GREATER MANCHESTER HEALTH AND SOCIAL CARE … · 2020. 2. 6. · Wigan Council Councillor Peter Smith (In the Chair) Donna Hall Wigan CCG Tim Dalton 01/16 WELCOME AND APOLOGIES Councillor

GREATER MANCHESTER

HEALTH AND SOCIAL CARE DEVOLUTION

Strategic Partnership Board

DATE: Friday 26 February 2016

TIME: 10:00am

VENUE: Banqueting Suite

Leigh Sports Village

Sale Way, Leigh

WN7 4GY (sat nav)

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AGENDA

1. APOLOGIES

2. MINUTES

To consider the approval of the minutes of the meeting held on 29 January 2016 (attached).

3. CHIEF OFFICER UPDATE

Report of Ian Williamson

4. STRATEGIC PLAN IMPLEMENTATION

a) Transformation Fund Criteria

Report of Katy Calvin-Thomas

b) Workforce

Report of Yvonne Rogers and Andrew Lightfoot

c) Estates

Report of Eammon Boylan

5. COMMISSIONING FOR GM REFORM Report of Steven Pleasant, Donna Hall and Andrew Lightfoot

6. REVIEW OF SERVICES FOR CHILDREN IN GM

Report of Jim Taylor and Andrew Lightfoot

7. MENTAL HEALTH STRATEGY

Report of Warren Heppolette

8. PROPOSED DATES OF FUTURE MEETINGS Friday 18 March – Rochdale

Friday 29 April – Salford

Friday 27 May – Stockport

Friday 24 June – Trafford

Friday 29 July – Bury

Friday 26 August – Manchester

Friday 30 September - Oldham

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GM HEALTH & SOCIAL CARE DEVOLUTION STRATEGIC PARTNERSHIP BOARD

MINUTES OF THE MEETING HELD ON 29 JANUARY 2016

Bolton CCG Wirin Bhatiani Bolton Council Councillor Cliff Morris Margaret Asquith Bridgewater Community Healthcare Dorothy Whittaker Bury Council Councillor Mike Connolly

Mike Owen Bury CCG Claire Wilson Central Manchester CCG Ed Dyson Central Manchester FT Darren Banks

Steve Mycio Community Pharmacy GM Varun Jairath GM Advocate Dementia Rt Hon Hazel Blears GMCA Andrew Lightfoot

Liz Treacy

GMCVO Alex Whinnom GM H&SC Devolution Team Rob Bellingham

Carol Culley Warren Heppolette Katy Calvin-Thomas Wendy Meredith Claire Norman Sarah Senior Ian Williamson

GM Interim Mayor Tony Lloyd GMIST Julie Connor Tim Griffiths

Nicola Ward Lindsay Dunn GMLMC/Primary Care Tracey Vell

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GM West Mental Health NHS Foundation Trust Alan Maden Healthwatch GM Network Alice Tiligui Heywood, Middleton and Rochdale CCG Simon Wooton Manchester CC Councillor Richard Leese Sir Howard Bernstein North Manchester CCG Mike Greenwood Oldham Council Councillor Jean Stretton Carolyn Wilkins Oldham CCG Majid Hussain Pennine Acute NHS Trust Gill Harris Pennine Care NHS FT Michael McCourt Rochdale BC Councillor Richard Farnell Steve Rumbelow Salford CC Councillor David Lancaster

Councillor Lisa Stone Jim Taylor

Salford CCG Hamish Stedman Salford Royal NHS Trust Maxine Power Shared Health Foundation Michael Oglesby South Manchester CCG Caroline Kurzeja Stockport CCG Gaynor Mullins Stockport NHS FT Ann Barnes Stockport MBC Councillor Iain Roberts Eamonn Boylan Tameside MBC Councillor Kieran Quinn

Steven Pleasant Tameside NHS FT Paul Connellan Giles Wilmore Tameside and Glossop CCG Steve Allinson

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Trafford Council Councillor Sean Anstee Theresa Grant UHSM Barry Clare Diane Whittingham Wigan Council Councillor Peter Smith (In the Chair) Donna Hall Wigan CCG Tim Dalton

01/16 WELCOME AND APOLOGIES

Councillor Peter Smith welcomed all present to meeting of the GM Health and Social Care Devolution Strategic Partnership Board.

Apologies were received as follows;

Trish Anderson, Simon Barber, Matt Colledge, Andrea Dayson, Councillor Sue Derbyshire, Alan Dow, Chris Duffy, Gillian Easson, Gillian Fairfield, Ranjit Gill, Denis Gizzi, Harry Holden, Karen James, Stuart North, Christine Outram, Mayor Ian Stewart, Bill Tamkin, Martin Whiting and Ian Wilkinson.

02/16 MINUTES OF THE MEETING HELD 18 DECEMBER 2016

The minutes from the meeting held on 18 December 2015 were submitted for consideration.

RESOLVED/–

1. To approve the minutes of the meeting held on 18 December 2015 as a correct record.

03/16 HEALTH & SOCIAL CARE – CHIEF OFFICERS UPDATE

Ian Williamson, Interim Chief Officer for Health and Social Care Devolution Team updated the meeting on the recent announcement that Manchester tops England’s mortality rates. An update report was presented to the Board which provided a high level overview of the GM Health and Social Care Devolution Programme. This included a summary of the key work streams, progress to date and upcoming milestones. The five main goals for April 2016 are:

A radical and achievable implementation plan for the Strategic Plan;

An investment plan for the Transformation Fund;

An operational plan – how we will deliver quality, safe health and social care in 16/17;

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GM, national stakeholders and GM public support including sound governance and communications;

Health and Social Care team and leadership system in place and working effectively.

This was supplemented by a short creative animation film ‘Taking Charge Together’. This provides a summary of the Strategic Plan.

RESOLVED/–

1. To note the progress of work to date. 2. To note the content of the paper attached at Appendix 1, specifically:

i. To broaden the range of stakeholders identified at Section 3 of the report;

ii. To note the existing statutory responsibilities that will remain between national bodies and Central Government;

iii. To note that a final draft report and final draft accountability agreement will be brought back to the February meeting of the Strategic Partnership board.

04/16 IMPLEMENTATION PLAN Warren Heppolette, Health and Social Care Devolution Team, presented a report to the Board on Implementing the GM Health and Social Care Strategic Plan. The paper outlines the work being undertaken to develop an Implementation Plan for the Strategic Plan. This work is describing how plans will reflect the transformation themes and what will be implemented and in what sequence over the next five years. It describes also shows the framework through which implementation will be managed and the range of linked work streams which are integral to the delivery of the Strategic Plan and its implementation. An Implementation Work Group has been established to deliver the ambition and vision of strategic plan and co-ordinate the key workstreams. Alongside this an operational management team has been formed to ensure there is an effective arrangement for the delivery of services linked to formal GM governance structures. Claire Norman, Health and Social Care Devolution Team updated the Board on the communication and engagement activities within the implementation plan. The Taking Charge Together model has been developed in order to increase public understanding of the impact and benefit of devolution and begin to harness the ideas, energy and collective intelligence of the people and communities of GM around the opportunities and challenges to taking charge and responsibility. A further paper will be brought to the Board to report progress on this. RESOLVED/–

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The GM Strategic Partnership Board is asked to comment and to:

1. To note the progress to develop a high level implementation plan and next steps to finalise the plan for the end of March 2016;

2. To endorse the proposed implementation framework; 3. To endorse the proposed leadership approach to the transformation

programme; 4. To endorse the identified next steps for GM and locality plans; 5. To note the high level risk register and next steps required to develop this as

a process of implementation by the end of March 2016. 05/16 LOCALITY PLAN Warren Heppolette provided a paper to the Partnership Board on locality plan implementation which follows on from ‘Implementing the GM strategic plan’. It outlines how the work to deliver an integrated health and social care system in each of the localities in GM is progressing and aligned to work at GM, along with the next steps towards implementation to reflect any changes with the Transformation Fund. The key next steps for locality plan development include:

High level implementation plan for each locality to be submitted to the GM Devolution team by the end of January 2016;

Ensure alignment across and between localities with the GM plan;

Final locality and accompanying implementation plans to be submitted for approval by Health and Wellbeing Boards by the end of March 2016.

RESOLVED/– The GM Strategic Partnership Board is asked to:

1. To note the progress made to produce 10 locality plans; 2. To endorse the identified next steps in the development of the locality plans

and the corresponding implementation plans.

06/16 GREATER MANCHESTER TRANSFORMATION FUND

Katy Calvin-Thomas, GM Health and Social Care Devolution Team presented a report which provides an overview of the work undertaken to date to effectively distribute, manage and evaluate the GM Transformation Fund.

In order to ensure that the fund is operational from March 2016, more detailed work

will be required. It is recognised that GM has a significant role to play in further

developing and then agreeing the proposals that will support the fund management

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processes. A copy of the report was shared with Board members last week followed

by a GM wide engagement session to seek input and guidance.

Michael Oglesby was invited to speak to the Board in regards to the work of the

Shared Health Foundation (SHF) to tackle inequalities in health across GM. SHF has

been established out of the ongoing work programme of the Oglesby Charitable

Trust.

He explained that SHF act as a catalyst by forming new partnerships between the

public sector and community groups to generate new, grassroots projects and to

scale up existing activity. This will support the most disadvantaged communities by

bringing together people, organisations and companies that want to create a

healthier future for the city region. They will encourage individuals to take

responsibility for their own health and to volunteer to help others do the same.

Members of the board welcomed utilisation of the Transformation Fund to not only

close the financial gap but address the gap of inequality.

RESOLVED/–

The Strategic Partnership Board is asked to:

1. Support the work undertaken to date and the direction of travel taken;

2. Note that a session was held on 27th January, and any amends that were

identified will be incorporated into final draft proposals, which will be taken

through February’s programme of meetings (including Strategic Partnership

Board on 26 February);

3. Note that further work will be undertaken with the GM system to further

develop the proposals as required.

07/16 JOINT COMMISSIOING BOARD

Steven Pleasant, Chief Executive, Tameside MBC introduced the paper which

updates the Board on the work undertaken to support the Shadow GM Joint

Commissioning Board transition from shadow to full status by April 2016.

The GMJCB will have significant commissioning decision making responsibility as

the largest single commissioning vehicle in GM. In order to capitalise on the

opportunity presented by devolution the remit of the JCB will need to extend beyond

health and social care and focus on holistic public service reform.

Rob Bellingham, GM Health &Social Care Devolution Team advised the Board that

to support the transition a detailed work programme has been developed. The next

steps for the Shadow Joint Commissioning Board include:

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Establishing how the remit of the GMJCB can be broadened to ensure it is

able influence all public service commissioning in GM; particularly the Public

Service Reform (PSR) priorities of integrated employment programmes, and

early years new delivery model;

GM has committed to the principle of co-design, a clear definition of what that

means and how it will be embedded into the commissioning cycle;

GM has committed to producing a commissioning strategy, work is now

progressing to shape and define that;

It was commented that devolution has provided an opportunity to create and form

new relationships to tackle health inequalities with the utilisation of the voluntary

sector. A further update will be brought to future Strategic Partnership Board

meeting.

RESOLVED/–


1. Note the contents of the report;

2. Note and support the next steps.

08/16 DEMENTIA

Hazel Blears, GM advocate for Dementia addressed the Board, setting out her

personal experience of Dementia. The Board were provided with the context and

background that highlights it is one of the most important health and care issues

facing the world.

Maxine Power, Director of Innovation and Improvement Science at Salford Royal

NHS Trust supplemented this and presented a report which updated the Board on

the 5 year improvement programme for dementia for Greater Manchester.

The Greater Manchester Dementia Vision for 2021 is ‘making GM the best place in

the world to live with dementia’. The challenge in GM is one of standardisation, care

pathway re-design and implementation.

The aim of the programme will be two fold. Firstly to determine how we can improve

the ‘lived experience’ for people living with dementia and their carers, and secondly,

to determine how to reduce dependence on health and care services.

The next steps have been identified as follows:

To develop the pledges in a business case to support a new care model for

dementia.

Engage the GM system in:

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o The redesign of the dementia pathway;

o Developing a single commissioning framework;

o The adoption a dashboard of GM system level measures for

dementia.

Implement the pilot of the key worker in 3 locality areas, Salford, Bury and

Wigan.

RESOLVED/ –

The GM Strategic Partnership Board is asked to:

1. Note the progress made to implement the key worker pilot and support the 5 year GM Dementia United programme;

2. Support the identified next steps and the development of the pledges into a business case. Noting that this will be subject to an agreed Transformation Fund process;

3. Commend the report for support at the Devolution Programme Board and the GM Strategic Partnership Board.

09/16 PRIMARY CARE TRANSFORMATION

Dr Tracey Vell, Chair of GM, LMCs presented a report to the Board which provides

an update on the progress made to develop primary care at scale as a driver

towards the delivery of integrated care across Greater Manchester.

Primary Care has a key role to play in the development of integrated models of care,

supporting neighbourhoods, including community, social, mental health and other

services. These integrated neighbourhood teams will provide a foundation for the

development of Local Care Organisations, operating at a borough/ city wide level.

Part of this process will require groups of GP practices to come together, working at

scale, in a collaborative arrangement.

Arrangements to nominate primary care representation representatives for the SPB

are being worked through and subject to logistical considerations, full attendance at

the SPB will be achieved from the February meeting.

It was commented that there needs to be an improvement in community mental

health as GP’s say that they do not have the expertise to deliver the outcomes. Tony

Lloyd, GM Interim Mayor asked how mental health services can be integrated into

primary care.

Dr Tracey Vell explained all partners need to be integrated and share responsibility

in order to ensure the delivery of better care. It is an ambitious encompassing piece

of work that requires reorganisation in community mental health.

RESOLVED/ –

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1. Note the progress with regard to primary care development;

2. Consider the Terms of Reference in Appendix 1 for approval.

10/16 MENTAL HEALTH

Warren Heppolette, provided the Strategic Partnership Board with an update on the

work undertaken to date to develop a Greater Manchester Mental Health Strategy.

Greater Manchester has made a clear commitment as part of devolution to develop

the current provision of Mental Health services. A draft strategy has been developed

which focuses on a whole system approach to the delivery of mental health and well-

being services that support holistic needs of individuals and their families within

communities.

The strategy brings together and draws on all parts of the public sector, focused on

community, early intervention and the development of resilience. GM is committed to

gaining system wide sign up and support for the proposed Mental Health Strategy

and is engaging now with stakeholders to endorse its focus, priorities and ambition.

Following this process, the strategy will be reported to the GM Strategic Partnership

Board for endorsement and sign off in February 2016.

RESOLVED/ –


1. Note the process of development;

2. Agree that a final version of the Strategy is taken to a future meeting of

the Strategic Partnership Board.

11/16 NEXT MEETING DATES

Future meetings of the Strategic Partnership Board are arranged as follows:

Friday 26 February 2016 Leigh Sports Village, Wigan

Friday 18 March 2016 Rochdale Council Offices, Rochdale

Friday 29 April 2016 A J Bell Stadium, Salford

Greater Manchester Health and Social Care Devolution Chief Officer Highlight Report – February 2016

Health and Social Care Devolution Chief Officer Highlight Report Date: 26 February 2016 Subject: Health and Social Care Devolution Chief Officer Highlight Report Report of: Ian Williamson – Chief Officer, GM Health and Social Care Devolution Programme PURPOSE OF REPORT The purpose of this report is to provide a high level overview of the GM Health and Social Care Devolution Programme including a summary of the key work streams, progress to date and upcoming milestones. RECOMMENDATIONS: The shadow GM Health and Social Care Strategic Partnership Board are invited to: Note the update and record the progress made. CONTACT OFFICERS: Ian Williamson [email protected]

Version Date Author Notes 1.0 05/02/16 BT First draft 1.1 15/02/16 BT Revised version with leads input 1.2 23/02/16 BT Update for SPB

1. Overview of Governance and Delivery

2. Key Messages for February

3. Transformation Programmes 1-5

4. Cross Cutting Themes and Communications and Engagement

5. Key Risks

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Strategic Partnership Board Trusts Councils CCGs Partners

Partnership Board Executive

Joint Commissioning Board

Provider Federation Board

Transforming Community Based Care & Support

Self Care & community resilience

Early Intervention

Start well, Live Well, Age Well

Primary Care at Scale

LCO Development

Standardising Acute Care

LCO Links

Single Services

GM Level Services

Standardised Pathways

Standardising Clinical Support & Back Office

Back Office

Care Co-ordination Centres

Shared Clinical Services

Enabling better Care & Support

Contracts & Payments

Estate Organisational Form Workforce

transformation Health Innovation IM&T

Operational Management Team

Operating Plans

NHS Mandate & Constitution

Devolved responsibilities

Implementation Working Group

Financial duties

Assurance

Headline Governance & Delivery

An Implementation Working Group will co-ordinate the delivery of the strategic plan. An Operational Management Group will be established to manage quality, safety and transition, including the delivery of NHS E responsibilities at the GM level. Both will be supported as appropriate by relevant Task Groups for key programme areas with leadership from across the GM system. The Health & Social Care Team will co-ordinate implementation & operations reporting through the formal governance structures

Radical Upgrade in population health & prevention

OD & Culture Change A new deal with the public Communications GM Outcomes Framework Transformation Funding

GM Mental Health Strategy

GM Cancer Vanguard

STANDARDISING ACUTE

& SPECIALIST CARE

The creation of “single shared

services” for acute services

and specialist services to

deliver improvements in

patient outcomes and

productivity through the

establishment of consistent

and best practice

specifications that decrease

variation in care and enabled

by the standardisation of

information management and

technology.

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2

TRANSFORMING

COMMUNITY BASED CARE

& SUPPORT

A new model of care closer to

home that includes scalable

evidence based models for

integrated primary, acute,

community, mental health and

social care. Key features will

be targeted case management

of the population most in need

delivered by upskilled multi-

disciplinary teams, together

with streamlined discharge

planning in order to reduce the

demand placed on acute

hospitals.

RADICAL UPGRADE IN

POPULATION HEALTH

PREVENTION

A shift in focus to

population health that

supports GM residents to

self-manage, innovates the

model for prescribers and

pharmacies, and tackles

the future burden of

cardiovascular disease and

diabetes.

STANDARDISING

CLINICAL SUPPORT AND

BACK OFFICE SERVICES

The transformational delivery

of clinical support and back

office services at scale across

GM, including the

establishment of coordination

centres to help navigate GM

residents through our complex

system to the right services.

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5 ENABLING BETTER CARE

The creation of innovative organisation forms, new ways of commissioning, contracting and

payment design and standardised information management and technology to incentivise ways

of working across GM, so that our ambitious aims can be realised.

Transformation Programmes





5. Key Risks

Key Messages

• The final draft of the Strategic Plan ‘Taking Charge of our Health and Social Care in Greater Manchester‘ is currently going through appropriate governance mechanisms via each of the 37 organisations.

• Locality plans have been developed and approved by Health and Well Being Boards. They show some variation in starting points, ambition and level of engagement. The focus now will be consistency in quality and relevance to Transformation Fund.

• Robust locality plans are a pre-requisite for successful access to the Transformation Fund – they need to deliver system changes and outcomes within localities.

• Not all locality plans are ready for implementation and we will work with localities to bring forward the right solutions over the next few months. If we do this well it will significantly enhance the approach to operational planning for 16/17.

• Following the SPB last month further work and engagement has taken place with the system to develop and refine the proposals, criteria and key messaging around the proposed £450m GM Transformation Fund.

• Work around GM Joint Commissioning continues to progress. A working party is now meet regularly and has a membership drawn from across the GM system. A draft GM commissioning strategy will be produced for April 2016.

• Significant work is being undertaken to finalise GM's assurance and accountability arrangements, in the light of the changes that will be made work is ongoing to develop GM systems to facilitate these new models of working.

These systems are being designed to ensure:

Appropriate levels of accountability are embedded within the new GM system, with associated assurance mechanisms

A direct read across to the Accountability Agreement being finalised with NHS England

A system which focusses on improving performance, with peer challenge and support across the GM system being amongst the main design principles

The outcome of this work will be a planning, commissioning and delivery Assurance Framework for GM.

• We launched our exciting ‘Taking Charge Together’ campaign on Monday 15th February. This campaign, running until March 31, will open the important conversation with many thousands of our staff and public and involves: The MEN, Key 103 radio, community roadshows across GM and more than 100 focus groups run by the voluntary sector and Healthwatch

• A recruitment timetable has been developed for the Executive lead roles for GM health and social care devolution. A plan is currently being developed to ensure interim leadership arrangements are in place to mitigate risks as a results of possible delays to any of the executive lead role appointments beyond April 2016.

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5. Key Risks

Overview of work since January

In January it was agreed that Wendy Meredith will act as Programme SRO, along with Lisa Stack and Ben Tomlinson in Assistant Director and Programme Manager capacity. The programme will be will be structured into six projects, these include; o People Looking after themselves and each other o Increase early intervention at scale and find the missing 1000’s o Starting well o Live well o Age well o Unified public health system Planning session are now underway with project leads to understand work to date and to agree next steps. In terms of overarching leadership for the programme, following recent discussions it has been proposed that both the Prevention and Early Intervention Board (PEIB) and the Public Service Reform Leadership Group are both disestablished and that a single GM Reform Board is formed, providing integrated leadership for the reform and prevention agenda across GM. This group could act as a programme board helping to drive the programme forward to deliver the outcomes and benefits whilst ensuring the appropriate coordination across the projects and activities that comprise the programme

Next steps

o Series of discovery meetings scheduled to inform the production of the programme definition document (PDD) with leads for the key projects.

o The first chapter of the PDD will be completed by 29th February. o Concurrently, work is underway to map out the implementation plan, identifying key milestones, interdependencies, resources and

outcomes. Deadline for completion 31 March 2016.

Programme 1 – Radical upgrade in population health prevention Lead: Wendy Meredith Date: 5 February 2016

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Programme 2 – Transforming community based care and support Lead: Rob Bellingham Date: 5 February 2016


Delivering integrated Out of Hospital Care All parts of GM are working on the development and implementation of integrated models as part of the development of Local Care Organisations and in realisation of the vision set out in the Locality Plans. These new integrated models of care, will support neighbourhoods with populations of circa 30k-50k and be inclusive of primary, community, social mental health and other services. As part of the development process, local systems were invited to consider options for developing primary care at scale as a driver towards integration, incorporating new contractual models, initially in shadow form during 2016/17. Proposals were received from all parts of Greater Manchester (with the exception of Stockport whose vanguard programme focusses on this work). A workshop took place on 14 January 2016 which provided the opportunity to work with the teams who put proposals which was attended by over 100 delegates from all parts of the system. A number of areas have indicated their readiness to be an early adopter early 16/17. This is now being followed up by a series of “surgery” sessions with each locality where plans are being discussed in more detail, linking back to the wider locality planning process. Primary Care Provider Involvement Established the Primary Care Advisory Group which is representative of the four primary care provider groups, (Dental, GP, Optometry and Pharmacy). The role of the Primary Care Advisory Group is to advise the Strategic Partnership Board of the views and perspectives of primary care providers in a unified voice, as described in the Terms of Reference agreed at the SPB meeting in January. The Primary Care representatives at the SPB will be drawn from this group. Refresh of GM Primary Care Strategy – Updating the existing GM Primary Care Strategy in conjunction with key stakeholders, reflecting developments made since the initial version was published in 2014.

Next steps

• Support local systems in firming up their proposals / delivery models over the period to the end of March. • Develop a system to share best practice, learning to support local systems to implement delivery models. • Finalise / ratify Primary Care Strategy and determine work programme and implementation of strategy, working with Localities • Completion of formal Programme Initiation process, making explicit the linkages between Programmes 1 and 2.

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Programme 3 – Standardising acute hospital care Lead: Leila Williams Date: 5 February 2016


Following agreement of the papers presented to the Devolution programme board in January, namely, ‘Implementing the GM Health and Social Care Strategic Plan’ and ‘Standarising Acute Care’, Ann Barnes ,Chris Brookes and Leila Williams will provide leadership to the programme. The Transformation unit have identified the initial planning and mobilisation team for Q4. Inline with the programme of work as set out in ‘Taking charge of our health and social care’, the programme team within the Transformation unit have agreed 4 workstreams, namely; 1. Mobilisation and prioritisation 2. Cluster Level Services 3. Greater Manchester Level Services 4. Standardising Treatment and Care Pathways Each of these workstreams will be fully scoped and a detailed implementation plan will be developed and agreed via the Devolution Programme Governance. The programme is currently in the mobilisation and prioritisation phase, which is focusing on identifying the scope, governance and key deliverables for the programme. It will also identify a methodology for approaching the prioritisation of acute services. This will help to identify an indicative phasing and sequencing for standardising acute hospital care. As part of this programme of work the Transformation unit are providing intensive support to the North East Sector Oversight Group to review the four Locality Plans, particularly the impact of these plans on the provision of acute, mental health and community services in the context of the GM devolution and the strategy. Clear next steps have been agreed following initial meetings. The Transformation unit are also supporting Trafford CCG in the transformation of specialised services .

Next steps

• Develop an implementation plan that identifies timescales for the 4 workstreams • Identify a methodology for prioritising the acute services at GM / Cluster level • Design and implement the governance structure for the programme

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Programme 4 – Standardising Clinical Support and Back Office Services Lead: Sarah Senior Date: 5 February 2016


NHSE transfer •To manage the safe transition of NHSE staff and functions to the GMH&SC team and create structures to deliver the GM requirements for the resources transferring Pan-GM efficiency •Support to pan-GM provider efficiency programmes including pathology & radiology, back office etc

Next steps

• Programme working session to be convened with all the leads of component work streams to review the objectives outlined in the strategic plan and agree:

• Programme vision • Programme scope • Key deliverables and timelines • Understand interdependences between other transformation programmes and locality plan developments

• NHS England transfer; develop an understanding of the assurance required for GM going forward and the capacity and structure of the team required to deliver this assurance.

• Pan GM efficiency; establishment of resources required for the initial scoping phase of the projects in order to understand the potential magnitude of the saving and next steps.

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Programme 5 – Enabling better care Lead: Geoff Little Date: 5 February 2016


Contracts and payment work stream (GM lead – Anthony Hassall. GM H&SC team lead – Helen Ibbott): • SPBE in January approved the recommendation to develop a specification and roadmap for this work. • A working group will be convened in order to agree the specification and roadmap for the work. • Work is underway to define ‘quick wins’ as part of 2016/17 contracts, such as GM CQUINs and risk share arrangements. IM&T (GM Lead – Stuart North. GM &HSC team lead – Vicky Sharrock): • Engagement session held to share and input to the visioning work to date, focused on the transformation areas of the strategic plan and

the life course model to identify how the IM&T vision can support delivery. • All localities undertaken the digital maturity self-assessments, the GM results have just been received. • GM-Connect singed off by Public Service Reform Leadership Group and Health and Social Care Governance. Health Innovation Manchester (GM lead - Clive Morris): • The initial business case priorities have been agreed with the HInM steering committee and planning for implementation has begun. Estates (GM Lead - Geoff Little. GM H&SC team lead – Neil Grice): • Progressed development of governance structure and MoU with DH & NHS England by the end of March 2016 • Commenced development of a GM commercial investment model funding sources to support GM capital developments to support

transformation and developing proposals on GM Estates Delivery unit. Workforce (GM H&SC Lead – Yvonne Rogers) Completion of Memorandum of Understanding with Health Education England. Assessing the impact of the Comprehensive Review

on the content of MoU and as a consequence, proposed establishment of a post bursary working group to assess impact of loss of bursaries on ability to attract, recruit and train future clinical workforce.

Agreed with HEE new Terms of Reference for a GM Strategic Workforce and Education Steering Group for health and social care staff. On-going discussions with existing workforce groups (Primary Care, Healthier Together, etc) to determine alignment with

Strategic/Locality plan(s). Submitted proposal to Strategic Partnership Board to establish new GM Health & Social Care Workforce Engagement Forum to enable

improved partnership working with Trade Unions.

