We currently have a number of people in the social care and health system who could
provide some support to Phyllis: district nurses, occupational therapists,
physiotherapists, carers/ domiciliary care workers, GPs, out of hours services, social
workers, community psychiatric nurses and hospital specialists.
What Phyllis wants:
A simple, single point of contact – she does not want one number for the nurses, one
number for the GP, one number for social services. The list of numbers is getting
confusing.
Responsive services – when she has the need, she wants it met now. She cannot wait a
long time.
She wants to tell her story only once.
She wants people who see her to talk to each other, so that those who look after her
know about her needs and make the best decision for her as her needs arise.
We aspire to change things for Phyllis and people like her – to identify what adds value to
her and stop the things that don’t. ‘We want to make the right thing to do the easiest
thing to do’.
Health and Wellbeing Strategy
Through the Joint Health and Wellbeing Strategy (JHWS), we have three shared priority
themes and actions to underpin delivering the right care in the right place at the right
time. The three themes are:
1 – Supporting a healthy population
2 – Early intervention and prevention
3 – Enable local people to maximise their capabilities and life chances
The JHWS has specific actions that demonstrate the way that each theme will be met
and highlights our shared principles for action, which puts the health and wellbeing of
people at the heart of the service.
Service Configuration
The CCGs and RBWM have deployed the existing Section 256 money to support the
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integration agenda and we start from a strong position to undertake a more radical and
transformational approach to services in the community. We will build on our excellent
track record of delivering integrated services such as our Joint Intermediate Care
Services (known as Short Term Support and Re-ablement) and Integrated Primary Care
Teams. Jointly commissioned services such as the early intervention & prevention
service and community equipment service will continue to be developed and enhanced,
supporting local people to maximise their health and wellbeing status. We will focus on
commissioning outcome based services and improve quality together, by managing
provider relationships effectively.
Our joint and innovative Quality in Care Homes
programme (recognised by NHS Clinical Commissioners in ‘Taking the Lead – how
clinical commissioning groups are changing the face of the NHS’) has demonstrated
success in this arena and an impact on hospital admissions. This will be extended to
encompass those living in sheltered housing during 2014/15.
Our commissioning
strategy encourages structures of cooperation between providers to maximise service
effectiveness and efficiency and demonstrate real improvements to our population. This
is likely to mean an increasing number of integrated commissioning service specifications
and the appointment of lead providers across health, social care and voluntary sector
provision.
GPs will play a key part in supporting people with multiple long terms conditions and the
frail elderly. The CCGs are developing a primary care strategy in conjunction with NHS
England this may mean a different approach from GP practices as providers which aligns
more to the Health and Wellbeing strategy and meeting its objectives. It is likely that GP
practices shall need to deliver services beyond their General Medical Services contract
and this has been signalled in the NHS Operating Plan which signals that additional
investment will be needed to achieve this. There are already plans in place for 2014/15
to identify a GP in every practice with dedicated time to identify those patients most at
risk of admission to hospital and provide more intensive support to these people in
conjunction with the integrated primary care teams.
Good progress has been made in the development of our integrated primary care teams
and a review is to be undertaken by the Kings Fund imminently to identify how these
teams and case management should develop further to support a wider cohort of
patients. Patients receiving this approach will be supported by telehealth and telecare
where it can benefit them.
Our plans for home carers becoming the eyes and ears of health, supporting people in
their own homes and providing early warning of escalation of health issues will support
people in their own homes and earlier intervention in health crises. This alongside the
early intervention, prevention and falls service that we have jointly commissioned from
the existing section 256 support our Prevention Strategy.
We have undertaken a joint review of intermediate care services and this will inform the
deployment of investment from the Better Care Fund into intermediate care during
2014/15. Consideration will be given to extending the existing 24/7 crisis response
service to develop a more integrated and efficient model with community health services.
Enhancing the team to support those with dementia, mental health and a learning
disability will also form part of the plan. As a result of the recommendations of this review
we are likely to review our commissioning specification to reflect a more integrated
service, potentially commissioned through a lead provider and integrating a number of
services that have been developed with the support of existing and future joint
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investment. Integration of community geriatrician support into these services will provide
a more comprehensive response to local people.
We will bring together professionals around the patient via innovative use of technology
at the point of care. Integration will foster innovation and we will work together through
the Health and Wellbeing Board to ensure that service developments are optimised.
We will underpin all of this with joint organisational development and working with front
line staff to develop a culture of person centred integrated working. This is set out in our
bid to Health Education Thames Valley. We recognise that without the commitment of
those providing care to work differently, our vision will not be delivered.