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Programme 5 – Enabling better care Lead: Geoff Little Date: 5 February 2016

Next steps

Contracts and payment work stream • GM Contracting and Pricing Working Group to meet and agree specification and roadmap for the GM work stream and external support

to be procured. Quick wins for 2016/17 contracts to be confirmed through the GM Contract Steering Group. IM&T • Prioritisation of the proposals within the GM vision and wider IM&T work, understanding the asks of other transformation areas based

on their developing implementation plans, develop implementation plan and prioritise the initial areas of focus for GM-Connect Health Innovation Manchester • Finalising implementation plans and agreeing final funding routes. The planning will move into implementation mode and an alignment

discussion with the Joint commissioning board is planned for their February meeting. Estates • Negotiate and agree MoU with DH by end of March 2016 and commence process on a GM MoU with public sector organisations • Complete 1 of the commercial investment model work by the end of March • Support development of Locality Strategic Estates Groups and establish interim Health and Social Care Estates Board • Provide appropriate estates input to support development of Locality Plans Workforce Submitting proposal for establishment of Strategic Workforce committee to Strategic Partnership Board and planning first meeting of

GM Workforce Engagement Forum for March Planning engagement event with Trade Unions to formally launch new Forum/partnership arrangements. Planning first meeting of GM Strategic Workforce and Education Steering Group, identifying new Chair, membership of Group, and

work programme. Commencing work with Locality HR Directors to develop work programme/implementation plan for individual Locality Workforce

plans. Planning first meeting of Post Bursary Group to engage with Providers and determine impact of loss of bursaries on future workforce

planning arrangements. Continuing development of the GM Leadership Framework and Community.





5. Key Risks

Mental Health - Overview of work since January

GM Mental Health Strategy developed and reported to various governance groups including: GM Mental Health Strategic Partnership; GM Health and Social Care Executive; Wider Leadership Team; Directors of Children’s Services; Directors of Adult Services.

Next steps

Final sign off following feedback will be sought from the GM Health and Social Care Devolution Strategic Partnership. Detail implementation planning started and review of governance arrangements for implementation phase proposed.

Cross Cutting Themes

Learning Disability- Overview of work since January

Project Plans for each of the work streams developed. Proposals for widening the focus to develop a GM wide whole system approach to Learning Disabilities drafted. Research project to understand the housing requirements in GM for people with LD established.

Next steps

Gain agreement to the re-scoping of the GM LD work. Report on the research phase of housing needs project. Establish the work programme to develop the GM strategy.

Cancer - Overview of work since January

Diagnostic capacity and demand review undertaken; value proposition submitted; recruitment commenced to key work stream and programme office leadership posts

Next steps

Finalise governance arrangements and establish all work groups and launch programme

Dementia - Overview of work since January

Dementia United presented, and well received by GM at the Strategic Partnership Board, Executive, and Devolution Programme Board during January.

Next steps

New Economy and Social Finance supporting the development of the cost benefit analysis which will inform the production of the business case in March.

Cross Cutting Themes - Finance and budgeting

1. INTRODUCTION

1.1 This section provides an overview of the ongoing finance and budgeting work, and sets out key considerations in relation to the same.

2. 2015/16 - UPDATED BUDGET SUMMARY

2.1 The 2015-16 budget is spending against profile, and expenditure is expected to be as forecast for the full year period.

3. 2016-17 BUDGET

3.1 In order to establish the level of funding required, the GMH&SC team structures (including resource transferring from NHSE) will need to be designed

and costed.

3.2 A detailed budget for 2016-16 will be taken to the Strategic Partnership Board in March. Responsibility for its production has been delegated to the

Head of Paid Service, GMCA and the interim Chief Officer. This budget will produced following further consultation with the Chair of the Strategic

Partnership Board, Chair of Association of Greater Manchester Clinical Commissioning Groups, and Chair of Provider Federation Board (or their

deputy).

4. FINANCE EXECUTIVE GROUP

4.1 The GM finance community has established several groups to progress the work required to deliver a developed health and social care system in GM.

This includes the Finance Working Group and Finance Advisory Group. These complement the extant structures that exist across AGMA, AGMCCGs and

NHS providers.

4.2 The Interim Chief Officer will create a small Finance Executive Group to provide high level strategic advice to the programme.

5. NATIONAL FUNDING APPLICATIONS

5.1 It is acknowledged that there are various funding streams that GM organisations can access through application processes. Many of these sit outwith

the GM health and social care devolution programme, and do not form part of the budgets to be delegated. GM organisations are asked to ensure that

application to such funds by GM organisations are done so in full sight of GM.

6. RECOMMENDATIONS

6.1 The Strategic Partnership Board are asked to:

1. Note the current budget position set out at section 2.

2. Note that a detailed budget for 2016-17 will be brought the Strategic Partnership Board in March.

3. Note the creation of a Finance Executive Group.

5. Agree that any applications from GM organisations to funding streams outwith those delegated to GM be done so in sight of GM.

17

Communications and Engagement update • Campaign launched Monday 15th Feb (finishes 31 March)

• Focus on getting people to ‘join the conversation’ to help shape the future of health and care in GM

• Successful initial first phase.

Excellent social media stats – with huge support from orgs across GM and overwhelmingly positive (thankyou to all who have supported)

• 65,000 engagements (retweets, likes etc) in first week ( 4x normal)

• Over a 1000 viewings of animation in first week

• Reach of over 900,000 of #takingcharge and #takingchargetogether

• 4,500 viewings of our website

• Over 500 viewings of our resources page

Excellent media coverage – key 103, MEN and further coverage in Oldham, Wigan, Bolton and Lancs

Exceeded expectations in terms of hits on crowdsourcing site www.takingchargetogether.org.uk from staff and public (carers to start later

designed and overseen by carers networks)

• 1,659 people have been on the site.

• 623 people completed survey (38% conversation rate – norm is only 5-20%)

• 505 out of 623 people joined the online workshop ( 81%. Dropout rate is 20%. Norm is 50%)

• 1 in 5 of people actively contributing to the detailed conversation. This is typical for a public engagement or a campaign that has never not

been done before.

• Public responses from all areas of GM with most from Manchester, Stockport and Wigan

• Staff responses from some locations, but most from UHSM, Central Manchester and Stockport FT highest, with primary care next.

VCS and HW engagement events underway – 13,000 booklets and posters sent out. Positive responses to booklet and animation

CCG/LA engagement on locality plans and strategic plan themes underway – all involved in Key 103 media bus.

First bus 22 February – Wigan:

50 surveys completed, over 100 contacts and information leaflets given out. Health Watch and CCG staff attended. Vox pop created to promote

online, hospital and community radio.

Next bus 24 Feb: Tameside, Asda Ashton:

Council, CCG and local Health Watch due to attend.

http://www.takingchargetogether.org.uk/




4. Cross Cutting Themes

5. Implementation risks and mitigating actions

Implementation risks and mitigating actions

Category Risk Impact Likely

Initial RAG

Mitigating factors Impact Likely RAG Deadline for

resolution Risk Owner

overall

Programme complexity - There is a risk that the implementation programme for the GM strategic plan and 10 locality plans is so complex and lengthy we are unable to take informed sequencing and prioritisation decisions and that implementation cannot commence from April. 4 3 12

• Consistent implementation plan framework in place across GM and used by the 10 localities. • GM strategic plan implementation plan developed and agreed through SPB and 10 locality implementation plans agreed through HWB Boards. • Implementation plan to identify key tasks Jan-March 2016; Year 1 in detail (including first 100 days); year 2 in detail and high level years 3-5. • GM system session to identify priorities and sequence implementation in the context of key dependancies.

3 1 3 31/03/2016 Katy Calvin Thomas

overall

Programme memory - As many of the programme team are secondees from various organisations, there is a risk that at the end of their secondment with the programme team the knowledge and experience will be lost, impacting the deliver of the plan.

3 4 12

• Ensure there is appropriate hand over of all work areas for each secondee before departure. • Each work stream compiled a 4 page summary document • Secondment agreements extended (where possible) to end September 2016.

2 2 4 31/06/2016

Katy Calvin Thomas Liz Treacy Sarah Senior Warren Heppolette Wendy Meredith and Rob Bellingham

Overall

Stakeholder Engagement - There is a risk that all relevant organisations are not appropriately engaged in the development of the implementation plan, therefore progress could stall/be slower.

3 4 12

• 2 system briefing events planned (15.01 and Feb) • Strategic plan sent out with clear key messages. To make clear the specific ask of each Board. • All 37 statutory organisations are members on the SPB, along with Healthwatch and key national bodies • Regular e-bulletins • Website refreshed

3 2 6 31/03/2016 Warren Heppolette

resources

Inadequate resource - There is a risk that we will be unable to deliver the strategic plan at a GM or locality level due to concerns around the following resources; - Programme Support Capacity - IT Equipment - Time constraints 4 3 12

• Localities and GM team reviewing capacity and capabilities required to implement plans – to remain under regular review • SRO group provides a forum to share learning and expertise • GM Health and Social Care team Director structure developed and due to be advertised by the end of Jan 2016. • All devolution programme team secondments extended until September 2016. • Consultancy support secured as required

3 2 6 31/03/2016 Ian Williamson

Comms

Staff comms - There is a risk that staff are not sufficiently engaged in devolution; if staff do not understand fully the delivery of the strategic plan will be affected.

4 4 16

• Comms team have defined a staff comms strategy – to be delivered through each locality / organisation. • Consistency of messaging pack developed and distributed • Work commenced with community and voluntary sector


Comms

Public comms - There is a risk that the public do not understand devolution and therefore may not support the direction of travel. 3 4 12

• Engagement strategy compiled • Jan-March a number of engagement events to be scheduled across GM to be delivered through localities. • Crowd-sourcing approach to be undertaken


Governance

Local governance - the current legislation does not allow for the required level of legislation at local and GM level, eg vertical integration at a local level and the establishment of joint fund holding at a GM level

4 4 16

• SROs to work with the legislative team to ensure that all legal requirements are considered and addressed. • GM contracting and pricing mechanisms work stream to be established • Need statement on s.75

3 3 9 31/03/2016 Liz Treacy

Taking Charge There is a risk that GM does not meet the aggregate standard in key Constitution and Mandate requirements i.e. A&E; IAPT; quality metrics

3 4 12

• Reporting performance, challenges and action plans at GM aggregate and organisational level. • GM system in process of developing process to self-assure within GM to provide assurance of GM aggregate delivery – to be agreed with NHS England, NHS Improvement and CQC

3 3 9 from 01/04/2016 Ian Williamson

Greater Manchester Health and Social Care Devolution Strategic Partnership Board Update

Key messages, Transformation Fund and

locality support

26 February 2016

Journey so far

MOU

February 2015

CSR

Summer 2015

Clinical and Financial

Sustainability (Strategic Plan)

December 2015

Transformation Fund

December 2015

Implementation

planning

@GMHSC_Devo #GMDevo

The Strategic Plan reflects the boldness of our leadership and the scale of our

collaboration

• The Greater Manchester (GM) ambition is to be a financially self-sustaining

city region, sitting at the heart of the Northern Powerhouse, with the size,

assets, skilled population and political and economic influence to rival any

global city.

• The integration of health and social care provision across Greater

Manchester is a fundamental component of that growth and reform strategy.

• Reform is not only essential to ensure that the Greater Manchester health

and social care system can support Greater Manchester’s priority of reducing

unemployment, supporting people back into employment and providing

growth through innovation. It is a pre-requisite to addressing the

fundamental challenge of ensuring that the health and social care

system becomes financially sustainable over time.

Transformation:

Case for change:

• Poor health outcomes and significant inequalities

• £2bn funding gap estimated by 2020/21

• Complex landscape of commissioners, providers, LAs, 3rd sector and voluntary

organisations.

It is widely accepted that Greater Manchester will not meet the challenges it faces over the next five years through

incremental change. Therefore Greater Manchester partners have agreed a need to take a more radical,

transformational approach based on exploiting the opportunities arising from devolution.

Engagement with the system, alongside best practice from national and international experts identified five key areas for

transformational change.

5

Our transformation themes

Transformation Fund

| 6

7

Transformation Fund key messages

• ‘Open for business’ by 1st April 2016 by invitation to apply

not a bidding process

• The aim is to support transformation solutions to deliver

clinical and financial sustainability across GM and at locality

level

• A robust Locality Implementation Plan is a pre-requisite for

access to the TF

• Locality Plan investment proposals will be the first call on

the TF, as well as GM wide proposals required to support

financial sustainability

• Locality Plans must be supported by all CCGs, Local

Authorities and all NHS providers as well as Health and

Wellbeing Boards

• Room for innovation, but a focus on plans already being

worked on in localities and GM wide

• Locality support to be put in place

The fund will have criteria against which

to judge investment decisions

• Our proposed operating criteria for the fund:

Deliver the GM

vision

Enable

transformational

change

Consolidate

resources

Secure value for

money

Facilitate

learning for

others

• The initiatives supported by the fund must be aligned with the transformation initiatives and the border

vision for health and social care reform in GM

• The initiatives supported by the fund need to contribute to the GM Public Sector Reform programme

• The fund must drive forward shifts in activity and productivity required to close locality gaps

• The fund should deliver initiatives that lead to lasting transformational change, as opposed to temporary

or “business as usual” activities

• The fund must support change at pace – allowing progress to happen quickly with a shift from planning to

implementation

• The fund should be used to support scalable integration across health and social care boundaries,

organisational boundaries and localities across Greater Manchester

• The fund should support organisations to remove waste and target resources to the front line

• The initiatives supported by the fund must deliver a high rate of return within the CSR period – and

should benchmark well in relation to ambition and replacement costs.

• The fund should be managed and governed efficiently with a commercial discipline, which is underpinned

by transparency, fairness and accountability

• The fund should support innovative initiatives which are evidence-based and take account of proven

best-practice in their design

• The fund should seek to build an evidence base of what works and support the open sharing of this

information to build a culture of learning

Locality support

| 9

10

Focus for Support

We should support localities to develop their Locality Plan / Implementation Plans to generate the strongest possible platform for transformation. That support should be focussed over the period of the next 2 months. We should seek to have a senior named lead from the H&SC Devolution Team to connect to individual localities to facilitate that support and plan development. With that in mind the support should seek to bridge: • The process to develop the locality implementation plan to align to the transformation

programmes and requirements to secure outcome shifts & sustainability • The impacts plan implementation is intended to achieve in relation to prevalence,

activity and productivity • The investment proposition relating to the Transformation Fund and • The criteria for application of the Fund. This approach has been discussed through SROs and it is proposed that a short paper outlining the approach to support be developed with the SROs for consideration by the Partnership Board Executive at its February meeting.

11

Transformation Fund – Locality Plan Approach

All localities will receive

additional support to assess

their current position against the

Locality Care Organisation

characteristics, Strategic Plan

and Transformation Fund

criteria.

This work will support the

development of the Locality

Implementation Plan and

investment propositions. Each Locality will reach a

collaborative and agreed view

of the key actions it needs to

take and its investment path,

which will be signed off by its

Health and Wellbeing Board.

The assessment will be used as

the basis to plan the likely

trajectory for each locality in

terms of readiness to apply to

the Fund and manage the Fund

profile over a five year period.

The Transformation Fund has to be invested in those changes which will achieve our goal of clinical and financial sustainability. The

implementation of locality plans therefore must be the basis of the investment and impact agreement which will underpin the operation of

the Fund.

The support to localities will be

expressly based on actions to

ensure locality plans are

“Fund Ready”. And further

support will be provided where

localities require it.

Fund readiness will need to be

confirmed as a quantifiable

and objective test drawn from

the criteria for Fund access

which includes:

Ambition – confirmed

shifts in prevalence, activity

and productivity

Alignment – confirmed

whole system agreement

(through formal stakeholder

sign up) to the application,

alignment to formally

submitted operational plans

for the 16/17 planning

round

Investment – clarity of

application of the

investment detailing the

characteristics and

construction of the LCO.

In order for this test to be applied the following

will need to be in place for each locality:

Benchmark picture – current GM

comparative picture of key data relating to

prevalence, activity and productivity

Data Request informing the

implementation plan

Latest version of locality plan and any

supporting documents ;

CCG financial and activity baseline

(including detailed assumptions on

growth, allocations and calculation);

Local authority financial and activity

baseline (including detailed

assumptions and calculation) ;

NHS Provider financial & activity

baseline;

Detailed assumptions on impact of

interventions (e.g. activity reduction, if

available)

Investment requirement (recurrent and

non-recurrent) for transformation,

including consideration for workforce,

IM&T and estates. This should include

as much detail as possible, including

costing approach and assumptions

Process driving assessment

& application

Setting the bar for robust

Implementation Plans

Data Driving Implementation

Plan

1

4a

GREATER MANCHESTER HEALTH AND SOCIAL CARE DEVOLUTION

STRATEGIC PARTNERSHIP BOARD

Date: 26 February 2016 Subject: GM Strategy – Transformation Fund Report of: Katy Calvin-Thomas

PURPOSE OF REPORT The purpose of this report is to gain support and endorsement from Strategic Partnership Board on the operating model for the Transformation Fund. The aim of the Fund is to support solutions which deliver clinical and financial sustainability across GM and at locality level and improve the outcomes included in the Strategic Plan. The paper includes key messages about the Fund to share across GM, the operating principles of the Fund, the proposed process for the operation of the fund and the design features that require additional work to support the operation of the Fund. RECOMMENDATIONS:

The Strategic Partnership Board is asked to: 1. Agree the Fund criteria (Table 1). 2. Agree that further work is undertaken on the fund, including development of the

approach to 'one off' and double running costs, and allocation approach. 3. Support the direction of travel thus far; and agree that final proposals be brought

to the Board for agreement in March 2016. 4. Agree that further work is undertaken on the design features of the Fund (see

Section 6); and agree that final proposals be brought to the Board for agreement in March 2016.

5. Note the engagement approach and endorse development of communication materials to support the Fund.

CONTACT OFFICERS: Katy Calvin-Thomas [email protected]

Item

mailto:[email protected]

2

Transformation Fund

Developing the operating model 1. Introduction

The paper provides an update to the GM system on how the Transformation Fund will be operated and managed. It builds on the ‘Driving value through design’ PWC/Carnall Farrar paper and the slides on the Transformation Fund which went to the Partnership Board on 29th January 2016. The paper builds on the consultation being undertaken with localities and transformational programmes about the Fund and begins to answer the key questions generated about the Fund during January and February 2015.

2. Key messages

Following a number of recent engagement sessions (GM system event, Senior Responsible Officers for localities, Finance Working Group), these key messages about the Fund have been agreed:

The Fund will be ‘Open for business’ by 1st April 2016 and will be applications and an invitation to apply, not a bidding process.

The aim of the Fund is to support solutions which deliver clinical and financial sustainability across GM and at locality level and improve the outcomes included in the Strategic Plan.

Locality Plans must be supported by local authorities and all NHS stakeholders, as well as being signed up to by Health and Wellbeing Boards.

A robust Locality Plan is a pre-requisite for access to the Fund.

The Locality Plan and investment proposals which come from it will be seen as the first call on the Fund, although GM wide transformation proposals will also be required to support financial sustainability.

While there is room for innovation, the Fund will focus on transformation plans that we already identified in the Strategic Plan and are progressing with through Locality Plans.

A process for supporting all Locality Plans and investment propositions to demonstrate how they achieve clinical and financial sustainability will be put in place in all localities and within the GM transformation programmes.

3. The GM Transformation Fund – our journey so far

In December 2015, the GM system endorsed our Strategic Plan. The Plan described our transformation journey towards clinical and financial sustainability across the five ‘transformation programmes’ (see below). This included how the GM system would work to improve the outcomes agreed as part of our Plan.

3

A critical part of this work was securing a Transformation Fund, which was focussed on investing to deliver clinical and financial sustainability, by the end of the Spending Review period. It was on this condition that the fund was secured.

Achieving financial and clinical sustainability for GM is therefore the touchstone for all our decisions on the Fund. The purpose of the Fund is to change how the £6bn is used and to close the projected £2 billion gap by 2021. We will be judged on these outcomes not by having a many stand-alone projects. The Fund cannot therefore be allocated on a fair shares or on a first come basis. It has to be invested in those changes which will achieve our goal of clinical and financial sustainability. But this must not lead us to treat this as a competitive bidding process. We will only succeed if we collaborate as partners within localities and as ten localities coming together as GM. The fund was calculated on the basis of us all - all ten localities and all five themes - succeeding. The use of the Fund cannot sit on top of mainstream funding, it has to change it. It has to fund the creation of new service models which are then funded from mainstream budgets when the Fund stops. We therefore need to see the GM Strategic Plan and Locality Plans reflected in the mainstream budgets and planning for each GM partner (LAs, CCGs and provider organisations). This next phase of making the first of many decisions on how to invest from the Fund will follow the same pattern as our previous work together - the GM position will be built up from work on the Locality Plans which will then inform the next stage of work on the Locality Plans. This iterative process has given us a creative tension which has worked but which must now be sustained through the added tension of deciding where and when to invest the fund. Not all of the changes we need to deliver clinical and financial sustainability require investment from the Fund or can be delivered the Fund. At both GM and locality levels we need to address how the Fund can underpin transformational change within the system. Investment made by the Fund will be subject to contractual arrangements between GM and localities to deliver system change. We will create flexibility. We have indicative allocations to themes at GM level which flow from the Comprehensive Spending Review submission. This can flex so long as

4

the overall totals still add up to financial sustainability. We need to work on how we can also create flexibility between years, if this is required. The agreements around the Fund will also be understood against the back drop of the broader GM Commissioning Strategy which is being progressed by the Joint Commissioning Board to ensure coherence and alignment between the two. Significant work is happening within the GM system to support the transformational changes we agreed in the Strategic Plan. Implementation plans for each transformation programme are due by March 2016. High level financial templates circulated on 24 February (see Return on Investment section of report) are to be discussed and returned by March 2016. Support for development of locality plans and progress against Local Care Organisation criteria is also being agreed.

4. Criteria for the Fund

As outlined in the ‘Driving value through design paper’ the proposed criteria for the fund (outlined below) have not been challenged.

Deliver the GM vision

Enable transformational change

Consolidate resources

Secure value for money

Facilitate learning for others

Table 1: Criteria for the Transformation Fund

Deliver the GM vision

• The initiatives supported by the fund must be aligned with the transformation initiatives and the broader vision for health and social care reform in GM

• The initiatives supported by the fund need to contribute to the GM Public Sector Reform programme

Enable transformational

change

• The fund must drive forward shifts in activity and productivity required to close locality gaps

• The fund should deliver initiatives that lead to lasting transformational change, as opposed to temporary or “business as usual” activities

• The fund must support change at pace – allowing progress to happen quickly with a shift from planning to implementation

Consolidate resources

• The fund should be used to support scalable integration across health and social care boundaries, organisational boundaries and localities across Greater Manchester

• The fund should support organisations to remove waste and target resources to the front line

Secure value for money

• The initiatives supported by the fund must deliver a high rate of return within the CSR period – and should benchmark well in relation to ambition and replacement costs.

• The fund should be managed and governed efficiently with a commercial discipline, which is underpinned by transparency, fairness and accountability

5

Facilitate learning for others

• The fund should support innovative initiatives which are evidence-based and take account of proven best-practice in their design

• The fund should seek to build an evidence base of what works and support the open sharing of this information to build a culture of learning

The principle building blocks of the fund which mean a separation into ‘one off up front costs’ and ‘double running’ have not been challenged.

4.1 Fund distribution

It is agreed that apart from the main fixed points of the Fund (£450 million given across set allocations for the next five years – see below) there is a need to retain flexibility within the categories.

However PwC/CF have used the modelling developed to secure the fund from NHS England to provide an indicative split of the transformation fund between the 5 transformation initiatives. While the majority of this funding is likely to flow directly to localities, there are some initiatives (notably enablers and standardising care) where GM or sector level leadership is likely to be required.

0

32

99

130

50 39

0 0 0

22

14

17

17

6

0 0 0

6

6

6

3

3

0 0 0

20

40

60

80

100

120

140

160

180

200

15/16 16/17 17/18 18/19 19/20 20/21 21/22 22/23

Double run subtotal Enabler support Additional programme support

Key constraints of the fund • A total of £450m • Phasing of Funding Over the Next 5 Years

Year 1: £60m of transformation funding; Year 2 :£120m of transformation funding; Year 3: £153m of transformation funding; Year 4: £70m of transformation funding; Year 5: £48m of transformation funding;

6

4.2 Developing our approach to the Fund It is important for us to consider how we allocate or deploy the Fund. We originally proposed a lot based approach as part of our Spending Review submission. However following this consultation, we will bring forward proposals on the approach once we have had the opportunity to review all the developed Locality Plans and have evaluated their relationship to the agreed Transformation Programmes. There is a critical interdependency between the Locality Plans, the GM Transformation Plans and the decision about the Fund. As we begin to make decisions about the Fund, these need to be firmly rooted against delivery of clinical and financial sustainability. The Locality Plans are the primary focus of the Fund and are therefore required to demonstrate, in the context of these transformation programmes, not only how outcomes for people are to be significantly improved, but also how they will contribute to closing the financial gap for GM as a whole. This contribution is likely to take two forms - how far the integration of health and social care (and all the programmes which underpin it) will directly reduce the gap at locality level, and how any remaining gap will be closed completely by the execution of GM-wide programmes. We will also produce detailed advice on how GM-wide programmes (service redesign, workforce, estates, IT), which the Fund must also deliver; need to be embraced by Locality Plans to support the achievement of the GM transformation where this is agreed. Support will be provided by the Devolution Team and their consultants to ensure Locality Plans achieve these objectives and crucially make the essential link with these plans and the GM system.

5. Proposed process for operation of the Fund

This section outlines the thinking to date on how the fund might be operated. 5.1 Proposed process for localities

All localities will receive additional support to assess their current position against the Locality Care Organisation characteristics, Strategic Plan and Transformation Fund criteria.

This work will support the development of the Locality Implementation Plan and investment propositions.

Each Locality will reach a collaborative and agreed view of the key actions it needs to take and its investment path, which will be signed off by its Health and Wellbeing Board.

The assessment will be used as the basis to plan the likely trajectory for each locality in terms of readiness to apply to the Fund and manage the Fund profile over a five year period.

All partners (including commissioners, primary care providers, community providers, secondary care providers and mental health providers) in a locality will need to have been part of the implementation planning work and to sign up to the locality investment proposals.

We know that there will be some capital investment needed to achieve the significant changes in service configuration required. The estates enabler work will be underpinned by a clear understanding of what transformational models are required rather than focusing on the redesign of existing estate. Work is

7

underway to ensure that the capital estates work becomes an integral part of the development of Locality Plan.

The work on locality performance and assurance against mandated national, GM and local targets will be linked via the GM statutory reporting processes to both access to the Fund and funding agreements.

The second paper presented to the SPBE on Support for Localities provides further detail.

5.2 Proposed process for GM transformation programmes

All GM transformation programmes will receive additional support to access their Implementation Plans and investment propositions against the Locality Plan requirements, Strategic Plan and Transformation Fund criteria.

Each programme will reach a system owned view of the key actions it needs to take and its investment, which will be signed off by the Strategic Partnership Board.

The assessment will be used as the basis to plan the likely trajectory of each programmes across the five years of the Fund.

5.3 Proposed process for pre-existing locality investment asks

Across GM there are a small but significant number of Locality Plan pre-existing investment asks. These include, but are not limited to the following Vanguards, Tameside Integrated Care Organisation etc.

These will be assessed as per the Locality Plan proposed process.

Discussions are in progress with NHS England to get firm confirmation of their view of potential pre-existing commitments against the Fund.

Discussions are also taking place with NHS England on the appraisal of vanguards and other proposals to ensure complete alignment with the GM Strategic Plan and transformational programmes.

5.4 Phasing and decision making

Work has begun on scoping out the decision making process and phasing of the fund. This will follow the steps outlined below:

1 Agreeing the Transformation Fund Principles and Operating Model

SPBE to agree the principles and operating model

2 Further developing the assessment process

A prototype assessment process has already been created and used for using pre-existing investment asks (Vanguards etc). See 6.2 below.

3 Locality and GM support is agreed

SPBE to agree locality support as per the next agenda item 4 Assessment and challenge

phase

5 Investable propositions are submitted

To be assessed by external support

6 Transformation Fund Plan

This will provide a position statement of all

investable propositions and recommendations

for first phase of decisions in May – June 2016 based on external independent evaluation. This

8

will include a profile of future decision making for 2016/17 options over the next five years, with regular review points rather than an annual event.

It is proposed that the following types of

decisions could be reached: Invest

Further work (to ensure investable propositions meet the criteria)

Consolidate (the potential to group or cluster propositions together to better achieve clinical or financial sustainability)

For ‘further work’ and ‘consolidate’ decisions there should be slots or deadlines for decisions on investment later in the year.

7 Independent assessment and recommendations to SPBE

SPBE to take investment decisions in line with the Fund principles/criteria, after fully taking into account the independent assessment.

6. Key design features required to support the operation of the Fund 6.1 Locality Care Organisation (LCO) criteria

The development of LCO criteria needs to become embedded in the assessment process for the Fund. We already have some working assumptions including:

Locality Plans must genuinely include and reflect all organisations in a place including commissioners and all providers, including primary care. They cannot be commissioning plans alone and they must include consideration and agreement of transformational change across the whole system.

Integrated commissioning needs to be in operation at a locality level to ensure clear commissioning intent and decision making.

The Locality Implementation Plans must show a robust roadmap of service change aligned to the activity and cost reduction targets. Plausibility of the plans will be assessed in relation to how plans for service models, workforce, ICT, estate and other tangible change relate to an Operating Model or similar.

Implementation Plans must include a four year financial plan showing sufficient ambition for activity and cost reduction.

Localities and their constituent organisations need to meet and adhere to their operational and financial responsibilities in order to qualify for the Fund and to keep receiving it.

6.2 Transformation Fund assessment model

The purpose of the support to localities is to test the assumptions being used to create their Implementation Plan and to stretch the ambition of the plans against the Strategic Plan. An initial assessment process has been developed, which will require further work to refine and test it.

9

It is acknowledged that the Fund need to be capable of being profiled against each year and each scheme based on the output from the Locality Plan and GM Transformation Programme outputs.

Work is required to ensure the Fund can track whether investment made within a certain locality or transformation area has achieved its intended benefits (clinical, financial or activity). This is a critical part of demonstrating how benefit for patients has been derived from the Fund.

6.3 Return on investment (ROI) approach

The Strategic Financial Framework (which underpins the Strategic Plan) is being developed to create a baseline of activity and finance information which can be used to underpin our ROI methodology at locality and GM level. This includes:

Recasting the overall financial and activity position with actual information for 16/17 and updated assumptions for the next five years

An updated logic model based on benchmarked activity data which should challenge and support localities on the level of their ambition

An updated activity and financial template for the locality plans with their five year finance and activity position

An agreed iterative process to support localities understand how they close the gap

A critical component which drives decision making within the Fund is the extent to which investment propositions able to demonstrate how it can achieve return on investment. This is currently based on an ROI of £1 to £3 across a system. Work is required to support localities to understand this better and use industry tested methods for deriving and tracking ROI. Linked to this is also the need to work through methodology and model on ‘double running’ propositions to ensure these are leading to change/disinvestment in agreed service areas rather than creating additional system capacity. This will be a crucial link to track as part of ROI.

6.4 Developing Fund agreements

Localities should have their own local agreements on how the Fund will be utilised between partners, which is signed off by the Health and Wellbeing Board. This needs to build on learn the lessons from the BCF performance regime. Decisions to invest will also be backed up by agreements between the Locality or GM and the Fund. Work is required to produce an outline of the sorts of metrics we will be looking for (including key milestones which drive whether investment continues or stops), the process by which we will monitor and evaluate progress and the contractual mechanism through which this will take place.

6.5 Agreeing the administration model for the Fund

The original paper posed four options for securing the management of the fund which included total outsourcing to GM control and outsourcing of key governance and appraisal processes. While there are short term advantages presented the outsourcing options, notably the ability to rapidly secure resources to support the administration of the first round

10

of funding, we do not believe this is the right approach for GM to take given the importance of the fund to the transformation of health and social care and environment within which it will operate. Independent evaluation of investment proposals is considered essential to underpin the requirement for transparency and the accountability for deploying public funds. We propose that GM should seek to build the majority of the capabilities required to operate the fund in house – but should make use of independent expertise to undertake the evaluation of applicants and monitoring of progress. This option would see Strategic Partnership Board Executive (or a committee there of) being the ultimate decision maker over initial and repeat funding, following consideration of external review and assurance as to the alignment of the scheme and its ability to deliver. The Strategic Partnership Board is asked to support this direction of travel to enable GM to begin a procurement process to secure external support for the administration of the Fund.

6.6 Governance and decision making about the Fund

As already agreed within the GM governance system, the SPB is requested to approve the Fund criteria, and then the SPB Executive will take the investment decisions based on the evaluation undertaken by the scheme. We will need to develop a set of principles to govern this process.

The fund will also need to think about its approach to transparency and audit given the high degree of scrutiny we should expect for the fund from within and beyond GM

6.7 Flow of funds

Work is ongoing to determine how funding will flow from NHS England through GM to localities. We are also seeking clarification on what we will have to demonstrate to NHSE in order to secure the money, where this money will flow to, or how we will then pass it on to localities. This issue needs further work with NHSE and must consider the financial implication of options.

7. Engaging and communicating about the Fund

As a principle, GM transformation programmes will be the subject of engagement at GM by GM and Locality Plans will require evidence of engagement by Health & Well Being Boards within localities. The range of queries about the fund itself, pre-commitments, applications etc is growing. Work is ongoing via the Finance working Group and SROs for the Locality Plans to feed the latest information into the system, however a key focus needs to be agreement on key communication messages about the process.

8. Next steps

The key actions outlined in this paper have been summarised into an action plan in Appendix 1 that will enable us to ensure we have the systems and process in place to run the Fund during quarter 1 2016/17.

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9. Recommendations


1. Agree the Fund criteria (Table 1). 2. Agree that further work is undertaken on the fund, including development of the

approach to 'one off' and double running costs, and allocation approach. 3. Support the direction of travel thus far; and agree that final proposals be brought

to the Board for agreement in March 2016. 4. Agree that further work is undertaken on the design features of the Fund (see

Section 6); and agree that final proposals be brought to the Board for agreement in March 2016.

5. Note the engagement approach and endorse development of communication materials to support the Fund.

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Appendix 1 Summary of key decision areas with aligned issues of the Transformation Fund

Summary of papers to be delivered for each key decision area

Transformation Fund key questions

Investment Assessment

Investment assessment process

Investment assessment evaluation

Messages to system

Overall timingsEngagement & Communications

Distribution Size and shapes of lots

Finalising agreements - NHSE Calls on the Fund

Delivering FundingFlow of funds within the fund

Flow of funds to applicants

Contracting

Contracting, Monitoring and Evaluation

Fund evaluation

Scheme turnaround

Scheme monitoring

Supporting localitiesSupport to Localities

Transparency

Administration & Governance Governance

Operations

4

1

2

5

9

10

11

12

13

14

15

16

3

6

7

8

Paper Title Decision area Issue NumberIdeal SPB

signoffFirst draft

to GM

Internal Days to first

draft

Final Paper Delivered

Investment Assessment

TF Investment Assessment Process & Evaluation

26/02 16/2 6 1/3

Administration and Governance

Operations and governance 26/02 19/2 6 24/2

Engagement & Communications

Overall timing & Communications

18/03 24/2 2 2/3

Distribution of the Fund

Shape and size of lots 18/03 24/2 4 2/3

Support to Localities Support to Localities 18/03 24/2 4 2/3

Delivering FundingFlow of funds to applicants

& within the fund 18/03 1/3 1 18/3

Calls on the FundFinalising agreements with

NHSE 18/03 1/3 5 16/3

Contracting,Monitoring and Fund Evaluation

Scheme turn around, Scheme monitoring, Fund

evaluation 18/03 8/3 6 18/3

9

1 2

4 5

10

11 12

6 7 8

13

15 16

14

3

13

The first opportunity for sign off on the elements of the Transformation Fund is at the February SPB Meeting; key meeting dates and decision points are listed below

w/c Feb 1 Feb 8 Feb 15 Feb 22 Feb 29 March 7 March 14 March 21 March 28

Decision Making Bodies

Strategic Partnership Board 26 18

Strategic Partnership Board Executive

18 7

Joint Commissioning Board 16

Executives AGG 1 16

CFO 16

Chief Officers 4 11

X-GM working groups

Implementation Working Group 4 12 25 10 31

Provider Federation Board 18 18

SRO meeting 5 19 26 4 18 22

Joint SRO / Finance Advisory Group

12 11

Finance Working Group 5 12 19 26 4 11 18 25 1

Local Authorities Treasurers Advisory Group 12

Wider Leadership Team (LAs) 16 15

CCGs CCG CFOs 16 15

CCG Chief Officers 22 4 11

The Association Governing Group(CCG Accountable and Clinical Officers)

16 1 15

Providers Acute Provider DOFs 12 11

Finance meetings

4b

GREATER MANCHESTER HEALTH AND SOCIAL CARE DEVOLUTION STRATEGIC PARTNERSHIP BOARD

Date: 26 February 2016 Subject: GM Health and Social Care Workforce Engagement Forum Report of: Andrew Lightfoot/Yvonne Rogers

PURPOSE OF REPORT

This paper updates the Strategic Partnership Board (SPB) on the revised working arrangements with Trade Unions as a consequence of health and social care devolution. Positive and meaningful employee engagement is integral to the successful achievement of GM ambitions and the delivery of the devolution agenda. It is acknowledged that:

Staff play a vital role in the delivery of high quality public services

High quality employment in public services plays a vital role in the functioning of the Greater Manchester economy and society.

To ensure appropriate arrangements are in place for meaningful and effective employee engagement, new arrangements are required at Greater Manchester level. Appendices 1 and 2 of this report outline the proposed terms of reference for two new strategic bodies. GM Strategic Workforce Engagement Board – this will meet quarterly and enable senior representatives from GMCA and the trade unions to consider the workforce implications relating to the delivery of the devolution agenda. GM Health and Social Care Workforce Engagement Forum - has also been established

to focus specifically on workforce issues relating to health and social care. This will feed into the new GM Strategic Workforce Engagement Board. This Forum has been developed in conjunction with both health and local government Trade Unions to ensure robust partnership working arrangements are in place to discuss issues arising from workforce transformation programmes and to ensure there is meaningful discussion at City Region level on matters arising from the planning and implementation of devolution in health and social care across Greater Manchester. This Forum has also been agreed with the NW Social Partnership Forum (which comprises full time officers from health unions) and mirrors previously created fora established to support major transformational change programmes for example, Making it Better and Healthier Together.

RECOMMENDATIONS

The Board is asked to:

Endorse establishment of a properly constituted GM Health and Social Care Workforce Engagement Forum comprising trade union and employer representatives to facilitate integrated working between health and social care trade unions and management representatives.

Identify a Chair for the new Forum from SPB partners

Acknowledge the requirement for the GM Health and Social Care Workforce Engagement Forum to provide regular updates to the GM Strategic Workforce Engagement Board.

Support the release of employer/management representatives to participate in the (quarterly) meetings.

Support the principle of positive, meaningful engagement with Trade Unions at locality level and ensure the development of staff engagement processes to facilitate key Devolution strategies and communication.

CONTACT OFFICER: Yvonne Rogers [email protected]


APPENDIX 1

Greater Manchester Protocol for Joint Working on Workforce Matters

Devolution Initiatives and high quality employment The Interim Mayor of Greater Manchester, the Greater Manchester Combined Authority (GMCA), the Chief Executive of the Greater Manchester Health and Social Care Partnership Board and the Greater Manchester public service trade unions recognise that:

Staff play a vital role in the delivery of high quality public services

High quality employment in public services plays a vital role in the functioning of the Greater Manchester economy and society.

The parties to this protocol are committed to working together and with full employee involvement and engagement to ensure that the devolution of powers to the Greater Manchester level can be of benefit to the citizens and employees of the city-region. The parties note that the broad GM Devolution agenda involves two strands that impact upon the organisation of public service delivery and on workers employed in public services: 1. Initiatives by Greater Manchester public sector organisations to work together in the delivery of public service functions. Some of these ‘shared services’ initiatives pre-date the formal devolution agreement of November 2014. These developments in part reflect the financial pressures on public bodies and the potential benefits to service provision of collaborative working across geographical and service boundaries. Some of these initiatives to date involve collaboration with public bodies outside the Greater Manchester city-region, and some involve a role for the private sector.

2. The development of a new institutional framework at the local and Greater

Manchester levels for commissioning health and social care services following the ‘Memorandum of Understanding’ in February 2015. These new arrangements hold the potential for more integrated forms of service provision, across geographical and service (Health and local government) boundaries.

Principles For public service workers, these devolution-related developments hold the prospect of considerable opportunities as well as some potential concerns. There are opportunities, because devolution offers the prospect of more integrated service delivery which can involve job enrichment, skills development, career progression and a more fulfilling experience of work through more effective delivery of services to the public providing greater job security. There is also scope for the greater provision of apprenticeship places in Greater Manchester, bringing through the next generation of public service workers.

There are though real concerns because of the possibilities of change that detriment may arise from transfers to new employers, privatisation, worsening of pay and terms and conditions, and in unreasonable relocation. The parties to this protocol agree that these concerns can be addressed through an undertaking that: 1) Where services are reconfigured involving more than one public service employer a partnership approach will be preferred. In all such cases the existing employees of the public sector/publicly funded service provider bodies within the GM ‘family’ of employers involved should remain in the employ of that particular employer unless there is a clear service benefit rationale and/or legal basis not to do so. 2) Every effort will be made to ensure wherever possible there will be no worsening of the pay arrangements, terms and conditions or pensions of staff during or following a change of employer arising from service reconfiguration or new partnership arrangements. 3) It is understood that future developments may involve direct partnership or framework partnership arrangements with private sector and voluntary sector employers. As a starting position, the existing employees of any public sector/publicly funded service provider bodies within the GM ‘family’ of employers involved will not have their employment transferred to the private sector or voluntary sector employer(s) as part of any such arrangement unless there was a clear service benefit rationale and/or legal basis to do so. 4) Positive employee engagement will be integral to the successful achievement of GM ambitions therefore; # There will be a properly constituted strategic Workforce Engagement Board comprising senior managers, political leaders and trade union representatives. This board will meet on at least a quarterly basis to exchange ideas and proposals, discuss relevant issues of joint concern and seek to reach agreements as appropriate on matters of workforce implications and workforce skills and development arising from or resulting from the early policy formulation, planning and implementation of GM devolution, decentralisation and public service redesign initiatives. # There will be a Health and Social Care Engagement Forum comprising trade union and employer representatives which will feed into the strategic Workforce Engagement Board and report to the Health and Social Care Engagement partnership board. # There will be a nominated GM trade union representative and a nominated GM employer ‘family’ representative who shall jointly and severally act as central contacts to support the strategic Workforce Engagement Board and facilitate clear communication and co-ordination between the GM trades unions and the GM ‘family’ of employers.

These points should guide practice in all shared service initiatives involving Greater Manchester public bodies, and by the new city-region and local level commissioning bodies developed in integration of health and social care. Consultation Arrangements The treatment of staff is a key component in delivering change and staff engagement via the union’s consultation processes is essential. Trade union involvement is central to the success of devolution. This has been evidenced nationally in Scotland, Wales and Northern Ireland. Greater Manchester will seek to build upon these models of partnership working. In order to ensure maximum staff engagement any proposals which will impact on staff must be the subject of early consultation. This requires meaningful engagement by employers before any major decision is confirmed or agreed. Where two or more Greater Manchester public bodies propose to deliver a service across geographical and/ or service boundaries, the Greater Manchester trade unions will create Workforce Project Leads to facilitate full consultation and staff engagement with all affected employers. The best means of supporting this work is through joint employer facility release. This approach has been successful in recent years in the implementation of Single Status and Job Evaluation in Local Government and Agenda for Change in Health. Any joint employer facility release would require clarity of outcomes and activity from such release and require agreement with the relevant employers. Significant proposals such as large scale reorganisation or workforce reconfiguration will be subject to consideration at the Greater Manchester Workforce Engagement Board as detailed below but all negotiation and collective bargaining remain within the exiting local employer arrangements. A Greater Manchester Workforce Engagement Board (WEB) will oversee workforce change in the city-region and the application, continuous review and interpretation of this workforce protocol. The parties to this protocol agree that a commitment to Greater Manchester-wide principles, overseen by the new WEB, combined with robust arrangements for meaningful local consultation, will together help facilitate consensual change in workforce matters that will best ensure that the potential gains from devolution are realised for Greater Manchester. The co-ordination of union representatives on the WEB will be overseen by the Public Services Committee of the North West TUC. It is proposed that these Terms of Reference are agreed as part of the development of the GM Workforce Engagement Board and are submitted to all parties on that basis for consideration.

Appendix 2 Greater Manchester Health and Social Care Devolution Draft Proposal - Greater Manchester Workforce Engagement Forum 1.1 In February 2015 an agreement (Memorandum of Understanding) between the Government, Greater Manchester Health Bodies, and Local Authorities and NHS England was signed with the aim of our region being given direct, local control of £6bn each year. 1.2 The governance for Health and Social Care Devolution is currently being developed and will be subject to agreement in the short term. It will be important that as these governance structures emerge that there is appropriate consideration to engagement of the workforce and their representatives. 1.3 It is proposed that a Greater Manchester Health and Social Care Workforce Engagement Forum is developed as a joint Greater Manchester wide forum for employers and trade unions to discuss at City Region level matters arising from the planning and implementation of devolution in health and social care across Greater Manchester. 1.4 Over the coming week’s discussions with Trade Union Representatives and Employers will take place to identify the role and remit of a Greater Manchester Health and Social Care Workforce Engagement Forum. Such a forum would seek to ensure that the principles of meaningful partnership working operate effectively throughout Greater Manchester and will promote good practice in all areas of staff engagement, development and management. 1.5 Areas for consideration in developing the Forum and its remit will be:

Provide constructive comments to all partner organisations on the planning and implementation of devolution matters at a formative stage and during development phases.

Contribute trade union and employer perspectives to the development and implementation of policy and practice.

Ensure there is early discussion at City Region level on emerging issues and maintain a dialogue on policy and priorities.

Contribute ideas on the workforce implications of service change.

romote effective communications between partners and a collective approach to supporting and developing staff affected by service changes.

The Forum will avoid simply replicating or reporting on the work of other bodies.

1.6 In addition to such a Greater Manchester Workforce Engagement Forum, it would also be proposed that each Locality would give consideration to having their

own Workforce Engagement Forum which will reflect these partnership structures to consider issues that relate to particular localities. 1.7 Discussions with the North West TUC and North West Health and Social Partnership Forum would be beneficial to assist in the consideration of Locality Workforce Engagement Forums and in particular appropriate representation from health and social care providers, trade unions and local elected members. 2.1 In developing a Greater Manchester Health and Social Care Workforce Engagement Forum it would be recognised that each organisation would conduct formal consultation and negotiation with its’ own local Trade Unions and the Greater Manchester Forum would not seek to duplicate or detract from that responsibility in any way. 2.2 The partners recognise that all organisations have individual responsibility for implementing any statutory obligations and national or local policy applicable to them and for consulting meaningfully within their own joint bargaining arrangements. 2.3 It would also be proposed that reports relevant to workforce issues from the Health and Wellbeing Board / Joint Commissioning Boards would be available to members of the Locality Workplace ngagement Forums via the relevant local oint Secretaries. ith minutes of the Forum being provided to the NW Social Partnership Forum, the GM Health and Social Care Partnership Board and the GM Devolution Workforce Engagement Board for information. 3. Membership of Forum 3.1 As part of the discussions consideration will be given to the composition of a GM Workforce Engagement Forum comprising of Trade Union representatives and employers, a draft outline is provided below as to what may be proposed:

Nominated members from health service unions (12 seats)

Nominated members from Local Government Unions (4 seats)

Employer side representatives (16 seats)

Other individuals co-opted as necessary following agreement of the Forum. 4. Meetings 4.1 It would be proposed that such a Forum would meet 4 times per year unless otherwise jointly agreed. 4.2 Working groups may also be established on an ad hoc basis to undertake specific pieces of work as required.

5 Joint Secretaries 5.1 Consideration will be given to Joint Secretaries which would be elected from the Employer side and Trade Union side who will jointly agree agendas and draw up draft minutes for meetings. 5.2 The Joint Secretaries (including assistants/advisers) would work together on any issues emerging between meetings which may require an immediate Forum response or intervention. 5.3 The Joint Secretaries would meet with the Chairs of Health and Wellbeing Board / Joint Commissioning Boards to discuss any emerging workforce issues prior to any proposals being tabled. 6. Administration of Forum 6.1 The Employers Side Secretary would be responsible for the administration and effective arrangements of meetings 7. Joint Liaison with Devo Manc Workforce Engagement Board 7.1 Where necessary and appropriate it would be proposed that the Forum would liaise with joint representatives of the GM Manchester Devolution Workforce Engagement Board in the joint interests of all parties’ in relation to issues which overlap areas of lead responsibility. 8. It is proposed that the draft intent outlined in this paper is subject to discussion as

part of the emerging governance proposals over the coming week and that a joint protocol and Terms of Reference is developed and agreed through the Health and Social Care Governance arrangements, NW TUC and NW Social Partnership Forum.

9. A report on progress will be submitted to the next meeting of this group.

1

4c



Date: 26 February 2016 Subject: Greater Manchester Health and Social Care Devolution - Estates Report of: Eammon Boylan

PURPOSE OF REPORT This report provides an update on progress on the capital and estate work stream, and sets out the next steps. RECOMMENDATIONS: The Strategic Partnership Board is asked to:

1. Note the contents of the report. 2. Agree the next steps; recognising that their progress is reliant on the

support and cooperation of all GM partners. CONTACT OFFICERS: Geoff Little [email protected] Neil Grice [email protected]



2

1. INTRODUCTION 1.1 A new approach to estates provision across the whole health and social care

systems is an essential component of the Enabling Better Care transformation programme of the GM Health and Social Care Strategic Plan along with workforce, information systems and aligning incentives through new methods of pricing and contracting. Work on estate and capital will therefore be key to the delivery of clinical and financial sustainability by 2021 and to enable individual stakeholders to discharge their obligations and account for their targets.

1.2 This report provides an update on progress on the capital and estate work

stream and explains the range of issues it needs to cover. It is clear from the work so far that the capital requirements of estate transformation will not be capable of being met from the normal sources of public sector capital funding over the next five years. This report therefore also includes proposals to explore public / private investment into the estate changes needed.

1.3 The GM Health and Social Care Strategic Plan “Taking Charge” will require a

reconfiguration of the whole of the health and social care estate in order to ensure that we can deliver our shared vision from a property base that is fit for purpose in terms of location, configuration and specification. As well as delivery of health and social care transformation this will also contribute to our devolution agreements on the GM Land Commission and One Public Estate. It will therefore help with joining up the management of the public sector estate as a whole, on a place basis, to underpin the reform of public services whilst also providing a pipeline of sites to contribute to the GM Spatial Strategy to provide land for housing and employment.

1.4. All of the transformation programmes within the Strategic Plan will have

significant capital and estates requirements. The Healthier Together Programme requiries an estimated £63m capital. Standardising acute hospital care and standardisng clinical support and back office services will generate their own capital requirements. Taken together with the transformation of care in communities, including primary care, the key features of estate changes needed for health and social care are:

hospitals will be reduced in size through standardisation of clinical

support and back office services and a reduction in the number of acute beds from the combined effect of a radical upgrade in prevention, scaling up primary care and the integration of community health and social care;

there will be requirements for multi purpose community based hubs accommodating integrated primary care, community health and adult social care services and enhanced provision of step down services preventing inappropriate demand for acute beds.

1.5. These changes will be driven by both of the GM-wide transformation

programmes and Strategic Estates Groups ( SEGs ) in each of the ten districts supporting delivery of the Locality Plans. The work at locality level will be supported by work at GM level to understand the scale of the estate

3

requirements and to secure the investment needed, bearing in mind that the Transformation Fund provides revenue only. Work at GM level will also create new coordinating governance and capacity to overcome the fragmentation and complexity of health estate ownership and management. The new arrangements will be agreed with the Department of Health (DoH) through a Memorandum of Understanding (MoU).

2. UNDERSTANDING THE SCALE OF CHANGE 2.1 At GM level a core team, drawn from the SEGs and supported by regional

NHS property agencies has produced a very high level GM Estates Strategy that has sought to draw together the outputs of the Locality Plans and the needs of the programme overall.

2.2 As part of the work required we will need to refine the analysis of investment

needed to support the programme. This analysis will be required in order to support and inform our discussions with DoH as we move rapidly toward full implementation of devolved decision making from April 2016.

3. NEW CAPITAL FUNDING MODELS TO ENABLE ESTATE CHANGE 3.1 Full support of the GM Provider Federation will be vital if asset disposals are

to be seen as part of the wider place based strategy. However, this will not impact upon organisational sovereignity or treatment of capital receipts.

3.2 The full range of options for funding capital projects will be explored :

borrowing by Foundation Trusts; NHSE capital for primary and community care developments; LIFT type schemes; and prudential borrowing via LAs. However, the availability of capital funds from the DoH / NHSE and other national sources will be very limited over the next four years and the GM Transformation Fund has no capital element. We will seek agreement that capital generated via asset sales over and above the GM share of the national DoH target for disposals can be retained by GM ( see section 4 below on the MoU ) but this will be limited given that much of the land likely to be released as surplus will be in areas of relatively low land value and may require significant remediation.

3.3 Although more work is needed to define the capital requirements across GM it

is clear from the above that the funding ask is well beyond the current national affordibility envelope. The current system is therefore incapable of enabling the delivery health and social care reform. We therefore need to examine other options for delivery our system changes including private/public funding models. These will need to be planned and executed at GM level. We are having exploratory discussions with institutional investors to gauge the appetite for creating a fund or partnership to provide investment in new facilities in return for long term revenue streams. This work is being coordinated by the MCC/ GM Core Investment Team and is being supported by PWC. This work will use examples from Locality Plans to test how a fund or partnership might attract private sector capital investment at the scale needed to deliver the GM Health and Social Care Strategic Plan.

4

4. MEMORANDUM OF UNDERSTANDING 4.1 A working group has been established to create the MoU between GM and

DoH by the end of March to articulate how we will deliver our objectives and how we will manage the estate overall. It is proposed that there will need to be two MoUs, a principal MoU between GM and DoH / along with NHS England, the Treasury and the Department of Communities and Local Government and a second linked MoU between the GM bodies that need to work together to better manage the public sector estate to deliver improved health outcomes.

4.2 Full support of the GM Provider Federation will be vital if capital receipts are

to be seen as part of the wider strategy for the place. NHS Trusts and Foundation Trusts own circa 85% of the NHS estate. It is therefore essential that these providers are fully involved in the development of the MoUs and this was discussed by the GM Provider Federation Board on 19th February. The relationships with GP’s in the primary care sector will also be vital and the involvement of the primary care is under discussion.

4.3 The estates principles to be set out in both MoUs will flow from the Health and

Social Care Devolution MoU of February 2015. A key principle will be that estate stays in its current ownership and decisions by those owners will be focussed on people and patients of GM and delivery of the GM Health and Social Care Strategic Plan “Taking Charge”.

4.4 The principal MoU will address relationships between DoH and other national

stakeholders and GM in relation to the effective management of the estate aligned with the GM Health and Social Care Strategic Plan. It will also will link the GM Health and Social Care Strategic Plan to the devolution agreements on the GM Land Commission and One Public Estate by providing a pipeline of sites to contribute to economic growth and/or housing delivery whilst underpinning public service reform.

4.5 The MoUs will define new governance structures which will enable GM

partners to work together to make decisions in relation to land and property assets that are strategically co-ordinated and aligned to maximise benefit across GM. This will set out how a Delivery Unit will be established a to coordinate management of the NHS Estate and how it will relate to existing local and national property functions within the NHS, LA’s and other public services.

4.6 The principal MoU will establish a process to agree a GM share of the DoH

targets of disposing of £2 billion of assets and enabling the development of 26,000 homes over the life of the Parliament. We will seek agreement that receipts above the target are retained within GM to contribute to the delivery of the changes needed for clinical and financial sustainability. The MoU will also set out the key principles underpinning the GM commercial mechanism referred to in paragraph 3.2 above to secure private sector investment for estates transformation.