Difference to Communities
We will also seek to maximise the potential of local community and voluntary sector
organisations. As a Big Society innovator, we have demonstrated the success of
communities coming together to support outcomes outside of statutory services, such as
through the Carebank Scheme. We will continue to empower communities to meet their
local needs and enhance outcomes from a “bottom up” approach.
On a population level we will invest to reduce hospital admissions; improve the
experience of health and social care; reduce, delay or remove completely the need for
statutory services and over the correct support at the right time.
This is what people have said to us that they would like to see:
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better services
their story once
encourages service providers to take responsibility
more planned and personalised care
care coordination linking Health & Social Care
early intervention
less duplication
better health outcomes
cost efficiency
We will track the benefits of our programme of work under these headings so
that we can continue the conversation with local people.
Difference to Individual Outcomes
We will focus our efforts on supporting people to remain safe in their own homes, identify
people early where their condition is deteriorating and provide rapid support to them and
provide support to carers. Increasing quality of life and adding life to years is essential
to optimise wellbeing. We will support people to understand their circumstances through
ensuring they have the information they need to manage, having confidence in self care
and their own skills. This will extend to self funders who make up a large proportion of
our local population. As essential partners, families and carers needs are fully
acknowledged and will be addressed through the implementation of our joint Carers
Strategy.
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We aspire to make a difference to local people and service users so that that they will be
able to state that:
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I can plan my care with people who work together to understand me and my carer
(s). This will give me control and confidence that I have the support to manage
crises, and bring together services to achieve the outcomes that are important to
me.
Care services are built around me and my individual circumstances, I am not just
involved in my care planning, I lead it.
My local community has networks of support that I can access and local
organisations offer suitable support.
Where I live is suitable for me, I am safe and well.
All of my experiences have been dignified and respectful.
Difference to Staff
As a part of integration, we are committed to supporting staff across the sector to develop
and innovate. We will look at up-skilling staff across health, social care and wider
services through a shared workforce development strategy that focuses on the
experience of the person.
People working in health and social care will be saying that:
“I am committed to achieving better outcomes for the people I care for and am inspired to
work with local leaders to provide better care”.
“Who Cares, We Care, We Want Better Care”
b) Aims and objectives
Please describe your overall aims and objectives for integrated care and provide
information on how the fund will secure improved outcomes in health and care in your
area. Suggested points to cover:
 What are the aims and objectives of your integrated system?
 How will you measure these aims and objectives?
 What measures of health gain will you apply to your population?
Aims and Objectives
We will initially focus the Better Care Fund on the frail elderly but will apply a similar
approach in the medium term to focus on mental health, learning disability and children’s
services.
As reflected in our Joint Health and Wellbeing Strategy (JHWS) our aims and objectives
for integration services are:
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That people have a seamless experience of health and social care services.
Outcomes for individuals are improved, through being met or exceeded.
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We work together as one to reduce health inequalities and support independence
through shared actions
To have efficient and effective integrated services
Support improvements for the wider determinants of health that influence health
status and wellbeing
Have aligned, streamlined and holistically connected services with the resident /
patient at the centre
To deliver the themes of our Joint Health and Wellbeing Strategy and our shared
priorities and actions
We will achieve this through:
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Joint leadership and governance
Engagement of local people in designing services for the future
Working with health and social care staff to develop an integrated culture
Being open about sharing information whilst keeping personal records secure
Commissioning jointly and effectively for improved outcomes through coordinated
service developments
Supporting community providers to offer choice and local services
Investing in the infrastructure which supports integration and is the foundation for
the future.
Measurement of the Aims and Objectives
These will
comparison
programme
dashboard.
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be measured through a combination of existing measures to provide
from an established and authoritative baseline. We will develop a BCF
dashboard/ balanced scorecard using the learning from our Care Homes
We intend to measure our success under four domains:
health gain (measured through the outcomes frameworks)
wellbeing (measured through a range of surveys and outcomes frameworks)
efficiency (measured by spend and activity)
leadership and staff satisfaction (measured by staff surveys, success of
organisational development initiatives).
Resident, patient and staff surveys, contract reports and outcomes framework measures
will be the foundation of demonstrating that aims have been met. They will be monitored
through our joint governance structure which reports to the Health and Wellbeing Board
(which meets in public) demonstrating our commitment to transparency and
accountability. We will share our progress with local residents as part of our continuing
narrative.
c) Description of planned changes
Please provide an overview of the schemes and changes covered by your joint work
programme, including:
 The key success factors including an outline of processes, end points and time
frames for delivery
 How you will ensure other related activity will align, including the JSNA, JHWS,
CCGs commissioning plan and Local Authority plan/s for social care
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We will consider pooling more resources in 2015/16 – a long list of potential services is
being produced and will be subject for further discussion during the first quarter of
2014/15 to test feasibility.
We intend to develop new services and build on successful existing services to ensure
that the savings and outcomes are achieved. This is a draft list but all of these projects
are currently being assessed.
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The development of an effective staffing infrastructure to develop monitor and
quality assure services between the two organisations. April 2014
The development of an integrated information system for caseload management
and to ensure that people only tell their story once is developed across health and
social care to ensure that outcomes are delivered. March 2015
Further development of the integrated primary care teams and the Rapid
Assessment Community Clinic to provide a cohesive and integrated approach to
the frail elderly and those with long term conditions. June 2014
An enhanced integrated telecare and telehealth service. June 2014
Investing in the jointly funded Short Term Reablement and Support service to
enhance the existing service to meet 7 day a week service requirements and the
need for additional OT and Physio input. June 2014
Enhancement of the quality of care that those living within sheltered
accommodation receive at the same time as developing successful improvement
of quality of care in care homes work already underway as a joint initiative.
September 2014
Meeting the increased demographic pressure of those with Dementia by providing
preventative schemes such as the Dementia advisor. June 2014
To develop the existing jointly funded Prevention service Keep Safe, Stay Well
service that is focused on falls prevention and other ways to prevent acute
admissions. Ongoing throughout 2014.
Continuation of successful winter pressures schemes such as Home from Hospital
and an in reach service to Wexham Park Hospital. April 2014
Workforce development to secure the cultural change that will be required to
develop truly integrated services and ensure a local workforce that can deliver the
agenda. This will include the development of new roles, training and awareness of
the new cultural environment. Co-production with staff of new service models.
December 2014.
Integrated Primary Care Team review and enhancement April – August 2014.
Enhanced Community Geriatrician service. November 2014.
The focus of these services will be to support the delivery of the savings in the acute
settings.
d) Implications for the acute sector
Set out the implications of the plan on the delivery of NHS services including clearly
identifying where any NHS savings will be realised and the risk of the savings not being
realised. You must clearly quantify the impact on NHS service delivery targets including
in the scenario of the required savings not materialising. The details of this response
must be developed with the relevant NHS providers.
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Our joint plans will integrate health and social care services that provide re-ablement and
ongoing care in the community. This will result in fewer patients needing to go to hospital
and those who do will be discharged earlier from elective and non-elective admissions.
This will potentially require tariff prices to be unbundled to fund different models of
provision along the pathway.
We have a challenged main provider and intend to develop our community resource and
response to support this trust by ensuring that local people are not admitted to hospital
where there is a safe alternative for them in the community. We will provide new
services in the community that will prevent urgent or emergency admissions for patients
who experience a health problem. We will also proactively prevent people becoming
unwell by actively monitoring and reviewing those patients who are likely to be at risk in
the community.
The patient flows from WAM and Bracknell and Ascot CCGs are complex as they are to
four acute hospitals – Heatherwood and Wexham Park (main provider), Frimley Park,
Royal Berkshire Hospital and Ashford & St Peters. WAM CCG commissions these
services collectively with Slough and Bracknell and Ascot CCGs.
There are discussions about changes to the governance arrangements for Heatherwood
and Wexham Park and Frimley Park which will have an impact on our planning.
The position we have signalled to acute providers is that we will be looking to reduce
investment in emergency care by 3% per annum over the 5 years of the strategic plan.
This will build to the 15% reduction as outlined in the planning guidance, but at a pace
which means that providers can respond to the change and remain sustainable.
It is expected that pathway redesign will result in an outreach model for many pathways,
including falls prevention, frail elderly, heart failure, dementia and respiratory disease
which will bring secondary care teams out into the community to support people and
avoid admissions.
The following approach will be taken to reduce risk for the acute sector
 The pace of change envisaged is realistic and will enable Trusts to reduce their cost
base in a planned way.
 Alternative support systems for patients will be invested in up front so that Trusts
have the confidence to take out excess capacity and cost.
 Acute providers are fully involved in the redesign of services and, either through
collaborative or competitive processes, will have the opportunity to provide services or
expert support outside traditional acute boundaries.