5. GOVERNANCE AND CAPACITY

5

5.1 Action has been take to develop the membership and functions of the SEGs across all districts. This includes the involvement of key individuals across the heath sector and the involvement of planning and housing as well as estates officers from LAs. The key requirement is for the estates plans of the SEGs to be driven by the Locality Plans. By doing so the SEGs will: use existing estate more effectively; reduce running and holding costs; reconfigure the estate to better meet commissioning needs;

share property (particularly with social care and the wider public sector);

dispose of surplus estate to generate capital receipts for reinvestment; and

ensure effective future investment. 5.2 A GM Strategic Estates Board will be formed to take responsibility for

translating the estates plans of the SEGs into a set of strategic requirements for GM and developing the framework of investment sources to ensure delivery of the estates changes needed for the GM Health and Social Care Strategic Plan.

5.3 Neil Grice, Area Director at Community Health Partnerships, has been

seconded to support the GM Devolution Team with the initial phases of work set out in section 6 below and to establish the Delivery Unit.

5.4 The role of the Delivery Unit will be to provide strategic capacity and multi-

disciplinary expertise to support the existing estates capacity across GM statutory public bodies in the delivery of housing, public service reform, and growth ambitions. Core responsibilities will include : (a) strategic planning of key land and property programmes including coordination of and direction for local estate strategies; (b) programming and delivery of strategic capital investment and land release programmes; and (c) designing, implementing and embedding common standards and practices for estates planning and delivery.

6. NEXT STEPS 6.1 Understanding the estates changes and investment needed to deliver it. 6.1.1 The work by PWC and the SEGs analysing the current estate and the high

level requirements of the Locality Plans now needs to be followed by more in depth work to gather information on the estate proposals from their Locality Plan Implementation Plans. This will complement work to support each district to develop their Locality Pans - see item elsewhere on this agenda. This needs to result in each district having a robust estates plan which flows directly from their Locality Plan. Locality Plans need to embrace the estate requirements to underpin the delivery of the switch from acute settings to community provision. This will be a major factor in helping to make the case for sensible investment propositions.

6.1.2 Further work in needed on projecting the expected impact on the acute sector

estate of developing and integrating out of hospital services. This will include

6

the full range of out of hospital services, including the future contribution of extra care housing and residential care. This will support work on the Transformation Fund by reviewing the assumptions by providers and commissioners of reductions in beds.

6.1.3 Work is required to connect work on estates with work on the other enabling

work streams of workforce and information management and technology so that the full requirements of co-located multi-disciplinary teams are understood and planned for.

6.1.4 Further more detailed work is needed to understand the potential impact on

estate requirements of single shared service models across hospitals and consolidation of clinical and back office support services in the acute sector.

6.2 Developing the MoUs, new governance and capacity. 6.2.1 Timescales are very tight to produce the two MoUs. The MoU between DoH

and GM needs to be completed by the end of March. Thereafter it will need to be considered by the GM and District level governance. Work on the GM MoU will need to be have been progressed sufficiently to give confidence that the arrangements set out in the MoU between GM and DH are workable.

6.2.2 An immediate priority is to extend the membership of the Working Group

developing the MoU to include CCGs, NHS Trsust and Foundation Trusts, and the Primary Care sector.

6.2.3 The key requirement is to describe how the new governance and capacity will

be different from the current arrangements and provide an effective base for delivery of the GM Health and Social Care Strategic Plan and the GM share of DoH disposals and housing targets.

6.2.4 Work is underway to estimate the level of disposals across GM over the life of

this Parliament. This will now be further developed by engaging the SEGs and the acute sector. The process to agree a realistic GM share of the DoH £2bn targets for receipts will run in parallel with the MoU process but on a longer timescale.

6.2.5 Proposals for the formation of a GM Health and Social Care Strategic Estates

Board were formulated at a workshop earlier this month. The Board will now be convened so that it can drive forward the GM MoU as well as overseeing the development of the Estates Strategy as a whole.

6.3 Securing access to the necessary investment. 6.3.1 Work will be led by the Core Investment Team and PWC to develop and test a

commercial model for estates transformation and rationalisation. The commercial model will show stakeholders how funding and disposal receipts will flow and how GM will, cost effectively, support delivery of key targets ( including capital receipts to DoH). Work on the investment model and the degree of risk involved will require an understanding of the emerging pipeline of schemes from the work with the SEGs. This will include working with the SEGs to identify and develop early win projects from current Locality Plans as

7

well as from the GM thematic programmes and the wider OPE programme. These projects will start to provide important data to test and illustrate how the commercial mechanism will work.

7. CONCLUSIONS AND RECOMMENDATIONS 7.1 The work required to deliver a capital and estates programme is complex and

vast. It will require the support of all GM partners and key national stakeholders.

7.2 It is clear that a clear programme of work will need to be developed, aligned to

the broader programmes of transformation as necessary. 7.3 Due to the complexity of the work, and the its potential impact across GM,

clear governance and reporting structures will need to be developed. It is imperative that these structures are robust, inclusive and are aligned to existing structures that have been created to support this area of work (both with health and social care and beyond).

7.4 The timeframe around the initial elements of the programme are tight; notably

to develop the governance arrangements, and MoU(s). Completion of both is reliant on support and cooperation of all GM partners.

7.5 The Strategic Partnership Board is asked to:

1. Note the contents of the report. 2. Agree the next steps; recognising that their progress is reliant on the

support and cooperation of all GM partners.

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Date: 26 February 2016

Subject: Commissioning for GM Reform

Report of: Steven Pleasant, Donna Hall and Andrew Lightfoot

PURPOSE OF THE REPORT:

To provide an overview of the opportunity presented to GM from jointly

commissioning activity and aligning the strategic objectives and priorities of both

Health and Social Care and wider Public Service Reform.

RECOMMENDATIONS


1. Note the content of the report;

2. Acknowledge that significant opportunity that is presented through

aligning public service reform across GM.

CONTACT OFFICERS:

Steven Pleasant

[email protected]

Donna Hall

[email protected]

Andrew Lightfoot

[email protected]




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1. GM AMBITION 1.1 In GM we want to enable a truly placed based approach to public service

reform, bringing together all of public service. This approach will enable GM organisations to make real changes to the lives of residents, in a way that is relevant to them, and is free from restriction and fragmentation created by organisational boundaries.

1.2 The Greater Manchester Strategy, Stronger Together, placed public service

reform at the heart of our strategic ambition. The subsequent Growth and Reform Plan, devolution agreements, and Health and Social Care Strategic Plan have restated that commitment to reshaping our services, supporting as many people as possible to contribute to and benefit from the opportunities growth brings.

1.3 With local services working together, focussed on people and place, we want

to transform the role of public services and take a more proactive approach rather than responding to crises. We want to transform the way we use information, empowering our frontline workforce to make more informed decisions about how and when they work with individuals and families. Building on the principles of early intervention and prevention, GM aims to deliver the appropriate services at the right time, supporting people to become healthier, resilient and empowered.

1.4 Delivering on our ambitions will also contribute to meeting the financial

challenge facing our public services: reducing demand on expensive, reactive public services through greater integration, prevention and early intervention.

1.5 Underpinning the delivery of this ambition will be a new approach to

commissioning services, that focuses on delivering outcomes for residents, putting artificial boundaries to one side.

2. GM JOINT COMMISSIONING 2.1 As part of its revised governance arrangements for health, social care and

reform, Greater Manchester has established a Joint Commissioning Board (JCB).

2.2 At its January meeting, the JCB agreed a series of next steps; chief amongst

these was a requirement to produce a Commissioning Strategy which connect the requirements set out in the GM Strategic Plan, (“Taking Charge of our Health and Social Care in GM”), to those described in the GM Strategy for Growth and Reform.

2.3 When the JCB moves from shadow to full status 1 April 2016, its “day one”

scope will incorporate the commissioning of over £800m of activity, currently commissioned directly by NHS England This will make it the largest single commissioning vehicle in GM. This day one scope includes:

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Specialised Services such as Cardiac Surgery, Specialised cancer services, Renal Dialysis for adults, HIV services and a range of others;

Dental, Optical and Community Pharmacy Services;

Screening and Immunisation services. 2.4 This means that, from the outset, the Board will immediately assume a live

role as a commissioner of significant volumes of activity. This provides it with an opportunity to shape and influence future public service commissioning intentions and interventions significantly beyond the scope of those set out above.

2.5 Whilst affording GM the ability to commission services and take decisions

jointly across a health and care economy, the Board presents GM with a significant opportunity to commission holistically for outcomes across the entire public service spectrum.

2.6 A more detailed paper on this was taken to the Joint Commissioning Board on

16 February 2016. 3. DEVELOPING OUR APPROACH TO COMMISSIONING REFORM 3.1 By understanding the adverse impact of single agency / single issue decision

making, we begin to see that the over-riding factor in limiting the impact our interventions make when we fail to place the individual and the family (in the context of their lives and their communities) at the heart of what we do. Driving an integrated, person-centered response will create a sustainable system that reduces the numbers in the overlapping ‘complex’ interventions.

3.2 Adopting an increasingly holistic approach will enable us to minimise the

number of residents whose issues escalate, placing ever increasing costs and demands on the system. It is already accepted that individuals and families with complex dependencies do not have single issues that can be effectively dealt with through a set of well-developed approaches that focus on single symptoms.

3.3 With this refocus in mind, the revised GM reform principles are:

A new relationship between public services and citizens, communities and businesses that enables shared decision making, democratic accountability and voice, genuine co-production and joint delivery of services. Do with, not to.

An asset based approach that recognises and builds on the strengths of individuals, families and our communities rather than focussing on the deficits.

Behaviour change in our communities that builds independence and supports residents to be in control

A place based approach that redefines services and places individuals, families, communities at the heart

A stronger prioritisation of well being, prevention and early intervention An evidence led understanding of risk and impact to ensure the right

intervention at the right time

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An approach that supports the development of new investment and resourcing models, enabling collaboration with a wide range of organisations.

3.4 These principles will inform our commissioning strategy and future

commissioning decision, ensuring that GM transitions from an organisation and locality based commissioning approach, to one that is place, person and outcome centric.

3.5 The graphic below illustrates how this process will evolve and be overseen

during the course of the strategic planning period:

4. MANAGING THE CHANGE 4.1 To ensure we are best placed to deliver an integrated approach to reform,

Greater Manchester has agreed to disestablish both the Public Service Reform Leadership Board and the Prevention and Early Intervention Board, forming a single GM Reform Board in their place.

4.2 The GM Reform Board will provide strategic leadership across the reform

agenda, ensuring:

delivery in line with the GM reform principles; and

GM takes an integrated cross-sector approach to achieving the transformation goals of the Health and Social Care Strategic Plan.

4.3 The membership of the GM Reform Board will reflect the priorities for holistic

public service reform across GM, and will provide a platform upon which to develop GM’s broader holistic place based commissioning ambitions.

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4.4 The GM Reform Board will provide a platform upon which to deliver the early

intervention and prevention agenda, which is intrinsically linked to the work required to transform community based care and support (see below).

Figure 1: Health and Social Care transformation priorities

4.5 A more detailed paper describing the creation of a GM Reform Board has been produced.

5. ALIGNMENT OF GM REFORM AGENDA 5.1 As the sections above highlight, it is clear there is recognition of the strategic

interdependencies between our different reform programmes. Recognition of these interdependencies needs to be broader than at a strategic level, it needs to reflected in locality based and GM operational planning.

5.2 Significant progress has been made in the past year to put GM wide and

locality based governance and operational structures in place to deliver health and social care reform. Building on these firm foundations, (and recognising the interdependencies with a wider reform agenda) there are a range of areas where aligning our work should be focused: a. GM Governance and commissioning A shadow Joint Commissioning Board (JCB) is already in place as part of the governance supporting health and social care in GM, and work is now underway to ensure the JCB is utilised as the vehicle to consider a wider range of commissioning decisions we may want to take as GM. For example, to deliver our employment and skills ambition there are decisions we will need to take that cut across health and social care commissioning, employment

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support provision and commissioning of skills provision. The GM Reform Board, described at Section 4 is a significant step in delivering this. b. Integrated place-based decision making Aligning work at a GM level will help create the structure to agree integrated approaches to reform. Complementing this, integrated leadership models at locality level are required. Locality plans have paved the way for local care organisations. Decision making that will sit with these organisations must align with the delivery of broader reform in places (particularly in aligning the range of service areas required to deliver a comprehensive early intervention and prevention strategy). c. Leadership and workforce development New models of delivery require new models of leadership. They also require new skills and new configurations of neighbourhood teams. Alignment of work to deliver leadership and workforce development in GM must therefore cut across all parts of the GM reform landscape. d. Enabling innovation Innovation must continue to be encouraged as we deliver reform in GM. The agreed Health and Social Care Transformation Fund and the Reform Investment Fund that is under discussion with Government can act as a catalyst for that innovation. e. Use of information Information sharing is required to inform front line decision making and to inform analysis, policy development and strategic decision making. This is an area that must be cross-sector if we are to deliver genuinely integrated services. The development of GM- Connect will be a genuinely cross-sector initiative and is a model GM should consider building on – capitalising on the opportunities working together as GM affords while ensuring the locality based impact delivers on our commitment to give our frontline staff the tools they need to deliver integrated services. f. Communications and engagement To deliver the GM reform agenda we must promote a new relationship between citizens and the state. An integrated approach to communications and engagement is therefore required. g. Research and evaluation Across Health and Social Care Reform and broader GM Reform there is a need for an ongoing focus on research, analysis and evaluation. New Economy has a key role to play in supporting the breadth of priorities of GMCA and we should seek to identify those opportunities where we can align research and evaluation, providing a more nuanced understanding of the opportunities and impact reform affords us. h. Effective use of estate Key to delivering our reform ambition will be making best use of the estate that we have. The public service estate in GM is both vast and diverse;

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through both the One Public Estate work, and the significant opportunity presented through the creation of a GM Land Commission, GM is able to deliver locality based assets, as well as well making best use of the land that is no longer required to form part of the public service estate.

5.3 It is important that GM capitalises on the significant opportunities that are presented by transforming strategic thinking into operational and practical responses. To support this a more detailed plan will need to be produced.

6. INVESTMENT IN REFORM 6.1 At the heart of the Commissioning Strategy will be an investment model

designed to ensure delivery of the reform objectives set out above. This model will need to be applied to the application of aspects of the Transformation Fund and the proposed Reform Investment Fund as the key to investment in testing reform to produce better evidence to drive decommissioning and commissioning decisions which alliance mainstream funding to local priorities.

6.2 Such a model will:

At Stage 1 – Facilitate informed investment decisions based on recognised Cost Benefit Analysis methodology, with funding identified to support double running during the transition phase;

At Stage 2 – Testing at scale implementation opportunity, cognisant of associated risks. Creating an evidence base of outcomes and activity;

At Stage 3 – Taking the evidence gleaned from Stage 2 to inform options to secure the long term funding streams for the new models, with associated decommissioning to support this.

6.3 The implementation of such an investment approach requires us to take a

longer view in terms of our commissioning interventions, moving away from annual commissioning cycles which apply to many areas of health and care currently. Part of our reform programme will signal a move to more multi-year, population (capitation) based contracting models, which will be necessary to facilitate this strategic direction.

6.4 Equally, the collaborative approach being adopted through the devolution

programme will allow us to track the impact of our investment decisions across organisational and sector boundaries. This will allow us to move towards more inclusive public service cost benefit analysis approaches, moving away from the perverse incentives that can sometimes arise from existing models.

7. RECOMMENDATIONS 7.1 The Strategic Partnership Board is asked to:

1. Note the content of the report; 2. Acknowledge that significant opportunity that is presented through

aligning public service reform across GM.

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Subject: Review of Services for Children in Greater Manchester

Report of: Jim Taylor, City Director, Salford City Council

PURPOSE OF REPORT This paper provides the Strategic Partnership Board with an update on the Review

of Services for Children in Greater Manchester which forms part of the Greater

Manchester Devolution Agreement. It highlights the clear links between the priorities

being identified through the different themes within the review and the objectives of

the Strategic Health and Social plan for Greater Manchester.

RECOMMENDATIONS: The Strategic Partnership Board is asked to:

1. Note the progress of the GM Services for Children review 2. Consider where there are clear links between the priorities for the GM

Review of Services for Children and for Health and Social Care Devolution

3. Consider how GM can ensure that the requirements of the Services for Children Review can best align to the Health and Social Care Strategic Plan in the design and implementation stages.

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CONTACT OFFICERS: Jim Taylor (City Director, Salford City Council) - [email protected]

Charlotte Ramsden (Director, Children’s Services, Salford City Council) -

[email protected]

Jacob Botham (GM PSR Team) – [email protected]

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1. INTRODUCTION 1.1 This paper provides the Strategic Partnership Board with an update on the

Review of Services for Children in Greater Manchester which forms part of the

Greater Manchester Devolution Agreement. It highlights the clear links

between the priorities being identified through the different themes within the

review and the strategic Health and Social plan for Greater Manchester.

2. BACKGROUND 2.1 At the Summer Budget 2015, it was announced that as part of the Devolution

Agreement Government and Greater Manchester Local Authorities would work together to undertake a fundamental review of all services for children. Alongside Health & Social Care Integration, the review of Services for Children is a significant priority for the Devolution Agreement and reform across Greater Manchester.

2.2 At a national level this review is seen as a vital piece of work and was

specifically cited within the 2015 Spending Review (below) alongside the commitment to develop new approaches to investing in prevention from 2017.

‘As a trailblazer for reform of the way that all services for children are

delivered, the Government will support Greater Manchester Combined Authority to develop and implement an integrated approach to preventative services for children and young people by April 2017.’

2.3 The review comes against a backdrop of Government wishing to drive

innovation amongst authorities with growing concern nationally that the quality of services for children requires improvement, even in ‘good’ authorities. It also recognises that there are significant barriers to ‘doing things differently, which may require a change in legislation. This reflects the importance of the review of services from a national perspective.

2.4 In Greater Manchester, the imperative to look at more radical approaches to

the way services for Children are delivered is acknowledged by Directors for Children's Services who also recognise that devolution must be extended to all services for children if we are to deliver the best outcomes for children within the resources available. Many areas in Greater Manchester have already developed plans to improve children’s services and reduce the number of children in care. This review will both help the implementation of their plans but also push the level of ambition.

3.0 THE AMBITION 3.1 The ambition for the review is to deliver improved outcomes for children

across GM by:

Improving outcomes for children and families; supporting parents and carers to be the best they can be.

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Reducing, appropriately, the number of Looked after Children – setting a high level ambition, e.g. 20% reduction in LAC.

Reducing, appropriately, the number of Children in Need and children with Child Protection Plans.

Developing a safe system that is financially sustainable within 5 years through joint investment of resources to reduce future demand.

Supporting more asset based interventions to promote resilience, confidence and wellbeing in families and local communities.

Applying a more effective organisational system in order to make best use of resources and expertise.

Increasing social worker capability and capacity, as part of wider workforce reform and development.

Reduction of caseload so more time can be spent with the families. Less sickness time and fewer agency staff.

Deepening commissioning arrangements and stimulating new models of early intervention, prevention and provision.

Learning from best practice and building on existing innovation.

3.2 The ambition is to develop new approaches for GM services for children that

as well as significantly improving outcomes will reduce demand for high end targeted and specialist services and future pressure on a range of public service budgets. Recent analysis undertaken to support the review considered the implications of a range of different scenarios make a strong financial case for looking at new approaches to the way we deliver services for children. It shows that, across GM, demographic and other pressures will place around £40m pressures on Children's services budgets under ‘business as usual’ over the next 5 years. However, the analysis also demonstrates the potential of taking different approaches with four basic assumptions about reducing LAC numbers; reducing referrals, reducing external foster care spend, and reducing agency social worker spend, potentially saving £70m against the business case.

4.0 PROGRAMME OF WORK 4.1 Since the announcement of the review in summer, Greater Manchester has

been tasked with developing a programme of activity which will aim to deliver improved outcomes for children across the region. The work involves developing innovative proposals to re-configure services for children across all ten local authorities and key public service and other partners. This is likely to involve a fundamental change in collaboration, which could be across the whole of GM for some areas of work, or on a clustered basis.

4.2 Charlotte Ramsden, Director of Children’s Services for Salford City Council

has responsibility for overseeing the Review reporting directly to Jim Taylor, as the lead GM Chief Executive. All the Directors of Children's Services across the ten authorities are acting as Senior Responsibility Owners for the

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individual workstreams and since the review was announced have been tasked with leading the work to scope what might be included under each priority theme. The decision making has been driven by the following factors:

Outcomes to be achieved for children, now and in five years time.

Collective understanding of data and intelligence, plus the current resources invested in services for children across all authorities and the anticipated resource in five years time.

The potential benefit of either efficiency with reduction in cost, improved quality of intervention, or increased effectiveness of outcomes for either the short or long term.

Opportunities to build on existing best practice and collaboration across partners both nationally and in Greater Manchester.

Consideration about where these themed areas link to opportunities that are emerging from other areas of devolution work, where current work programmes can or should be extended.

4.3 This has culminated in the identification of seven priority workstreams

(themes) each led by an individual GM Director of Children's Services. The workstreams are:

1) Youth Offending - led by John Pearce (Trafford)

2) Integrated health commissioning and delivery for children - led by Steph Butterworth (Tameside) and Chris Mcloughlin (Stockport)

3) Education – led by Mark Carriline (Bury)

4) Complex Dependency & Early Help – led by Maggie Kufeldt (Oldham) and James Winterbottom (Wigan)

5) Quality Assurance Functions in Statutory Children’s Services – led by Andrew Webb (Stockport)

6) Complex Safeguarding – led by Gail Hopper (Rochdale)

7) Looked After Children – led by John Daly (Bolton)

A list of some of the main opportunities identified as part of the scoping work

under each work stream are summarised in the Appendix. 4.4 Directors of Children’s Services leading on each workstream are now

developing the key opportunities identified in the initial scoping work into business cases which also includes the identification of specific ‘asks’ of Government. They are being supported on the immediate task of developing the business cases by a programme team providing a mix of policy, project management and analytical skills. In addition ‘subject experts’ have been identified by DCS’s to work on individual workstreams. The deadline for the business cases is the w/c 7th March. Overall progress is being reported to Charlotte Ramsden as lead DCS on a weekly basis and there is a monthly

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Programme Board chaired by Jim Taylor. The monthly GM DCS meeting is acting act as a steering group for the Review.

4.5 In addition to the ongoing work to develop the business cases which has

involved a number of design workshops to flesh out the proposals, regular meetings are also being held with DfE and senior policy advisors to work through some of the ‘asks’ of government recognising that there are significant barriers to ‘doing things differently’, which may require a change in legislation. To date detailed discussions have focussed on three key areas. The first is potential alternative Quality Assurance models at a GM level including the role of Local Safeguarding Boards and the role of Independent Reviewing Officers, linked to CAFCASS. The second is the strategic planning of school places and school improvement work linked to the role of the Regional Schools’ Commissioner, plus the role of schools in providing early help and the potential for this to expand to more specific responsibility for children in their early years. The third area involves specific asks in relation to tackling Complex Safeguarding issues including Child Sexual Exploitation, organised crime, sham marriages, female genital mutilation modern slavery and radicalisation. Progress on these discussions is being reviewed through three weekly meetings with DfE. Both DfE and DCLG are also in the process of identifying officers to be seconded to work directly with GM on the review.

5.0 LINKS WITH HEALTH AND SOCIAL CARE 5.1 There is significant overlap and potential dependency between the proposals

identified thus far through Services for Children Review and the ambitions in the Health and Social Care Strategic Plan which should strengthen the potential to create an approach across all ages on a start well, live well, age well basis. The learning from the increased integration of commissioning across councils and CCGs for adult services will inform future plans for services for children in the widest sense. The Integrated Health Commissioning and Delivery theme within the children’s work has direct relevance to the Health and Social Care strategy and health is central to many of the areas of work being developed across the workstreams. Of particular note are the following:

Commissioning of Mental Health provision – The ambition to develop simpler models for commissioning and service provision of Child & Adolescent Mental Health Services (CAMHS) including early help, plus explore how Perinatal Mental Health services could be improved through greater co-ordination. A focus on early intervention and prevention is also key priority in the Integrated Health Services for Children workstream and is fundamentally intertwined with delivery of an all age mental health strategy for GM which has strategic initiatives that focus on children and young people.

Early Years – The GM early years new delivery model already has the full engagement of all authorities. There is however an ambition in the Services for Children work to build on this to develop a truly integrated, multi-agency

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approach to ‘Early Years’ (0-5 years) and Early Help (0-18) to help secure positive health, wellbeing and educational outcomes, plus the potential to develop a model where primary schools take a lead role in progressing the learning and educational development of children from the age of two linked to the early years pathway. This will require joint planning, commissioning and delivery linked to the Health & Social Care Strategy, including defining health visiting, midwifery, pre/post-natal and primary care alongside the role of schools. Ensuring that more children are reaching good level of development cognitively, socially and emotionally (as cited in the Devolution Agreement) should act as a shared outcome for targeted improvement alongside the ambition for fewer babies with low birth weight.

. Quality Assurance – This workstream includes an aspiration for a single GM outcomes and quality assurance framework in statutory children’s services which involves the impact of the work of all partners with children in this cohort In addition, there exists the opportunity to develop a pilot model of a GM LSCB linked to modified local arrangements and such an arrangement would need the commitment of all partners with regard to revised information sharing and governance arrangements. Complex Dependency & Early Help – The Services for Children Review advocates the development of systematic prevention system for children and families (start well) that needs to be a fully integrated part of the whole life course (with live well and age well), placed based prevention system in order to reduce demand on acute and specialist services. A ‘whole system’ approach which can articulate how health services can best integrate with services for children in a place is a key area of work linked to the Locality Plan implementation. It is based firmly on the development of resilient and healthy communities and in particular the Health and Social Care focus on 7 day GP access and community health care will support the Complex Dependency and Early Help priorities of the children’s work. Targeted and specialist support – Being able to target particularly vulnerable groups of young people more effectively including Looked After Children, those that are vulnerable to Complex Safeguarding issues, young people with Special Education Needs or Disabilities (including linking into the development of a Learning Disability Fast LD Fast Track)and those transitioning from children to adult care requires a better understanding of the needs of these groups if we are to ensure that they receive the ‘wrap around’ support needed. This may include different commissioning and delivery models to support improved access rates for vulnerable children, looking at options for 24/7 crisis care support and the better integration of children to adult care.

Integrated Commissioning – Aligning the proposals within the Services for Children Review with the Health and Social Care Strategic Plan will offer the opportunity for integrated commissioning of specific services or interventions for children and parents at a GM level. The Joint Commissioning Board will have a key role to play in understanding where maximum value and impact can be achieved through an integrated approach to commissioning.

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Workforce Development – A common set of values, behaviours a more flexible workforce will be vital for both programmes areas work. There is opportunity to develop these jointly and consider how workforce development activity can be jointly commissioned/delivered using pooled resources. Data sharing and analytics capability – The need to understand the needs of our populations better and understand/predict demand is a vital element of the Services for Children Review. This will require new approached to how we jointly tackle barriers around data sharing (GM Connect) but also how we maximise the information we hold and the analytical resources we have at our disposal. There is an opportunity to explore how we can develop better integrated needs assessments for GM that will support more effective commissioning / provision / monitoring.

6.0 NEXT STEPS 6.1 A number of steps are being undertaken that it is proposed will help ensure

the alignment of proposals in the Services for Children Review and Health & Social Care Strategic Plan. These include:

- Positioning the Director of Children’s Services for the Integrated Health

Commissioning Children’s Workstream on the Joint Commissioning Board. - Ensuring programme teams supporting the Children’s Review and Health

& Social Care are meeting regularly to align activity and that appropriate Health and Local Authority representatives are involved in the different workstreams/strands for the each programme of work.

- The Service Director for Children’s Safeguarding & Prevention at Stockport Council spending two sessions per week working with the Health and Social Care Programme Team to help ensure that there is alignment across the Integrated Health Commissioning and Delivery workstream and related areas of work.

7.0 RECOMMENDATIONS 7.1 The Strategic Partnership Board is asked to:

1. Note the progress of the GM Services for Children review;

2. Consider where there are clear links between the priorities for the GM Review of Services for Children and for Health and Social Care Devolution;

3. Consider how GM can ensure that the requirements of the Services for Children Review can best align to the Health and Social Care Strategic Plan in the design and implementation stages.

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Appendix – Key Opportunities identified within the scoping of the workstreams within the GM Services for Children Review

Youth Offending

Review pathways in and out of the existing Youth Offending Teams.

Explore possibilities of moving to a single commissioned Youth Justice System.