 The Health and Wellbeing Board (HWB) recognises that the BCF will, in the short
term, be continuing to support activity in secondary care, until service transformation
changes patient and money flows.
 The HWB also recognises the need to share in the cost risk if plans do not result in
the expected change in patient flows.
These changes will enable hospital trusts to manage their services for example through
less admissions, fewer unplanned tests and distributions to planned care. Reduced
lengths of stay will mean that efficiencies can be made in staffing wards, organisation of
elective activity that will reduce stays over a weekend. There will be opportunities for
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acute trusts to develop outreach services into the community as an alternative to the
current bed based model.
This will require joint leadership to encourage the practise of population medicine.
e) Governance
Please provide details of the arrangements are in place for oversight and governance for
progress and outcomes
Current Governance
Formal governance for the Better Care Fund integration will be through the Joint Health
and Wellbeing Board (HWB) for oversight and governance. The HWB has representation
from both of our CCGs to ensure that there is collaboration and consistency for local
people across the whole locality. Healthwatch is a key contributing partner on the HWB.
Final accountability will sit with the Council and the CCGs Governing Bodies.
We have an integrated management approach to the decisions and strategic direction set
by the Health and Wellbeing Board, through the Health and Social Care Executive, which
has CCG representation, Adult and Children services and Public Health. This group will
oversee the delivery of the changes needed to meet the integration.
There are fortnightly meetings between RBWM and WAM CCG about the development of
the Better Care Fund. These are soon to be supported by a project management post for
the Better Care Fund and a Programme Manager, which will provide additional capacity
to drive forward the development of the governance of the Fund and importantly the
service transformation required.
Public Overview of Changes
As all of the HWB meetings are in public, governance will come through transparent
reporting of Better Care Fund so that residents can see the progress being made.
Reports of progress of the BCF will be available to Healthwatch, our multi-agency
Partnership Boards and through the Local Quality Account.
There have been many jointly hosted stakeholder engagement events and activities,
attended by service providers, community and voluntary sectors, members of the public
and service users, and the BCF has been discussed at the most recent events. We will
continue our commitment to engage and feed those contributions into our actions, so that
we are integrating health, social care and public views into the service configurations.
This offers external governance and true co-production.
As a vanguard for transparency, RBWM and the CCGs will continue to share the
progress with the local population, who ultimately are able to hold us all to account.
Future Governance
It is recognised by all that a review of governance will be required once the details of the
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national pooled budget guidelines are confirmed. Any changes that may be needed will
managed through formal and transparent governance arrangements.
We will develop a programme approach to the delivery of the BCF and this will be
supported by a Programme Manager and Project Manager. We will align our existing
resources to the programme of work to support it, recognising that this is the core
business of our organisations. The workstreams for this programme will include:




workforce development
governance and pooled budgets
commissioning integrated models (taking forward the reviews of intermediate care,
integrated primary care teams and the frail elderly pathway)
information sharing and systems
We have already drafted options for future governance structures which will be discussed
through our existing partnership arrangements to establish the way forward.
We foresee that this could require a change the Constitutions to both CCGs, an update
to the Health and Wellbeing Board Terms of Reference and the existing Health and
Social Care Executive responsibilities. It is an agreed and shared priority to ensure
robust governance structures.
WAM CCG is developing a shared area of its members website to allow those involved in
the development of the Better Care Fund across the CCGs and RBWM to actively share
documentation and discuss issues as they arise, in the knowledge that face to face
meetings do not always provide a timely opportunity for discussions. This will not detract
from our existing governance structures which will underpin any decision making and
maintain transparency.
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3)
NATIONAL CONDITIONS
a) Protecting social care services
Please outline your agreed local definition of protecting adult social care services.
Protecting adult social care services in RBWM means maintaining the current social care
eligibility criteria with effective service provision.
By proactively intervening to support people at the earliest opportunity and ensuring that
they remain well, are engaged in the management of their own wellbeing, and wherever
possible enabled to stay within their own homes, our focus is on protecting and
enhancing the quality of care by tackling the causes of ill-health and poor quality of life,
rather than simply focussing on the supply of services.
Please explain how local social care services will be protected within your plans.
Services will be protected from demographic and economic pressures by continuing to
transform services and operating models to further develop prevention services that are
community based, such as the successful reablement service that have the potential to
delay or completely prevent entry into the health and social care system.
b) 7 day services to support discharge
Please provide evidence of strategic commitment to providing seven-day health and
social care services across the local health economy at a joint leadership level (Joint
Health and Wellbeing Strategy). Please describe your agreed local plans for
implementing seven day services in health and social care to support local people being
discharged and prevent unnecessary admissions at weekends.