Consider different spatial delivery models (population and needs based).

Scope out possible alternative models for community based provision.

Develop a GM whole-system approach to an integrated youth support service offer

Explore potential for non-custodial budgets to be devolved to a GM level

Integrated Health Commissioning and Delivery for Children

Develop simpler models for commissioning and service provision of Child & Adolescent Mental Health Services (CAMHS), which can improve the quality of care, reducing delays and reduce cost.

To implement the early years new delivery model and agree appropriate links with the wider early help and complex dependency work

To explore opportunities for greater integrated working in relation to children with disabilities

Explore how Perinatal Mental Health services could be improved either through greater co-ordination

Undertake further analysis around transition to adult mental health services and evaluate options for the redesigning service provision for young people in transition.

Education

To develop an improved model for determining school improvement priorities across GM and to strategically align resources.

Develop a strong ‘place based’ partnership with GM and the Regional Schools Commissioner regarding the future need for school places.

Explore how the workforce across early years be better brought together to align resource to those children and families in most need and for a continued relationship with the child and parents up to the age of 16.

Explore options for a multi disciplinary team to be led from within the school in order to bring the best co-ordinated care to children and families prior to starting school.

Complex Dependency & Early Help

Develop an integrated, whole system, place-based model of early intervention and prevention, which builds on learning from the Troubled Families

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programme, to provide consistent GM delivery for Complex Dependency and Early Help.

Place individuals and community assets at the centre of services, supported by a workforce that takes a whole family approach in order to build capacity and promote resilience.

Develop early help and self-help pathways and support linked to an early help commissioning framework, which maximises the role of the third sector, and can be used in localities and by schools.

Explore options for integration with other provision:

- Early Years

- Universal services such as Schools and Health Visitors

- Work and Skills

Quality Assurance Functions in Statutory Children’s Services

Work with DfE and Government Inspectorates to review current approach to Quality Assurance (QA), with a focus on promoting innovation, improving the quality of services and delivering better outcomes for children and young people.

Develop and implement a Greater Manchester approach to a Quality Assurance function in statutory children’s services.

Consider options for structural change, including the creation of a single GM-wide QA function.

Complex Safeguarding

Develop clearer pathway and referral protocols for complex safeguarding to be shared and communicated with all front line staff.

Explore the potential for the development of a GMCA safeguarding ‘hub and spoke’ model for Complex Safeguarding.

Consideration of how more integrated approaches with GMP and other partners (DWP, Community Safety, Immigration, etc.) might be achieved.

Expansion of existing successful programmes such as Project Phoenix and Challenger, good practice which already exists across GM.

Develop pan-GM quality standards to clarify and achieve consistency of response by partners at each stage.

Develop the skills and the capacity of professional and communities to understand risk factors and identify them early.

Looked After Children

Identify early interventions which have been demonstrated to work. Invest in proven early interventions on a consistent basis across Greater Manchester.

Reduction on reliance on the external market for placements.

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Learn from other models with a strong evidence base and roll out consistently across Greater Manchester.

Review the existing approach to service provision, with the aim of simplifying all aspects of the process, improving the quality of care and saving money.

Develop and implement a Greater Manchester Looked After Children strategy

Develop a cluster approach to in-house foster placement commissioning.

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Subject: Greater Manchester Mental Health Strategy

Report of: Warren Heppolette

PURPOSE OF REPORT: This paper provides the Strategic Partnership Board with an update on the work

undertaken to date to develop a pan Greater Manchester Mental Health Strategy.


1. Note the process of development 2. Consider the proposed strategy and provide comments 3. Sign off the strategy and proposal to move into implementation phase.

CONTACT OFFICERS: Warren Heppolette [email protected] Vicky Sharrock [email protected]

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work undertaken to date to develop a pan Greater Manchester Mental Health Strategy.

2. BACKGROUND 2.1 Greater Manchester has made a clear commitment as part of devolution to

develop the current provision of Mental Health services, working towards parity of esteem. As a result the Greater Manchester Mental Health Partnership Board was revised to ensure system wide membership, with a focus on developing a GM Mental Health Strategy (Appendix A contains revised membership).

2.2 This system wide approach to understanding our current position and

challenges has led to the development of a draft strategy (attached) with a single compelling vision: “Improving child and adult mental health, narrowing their gap in life expectancy, and ensuring parity of esteem with physical health is fundamental to unlocking the power and potential of GM communities. Shifting the focus of care to prevention, early intervention and resilience and delivering a sustainable mental health system in GM requires simplified and strengthened leadership and accountability across the whole system. Enabling resilient communities, engaging inclusive employers and working in partnership with the third sector will transform the mental health and well-being of GM residents.”

3. The Development of the GM Mental Health Strategy 3.1 Through the development of a single Mental Health Strategy GM is working

towards a whole system approach to the delivery of mental health and well-being services that support holistic needs of individuals and their families within communities.

3.2 The strategy brings together and draws on all parts of the public sector,

focused on community, early intervention and the development of resilience. Improving child and parental mental health and wellbeing is key to the overall future health and wellbeing of Greater Manchester communities.

3.3 Through implementation of new approaches services will be much more

closely integrated within each of the ten GM localities as well as across the wider GM conurbation and accessed in a consistent, simple way. This will see integration within the place at district level bringing social care, primary care and mental health provision together at the community level. It will also see mental health providers collaborating formally across GM in relation to specialist provision. The commissioning and provider landscape will need to be transformed to deliver stronger outcomes, deeper integration, needs based

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pathway models, pooled budgets and more community based models of support.

3.4 The GM Mental Health Strategy provides the basis for future collaboration. It

highlights four priority areas:

Prevention - Place based and person centred life course approach improving outcomes, population health and health inequalities through initiatives such as health and work.

Access - Responsive and clear access arrangements connecting people to the support they need at the right time

Integration - Parity of mental health and physical illness through collaborative and mature cross-sector working across public sector bodies & voluntary organisations

Sustainability - Ensure the best spend of the GM funding through improving financial and clinical sustainability by changing contracts, incentives, integrating and improving IT & investing in new workforce roles.

3.5 Within these four pillars of the strategy, 33 strategic initiatives have been

identified, the implementation of which will transform services in GM. Seven of these have been specifically identified as priority initiatives:

1. Suicide prevention 2. Workplace and employment support 3. Introducing 24/7 mental health services and 7 day community provision

for children and young people 4. Consistent implementation of the 24/7 mental health service and 7 day

community provision for adults across GM 5. Integrated place based commissioning and contracting aligned to place

based reform 6. Integrated monitoring, standards and key performance indicators 7. Provider landscape redesign

4. WIDER STRATEGIC LINKAGES 4.1 The GM Health & Social Care Strategic Plan sets the framework for bold and

ambitious health & social care reform; the first of its kind in the country. We are taking charge of GM through our strategy of growth and reform. The Plan confirms the need for focussed attention and leadership to be given to improvements in mental health and wellbeing and the Joint Board is established to secure that attention and leadership to the delivery of GM’s Mental Health Strategy

4.2 In drafting the GM Mental Health Strategy we have developed links to wider

devolution and reform activity including:

Existing GM reform programmes for Working Well, Troubled Families, Early Years and Justice. This will ensure we build on evidence based approaches, support early intervention and prevention and will raise the profile of mental health across this wider activity.

4

The developing GM review of services for children is currently being scoped on the back of a clear devolution commitment to making fundamental transformation in services for children. CAMHS are an essential element of this review. Implementation of the strategy will therefore be closely linked to this work and inform the review.

GM is a Learning Disability Fast Track area. This programme of activity is also focused on supporting the holistic needs of individuals, close to home, within a community based setting. There are already strong linkages across the two programmes of activity and cross representation through the governance arrangements.

GM is committed to the development of a programme of activity to support people with dementia and their families. The mental health strategy outlines the ambition for our GM dementia programme, Dementia United and the five GM pledges to support the delivery of the vision. As this develops further we will align it to the implementation of the wider GM Mental Health Strategy.

5. NEXT STEPS 5.1 GM is committed to gaining system wide sign up and support for the proposed

Mental Health Strategy and has engaged with stakeholders on the draft to endorse its focus, priorities and ambition. In addition the strategy has been shared for comment and input with Strategic Partnership Board Executive, Greater Manchester combined Authority, AGG, GM Wider Leadership Team, GM Directors of Adult Services and GM Directors of Children’s Services.

5.3 Implementation of the strategy will require significant shifts in current service

provision. To support this move, the current governance and reporting arrangements will be reviewed as previously agreed by the GM Strategic Mental Health Partnership Board. These new arrangements will need to take responsibility for:

Bringing forward the proposals for GM level mental health services, determining which are best provided at the neighbourhood, locality, cluster or GM levels

Development of new commissioning approaches

Strategic planning of specialist mental health services

Reviewing existing patterns of investment

Utilisation of academic assets

Developing collaborative models of care 6. RECOMMENDATIONS 6.1 The Strategic Partnership Board is asked to:

Note the process of development

Consider the proposed strategy and provide comments

Sign off the strategy and proposal to move into implementation phase.

5

Appendix A: GM Strategic Mental Health Partnership Board Membership

Jim Battle (Chair) GM Police & Crime Commissioner

Adele Owen GM Police

Neil Evans GM Police

Chris Mcloughlin Stockport Council

Andrea Fallon Rochdale MBC

Cath Green First Choice Housing

Rachel Tanner Bolton MBC

Craig Harris Central Manchester CCG

Simon Barber 5BP

Alex Little New Economy Manchester

Julian Cox New Economy Manchester

Linda Curran 5BP

Louisa Sharples Health and Justice Social Care

Maqsood Ahmed Strategic Clinical Networks

Marie Boles NHS England

Annie Murray PHE

Michael McCourt Pennine Care

Michelle Moran MMHSCT

Nicky Lidbetter Self Help Services

Sandy Bering Trafford CCG

Warren Heppolette Central Manchester CCG

Martin Whiting North Manchester CCG

Wayne Sheilds GM Fire & Rescue

Alison McDonald GM Fire & Rescue

Laura Mercer GM Police & Crime Commissioner

6

Tony Hunter GM Fire and Rescue

Joanne Griffin First Choice Housing

Steve Taylor Pennine Acute

Kim Neill Pennine Acute

Chris Edwards Probation Service

Kevin Bulman Probation Service

Beverley Humphrey GMW

Hazel Summers Manchester CC

Carolyn Wilkins Oldham MBC

Adam Allen GM Police & Crime Commissioner

Stephanie Butterworth Tameside MBC

Jeff Pollard Probation

Andrew Sidebotham GMP Police

Clair Carson Pennine Care

Keith Walker Pennine Care

Joe McGuigan Trafford CCG

Greater Manchester Mental Health and Wellbeing Strategy

23 February 2016

1

Contents

Page

Compelling Vision

GM Vision: Aims

Stakeholder engagement and feedback

Stakeholder engagement

Strategic Plan on a Page

Current Position

System Challenges and Best Practice

Priority initiatives for early implementation

Economic case

Summary: Investment Case and the Potential Benefits

Assumptions

Strategic Initiatives by Pillar

2

3

4

5

6

7

8

11

17

22

23

27

2

Compelling Vision

GM Mental Health and Wellbeing Strategy

Improving child and adult mental health, narrowing their gap in life expectancy, and ensuring parity of esteem with physical health is

fundamental to unlocking the power and potential of GM communities. Shifting the focus of care to prevention, early intervention and

resilience and delivering a sustainable mental health system in GM requires simplified and strengthened leadership and accountability across the whole system. Enabling resilient communities, engaging

inclusive employers and working in partnership with the third sector will transform the mental health and well being of GM residents.

3

GM Vision: Aims ● We propose a whole system approach, that includes involvement from the independent and third sector, to improve the mental health and wellbeing of

individuals and their families, supported by resilient communities, inclusive employers and services that maximise independence and choice.

● The GM strategy aims to build on existing best practice to lift patients’ experience of care and support through the development & application of national and GM standards relating to access and care delivery.

● We will simplify the provider system and bring together commissioning across GM focused on the delivery of agreed GM level outcomes and standards to deliver, deeper integration, needs based pathway models, pooled budgets and more community-based recovery-focussed models of support.

● Children and Young People’s mental health forms an integral part of our overall strategy. We will use the opportunities through devolution to collectively respond to the challenges outlined within Futures in Mind and in doing so transform the provision of services for the young people in GM

● We will support and develop our GM workforce to work in new ways to deliver our vision recognising their importance to delivering a sustainable whole system approach to mental health

● Greater integration across mental and physical health and social care services within each of the ten GM localities as well as across the wider GM conurbation. These will be patient, carer and family focused, accessed in a consistent, simple way. We will invest in community and crisis support to reduce the requirement for acute and long term care.

● Develop Prime Provider models to improve pathway design, capacity and efficiency for specialist services

● We will promote employment for people with mental health problems and provide timely and effective support to help people stay in employment through building on the current GM Mental Health and Employment Programme of activity.

● We will support those most vulnerable in society to help reduce the risk of developing poor mental health, and those with existing mental health conditions from deteriorating further. In doing this we will build on GMs existing approach to supporting people with complex needs with a particular focus on looked after children, child sexual exploitation, those with learning difficulties and disabilities.

● Ensure our focus on mental health is integrated with Local Care Organisations

● Through the implementation of the GM strategy, address the wider financial impact of poor mental health on the wider public sector system and deliver against the £146m potential financial benefits identified

● Provider system leader

● GM Commissioning

Simplify Landscape

● Inclusive training and employment

● Community resilience

● School involvement

Better Health

and Wellbeing

Improve Services

● GM Wide standards based on the best practice

● GM wide 24/7 crisis response for children and greater consistency for adults

4


Themes from stakeholder engagement In developing the strategy we have undertaken a number of conversations and engagement sessions across GM. The key themes arising from these discussions are summarised below, set against each of the 4 strategic principles for improved mental health and wellbeing in GM.

● Eliminate the vast majority of out of area placements.

● Group GM resources to commission more efficiently and effectively.

● Untangle the current governance to streamline decision making and actions.

● Agree common delivery outcomes across GM (the what).

● Allow local delivery methodology (the how).

SUSTAINABILITY

● Mental health support should be embedded in physical healthcare.

● Improve access for cohorts of population who currently find it difficult to access.

● Reduce waits and increase consistency of access for IAPT therapies.

● Eliminate inconsistency of service outcomes across GM.

● Improved integration and transition of children to adult services.

● Single point to access care and support.

● Commissioners (health and local authority) to act as one to give clarity of purpose for providers.

● Providers to be encouraged to build collaborative approach.

● Develop consistent minimum standards that allow for local delivery choices.

● Increase low level intervention spend.

● Focus should be on prevention in order to reduce service demand in higher tiers.

● Target children through use of schools and communities.

● Appropriate mental health training for front line staff.

● Long wait for IAPTs therapies.

PREVENTION

INTEGRATION

ACCESS

5


What does great look like?

Sustainability Integration Access Prevention

● Single point of entry.

● Service users access the appropriate level, setting, and location of services.

● Service users access services earlier.

● Directory of voluntary sector providers.

● First response at single point of access is consistent.

● Service users understand where to get the help they need.

● Access equitable to minority groups.

● Reduction in interfaces, more self-referral.

● Information is consistent and available in one location.

● High quality short-term interventions of high intensity when ill.

● Improve opportunities for self-care.

● Not just about Tier 3/4 services – need lower level Tier 2 services for children and young people.

● Workforce is trained in a range of disciplines, knowledge of the relevant services for referral. Core skills defined and consistent across GM.

● Holistic approach -supporting people to self-manage, maintain work, looking at mental health in the context of areas such as justice, troubled families.

● Embracing technology.

● Community resilience – “community manages itself”.

● Adequate funding for mental health.

● Sustainable recovery – follow up.

● Funding to release people to conduct peer challenge.

● Information sharing and data.

● Reduction in prescribing drugs.

● Mental health support for staff.

● Every GP has mental health champion across the system.

● Multi-agency hubs, “mental health is my job”.

● Stronger links to employment and skills and supporting people with complex needs

● Local commissioner that boroughs feed into – note some participants did not agree on this point.

● Integrated children and young people services across public sector boundaries e.g. CAMHS in schools.

● Care co-ordination.

● Services are co-designed and co-evaluated between commissioners, providers and the public.

● Less separation of mental and physical wellbeing.

● Fewer pathways, fragmentation and organisations. More joined up governance and leadership.

● Integration with 3rd sector.

● Whole person care.

● Role of family and circumstances acknowledged.

● Asset based community model.

● Shared information and communication.

● Joined up working to avoid duplication of assessment.

● Recruitment, promotion and performance framework based on shared principles.

● Economies of scale/one stop shop co-located services in community hubs so we are all working together.

● Mental health feels “less separate” from the rest of the “caring infrastructure”.

● Mental health on education curriculum.

● Intervene earlier in children’s and young people services as method of prevention.

● Support for families and carers.

● Support people with mental health problems to improve their general health for example to quit smoking

● Reduced crisis/demand management.

● Shift to self help.

● Public behaviour change.

● Training to employers and communities about mental health.

● Community support features in care plans.

● Service users offer back to the community.

● No stigma – rebadge mental health.

● Peer support.

● Commissioning research to find out what works.

● Mental health media campaign

to demonstrate prevention.

Through discussions, our stakeholders have articulated what great services would look like. Their suggestions on how we could do things differently are

highlighted below under each of the four strategic principles

6

Compelling Vision


Early Years: Children & Family

Building Capacity for Self care

Early intervention

Improve Mental Wellbeing

Supporting vulnerable people

Workplace and employment support

Targeted public health campaigns

Parity of Esteem

Research Deployed to Inform Best Practice

Technology providing new innovative forms of support

Leverage Successful Programmes e.g. Troubled Families

Prepare the Workforce for Integrated Joined Up System

CHARACTERISTICS TO UNDERPIN VISION

Place based and person centred life course approach improving outcomes, population health and health inequalities through initiatives such as health and work.

Ensure the best spend of the GM funding through improving financial and clinical sustainability by changing contracts, incentives, integrating and improving IT & investing in new workforce roles

Parity of mental health and physical illness through collaborative and mature cross-sector working across public sector bodies & voluntary organisations

Responsive and clear access arrangements connecting people to the support they need at the right time

PREVENTION

SUSTAINABILITY

INTEGRATION

ACCESS

CASE FOR CHANGE PRIORITY POPULATION GROUPS STRATEGIC INITIATIVES

MENTAL HEALTH AND WELLBEING STRATEGY

STR

ATE

GIC

GO

LDEN

TH

REA

DS

Integrated place based commissioning & contracting aligned to place based reform

Vertical & horizontal integration across community, primary & acute care

Whole person integrated vertical care pathway across a horizontal integration of care

A strong partnership with the community and voluntary sector

Asset-based approach and devolution estate managed centrally

Integrated monitoring, standards and KPIs

Integrated data sharing

PREVENTION ACCESS INTEGRATION SUSTAINABILITY

System leadership

Pooling of mental health budgets

Programme prioritsation

Provider Landscape Redesign

Payment and incentives

Regulation reform

New investment streams

Working practices

Single Point of Access and Care Co-ordination

Introduce 24/7 Mental Health and 7 Day Community Provision for CYP

Improving Support for Carers and Parents at Risk

Consistent Standards and Protocols for Step Up and Step Down

Self-sufficiency in GM Provision (out of area placements)

Eating Disorders for Children and Young People

Consistent ADHD services for all age groups

IAPT Services of Consistent High Quality for GM

Priorities Identified for Years 1 and 2

The Strategic Initiatives

Ensure consistent 24/7 Mental Health and 7 Day Community Provision for adults including crisis concordat

Suicide Prevention

7

Current Position

● By 2020/21 the GM health and social care system faces an estimated financial deficit of £2bn demonstrating the need for radical transformation.

● Costs to the wider health care system of our current approaches are significant:

– Poor mental health makes physical illness worse and raises total health care costs by at least 45% for each person with a long-term condition.

– This suggests between 12% and 18% of all NHS expenditure on long-term conditions is linked to poor mental health and wellbeing – between £8 billion and £13 billion in England each year (GM, between £420m and £1.08bn).

– Transforming mental health (along with physical health) services has the ability to contribute significantly to the £2bn projected financial deficit for Health and Social Care in GM by 2021

● There are 3,981 people in GM in contact with mental health services for every 100,000 of the population compared to 2,176 nationally.

● At the current estimated rate of prevalence, there will be 34,973 people living with dementia in Greater Manchester by 2021

● £615m is spent on mental health services across Greater Manchester, with a wide variance across localities. This is made up of:

– LA spend (£97.05m).

– CCG Learning Disability spend (£38.3m).

– CCG MH Specialist Commissioning (£76.5m) (which includes specialist units.

– CCG MH Spend (£403.4m) - Approximately £30.1m of this is spent on out-of-area inpatient treatment (7.27% total CCG spend) including acute admissions due to capacity shortfalls and longer terms placements with complex needs

● The wider economic cost to GM of mental health is approximately £3.5bn (see page 21 for breakdown)

● In addition to the above, further costs are incurred within the GM economy as a consequence of poor mental health. These include the wider costs of mental health associated with unemployment, children with conduct disorder, alcohol and substance misuse and suicides. The impact of these costs on the GM economy are presented in the economic case on pages 23 onwards.

8

System Challenges ● The provider landscape is complex with 5 Adult and Children’s Mental Health NHS Providers, many independent and voluntary sector

providers and a range of specialist mental health services provided outside of GM.

● The commissioning landscape is fragmented. 10 LA’s, 12 CCG’s and an estimated 82 Mental Health and Wellbeing Programmes, dedicated expertise and capacity is scarce and it is therefore difficult to achieve focus, shared solutions and shared priorities.

● There is variability in service provision and outcomes across GM and a lack of consistent and accurate data on activity and outcomes. KPIs are outdated, which makes it difficult to accurately evaluate performance across GM. Social care and Housing are underrepresented in service provision leading to higher health activity and costs. Reforming social care to improve information, prevention, personal budgets, choice and control will yield benefits across the whole service.

● A lack of mental health expertise in GP surgeries and wider primary care and A&E departments is consistently reported and delays getting access to the right care.

● Improving the mental health of GM residents, and providing reliable access to early help redressing the balance towards early intervention and prevention will improve family circumstances, help people find and keep good work, improve school attainment and strengthen communities.

● Lack of integration with wider pubic services

● There is a lack of out of hours, 24/7 crisis care services for children and young people, and inconsistent delivery for adults.

● Services for children and young people and their families and carers, are inconsistent, misaligned and disrupted by transition points. Young teenage people are often caught in between services and often don’t meet thresholds

● Mental health problems in children and young people are associated with educational failure, family disruption, disability, offending and antisocial behaviour, demands on social services and the youth justice system. Untreated mental health problems create distress not only in the children and young people, but also for their families and carers, continuing into adult life and affecting the next generation.

● Mental Health problems are often part of a wider set of complex issues for individuals and families. For example:

● Mental health problems consistently arise with the families we are supporting trough our Troubled Families Programme,

● 68% of the clients on our Working Well Programme (aimed at supporting long term unemployed into sustainable employment) highlight mental health as an issue

● 18% of secondary care patients in Manchester are not in stable accommodation, mental health problems can be a cause and effect of housing issues

9

Learning from local best practice examples and academic research There are many examples of best practice across GM which could feasibly be scaled up.

The implementation plan will set out how this can be achieved and identify mechanisms through which we can scale up local exemplars.

At the GM level the SelfHelp sanctuary crisis model is being rolled out. This will divert people from A&E, reduce the number of section 136s and provide a suicide prevention service

Perfect Weeks - Wigan This is an initiative to ‘suspend the rules’ for a week to test parts of the system. This has had success in Wigan where Adult Mental Health workers were linked in to schools and referred a mother for services, subsequently establishing a good outcome for both mother and child.

Crisis Concordat - Oldham GMP in Oldham and Pennine Care NHS FT jointly developed Oldham Phone Triage/RAID Pilot Project to provide a service available to local police officers who attend incidents where an individual appears to be experiencing mental health problems; police able to contact dedicated 24 hour telephone number for assistance from the Trust’s psychiatric liaison service RAID (Rapid Assessment Interface and Discharge). This has now been rolled out across GM

Key Workers - Trafford Key workers have been used in the Stronger Families Phase 1 in Trafford to improve integration, coordination, prioritisation of support for people with mental health problems, focused on evidence based interventions and greater levels of flexibility going beyond the status quo.

GM West RAID – Bolton and Trafford Successfully implemented RAID – Rapid Access Interface Discharge for its Bolton and Trafford facility, reducing bed days by supporting more timely discharge and hence drive efficiencies.

Tameside, Oldham and Glossop MIND Approached by the local authority to build a wellbeing centre. Transformation of the building took 12 months and c.£250k. The result is used by the community and well regarded nationally as a modern wellbeing centre.

School Model in Chiltern High Manchester – 42nd Street

Resilience workshops and assemblies, mental health workers with case load and drop in, dedicated help line for staff and services offered over the school holidays.

Centre for Mental Health and Safety Develop the links between research base to practice across GM.

5 Ways to Well-being in Stockport Aimed at improving mental health and well-being across the population and enabling people to reach their full potential

10

Learning from social models across the UK and beyond There are many examples of services that enable people to manage their own care, to work together with peers, and to be supported at home with complex needs. Learning from these have fed into the development of the GM Strategy and initiatives.

Mind and Body (Sheffield)

85% of participants sustained a change in life

style and better health

Mental Health First Aid (Australia)

Training citizens and volunteers to recognise, respond to and support

people in mental distress

Clubhouse International (worldwide)

Where service users come together to work join in

activities, cook and participate in their

community

Big White Wall (UK)

Internet based anonymous community

where 95% report improved health –

better than many IAPT programmes

THISWAYUP (Aus, NZ, USA and

Canada) Computer aided

recovery course with 50% complete recovery

Acute hospital A&E liaison

(Birmingham) Comprehensive

RAID support available 24/7 to all people aged 16 in

hospital

Single Point Access Service

(NHS 111 and MIND) Developing training courses designed by

people with lived experiences to support call handlers in times of crisis

Street Triage 26 street triage schemes across

England showing a reduction in use of police custody as a

place of safety

Whole System Redesign (Northumberland, Tyne

and Weir) Large scale acute care pathway redesign integrated triage and telehelath and rapid access to housing services, social care,

third sector and specialist services

Crisis Home Treatment (Leeds)

Survivor led crisis services ,commissioned for 24/7

response and care

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Priority Initiatives for Early Implementation

Where are we now and where do we want to be?

Current state Future state

Place-based cohesive and collaborative commissioning care pathways, pan-Greater Manchester for specialised services, to deliver stronger outcomes, deeper integration, needs-based

pathway models, pooled budgets and more community based models of support linked to wider GM reform activity.

Mental health is ‘everyone’s business’, enabling local areas to make decisions for system wide outcomes

supported by shared information. This includes mental health and social care, but more broadly the opportunities to consider the best approach across public services and the 3rd sector with a focus on community, early intervention and resilience building

on 5 Ways to Well Being

Standardised outcomes framework with minimum standards, outcomes and access across all providers of health

and social care and shared approaches to strengthening communities and voluntary sector effectiveness.

All employers promote good employment practice for MH, building capacity for conversations to support suicide

prevention. Employees will be supported to feel happy at work and helped to achieve life satisfaction. Build on GMs existing

Working Well programme to deliver better outcomes.

Complex and fragmented commissioning for GM’s 2.9 million residents across 10 LAs, 12 CCGs and 82

Mental Health and wellbeing programmes.

Discrepancies in outcomes and quality standards across 4 Adult MH NHS providers, 4 CAMHS providers,

specialist provision and numerous voluntary sector providers results in care that can be inconsistent, misaligned and

disrupted by transition points.

Mental health and well being not prioritised in the workplace and workforce development.

Medical-focussed model of care, which does not always pick up on the holistic and complex needs of the individual and

their environment.

1

2

3

4

1

2

3

4

12


How do we get to the future state?

A self-sufficient mental health system for GM

residents We will sign up organisations across GM to

a Best Workplace Charter in relation to managing stress, mental health issues, and

drive wellbeing in the workplace. We will also ensure there is consistent support available across GM for those currently unemployed and seeking employment

building on the GM Working Well programme.

Develop minimum standards, with a set of KPIs, which also cut across non-care settings, for all providers of health and social care which can be expanded as necessary at the local level to reduce variations between different communities.

Through our GM Reform Programme we will take a preventative and early intervention approach

supporting people with a range of complex needs, working collaboratively across local services to

deliver the right support at the right time to help people address the factors which prevent them

from realising their potential. Mental Health provides a unique connection across all our Public Service Reform objectives and is driving the wider

strategic partnerships required beyond core NHS and social care to wider local government services, GMP, GMFRS, NWAS and others

to ensure mental health is everyone’s business as part of wider Public

Service Reform.

Place-based commissioning and place-based delivery, pan-Greater Manchester for specialised services. Simplify, consolidate and streamline the current commissioning landscape to create a robust and accountable commissioning function which removes duplication, creates economies of scale and provides consistency. Determine a clear vision and understanding of what services should be provided at the GM and locality levels. Consolidate commissioning expertise and develop new payment and incentive mechanisms.

Minimum standards will be built around best practice interventions incorporating a focus on prevention and reducing future demand, taking into account a need for local variations dependent on different demographics. GM is committed to ensuring the new national waiting time standards are achieved and where possible exceeded.

13

Wider Strategic Considerations – GM H&SC Devolution GM has an ambition to become a self sustaining city region supporting growth and connecting GM residents to the benefits growth brings.

In Nov 2014 GM settled a historic devolution agreement which give local representatives control over decisions previously taken at a national level.

Taking Charge of our Health and Social Care

On 25 February 2015 Greater Manchester entered into a ground-breaking agreement with government for the devolution of health and social care . The Memorandum of Understanding formally gave GM control of £6billion of pubic sector funding from 1 April 2016. “Taking Charge of our Health and Social Care” describes how clinical and financial sustainability will be achieved in GM, aligned to the Five Year Forward View.

GM is committed to achieving parity of esteem for people with mental health issues, tackling access and waiting time standards and breaking down barriers to how care is provided.

Reimagining services across our whole care system

The GM Strategic Plan, “Taking Charge of our Health and Social Care”, identified five key areas for transformation change: • Radical upgrade in population health prevention – a shift on focus to population health that

supports GM residents to self-manage, innovates the model for prescribers and pharmacies and tackles the future burden on cardiovascular disease and diabetes

• Transforming community based care and support – a new model of care closer to home that includes scalable evidence based models for integrated primary, acute, community, mental health and social care.

• Standardised acute and specialist care – the creation of single shared services for acute hospital and specialist services to deliver improvements in patient outcomes and productivity through establishment of consistent best practice and reduced variation

• Standardised clinical support and back office support – The transformational delivery of clinical support and back office services at scale, including the establishment of coordination centres to help navigate GM residents through our complex system

• Enabling better care – Creating innovative organisation forms, new ways of commissioning, contracting and payment design, standardised information management and technology to incentivise new ways of working

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Wider Strategic Considerations - National Five Year Forward View (2014)

The Five Year Forward view set out a clear ambition for the future of mental health services in England: • To create genuine parity of esteem between physical and mental health. • Improved waiting times so that 95% of people referred for psychological therapies start treatment in 6 weeks or a fortnight for those

experiencing their first episode. • Provision close to home for those with intensive needs, particularly for young people • New commissioning approaches to transform service delivery

Five Year Forward View for Mental Health Taskforce (2016)

The taskforce’s report sets out a number of priorities for change over the next five years, including: Supporting people experiencing a mental health crisis – by 2020/21 expand crisis resolution and home treatment teams to ensure

24/7 community-based mental health crisis response is available Improving responses to mental and physical health needs – by 2020/21 more people living with severe mental illness have their

physical needs met Transforming perinatal care for children and young people – fundamental change in the way children and young people’s services are

commissioned and delivered, more children and young people having access to high-quality mental health care when they need it and more women accessing evidence-based specialist mental health care during the perinatal period

Access standards and care pathways – by 2020/21 clear and comprehensive set of care pathways with accompanying quality standards and guidance for the full range of mental health conditions

Models of payment – developing payment models that incentivise swift access, high-quality care and good outcomes Acute and secure care – partnership led co-produced standards to ensure acute mental health care is provided in the least restrictive

manner and as close to home as possible Tackling inequalities in access and outcomes – addressing inequalities in access to early intervention and crisis care and rates of

detentions Supporting employment – recognising employment as a crucial health outcome and supporting people with mental health problems

to find and stay in work. Transparency in data – to support improvements in commissioning, inform effective decision-making and promoting choice, efficiency,

access and quality Workforce – good management of mental health in the workplace and the provision of occupational mental health expertise and

effective workplace interventions

15

Wider Strategic Considerations - National (cont.)

National Suicide Prevention Strategy

GM is committed to preventing mental ill health, reducing suicides and promoting mental well-being. Suicide prevention is a key strategic initiatives of our overall strategy. In taking this forward we will build on the national strategy “Preventing Suicide in England”. This strategy highlights key risk groups: young and middle aged men; people in the care of mental health services including inpatients; people with a history of self-harm; people in contact with the criminal justice system and those form specific occupational groups.

In response to the national evidence GM will work towards the development of a suicide prevention strategy aimed at becoming a ‘suicide safer city region’

No Health Without Mental Health

The national strategy focuses on delivering improved mental health outcomes for people of all ages and identifies participation in meaningful activity, secure accommodation and schools relationships as supporting recovery from mental ill-health and promoting mental well being. The strategy highlights five key outcomes:

More people will have good mental health

More people with mental health problems will recover

More people with mental health problems will have good physical health

Fewer people will suffer avoidable harm

Fewer people will experience stigma and discrimination

16

Wider Strategic Considerations – Greater Manchester

Greater Manchester Principles of Reform

Our GM Mental Health Strategy will work to address identified difficulties and create stronger links between mental health services and locality based integrated working. Ensuring flexibility in mainstream services and developing evidence based packages of support aligned to our GM principles of reform:




Integrated services that place individuals, families, communities at the heart

A stronger prioritisation of well being, prevention and early intervention

An evidence based understanding of risk and impact to ensure the right intervention at the right time.

Greater Manchester Public Service Reform Programme

The existing GM Public Service Reform programme, focused on supporting people with complex needs, will enable people and families to develop resilience and promote independence. Transforming community based care and supporting integrated place based working provides the opportunity to integrate mental health into wider reform activity focused on the delivery of key outcomes including:

Supporting 50,000 people facing complex challenges move towards employment

Engaging and supporting over 27,000 families through the expanded Troubled Families programme

Reductions in reoffending through the implementation of Intensive Community Orders

Reductions in reoffending as a result of transforming the work of Women’s Centres

Implementation of our GM Early Years new delivery model

Reductions in duplication through better integrated local service provision

17

Wider Strategic Considerations – Greater Manchester (cont.)

Greater Manchester Programme for Dementia Care – Dementia United

2013 data indicated that the number of people with dementia in Greater Manchester was 29,560, affecting 7.1% over 65s. This is expected to rise rapidly over the next 12 years. Greater Manchester currently spends £221m per year on dementia across health and social care. If we diagnosed everyone in GM who we think currently has the disease this would raise to £320m per year.

As part of our wider work on mental health Greater Manchester has been developing a programme of activity with an agreed vision to:

Make Greater Manchester the best place in the world to live with Dementia

Greater Manchester has made 5 pledges that will support the delivery of this vision:

18


What we will have in place by January 2017

By 1 January 2017

How will the system look different

● GM will be working towards the standards set out in the Crisis Concordat.

● There will be a reduction in need for Section 136 powers which when needed will be used consistently across all 10 LAs in GM through a better understanding of ‘places of safety’ and introduction of street triage support.

● We will have agreed an approach for Place based commissioning and provision at locality level with increased collaboration between providers for specialist services. Integrated commissioning approach based on outcomes aligned with GM commissioning standards framework. Social Care and Housing will be fully engaged in commissioning and delivery.

● We will develop links with the Centre for mental Health and Safety to inform systematic reduction in suicide across GM.

● We will have established formal provider collaboration to achieve self-sufficiency in GM.

● The PHE Workplace Charter will be signed by all public sector agencies in GM.

● Increased integration of RAID into acute services and A&E facilities across GM.

● Create fit for purpose governance arrangements responsible for delivering the GM wide all-age mental health strategy.

● GM Children and Young People outcomes and standards developed and agreed.

● We will have identified leaders and champions to deliver this strategy and they will have produced delivery plans for each of the initiatives.

● Enhanced GM wide suicide prevention strategy.

How we will measure success:

1. Number of employers signed up to the PHE Workplace Charter.

2. Increased number of patients referred to Raid services.

3. Reduction in the requirement for S136 powers used and evidence of consistent application across GM.

4. Increased focus on prevention through wider implementation of Connect 5 and 5 Ways to well Being

Anticipated Financial Benefits

High level financial savings will be achieved through better commissioning, simplified provider landscape, earlier intervention through RAID and a focus on resilience in the workplace and community.

19



By 1 January 2018


● A single system, with clear leadership and partnership working across all public sector organisations.

● We will simplify the provider landscape across GM including the integration with social care and housing by rolling out integrated place-based commissioning using a prime-provider model, with routine outcome measures.

● Consistent GM wide implementation of 24/7 crisis care and community support for adults including full implementation of GM Crisis Care concordat.

● Development and implementation of 24/7 crisis care support for children and young people providing easy access to services that are responsive and provide appropriate help across all GM.

● Established and published the “citizens deal” with a set of all age standards or citizens rights for commissioners to use as a floor that no GM services can fall below.

● Strategic partnership arrangements with positive and mature engagement between the private, public, community, voluntary sector and social enterprises.

● Implementation and application of standards for Children and Young People’s services, focused on young people’s perspectives and expectations building on the national work, Young Minds, and work already taking place in GM.

● All acute provision (acute beds, PICU, active rehabilitation, LA alcohol and drugs services and residential care) will be within GM, and patients will only be sent out of area for inpatient or outpatient services in exceptional specialist circumstances.

● Wider implementation of the PHE Workplace Charter on mental health across private sector in GM delivered in collaboration with the LEP and local Universities and organisations commissioned by GM public sector organisations.


1. Improved quality across the Sector (patient satisfaction, reduced serious untoward incidents, and reduced never events, e.g. a reduced suicide rate).

2. Improved access and reduced waiting times.

3. Consistent standards across Greater Manchester


High level financial savings will be achieved through removal of Out of Area placements and reduced spend in high-end acute settings and reduced unemployment because of mental health.

20

Economic Case

Markers of Activity/Demand, Opportunities to Address (1) The table below summarises the key drivers of activity and demand this strategy aims to influence and successfully address

● Strategic initiatives have been developed to better manage the drivers of activity and demand based around the 4 strategic pillars for transformation (prevention, access, integration, sustainability). There are also cross-cutting themes or “golden threads” running through all four pillars. Communication is needed to change behaviour and create social movement changes to ensure these strategic initiatives deliver the expected transformation.

● The economic benefits of this strategy are generated by the areas for intervention outlined below:

– A shift towards early intervention and prevention where those with mental health issues currently in the health system are supported to access evidence-based less cost-intensive models of care. This will result in reduced spend in acute in-patient settings.

– A more general increase in the support for those with mental health conditions to move back into work. The benefits here are in a reduction in public sector spend more generally.

– Early identification and intervention as soon as mental health problems emerge.

– The promotion of mental wellbeing and prevention of mental health problems in childhood and adolescence.

– The promotion of mental wellbeing and prevention of mental health problems in adults.

– Addressing the social determinants and consequences of mental health problems.

– Improving the quality and efficiency of current services.

● An important long-term goal is to repatriate GM NHS and LA patients being treated long-term in out of area placements. This will be dependent on freeing up capacity in local in-patient settings, which is in turn dependent in enabling community or home-based models. Numerous initiatives for this are already underway in GM, including:

– The out-of-hospital schemes introduced by Pennine care.

– RAID (rapid assessment, interface and discharge), which installs psychiatric liaison teams in acute hospitals, reducing admissions and length of stay for patients with mental illnesses.

– Intermediate care for patents with delirium, providing a further deflection in acute admissions. It is also logical to assume a further 10% reduction in acute in-patient mental health stays through a combination of these initiatives.

● Further savings are likely to be achieved in the reduction of the number of mental health trusts and the number of commissioners involved in commissioning mental health.

Improved life chances for

children with mental health

conditions

Reduced inpatient

admissions and bed days

Reduced out of area

placements

Reduced number of life years lost to

mental health

Outcomes

Reduced running costs for integrated commissioning

21

Economic Case


Specific economic evidence to support this approach aligned to the strategic initiatives developed includes the Department of Health Report, ‘No Health Without Mental Health’ 2011, which identified the following costs of mental disorders across the life course:

● Mental illness during childhood and adolescence results in UK costs of £11,030 to £59,130 annually per child.

● Conduct disorder: Lifetime costs of a one year cohort of children with conduct disorder (6% of the child population) has been estimated at £5.2 billion. Cost of crime attributable to adults who had conduct problems in childhood is estimated at £60 billion a year in England and Wales, of which £22.5 billion a year is attributable to conduct disorder and £37.5 billion a year to sub-threshold conduct disorder.

● Depression: Total annual costs of depression in England in 2007 were £7.5 billion, of which health service costs comprised £1.7 billion and lost earnings £5.8 billion. This does not include informal care or other public service costs. Lower productivity accounts for a further £1.7–£2.8 billion and human costs for another £9.9–£12.4 billion, bringing the total annual cost of depression to £20.2–23.8 billion a year.

● Anxiety: Health service costs of anxiety disorders in 2007 were £1.2 bn. The addition of lost employment brings the total costs to £8.9 billion.

● Schizophrenia: Total costs of schizophrenia were approximately £6.7 billion per year in England in 2004–05. Cost of treatment and care was £2 billion, annual costs of welfare benefits were £570 million and the cost to families of informal care and private expenditure amounted to £615 million. Costs of lost productivity due to unemployment, absence from work and premature mortality were £3.4 billion. The opportunity therefore to make efficiency savings is significant.

● Dementia: Total annual UK costs of dementia are £17 billion. Accommodation accounted for 41% of the total, health services eight per cent, social care services 15% and estimated costs for informal care support and lost employment 36%. Numbers with dementia in England are predicted to rise from 680,000 in 2007 to 1.01 million people by 2051. Long-term care for older people with cognitive impairment in England could rise from £5.4 billion to £16.7 billion between 2002 and 2031.

● Suicide: Average cost per suicide is £1.7 million in England, £1.3 million in Scotland and £1.5 million in Ireland. Better identification of risk in primary care and in drug and alcohol services. In 70% of suicides the person has seen a GP in the last month, so better access to primary care is critical.

● Alcohol misuse is estimated to cost the health service £2.7 billion every year and results in output losses of £6.0-7.3 billion due to sickness absence, reduced employment and premature death while annual cost of alcohol related crime and disorder is £9-15 billion. Total cost of alcohol misuse is estimated at £17.7–£25.1 billion a year, which includes costs of treating alcohol-related disorders and disease, crime and anti-social behaviour, loss of productivity in the workplace and social support for people who misuse alcohol and their families.

● Smoking: Annual direct cost of smoking to the NHS is £5.2 billion with smoking responsible for 462,900 hospital admissions in 2008/9.97 Almost half of total tobacco consumption is by those with mental disorder.

● Inequality: At the national level substantial costs are generated by inequalities in mental health. Estimated to be £56 -68 billion nationally (No Health without Mental Health)

Increased productivity

and employment

across GM

Reduced cost and demand (particularly

repeat demand) to

GMP

Reduced suicide rates

Increased life expectancy for mental health

patients

Outcomes

Reduced alcohol-and substance

misuse related MH A&E

admissions

22

Economic Case

GM Wide Direct Costs of Mental Health

● Greater Manchester spends significantly more on mental health than the majority of UK cities and £30.1m of that is inpatient treatment spent out-of-area (7.27% total CCG spend).

● Excluding specialised commissioning and non-identifiable data, GM spends £35m per year on children’s mental health, £248m on adult mental health and £130m on older adult mental health.

● The Local Authority’s social care expenditure on mental adult comprises of mental health support services and excludes learning disability spend (£216m on adults 18-64 and £34.5m on adults over 65). It also excludes physical, sensory or social support costs.

● Based on inflation anticipated figures (using FYFV assumptions), this projected health and social care spend on mental health services if we don’t change is set to increase to £644m by 2021.

● However, in addition to the above, costs are incurred within the GM economy as a consequence of poor mental health as illustrated on page 21.

Between CCGs, locals authorities and specialised commissioning, GM spends c.£615m across on Mental health services across health and social care. £403.4m

£38.3m

£97.05m

£76.5m

CCG mental health

CCG learning disability

Local authorities

Specialised commissioning

2014/15 2020/21

£m £m

Local Authority Spend 97.05 110.8

CCG Learning Disability Spend 38.3 39.4

CCG MH Specialist Commissioning 76.5 78.8

CCG MH Spend 403.4 415.2

615.3 644.3

Source: Local authority budgets, CCG programme budgeting returns and CCG reported data. NB - The specialist commissioning figure does not include learning disabilities and is based on the Secure & Specialised Mental Health Database.

23

Economic Case

Cost of Mental Health services in GM

CCG commissioned spend

The 12 CCGs in GM spent approximately £403m on mental health services in 2014/15 compared to £441m in 2013/14.

The CCG spend analysis above demonstrates the constrained budgets available for CCGs as only Trafford and Tameside and Glossop were able to spend more in 2014/15 than in the previous year.

When plotted against the registered population, Salford and the Manchester CCGs were found to be spending the most per capita at over £170 per head of population.

The average spend in the North was £124 and Wigan, Oldham, Bury Stockport and Bolton spent under this in 2014/15.

Learning from localities has fed into this GM wide strategy.

Across GM approximately £403m is directly spent on Mental Health services by CCGs.

When adjusted for population variances Salford and Manchester CCGs spend the most.

Wigan, Oldham, Bury, Stockport and Bolton spend below the average in the North per CCG.

Source: 2013/14 and 2014/15 CCG programme budgeting returns.

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24

Economic Case

Wider Cost of Mental Health across Greater Manchester

Cohort Volume/Impact on GM economy Cost (£)

GM Population Unemployed with Mental health conditions

● 144,000 Individuals on Employment Support Analysis/Incapacity benefit across GM. Up to 80% of benefits claimants have a mental health condition.1

£1.05 bn

Based on £9,091 fiscal cost per claimant per year.

Children with conduct disorder

● 5.8% of children (~2200 in each GM year group cohort) estimated to have conduct disorders. 2

£330m public sector costs

Based on £150,000 over the lifetime of each child (including NHS, social services, education and criminal justice). 2

Alcohol misuse ● 504,263 Alcohol-related hospital admissions and attendances across GM (2013) (1,155 deaths directly attributable to alcohol).

£167m 3

(hospital admissions, A & E attendances).

£1.2bn in wider costs due to lost productivity, crime, health and social care costs

Substance misuse ● 2,994 Estimated OCU (Opiate or Crack) Users not in treatment in GM in 2014/15. 4

● 86% of Troubled Families with mental health issues also have issues with substance misuse

£78m cost of crime (this is a conservative estimate and does not include other drugs such as Amphetamines, Cannabis, prescription drugs and legal highs) 4

Based on cost of crime for those not in treatment of £2924 per person.

Mental Health bed based-inpatients

● 44% of total CCG MH spend on bed-based inpatients. 5

● On average, 10,495 occupied bed days for MH inpatients in GM per 100, 000 population

( higher than the 7,199 national average).

£176m CCG spend on bed based-inpatients. 5

(£21m uncategorised by CCGs).

Suicides ● 277 suicides registered in Greater Manchester (2014). 6 £2.9m in direct costs to the NHS and policing

£442.7m wider costs due to lost waged and non-waged output, as well as intangible human costs .

Based on total cost per suicide of £1.6m 6

Homelessness ● 25-35% of all those accessing homelessness services present with mental health as their main need.

£2.8m cost to Local Authorities

Based on total GM spend on homelessness of £9.45m per year7

Source: (1) GMCA Mat Ainsworth Working Well: Supporting long term ESA claimants into sustained employment. http://stats.cesi.org.uk/events_presentations/SeminarSeries2014/Tacklingemployment/MatAinsworth.pdf

(2) a) http://www.hscic.gov.uk/catalogue/PUB06116; b) http://www.nice.org.uk/guidance/qs59/documents/qs59-antisocial-behaviour-and-conduct-disorders-in-children-and-young-people-support-for-commissioning2

(3) http://www.alcoholconcern.org.uk/training/alcohol-harm-map/

(4) a) ‘ITEM 6 - Substance Misuse in Greater Manchester’, GMCA; b) http://www.nta.nhs.uk/uploads/whyinvest2final.pdf

(5) a) CCG programme budget returns; b) Mental Health Benchmarking 2012to13 vs 2013to14 v4.

(6) a) ONS, Suicides in England and Wales by local authority, 2016; b) Scottish Executive, Evaluation of Choose Life, 2006

(7) Local authority outturn returns 2014/15

http://stats.cesi.org.uk/events_presentations/SeminarSeries2014/Tacklingemployment/MatAinsworth.pdf

http://www.hscic.gov.uk/catalogue/PUB06116

http://www.nice.org.uk/guidance/qs59/documents/qs59-antisocial-behaviour-and-conduct-disorders-in-children-and-young-people-support-for-commissioning2




























http://www.alcoholconcern.org.uk/training/alcohol-harm-map/





http://www.nta.nhs.uk/uploads/whyinvest2final.pdf

25

Summary: Investment Case and the Potential Benefits The following sets out a summary of the impact of some of the strategic initiatives within the strategy across GM. These figures relate to opportunities and based on publically available information and published studies. All figures are given on an annual basis. Further detail including assumptions and referencing are provided on the next four pages. Detailed financials relating the actual activity to be delivered will be developed as part of the implementation planning for the strategy.

Scheme

Cost

Fiscal Benefits1

Additional Public Value Benefits2

Early years £15.1m £15.8m £28.1m

Education: School based social and emotional learning £5.8m £44.4m Unknown

Troubled families £22.8m £33.4m £75.2m

Alcohol Misuse: Screening and brief early intervention £1.3m £5.9m Unknown

Suicide Prevention: Suicide awareness training and intervention £0.4m £0.3m £48.0m

Working well £3.0m £5.1m £13.0m

Workplace screening for depression and anxiety £1.2m £0.7m £2.2m

Promoting wellbeing in the workplace £0.04m £0.0m £0.5m

Housing step down support facility £0.5m £5.2m Unknown

RAID - Psychiatric Liaison £1.5m £2.4m £0.2m

Intermediate Care for patients with delirium £9.6m £12.7m Unknown

Crisis prevention through IAPT £6.9m £11.6m Unknown

Assertive Outreach for individuals with complex dependency £1.0m £1.5m £1.4m

Total of above schemes £69.3m £139.0m £168.4m

1 the financial or ‘fiscal’ impacts to government agencies

2 the overall public value created by a project including economic benefits to individuals and society; and wider social welfare/wellbeing benefits

26

Assumptions

The Investment Case and the Potential Benefits (1) GM MH Strategy &

Underlying Assumptions

Note: (1) New Economy – Early Years Cost/Benefit Analysis (2015) (2) Mental health promotion and mental illness prevention: The economic case. LSE/PSSRU, Institute of Psychiatry, Kings college London (April 2011). (3) New Economy – Troubled Families Cost/Benefit Analysis (2014)

Early Years: Children & family

Early Years Programme1

● Though investment in parenting support, maternal/postnatal health, and early childhood education yields major, long-term social and economic growth, and also help prevent children develop anti-social personality disorders as adults. Based on a cohort of 38,000 children across GM.

● Costs and benefits of the Early Years programme were modelled over 25 years, with returns increasing annually. Some benefits, e.g. reduced A&E attendances/improved school readiness, to be accrued in the short term. Others e.g. increased employment when children leave school to be accrued long-term.

● Division of fiscal benefits between agencies: DWP 53%; Schools 17%; Local Authority 14%; NHS 10%; Police 3%; Other CJS 3%; Housing Providers < 1%.

School-based social and emotional learning2

● Programmes to help children and young people recognise and manage emotions, and to set and achieve positive goals. Based on a cohort of 38,000 children, as per Early Years. ● Costs of intervention include teacher training, programme coordinator and materials. ● Cumulative benefits taken as an annual average from across ten years of operation. Recognition is given to the build-up in benefit over time. ● Division of fiscal benefits between agencies: Criminal Justice System 58%; NHS 36%; Education 6%; Social Services 1%; Voluntary Sector <1%.

Education

Troubled Families

Troubled Families Programme3

● Interventions to support such families characterised by there being no adult in the family working, children not being in school and family members being involved in crime and anti-social behaviour. These problems are associated with mental health issues and wider determinants of mental health such as domestic violence, relationship breakdown, mental and physical health problems. Assumptions based on cohort of 13,561 troubled families (out of total of 27,200 troubled families across GM).

● All figures are an annual average based on a ten-year intervention. The average reflects the fact that costs are only incurred in the first six years, whereas benefits are accrued for all ten. Significant lead-in time for benefits, with increases from £4.4m in the first year to £41m in the fifth.

● Division of fiscal benefits between agencies : Local Authority 44%; NHS 17%; Housing Providers 11%; CJS (exc. police) 10%; DWP 9%; Police 9%; HMRC/Schools/Department for Education < 1%.

Alcohol Misuse Intervention

Alcohol screening and advice2

● An inexpensive intervention in primary care which combines screening by GPs, followed by a 5 minute advice session for those who screen positive. ● Brief interventions in primary care settings achieve an average 12.3% reduction in alcohol consumption per individual. ● Based on approximately 30% of 66,000 patients screened registering as positive. ● Division of fiscal benefits between agencies: Criminal Justice System (including police) 73%; NHS 27%.

Suicide Prevention

Population-level suicide awareness training and intervention2

● Suicide prevention education for GPs can have an impact as a population level intervention to prevent suicide through greater identification of those at risk. Individuals can receive cognitive behavioural therapy (CBT), followed by ongoing pharmaceutical and psychological support to help manage underlying depressive disorders. The cost of this type of intervention includes ten sessions of CBT in the first year with further ongoing pharmaceutical and psychological therapy together with suicide prevention training for GPs. By applying the England-wide economic model to the GM context, this amounts to approximately 30 potential suicides.

● Division of fiscal benefits between agencies: NHS 63%; police 37%. ● Public value benefits include the prevention of lost wages and non-waged output as well as associated intangible human costs.

27

Assumptions



Note: (1) New Economy – Working Well Cost/Benefit Analysis (2015) (2) Mental health promotion and mental illness prevention: The economic case. LSE/PSSRU, Institute of Psychiatry, Kings college London (April 2011). (3) Health and housing: worlds apart?:Housing care and support solutions to health challenges. National Housing Federation 2009.

Employment Support

Working Well Programme1

● This includes expansion of the Working Well programme across GM to help people with MH conditions who are on Employment and Support Allowance (ESA) to overcome their barriers to work. The benefits provide a prudent estimate related to a cohort of people (1,500) directly identified as having a MH condition. However, the number of people within the overall programme is greater and may also include those be impacted by mental health issues.

● Each person taking part in the scheme will receive individually-tailored packages of support ensuring, through careful co-ordination, that the issues which are holding them back from work are tackled at the right time and in the right order.

● Division of benefits between agencies: DWP 64%; NHS 30%; Police 2%; Prisons 1%; Courts/Legal Aid 1%; Other CJS 1%.

Employment Support

Workplace screening for depression and anxiety2

● Work place based enhanced depression care consists of completion by employees of a screening questionnaire, followed by care management for those found to be suffering from, or at risk of developing, depression and/or anxiety disorders. Those identified as being at risk of depression or anxiety disorders are offered a course of cognitive behavioural therapy (CBT) delivered in six sessions over 12 weeks. The assumption is made that 25,000 employees will be screened. The cost of intervention covers the cost of facilitating the completion of the screening questionnaire, follow up assessment to confirm depression, and care management costs. This also includes six sessions of CBT for those identified as being at risk.

● Figures are based on a benefit which includes a one-year lead in. Benefits to the HSC system only accrued in the second year. Therefore numbers are annual averages from a five year programme.

● 100% of fiscal benefits are attributable to the health sector, and accrued in the year following the intervention. Further potential fiscal benefits to the exchequer through reductions in unemployment, but these have not been quantified. Public value benefits relate to increased productivity through reduced absenteeism and presenteeism.