We were unsuccessful in our bid to become a 7 day working pilot but have taken the
opportunity of using the winter pressures funding to pilot 7 day working in a number of
areas and we are currently evaluating the extent of these benefits to the system.
This includes – intermediate care team which includes a 24/7 rapid response service,
Rapid Assessment Community Clinic (currently funded from winter pressures), early
intervention and prevention service, home from hospital services (commissioned from the
voluntary sector), Care Bank and the post acute community enablement service.
We would aim to link this into our primary care strategy which is in development.
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c) Data sharing
Please confirm that you are using the NHS Number as the primary identifier for
correspondence across all health and care services.
25% of local social care records have an NHS number at this point in time and it is a
commitment that this will be in place on new records from this point onwards.
All NHS providers use the NHS Number.
Local people on the integrated primary care team caseload have an integrated record
which includes the NHS number.
The jointly commissioned STSR service has NHS number for 85% of its records
NHS Number is the primary identifier on NHS based systems; and the use of both the
Summary Care Record and Demographics Batch Service has proven to be up to 95%
successful in pilots in Wiltshire & Berkshire CCGs (and former PCTs).
If you are not currently using the NHS Number as primary identifier for correspondence
please confirm your commitment that this will be in place and when by
Commitment is in place for NHS organisations; and the ability to enable non NHS
providers through SCR and DBS to populate NHS Number is viable for a first run of
systems.
Please confirm that you are committed to adopting systems that are based upon Open
APIs (Application Programming Interface) and Open Standards (i.e. secure email
standards, interoperability standards (ITK))
We are committed to adopting systems which make use of open standards for
interoperability; technologies used in the past include Cache, HL7 and other open source
integration engines as long as they align to our IG requirements.
Please confirm that you are committed to ensuring that the appropriate IG Controls will
be in place. These will need to cover NHS Standard Contract requirements, IG Toolkit
requirements, professional clinical practise and in particular requirements set out in
Caldicott 2.
Central Southern Commissioning Support Unit, which holds data on behalf of the CCGs,
both hosts an office of the Data Service for Commissioners and has achieved Accredited
Safe Haven (ASH) Status; with a Caldicott Guardian in place and a thorough IG
Framework which is currently being implemented throughout the organisations. Central
Southern has IGT Level 2 and is working towards Level 3 for its Data Service for
Commissioners Office by 31st March 2014.
While these accreditations are good for assurance there must be a legal basis for the
sharing, processing and linkage of social and health data and where possible work
should take place making use of pseudo data at acceptable ‘small number’ levels.
It is important that suitable advice is sought when drawing up sharing agreements to
ensure that local people are not wrongly identified and that where local people have
opted out of data sharing this is recognised.
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d) Joint assessment and accountable lead professional
Please confirm that local people at high risk of hospital admission have an agreed
accountable lead professional and that health and social care use a joint process to
assess risk, plan care and allocate a lead professional. Please specify what proportion of
the adult population are identified as at high risk of hospital admission, what approach to
risk stratification you have used to identify them, and what proportion of individuals at risk
have a joint care plan and accountable professional.
100% of our population (as at November 2013, to be refreshed in six months) have been
assessed through the Adjusted Care Group methodology for their risk of admission to
hospital. High risk individuals are being entered onto the Integrated Primary Care Team
caseload. These teams comprise of community matrons, GPs, social workers and other
professionals who may need to attend for individual local people. These individuals have
a lead professional and a joint assessment and care plan.
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4) RISKS
Please provide details of the most important risks and your plans to mitigate them. This
should include risks associated with the impact on NHS service providers
Risk
Risk that the acute sector
may be de-stabilised by
reduction of activity
Risk rating
High
Lack of delivery of plans
Medium
Recruitment of staff to posts
Medium
Cultural change in staff,
providers and local people
High
Mitigating Actions
Early discussions with
provider trusts
Collaborative working to
develop approaches to
vertical integration for some
services
Exploit opportunities
provided by potential
changes to governance
structure between acute
trusts
Strong project management
and monitoring of outcomes
Commitment to projects
beyond a one year
timescale
Contingency plans to deploy
where required
Strong communication
about the culture change
behind this programme
Effective training
programmes
Commitment to projects
beyond a one year
timescale
Influence local people and
staff to make the right
choices and promote
independence.
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