Employment Support

Promoting wellbeing in the workplace2

● A multi component health promotion intervention consisting of personalised health and wellbeing information and advice; a health risk appraisal questionnaire; access to a tailored health improvement web portal; wellness literature; and seminars and workshops focused on identified wellness issues.

● Evaluation of this type of programme has reported significantly reduced stress levels among workers, as well as reduced absenteeism. All benefits derived are therefore attributable to employers, not health or necessarily even other public services. As such, benefits are expressed of public value rather than fiscal in nature.

Housing Support

Supported housing step down facility3

● A step-down facility to enable prompt discharges from psychiatric hospitals into the community. The provision of four weeks of floating support to clients immediately after they move on provides vital continuity of support during transition. This helps to reduce the revolving door scenario where people relapse during stressful changes in circumstances and need more intensive support again.

● Based on a cohort of 200 clients per annum. brings net saving of approximately £25,900 per client, per year. ● All figures are annual. Costs within reference material are not divided between agencies more deeply than a broad attribution to the 'wider health and social care system‘.

28

Assumptions



Note: (1) New Economy – Hospital-based Liaison Care Cost/Benefit analysis (2012). (2) Frontier Economics – Evidencing Pennine Care’s Impact (2015) GM NHS Provider Trusts Federation – A standardised offer for community Care (2015).

Acute Admission Avoidance

(RAID)

RAID: Psychiatric Liaison1

● RAID teams working in wards and A&E depending on the focus of their team (including A &E, Older people, Alcohol Addiction). Includes reduced hospital admissions/readmissions, reduced bed days, and reduced residential care admissions,

● Division of benefits between agencies: CCGs 61%; Acute Trusts 25%; Local Authorities 14%; DWP < 1%.


(MH Intermediate Care)

Intermediate Care for patients with delirium2

● Based on a scaling of Saffron Ward , an intermediate care ward, across ten GM boroughs. Delirium appropriately identified and treated by a trained multidisciplinary team able to identify and design targeted appropriate packages of care for the patient. Additional benefit from new appropriate onward referrals. Intermediate care is cheaper than standard ward care, and more likely to prevent escalation into residential care. 90% of total occupied bed days in standard ward care are reduced from Saffron ward for patients with delirium. Costs are mainly derived from workforce figures.

● 100% of fiscal benefits are accrued by the NHS, although there are potential further unquantified savings to the social care system as the result of prevented entry into residential care.

Crisis prevention through IAPT

Using IAPT to reduce patients in crisis in A&E3

● Analysis disperses the prevalence of incidents proportionately across the national population, equating to 9,321 A&E attendance due to self-harm in GM per year. ● Early intervention, including the use of IAPT services earlier on, results in a lower acuity of treatment. Assumes that GM meets the target of a 50% success rate, which it

regularly exceeds. This reduces the cost of more intense treatment and the number of A & E attendances, generating net savings. ● Division of benefits across agencies: HMRC (tax gains) 40%; Health and Social Care 39%; DWP 21%.

Reduction in police call outs for MH

(S.136)

Assertive Outreach and problem solving for individuals with complex dependency4

● Section 136 is used by the police to remove a person (who appears to be suffering from a mental health disorder) from a public place to a place of safety. In Trafford, a system has been piloted which involves embedding a specialist nurse practitioner within response teams to provide assertive outreach support for individuals who present with need on a repeated basis. Through intensive problem solving, the long-term demand which these individuals present on services has been curtailed.

● Division of benefits across agencies: CCGs 79%; GMP 11%; NWAS 10%; Other CJS/Housing Providers/Local Authorities <1%.

(3) Department of Health – Impact Assessment of the expansion of talking therapies services as set out in the Mental Health Strategy (2011)

(4) New Economy – Home Office Innovation Fund Specialist Mental Health Practitioner Pilot (2015)


Prevention

Access

Integration

Sustainability

Golden Threads

1

2

3

4

5

30

Strategic Initiatives

Prevention

Targeted Mental Health Campaign A targeted public mental health and wellbeing campaign to raise awareness of mental health issues, reducing stigma and discrimination and helping the public in understanding their role in own wellbeing and how they can support others to deal with such issues. Campaigns will also enable improved access to appropriate support.

1.6

Supporting those most vulnerable in society to help reduce the risk of developing poor mental health, or from any existing mental health conditions in deteriorating further. Aims to address inequalities in access, experience and outcomes for vulnerable people including looked after children, child sexual exploitation and learning disabilities. Interventions include ‘wrap around’ services for those with complex needs such as housing support, drug/alcohol counselling, education programmes. Better targeted case management and outreach support for frequent attenders.

1.7 Supporting Vulnerable People

1.2

A GM wide system approach to helping people improve their wellbeing by using the principles of the ‘Five ways to wellbeing’ framework - Connect; Be Active, Take Notice, Give, Keep Learning (New Economics Foundation). This aims to improve physical and mental health, and protect people from loneliness and depression such as engaging in activities, building support networks within communities, and social prescribing.


Improving perinatal, child and parental mental health and wellbeing is key to the overall future health and wellbeing of our communities. We will look to direct activities towards the whole family and school life experiences including maternal mental health, family support (at all points during the whole life course), tackling domestic abuse; together with Community, Schools and Education programmes.

1.1 Early Years: Children and Family

1.3

Aims to build the individual’s capacity to better manage their own care and increase their resilience through providing self management resources, creating on-line communities and peer support. Also, raising awareness of the benefits of self care and the individual’s role in taking responsibility for their own health and wellbeing with support from the people involved in their care.

Building Capacity for Self Care

1.8

By focusing on wellbeing in the workplace, we will support working individuals in feeling happy at work and help achieve life satisfaction. We will sign up organisations across GM to a Best Employment Practice charter in relation to managing stress, mental health issues and drive wellbeing in the workplace. We will also ensure there is consistent support available across GM for those currently unemployed and seeking employment, including access to CV clinics, coaching and mentoring.. We will build on the Working Well Programme.

Workplace and Employment Support

1.5

Increase GM wide interventions to build good wellbeing and resilience including universal approaches for the general population and targeted wellbeing interventions for those facing particular risk factors, including mental illness to improving health and social outcomes, reducing prevalence of mental illness and supporting recovery. GM will also provide support on the wider determinants of mental health; addressing lower levels of mental distress earlier on helping to reduce the likelihood of a more chronic and debilitating illness.

Early Intervention

Suicide Prevention 1.4

Working with the GM Suicide Prevention Executive to reduce suicide risk by reflecting the main elements of the national strategy ie men’s mental health, mental health services, self-harm, young people, suicide hotspots, working with the media. Highlighting the features of MH services we have shown to be linked to lower suicide rates eg outreach, early follow-up on hospital discharge, adopting NICE guidance on depression and self harm. Supporting the development of real time data and information and workforce development to support suicide prevention.

31


Access

2.1

Strengthen the role of the GP as an initial point of contact, and ensuring there is a consistent care co-ordinator role with the right skills and competencies across GM. This will bring together primary mental health care and social care support. Train practice nurses and other primary care workers in early intervention and ensure access to EIP, perinatal MH and IPT.

Identify single points of access across primary and secondary care and develop a

care co-ordination role

2.2

We will look at national best practice and aim to build our minimum standards around these interventions, taking into the account a need for local variations dependent on different demographics. We will work across the 10 Local Authorities to develop consistent approaches to social care for mental health. Introduce combined mental and physical enablement and group based practice.

IAPT services of consistent high quality across GM

2.3 Support services for parents at risk through home visits by professionals, GMs troubled families’ programmes and/or befriending initiatives by voluntary organisations. This will encompass the full range of community support in the NHS, Local councils and the Voluntary Sector. Improve police training and support services.

Improving support for carers and parents at risk

2.4 We will create 24/7 crisis care for children and provide 7 day access to Community mental health teams that are able to provide support across GM.

24/7 mental health services and 7 day community provision for children

2.5 We will ensure consistency is achieved in the delivery of 24/7 crisis care for adult service users and ensure consistent 7 day access to Community mental health teams that are able to provide support across GM including full implementation of the GM crisis care concordat

Ensure consistency of 24/7 mental health services and 7 day community provision for adults including crisis care concordat

2.6 We will work with clinicians, care managers, including the third sector to review the thresholds for access to all mental health services and ensure these are explicit within operational policies.

Standards and protocols for step up and step down (Inc. prisons)

2.7 Increase collaboration across providers to tackle current out of area provision, using GM capacity on GM residents, improving care and driving efficiency

Self Sufficiency in provision for GM (out of area placements)

2.8 Flexible specialist Children and Adolescent Eating Disorder (CAEDS) service model through Multidisciplinary community based teams

Eating disorders in CYP

2.9 Co-commissioned multi-agency care pathway for children and young people with ADHD across the lifespan into early adulthood and service expansion into adulthood.

ADHD in CYP and service expansion for adults

32


Integration

3.1

Simplify, consolidate and streamline the current commissioning landscape to create a robust and accountable commissioning function which removes duplication, creates economies of scale and provides consistency. Commissioning will be both place-based (as part of new care organisations) and across GM providers. Commissioners will have specialist competency training.

Integrated place-based commissioning and contracting

3.2 Design and implement appropriate MH services at suitable spatial levels -GM level and place-based settings. MH will be an assumed part of place-based commissioning and local care organisations will be a major contribution to parity of esteem with integrated leadership and collective accountability across the public sector.

Locality Care Organisations to integrate care both vertically and horizontally across

community, primary and acute settings

3.3 This involves 4 elements: all-age, integration between physical and mental health, integration across care settings and integration with the individual’s wider environment. This will engage the whole range of local services including housing, leisure and learning.

A whole person integrated vertical care pathway across a horizontal integration of

care providers

3.4 Building a stronger partnership with the voluntary sector will ensure the third sector is an integral part of each patient’s pathway and that the third sector can work in an integrated way to ensure appropriate care is provided in the right place. The service will operate on an outreach as well as responsive model to reduce inequalities.


3.5 Provide a GM environment that is appropriate for 21st Century mental health care by reviewing, assessing and managing all MH physical assets and facilities management across GM and ensure alignment with place-based working across the public sector. Make services available by telephone and over the internet.

Asset-based approach and devolution estate managed centrally for the benefit

of GM

3.6 Develop a consistent set of shared minimum standards and outcomes for GM with a set of standard KPIs that cover the whole range of mental health services that are involved in changing and promoting positive mental well being.


3.7 Improve information sharing between agencies to facilitate collaboration and drive integrated care, through integrated patient records and/or patient ownership of information.


33


Sustainability

4.1 Systems leadership is necessary in driving new integrated care models, and it requires a real commitment across senior leadership to align their organisation’s goals with the goals of the wider system. ONE LEADER.

System leadership

4.2 Our vision for mental health is that it is led by wider primary care (including community pharmacies, schools and adult education), fully integrated with social care and supported by specialist interventions provided where necessary, based on an integrated, neighbourhood management model.

Improve SOCIAL CARE, community and primary care capacity

4.3 Changes to working practices and training to facilitate a culture of shared leadership accountability linking with the Academic Health Science Network and others to develop new curricula and qualifications.

Working practices

4.4 Establishing a consistent standard benchmark for programmes which must be implemented in all areas, and a more robust methodology for evaluating the success of a programme and the next steps.

Programme prioritisation

4.5 Pooling of budgets to enable joint decision making for the system as an integrated whole. Pooling of Mental Health budgets

4.6 A: Strengthen collaboration between providers, more substantially than integration of back office functions, to enable full needs based pathways.

B: Short-term solution for MMHSC unsustainability.


4.7 Recognising the value in alternative sources of investment, for example social impact bonds. Payment and incentives

4.8 Freedom to relax or reform regulation in areas where radical change to the system is proposed. Regulation reform

4.9 Recognising the value in alternative sources of investment, for example social impact bonds. New investment streams

34


Cross-cutting Golden Threads

5.1 Initiatives to address this parity must address the multiple sources of this inequality – financial, attitudes and beliefs, both within and beyond health and social care and as MH accounts for 23% disease burden, need greater equality re resource through reducing unnecessary acute trust admissions, OPCs, investigations.

Ensure parity of esteem between mental and physical health

5.2 We will work in partnership with HInM and the Centre for Mental Health and Safety to ensure mental health research is sufficiently prioritised, drive better co-ordination, and that interventions which have been proven to be effective are swiftly rolled out.

Improve deployment of research to inform best practice care across GM

5.3 Staff must be enabled to become more adaptable in order to respond to systems-wide changes, and more multidisciplinary, in order to drive integrated care. This will require leadership, training and culture change.

Prepare a workforce to work as part of an integrated, joined-up system

5.4 Technology offers the opportunity to transform mental health and support self-care, but we need to ensure that all interventions are carefully assessed and evidence-based.

Utilise technology to provide new forms of support

5.5 These programmes must have access to the right mental health treatment, and they should be effectively integrated with other health and social care services. Target the 10% of people that generate 40% of activity and cost.

Leverage the success of existing programmes (e.g. Troubled Families,

Working Well) which prioritise the top 10% which account for 40% resources

through repeat admissions, detention and crises

1

7




Subject: Greater Manchester Mental Health Strategy

Report of: Warren Heppolette

PURPOSE OF REPORT: This paper provides the Strategic Partnership Board with an update on the work

undertaken to date to develop a pan Greater Manchester Mental Health Strategy.


1. Note the process of development 2. Consider the proposed strategy and provide comments 3. Sign off the strategy and proposal to move into implementation phase.

CONTACT OFFICERS: Warren Heppolette [email protected] Vicky Sharrock [email protected]

2


work undertaken to date to develop a pan Greater Manchester Mental Health Strategy.

2. BACKGROUND 2.1 Greater Manchester has made a clear commitment as part of devolution to

develop the current provision of Mental Health services, working towards parity of esteem. As a result the Greater Manchester Mental Health Partnership Board was revised to ensure system wide membership, with a focus on developing a GM Mental Health Strategy (Appendix A contains revised membership).

2.2 This system wide approach to understanding our current position and

challenges has led to the development of a draft strategy (attached) with a single compelling vision: “Improving child and adult mental health, narrowing their gap in life expectancy, and ensuring parity of esteem with physical health is fundamental to unlocking the power and potential of GM communities. Shifting the focus of care to prevention, early intervention and resilience and delivering a sustainable mental health system in GM requires simplified and strengthened leadership and accountability across the whole system. Enabling resilient communities, engaging inclusive employers and working in partnership with the third sector will transform the mental health and well-being of GM residents.”

3. The Development of the GM Mental Health Strategy 3.1 Through the development of a single Mental Health Strategy GM is working

towards a whole system approach to the delivery of mental health and well-being services that support holistic needs of individuals and their families within communities.

3.2 The strategy brings together and draws on all parts of the public sector,

focused on community, early intervention and the development of resilience. Improving child and parental mental health and wellbeing is key to the overall future health and wellbeing of Greater Manchester communities.

3.3 Through implementation of new approaches services will be much more

closely integrated within each of the ten GM localities as well as across the wider GM conurbation and accessed in a consistent, simple way. This will see integration within the place at district level bringing social care, primary care and mental health provision together at the community level. It will also see mental health providers collaborating formally across GM in relation to specialist provision. The commissioning and provider landscape will need to be transformed to deliver stronger outcomes, deeper integration, needs based

3

pathway models, pooled budgets and more community based models of support.

3.4 The GM Mental Health Strategy provides the basis for future collaboration. It

highlights four priority areas:

Prevention - Place based and person centred life course approach improving outcomes, population health and health inequalities through initiatives such as health and work.

Access - Responsive and clear access arrangements connecting people to the support they need at the right time

Integration - Parity of mental health and physical illness through collaborative and mature cross-sector working across public sector bodies & voluntary organisations

Sustainability - Ensure the best spend of the GM funding through improving financial and clinical sustainability by changing contracts, incentives, integrating and improving IT & investing in new workforce roles.

3.5 Within these four pillars of the strategy, 33 strategic initiatives have been

identified, the implementation of which will transform services in GM. Seven of these have been specifically identified as priority initiatives:

1. Suicide prevention 2. Workplace and employment support 3. Introducing 24/7 mental health services and 7 day community provision

for children and young people 4. Consistent implementation of the 24/7 mental health service and 7 day

community provision for adults across GM 5. Integrated place based commissioning and contracting aligned to place

based reform 6. Integrated monitoring, standards and key performance indicators 7. Provider landscape redesign

4. WIDER STRATEGIC LINKAGES 4.1 The GM Health & Social Care Strategic Plan sets the framework for bold and

ambitious health & social care reform; the first of its kind in the country. We are taking charge of GM through our strategy of growth and reform. The Plan confirms the need for focussed attention and leadership to be given to improvements in mental health and wellbeing and the Joint Board is established to secure that attention and leadership to the delivery of GM’s Mental Health Strategy

4.2 In drafting the GM Mental Health Strategy we have developed links to wider

devolution and reform activity including:

Existing GM reform programmes for Working Well, Troubled Families, Early Years and Justice. This will ensure we build on evidence based approaches, support early intervention and prevention and will raise the profile of mental health across this wider activity.

4

The developing GM review of services for children is currently being scoped on the back of a clear devolution commitment to making fundamental transformation in services for children. CAMHS are an essential element of this review. Implementation of the strategy will therefore be closely linked to this work and inform the review.

GM is a Learning Disability Fast Track area. This programme of activity is also focused on supporting the holistic needs of individuals, close to home, within a community based setting. There are already strong linkages across the two programmes of activity and cross representation through the governance arrangements.

GM is committed to the development of a programme of activity to support people with dementia and their families. The mental health strategy outlines the ambition for our GM dementia programme, Dementia United and the five GM pledges to support the delivery of the vision. As this develops further we will align it to the implementation of the wider GM Mental Health Strategy.

5. NEXT STEPS 5.1 GM is committed to gaining system wide sign up and support for the proposed

Mental Health Strategy and has engaged with stakeholders on the draft to endorse its focus, priorities and ambition. In addition the strategy has been shared for comment and input with Strategic Partnership Board Executive, Greater Manchester combined Authority, AGG, GM Wider Leadership Team, GM Directors of Adult Services and GM Directors of Children’s Services.

5.3 Implementation of the strategy will require significant shifts in current service

provision. To support this move, the current governance and reporting arrangements will be reviewed as previously agreed by the GM Strategic Mental Health Partnership Board. These new arrangements will need to take responsibility for:

Bringing forward the proposals for GM level mental health services, determining which are best provided at the neighbourhood, locality, cluster or GM levels

Development of new commissioning approaches

Strategic planning of specialist mental health services

Reviewing existing patterns of investment

Utilisation of academic assets

Developing collaborative models of care 6. RECOMMENDATIONS 6.1 The Strategic Partnership Board is asked to:

Note the process of development

Consider the proposed strategy and provide comments

Sign off the strategy and proposal to move into implementation phase.

5

Appendix A: GM Strategic Mental Health Partnership Board Membership

Jim Battle (Chair) GM Police & Crime Commissioner

Adele Owen GM Police

Neil Evans GM Police

Chris Mcloughlin Stockport Council

Andrea Fallon Rochdale MBC

Cath Green First Choice Housing

Rachel Tanner Bolton MBC

Craig Harris Central Manchester CCG

Simon Barber 5BP

Alex Little New Economy Manchester

Julian Cox New Economy Manchester

Linda Curran 5BP

Louisa Sharples Health and Justice Social Care

Maqsood Ahmed Strategic Clinical Networks

Marie Boles NHS England

Annie Murray PHE

Michael McCourt Pennine Care

Michelle Moran MMHSCT

Nicky Lidbetter Self Help Services

Sandy Bering Trafford CCG

Warren Heppolette Central Manchester CCG

Martin Whiting North Manchester CCG

Wayne Sheilds GM Fire & Rescue

Alison McDonald GM Fire & Rescue

Laura Mercer GM Police & Crime Commissioner

6

Tony Hunter GM Fire and Rescue

Joanne Griffin First Choice Housing

Steve Taylor Pennine Acute

Kim Neill Pennine Acute

Chris Edwards Probation Service

Kevin Bulman Probation Service

Beverley Humphrey GMW

Hazel Summers Manchester CC

Carolyn Wilkins Oldham MBC

Adam Allen GM Police & Crime Commissioner

Stephanie Butterworth Tameside MBC

Jeff Pollard Probation

Andrew Sidebotham GMP Police

Clair Carson Pennine Care

Keith Walker Pennine Care

Joe McGuigan Trafford CCG

Greater Manchester Mental Health and Wellbeing Strategy

23 February 2016

1

Contents

Page

Compelling Vision

GM Vision: Aims




Current Position

System Challenges and Best Practice

Priority initiatives for early implementation

Economic case

Summary: Investment Case and the Potential Benefits

Assumptions


2

3

4

5

6

7

8

11

17

22

23

27

2

Compelling Vision

GM Mental Health and Wellbeing Strategy

Improving child and adult mental health, narrowing their gap in life expectancy, and ensuring parity of esteem with physical health is

fundamental to unlocking the power and potential of GM communities. Shifting the focus of care to prevention, early intervention and

resilience and delivering a sustainable mental health system in GM requires simplified and strengthened leadership and accountability across the whole system. Enabling resilient communities, engaging

inclusive employers and working in partnership with the third sector will transform the mental health and well being of GM residents.

3

GM Vision: Aims ● We propose a whole system approach, that includes involvement from the independent and third sector, to improve the mental health and wellbeing of

individuals and their families, supported by resilient communities, inclusive employers and services that maximise independence and choice.

● The GM strategy aims to build on existing best practice to lift patients’ experience of care and support through the development & application of national and GM standards relating to access and care delivery.

● We will simplify the provider system and bring together commissioning across GM focused on the delivery of agreed GM level outcomes and standards to deliver, deeper integration, needs based pathway models, pooled budgets and more community-based recovery-focussed models of support.

● Children and Young People’s mental health forms an integral part of our overall strategy. We will use the opportunities through devolution to collectively respond to the challenges outlined within Futures in Mind and in doing so transform the provision of services for the young people in GM

● We will support and develop our GM workforce to work in new ways to deliver our vision recognising their importance to delivering a sustainable whole system approach to mental health

● Greater integration across mental and physical health and social care services within each of the ten GM localities as well as across the wider GM conurbation. These will be patient, carer and family focused, accessed in a consistent, simple way. We will invest in community and crisis support to reduce the requirement for acute and long term care.

● Develop Prime Provider models to improve pathway design, capacity and efficiency for specialist services

● We will promote employment for people with mental health problems and provide timely and effective support to help people stay in employment through building on the current GM Mental Health and Employment Programme of activity.

● We will support those most vulnerable in society to help reduce the risk of developing poor mental health, and those with existing mental health conditions from deteriorating further. In doing this we will build on GMs existing approach to supporting people with complex needs with a particular focus on looked after children, child sexual exploitation, those with learning difficulties and disabilities.

● Ensure our focus on mental health is integrated with Local Care Organisations

● Through the implementation of the GM strategy, address the wider financial impact of poor mental health on the wider public sector system and deliver against the £146m potential financial benefits identified

● Provider system leader

● GM Commissioning

Simplify Landscape

● Inclusive training and employment

● Community resilience

● School involvement

Better Health

and Wellbeing

Improve Services

● GM Wide standards based on the best practice

● GM wide 24/7 crisis response for children and greater consistency for adults

4


Themes from stakeholder engagement In developing the strategy we have undertaken a number of conversations and engagement sessions across GM. The key themes arising from these discussions are summarised below, set against each of the 4 strategic principles for improved mental health and wellbeing in GM.

● Eliminate the vast majority of out of area placements.

● Group GM resources to commission more efficiently and effectively.

● Untangle the current governance to streamline decision making and actions.

● Agree common delivery outcomes across GM (the what).

● Allow local delivery methodology (the how).

SUSTAINABILITY

● Mental health support should be embedded in physical healthcare.

● Improve access for cohorts of population who currently find it difficult to access.

● Reduce waits and increase consistency of access for IAPT therapies.

● Eliminate inconsistency of service outcomes across GM.

● Improved integration and transition of children to adult services.

● Single point to access care and support.

● Commissioners (health and local authority) to act as one to give clarity of purpose for providers.

● Providers to be encouraged to build collaborative approach.

● Develop consistent minimum standards that allow for local delivery choices.

● Increase low level intervention spend.

● Focus should be on prevention in order to reduce service demand in higher tiers.

● Target children through use of schools and communities.

● Appropriate mental health training for front line staff.

● Long wait for IAPTs therapies.

PREVENTION

INTEGRATION

ACCESS

5


What does great look like?

Sustainability Integration Access Prevention

● Single point of entry.

● Service users access the appropriate level, setting, and location of services.

● Service users access services earlier.

● Directory of voluntary sector providers.

● First response at single point of access is consistent.

● Service users understand where to get the help they need.

● Access equitable to minority groups.

● Reduction in interfaces, more self-referral.

● Information is consistent and available in one location.

● High quality short-term interventions of high intensity when ill.

● Improve opportunities for self-care.

● Not just about Tier 3/4 services – need lower level Tier 2 services for children and young people.

● Workforce is trained in a range of disciplines, knowledge of the relevant services for referral. Core skills defined and consistent across GM.

● Holistic approach -supporting people to self-manage, maintain work, looking at mental health in the context of areas such as justice, troubled families.

● Embracing technology.

● Community resilience – “community manages itself”.

● Adequate funding for mental health.

● Sustainable recovery – follow up.

● Funding to release people to conduct peer challenge.

● Information sharing and data.

● Reduction in prescribing drugs.

● Mental health support for staff.

● Every GP has mental health champion across the system.

● Multi-agency hubs, “mental health is my job”.

● Stronger links to employment and skills and supporting people with complex needs

● Local commissioner that boroughs feed into – note some participants did not agree on this point.

● Integrated children and young people services across public sector boundaries e.g. CAMHS in schools.

● Care co-ordination.

● Services are co-designed and co-evaluated between commissioners, providers and the public.

● Less separation of mental and physical wellbeing.

● Fewer pathways, fragmentation and organisations. More joined up governance and leadership.

● Integration with 3rd sector.

● Whole person care.

● Role of family and circumstances acknowledged.

● Asset based community model.

● Shared information and communication.

● Joined up working to avoid duplication of assessment.

● Recruitment, promotion and performance framework based on shared principles.

● Economies of scale/one stop shop co-located services in community hubs so we are all working together.

● Mental health feels “less separate” from the rest of the “caring infrastructure”.

● Mental health on education curriculum.

● Intervene earlier in children’s and young people services as method of prevention.

● Support for families and carers.

● Support people with mental health problems to improve their general health for example to quit smoking

● Reduced crisis/demand management.

● Shift to self help.

● Public behaviour change.

● Training to employers and communities about mental health.

● Community support features in care plans.

● Service users offer back to the community.

● No stigma – rebadge mental health.

● Peer support.

● Commissioning research to find out what works.

● Mental health media campaign

to demonstrate prevention.

Through discussions, our stakeholders have articulated what great services would look like. Their suggestions on how we could do things differently are

highlighted below under each of the four strategic principles

6

Compelling Vision


Early Years: Children & Family

Building Capacity for Self care

Early intervention


Supporting vulnerable people

Workplace and employment support

Targeted public health campaigns

Parity of Esteem

Research Deployed to Inform Best Practice

Technology providing new innovative forms of support

Leverage Successful Programmes e.g. Troubled Families

Prepare the Workforce for Integrated Joined Up System

CHARACTERISTICS TO UNDERPIN VISION

Place based and person centred life course approach improving outcomes, population health and health inequalities through initiatives such as health and work.

Ensure the best spend of the GM funding through improving financial and clinical sustainability by changing contracts, incentives, integrating and improving IT & investing in new workforce roles

Parity of mental health and physical illness through collaborative and mature cross-sector working across public sector bodies & voluntary organisations

Responsive and clear access arrangements connecting people to the support they need at the right time

PREVENTION

SUSTAINABILITY

INTEGRATION

ACCESS

CASE FOR CHANGE PRIORITY POPULATION GROUPS STRATEGIC INITIATIVES

MENTAL HEALTH AND WELLBEING STRATEGY

STR

ATE

GIC

GO

LDEN

TH

REA

DS

Integrated place based commissioning & contracting aligned to place based reform

Vertical & horizontal integration across community, primary & acute care

Whole person integrated vertical care pathway across a horizontal integration of care


Asset-based approach and devolution estate managed centrally



PREVENTION ACCESS INTEGRATION SUSTAINABILITY

System leadership

Pooling of mental health budgets

Programme prioritsation


Payment and incentives

Regulation reform

New investment streams

Working practices

Single Point of Access and Care Co-ordination

Introduce 24/7 Mental Health and 7 Day Community Provision for CYP

Improving Support for Carers and Parents at Risk

Consistent Standards and Protocols for Step Up and Step Down

Self-sufficiency in GM Provision (out of area placements)

Eating Disorders for Children and Young People

Consistent ADHD services for all age groups

IAPT Services of Consistent High Quality for GM

Priorities Identified for Years 1 and 2

The Strategic Initiatives

Ensure consistent 24/7 Mental Health and 7 Day Community Provision for adults including crisis concordat

Suicide Prevention

7

Current Position

● By 2020/21 the GM health and social care system faces an estimated financial deficit of £2bn demonstrating the need for radical transformation.

● Costs to the wider health care system of our current approaches are significant:

– Poor mental health makes physical illness worse and raises total health care costs by at least 45% for each person with a long-term condition.

– This suggests between 12% and 18% of all NHS expenditure on long-term conditions is linked to poor mental health and wellbeing – between £8 billion and £13 billion in England each year (GM, between £420m and £1.08bn).

– Transforming mental health (along with physical health) services has the ability to contribute significantly to the £2bn projected financial deficit for Health and Social Care in GM by 2021

● There are 3,981 people in GM in contact with mental health services for every 100,000 of the population compared to 2,176 nationally.

● At the current estimated rate of prevalence, there will be 34,973 people living with dementia in Greater Manchester by 2021

● £615m is spent on mental health services across Greater Manchester, with a wide variance across localities. This is made up of:

– LA spend (£97.05m).

– CCG Learning Disability spend (£38.3m).

– CCG MH Specialist Commissioning (£76.5m) (which includes specialist units.

– CCG MH Spend (£403.4m) - Approximately £30.1m of this is spent on out-of-area inpatient treatment (7.27% total CCG spend) including acute admissions due to capacity shortfalls and longer terms placements with complex needs

● The wider economic cost to GM of mental health is approximately £3.5bn (see page 21 for breakdown)

● In addition to the above, further costs are incurred within the GM economy as a consequence of poor mental health. These include the wider costs of mental health associated with unemployment, children with conduct disorder, alcohol and substance misuse and suicides. The impact of these costs on the GM economy are presented in the economic case on pages 23 onwards.

8

System Challenges ● The provider landscape is complex with 5 Adult and Children’s Mental Health NHS Providers, many independent and voluntary sector

providers and a range of specialist mental health services provided outside of GM.

● The commissioning landscape is fragmented. 10 LA’s, 12 CCG’s and an estimated 82 Mental Health and Wellbeing Programmes, dedicated expertise and capacity is scarce and it is therefore difficult to achieve focus, shared solutions and shared priorities.

● There is variability in service provision and outcomes across GM and a lack of consistent and accurate data on activity and outcomes. KPIs are outdated, which makes it difficult to accurately evaluate performance across GM. Social care and Housing are underrepresented in service provision leading to higher health activity and costs. Reforming social care to improve information, prevention, personal budgets, choice and control will yield benefits across the whole service.

● A lack of mental health expertise in GP surgeries and wider primary care and A&E departments is consistently reported and delays getting access to the right care.

● Improving the mental health of GM residents, and providing reliable access to early help redressing the balance towards early intervention and prevention will improve family circumstances, help people find and keep good work, improve school attainment and strengthen communities.

● Lack of integration with wider pubic services

● There is a lack of out of hours, 24/7 crisis care services for children and young people, and inconsistent delivery for adults.

● Services for children and young people and their families and carers, are inconsistent, misaligned and disrupted by transition points. Young teenage people are often caught in between services and often don’t meet thresholds

● Mental health problems in children and young people are associated with educational failure, family disruption, disability, offending and antisocial behaviour, demands on social services and the youth justice system. Untreated mental health problems create distress not only in the children and young people, but also for their families and carers, continuing into adult life and affecting the next generation.

● Mental Health problems are often part of a wider set of complex issues for individuals and families. For example:

● Mental health problems consistently arise with the families we are supporting trough our Troubled Families Programme,

● 68% of the clients on our Working Well Programme (aimed at supporting long term unemployed into sustainable employment) highlight mental health as an issue

● 18% of secondary care patients in Manchester are not in stable accommodation, mental health problems can be a cause and effect of housing issues

9

Learning from local best practice examples and academic research There are many examples of best practice across GM which could feasibly be scaled up.

The implementation plan will set out how this can be achieved and identify mechanisms through which we can scale up local exemplars.

At the GM level the SelfHelp sanctuary crisis model is being rolled out. This will divert people from A&E, reduce the number of section 136s and provide a suicide prevention service

Perfect Weeks - Wigan This is an initiative to ‘suspend the rules’ for a week to test parts of the system. This has had success in Wigan where Adult Mental Health workers were linked in to schools and referred a mother for services, subsequently establishing a good outcome for both mother and child.

Crisis Concordat - Oldham GMP in Oldham and Pennine Care NHS FT jointly developed Oldham Phone Triage/RAID Pilot Project to provide a service available to local police officers who attend incidents where an individual appears to be experiencing mental health problems; police able to contact dedicated 24 hour telephone number for assistance from the Trust’s psychiatric liaison service RAID (Rapid Assessment Interface and Discharge). This has now been rolled out across GM

Key Workers - Trafford Key workers have been used in the Stronger Families Phase 1 in Trafford to improve integration, coordination, prioritisation of support for people with mental health problems, focused on evidence based interventions and greater levels of flexibility going beyond the status quo.

GM West RAID – Bolton and Trafford Successfully implemented RAID – Rapid Access Interface Discharge for its Bolton and Trafford facility, reducing bed days by supporting more timely discharge and hence drive efficiencies.

Tameside, Oldham and Glossop MIND Approached by the local authority to build a wellbeing centre. Transformation of the building took 12 months and c.£250k. The result is used by the community and well regarded nationally as a modern wellbeing centre.

School Model in Chiltern High Manchester – 42nd Street

Resilience workshops and assemblies, mental health workers with case load and drop in, dedicated help line for staff and services offered over the school holidays.

Centre for Mental Health and Safety Develop the links between research base to practice across GM.

5 Ways to Well-being in Stockport Aimed at improving mental health and well-being across the population and enabling people to reach their full potential

10

Learning from social models across the UK and beyond There are many examples of services that enable people to manage their own care, to work together with peers, and to be supported at home with complex needs. Learning from these have fed into the development of the GM Strategy and initiatives.

Mind and Body (Sheffield)

85% of participants sustained a change in life

style and better health

Mental Health First Aid (Australia)

Training citizens and volunteers to recognise, respond to and support

people in mental distress

Clubhouse International (worldwide)

Where service users come together to work join in

activities, cook and participate in their

community

Big White Wall (UK)

Internet based anonymous community

where 95% report improved health –

better than many IAPT programmes

THISWAYUP (Aus, NZ, USA and

Canada) Computer aided

recovery course with 50% complete recovery

Acute hospital A&E liaison

(Birmingham) Comprehensive

RAID support available 24/7 to all people aged 16 in

hospital

Single Point Access Service

(NHS 111 and MIND) Developing training courses designed by

people with lived experiences to support call handlers in times of crisis

Street Triage 26 street triage schemes across

England showing a reduction in use of police custody as a

place of safety

Whole System Redesign (Northumberland, Tyne

and Weir) Large scale acute care pathway redesign integrated triage and telehelath and rapid access to housing services, social care,

third sector and specialist services

Crisis Home Treatment (Leeds)

Survivor led crisis services ,commissioned for 24/7

response and care

11


Where are we now and where do we want to be?

Current state Future state

Place-based cohesive and collaborative commissioning care pathways, pan-Greater Manchester for specialised services, to deliver stronger outcomes, deeper integration, needs-based

pathway models, pooled budgets and more community based models of support linked to wider GM reform activity.

Mental health is ‘everyone’s business’, enabling local areas to make decisions for system wide outcomes

supported by shared information. This includes mental health and social care, but more broadly the opportunities to consider the best approach across public services and the 3rd sector with a focus on community, early intervention and resilience building

on 5 Ways to Well Being

Standardised outcomes framework with minimum standards, outcomes and access across all providers of health

and social care and shared approaches to strengthening communities and voluntary sector effectiveness.

All employers promote good employment practice for MH, building capacity for conversations to support suicide

prevention. Employees will be supported to feel happy at work and helped to achieve life satisfaction. Build on GMs existing

Working Well programme to deliver better outcomes.

Complex and fragmented commissioning for GM’s 2.9 million residents across 10 LAs, 12 CCGs and 82

Mental Health and wellbeing programmes.

Discrepancies in outcomes and quality standards across 4 Adult MH NHS providers, 4 CAMHS providers,

specialist provision and numerous voluntary sector providers results in care that can be inconsistent, misaligned and

disrupted by transition points.

Mental health and well being not prioritised in the workplace and workforce development.

Medical-focussed model of care, which does not always pick up on the holistic and complex needs of the individual and

their environment.

1

2

3

4

1

2

3

4

12


How do we get to the future state?

A self-sufficient mental health system for GM

residents We will sign up organisations across GM to

a Best Workplace Charter in relation to managing stress, mental health issues, and

drive wellbeing in the workplace. We will also ensure there is consistent support available across GM for those currently unemployed and seeking employment

building on the GM Working Well programme.

Develop minimum standards, with a set of KPIs, which also cut across non-care settings, for all providers of health and social care which can be expanded as necessary at the local level to reduce variations between different communities.

Through our GM Reform Programme we will take a preventative and early intervention approach

supporting people with a range of complex needs, working collaboratively across local services to

deliver the right support at the right time to help people address the factors which prevent them

from realising their potential. Mental Health provides a unique connection across all our Public Service Reform objectives and is driving the wider

strategic partnerships required beyond core NHS and social care to wider local government services, GMP, GMFRS, NWAS and others

to ensure mental health is everyone’s business as part of wider Public

Service Reform.

Place-based commissioning and place-based delivery, pan-Greater Manchester for specialised services. Simplify, consolidate and streamline the current commissioning landscape to create a robust and accountable commissioning function which removes duplication, creates economies of scale and provides consistency. Determine a clear vision and understanding of what services should be provided at the GM and locality levels. Consolidate commissioning expertise and develop new payment and incentive mechanisms.

Minimum standards will be built around best practice interventions incorporating a focus on prevention and reducing future demand, taking into account a need for local variations dependent on different demographics. GM is committed to ensuring the new national waiting time standards are achieved and where possible exceeded.

13

Wider Strategic Considerations – GM H&SC Devolution GM has an ambition to become a self sustaining city region supporting growth and connecting GM residents to the benefits growth brings.

In Nov 2014 GM settled a historic devolution agreement which give local representatives control over decisions previously taken at a national level.

Taking Charge of our Health and Social Care

On 25 February 2015 Greater Manchester entered into a ground-breaking agreement with government for the devolution of health and social care . The Memorandum of Understanding formally gave GM control of £6billion of pubic sector funding from 1 April 2016. “Taking Charge of our Health and Social Care” describes how clinical and financial sustainability will be achieved in GM, aligned to the Five Year Forward View.

GM is committed to achieving parity of esteem for people with mental health issues, tackling access and waiting time standards and breaking down barriers to how care is provided.

Reimagining services across our whole care system

The GM Strategic Plan, “Taking Charge of our Health and Social Care”, identified five key areas for transformation change: • Radical upgrade in population health prevention – a shift on focus to population health that

supports GM residents to self-manage, innovates the model for prescribers and pharmacies and tackles the future burden on cardiovascular disease and diabetes

• Transforming community based care and support – a new model of care closer to home that includes scalable evidence based models for integrated primary, acute, community, mental health and social care.

• Standardised acute and specialist care – the creation of single shared services for acute hospital and specialist services to deliver improvements in patient outcomes and productivity through establishment of consistent best practice and reduced variation

• Standardised clinical support and back office support – The transformational delivery of clinical support and back office services at scale, including the establishment of coordination centres to help navigate GM residents through our complex system

• Enabling better care – Creating innovative organisation forms, new ways of commissioning, contracting and payment design, standardised information management and technology to incentivise new ways of working

14

Wider Strategic Considerations - National Five Year Forward View (2014)

The Five Year Forward view set out a clear ambition for the future of mental health services in England: • To create genuine parity of esteem between physical and mental health. • Improved waiting times so that 95% of people referred for psychological therapies start treatment in 6 weeks or a fortnight for those

experiencing their first episode. • Provision close to home for those with intensive needs, particularly for young people • New commissioning approaches to transform service delivery

Five Year Forward View for Mental Health Taskforce (2016)

The taskforce’s report sets out a number of priorities for change over the next five years, including: Supporting people experiencing a mental health crisis – by 2020/21 expand crisis resolution and home treatment teams to ensure

24/7 community-based mental health crisis response is available Improving responses to mental and physical health needs – by 2020/21 more people living with severe mental illness have their

physical needs met Transforming perinatal care for children and young people – fundamental change in the way children and young people’s services are

commissioned and delivered, more children and young people having access to high-quality mental health care when they need it and more women accessing evidence-based specialist mental health care during the perinatal period

Access standards and care pathways – by 2020/21 clear and comprehensive set of care pathways with accompanying quality standards and guidance for the full range of mental health conditions

Models of payment – developing payment models that incentivise swift access, high-quality care and good outcomes Acute and secure care – partnership led co-produced standards to ensure acute mental health care is provided in the least restrictive

manner and as close to home as possible Tackling inequalities in access and outcomes – addressing inequalities in access to early intervention and crisis care and rates of

detentions Supporting employment – recognising employment as a crucial health outcome and supporting people with mental health problems

to find and stay in work. Transparency in data – to support improvements in commissioning, inform effective decision-making and promoting choice, efficiency,

access and quality Workforce – good management of mental health in the workplace and the provision of occupational mental health expertise and

effective workplace interventions

15

Wider Strategic Considerations - National (cont.)

National Suicide Prevention Strategy

GM is committed to preventing mental ill health, reducing suicides and promoting mental well-being. Suicide prevention is a key strategic initiatives of our overall strategy. In taking this forward we will build on the national strategy “Preventing Suicide in England”. This strategy highlights key risk groups: young and middle aged men; people in the care of mental health services including inpatients; people with a history of self-harm; people in contact with the criminal justice system and those form specific occupational groups.

In response to the national evidence GM will work towards the development of a suicide prevention strategy aimed at becoming a ‘suicide safer city region’

No Health Without Mental Health

The national strategy focuses on delivering improved mental health outcomes for people of all ages and identifies participation in meaningful activity, secure accommodation and schools relationships as supporting recovery from mental ill-health and promoting mental well being. The strategy highlights five key outcomes:

More people will have good mental health

More people with mental health problems will recover

More people with mental health problems will have good physical health

Fewer people will suffer avoidable harm

Fewer people will experience stigma and discrimination

16

Wider Strategic Considerations – Greater Manchester

Greater Manchester Principles of Reform

Our GM Mental Health Strategy will work to address identified difficulties and create stronger links between mental health services and locality based integrated working. Ensuring flexibility in mainstream services and developing evidence based packages of support aligned to our GM principles of reform:




Integrated services that place individuals, families, communities at the heart

A stronger prioritisation of well being, prevention and early intervention

An evidence based understanding of risk and impact to ensure the right intervention at the right time.

Greater Manchester Public Service Reform Programme

The existing GM Public Service Reform programme, focused on supporting people with complex needs, will enable people and families to develop resilience and promote independence. Transforming community based care and supporting integrated place based working provides the opportunity to integrate mental health into wider reform activity focused on the delivery of key outcomes including:

Supporting 50,000 people facing complex challenges move towards employment

Engaging and supporting over 27,000 families through the expanded Troubled Families programme

Reductions in reoffending through the implementation of Intensive Community Orders

Reductions in reoffending as a result of transforming the work of Women’s Centres

Implementation of our GM Early Years new delivery model

Reductions in duplication through better integrated local service provision

17

Wider Strategic Considerations – Greater Manchester (cont.)

Greater Manchester Programme for Dementia Care – Dementia United

2013 data indicated that the number of people with dementia in Greater Manchester was 29,560, affecting 7.1% over 65s. This is expected to rise rapidly over the next 12 years. Greater Manchester currently spends £221m per year on dementia across health and social care. If we diagnosed everyone in GM who we think currently has the disease this would raise to £320m per year.

As part of our wider work on mental health Greater Manchester has been developing a programme of activity with an agreed vision to:

Make Greater Manchester the best place in the world to live with Dementia

Greater Manchester has made 5 pledges that will support the delivery of this vision:

18



By 1 January 2017


● GM will be working towards the standards set out in the Crisis Concordat.

● There will be a reduction in need for Section 136 powers which when needed will be used consistently across all 10 LAs in GM through a better understanding of ‘places of safety’ and introduction of street triage support.

● We will have agreed an approach for Place based commissioning and provision at locality level with increased collaboration between providers for specialist services. Integrated commissioning approach based on outcomes aligned with GM commissioning standards framework. Social Care and Housing will be fully engaged in commissioning and delivery.

● We will develop links with the Centre for mental Health and Safety to inform systematic reduction in suicide across GM.

● We will have established formal provider collaboration to achieve self-sufficiency in GM.

● The PHE Workplace Charter will be signed by all public sector agencies in GM.

● Increased integration of RAID into acute services and A&E facilities across GM.

● Create fit for purpose governance arrangements responsible for delivering the GM wide all-age mental health strategy.

● GM Children and Young People outcomes and standards developed and agreed.

● We will have identified leaders and champions to deliver this strategy and they will have produced delivery plans for each of the initiatives.

● Enhanced GM wide suicide prevention strategy.


1. Number of employers signed up to the PHE Workplace Charter.

2. Increased number of patients referred to Raid services.

3. Reduction in the requirement for S136 powers used and evidence of consistent application across GM.

4. Increased focus on prevention through wider implementation of Connect 5 and 5 Ways to well Being


High level financial savings will be achieved through better commissioning, simplified provider landscape, earlier intervention through RAID and a focus on resilience in the workplace and community.

19



By 1 January 2018


● A single system, with clear leadership and partnership working across all public sector organisations.

● We will simplify the provider landscape across GM including the integration with social care and housing by rolling out integrated place-based commissioning using a prime-provider model, with routine outcome measures.

● Consistent GM wide implementation of 24/7 crisis care and community support for adults including full implementation of GM Crisis Care concordat.

● Development and implementation of 24/7 crisis care support for children and young people providing easy access to services that are responsive and provide appropriate help across all GM.

● Established and published the “citizens deal” with a set of all age standards or citizens rights for commissioners to use as a floor that no GM services can fall below.

● Strategic partnership arrangements with positive and mature engagement between the private, public, community, voluntary sector and social enterprises.

● Implementation and application of standards for Children and Young People’s services, focused on young people’s perspectives and expectations building on the national work, Young Minds, and work already taking place in GM.

● All acute provision (acute beds, PICU, active rehabilitation, LA alcohol and drugs services and residential care) will be within GM, and patients will only be sent out of area for inpatient or outpatient services in exceptional specialist circumstances.

● Wider implementation of the PHE Workplace Charter on mental health across private sector in GM delivered in collaboration with the LEP and local Universities and organisations commissioned by GM public sector organisations.


1. Improved quality across the Sector (patient satisfaction, reduced serious untoward incidents, and reduced never events, e.g. a reduced suicide rate).

2. Improved access and reduced waiting times.

3. Consistent standards across Greater Manchester


High level financial savings will be achieved through removal of Out of Area placements and reduced spend in high-end acute settings and reduced unemployment because of mental health.

20

Economic Case


● Strategic initiatives have been developed to better manage the drivers of activity and demand based around the 4 strategic pillars for transformation (prevention, access, integration, sustainability). There are also cross-cutting themes or “golden threads” running through all four pillars. Communication is needed to change behaviour and create social movement changes to ensure these strategic initiatives deliver the expected transformation.

● The economic benefits of this strategy are generated by the areas for intervention outlined below:

– A shift towards early intervention and prevention where those with mental health issues currently in the health system are supported to access evidence-based less cost-intensive models of care. This will result in reduced spend in acute in-patient settings.

– A more general increase in the support for those with mental health conditions to move back into work. The benefits here are in a reduction in public sector spend more generally.

– Early identification and intervention as soon as mental health problems emerge.

– The promotion of mental wellbeing and prevention of mental health problems in childhood and adolescence.

– The promotion of mental wellbeing and prevention of mental health problems in adults.

– Addressing the social determinants and consequences of mental health problems.

– Improving the quality and efficiency of current services.

● An important long-term goal is to repatriate GM NHS and LA patients being treated long-term in out of area placements. This will be dependent on freeing up capacity in local in-patient settings, which is in turn dependent in enabling community or home-based models. Numerous initiatives for this are already underway in GM, including:

– The out-of-hospital schemes introduced by Pennine care.

– RAID (rapid assessment, interface and discharge), which installs psychiatric liaison teams in acute hospitals, reducing admissions and length of stay for patients with mental illnesses.

– Intermediate care for patents with delirium, providing a further deflection in acute admissions. It is also logical to assume a further 10% reduction in acute in-patient mental health stays through a combination of these initiatives.

● Further savings are likely to be achieved in the reduction of the number of mental health trusts and the number of commissioners involved in commissioning mental health.

Improved life chances for

children with mental health

conditions

Reduced inpatient

admissions and bed days

Reduced out of area

placements

Reduced number of life years lost to

mental health

Outcomes

Reduced running costs for integrated commissioning

21

Economic Case


Specific economic evidence to support this approach aligned to the strategic initiatives developed includes the Department of Health Report, ‘No Health Without Mental Health’ 2011, which identified the following costs of mental disorders across the life course:

● Mental illness during childhood and adolescence results in UK costs of £11,030 to £59,130 annually per child.

● Conduct disorder: Lifetime costs of a one year cohort of children with conduct disorder (6% of the child population) has been estimated at £5.2 billion. Cost of crime attributable to adults who had conduct problems in childhood is estimated at £60 billion a year in England and Wales, of which £22.5 billion a year is attributable to conduct disorder and £37.5 billion a year to sub-threshold conduct disorder.

● Depression: Total annual costs of depression in England in 2007 were £7.5 billion, of which health service costs comprised £1.7 billion and lost earnings £5.8 billion. This does not include informal care or other public service costs. Lower productivity accounts for a further £1.7–£2.8 billion and human costs for another £9.9–£12.4 billion, bringing the total annual cost of depression to £20.2–23.8 billion a year.

● Anxiety: Health service costs of anxiety disorders in 2007 were £1.2 bn. The addition of lost employment brings the total costs to £8.9 billion.

● Schizophrenia: Total costs of schizophrenia were approximately £6.7 billion per year in England in 2004–05. Cost of treatment and care was £2 billion, annual costs of welfare benefits were £570 million and the cost to families of informal care and private expenditure amounted to £615 million. Costs of lost productivity due to unemployment, absence from work and premature mortality were £3.4 billion. The opportunity therefore to make efficiency savings is significant.

● Dementia: Total annual UK costs of dementia are £17 billion. Accommodation accounted for 41% of the total, health services eight per cent, social care services 15% and estimated costs for informal care support and lost employment 36%. Numbers with dementia in England are predicted to rise from 680,000 in 2007 to 1.01 million people by 2051. Long-term care for older people with cognitive impairment in England could rise from £5.4 billion to £16.7 billion between 2002 and 2031.

● Suicide: Average cost per suicide is £1.7 million in England, £1.3 million in Scotland and £1.5 million in Ireland. Better identification of risk in primary care and in drug and alcohol services. In 70% of suicides the person has seen a GP in the last month, so better access to primary care is critical.

● Alcohol misuse is estimated to cost the health service £2.7 billion every year and results in output losses of £6.0-7.3 billion due to sickness absence, reduced employment and premature death while annual cost of alcohol related crime and disorder is £9-15 billion. Total cost of alcohol misuse is estimated at £17.7–£25.1 billion a year, which includes costs of treating alcohol-related disorders and disease, crime and anti-social behaviour, loss of productivity in the workplace and social support for people who misuse alcohol and their families.

● Smoking: Annual direct cost of smoking to the NHS is £5.2 billion with smoking responsible for 462,900 hospital admissions in 2008/9.97 Almost half of total tobacco consumption is by those with mental disorder.

● Inequality: At the national level substantial costs are generated by inequalities in mental health. Estimated to be £56 -68 billion nationally (No Health without Mental Health)

Increased productivity

and employment

across GM

Reduced cost and demand (particularly

repeat demand) to

GMP

Reduced suicide rates

Increased life expectancy for mental health

patients

Outcomes

Reduced alcohol-and substance

misuse related MH A&E

admissions

22

Economic Case

GM Wide Direct Costs of Mental Health

● Greater Manchester spends significantly more on mental health than the majority of UK cities and £30.1m of that is inpatient treatment spent out-of-area (7.27% total CCG spend).

● Excluding specialised commissioning and non-identifiable data, GM spends £35m per year on children’s mental health, £248m on adult mental health and £130m on older adult mental health.

● The Local Authority’s social care expenditure on mental adult comprises of mental health support services and excludes learning disability spend (£216m on adults 18-64 and £34.5m on adults over 65). It also excludes physical, sensory or social support costs.

● Based on inflation anticipated figures (using FYFV assumptions), this projected health and social care spend on mental health services if we don’t change is set to increase to £644m by 2021.

● However, in addition to the above, costs are incurred within the GM economy as a consequence of poor mental health as illustrated on page 21.

Between CCGs, locals authorities and specialised commissioning, GM spends c.£615m across on Mental health services across health and social care. £403.4m

£38.3m

£97.05m

£76.5m

CCG mental health

CCG learning disability

Local authorities

Specialised commissioning

2014/15 2020/21

£m £m

Local Authority Spend 97.05 110.8

CCG Learning Disability Spend 38.3 39.4

CCG MH Specialist Commissioning 76.5 78.8

CCG MH Spend 403.4 415.2

615.3 644.3

Source: Local authority budgets, CCG programme budgeting returns and CCG reported data. NB - The specialist commissioning figure does not include learning disabilities and is based on the Secure & Specialised Mental Health Database.

23

Economic Case

Cost of Mental Health services in GM

CCG commissioned spend

The 12 CCGs in GM spent approximately £403m on mental health services in 2014/15 compared to £441m in 2013/14.

The CCG spend analysis above demonstrates the constrained budgets available for CCGs as only Trafford and Tameside and Glossop were able to spend more in 2014/15 than in the previous year.

When plotted against the registered population, Salford and the Manchester CCGs were found to be spending the most per capita at over £170 per head of population.

The average spend in the North was £124 and Wigan, Oldham, Bury Stockport and Bolton spent under this in 2014/15.

Learning from localities has fed into this GM wide strategy.

Across GM approximately £403m is directly spent on Mental Health services by CCGs.

When adjusted for population variances Salford and Manchester CCGs spend the most.

Wigan, Oldham, Bury, Stockport and Bolton spend below the average in the North per CCG.

Source: 2013/14 and 2014/15 CCG programme budgeting returns.

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24

Economic Case

Wider Cost of Mental Health across Greater Manchester

Cohort Volume/Impact on GM economy Cost (£)

GM Population Unemployed with Mental health conditions

● 144,000 Individuals on Employment Support Analysis/Incapacity benefit across GM. Up to 80% of benefits claimants have a mental health condition.1

£1.05 bn

Based on £9,091 fiscal cost per claimant per year.

Children with conduct disorder

● 5.8% of children (~2200 in each GM year group cohort) estimated to have conduct disorders. 2

£330m public sector costs

Based on £150,000 over the lifetime of each child (including NHS, social services, education and criminal justice). 2

Alcohol misuse ● 504,263 Alcohol-related hospital admissions and attendances across GM (2013) (1,155 deaths directly attributable to alcohol).

£167m 3

(hospital admissions, A & E attendances).

£1.2bn in wider costs due to lost productivity, crime, health and social care costs

Substance misuse ● 2,994 Estimated OCU (Opiate or Crack) Users not in treatment in GM in 2014/15. 4

● 86% of Troubled Families with mental health issues also have issues with substance misuse

£78m cost of crime (this is a conservative estimate and does not include other drugs such as Amphetamines, Cannabis, prescription drugs and legal highs) 4

Based on cost of crime for those not in treatment of £2924 per person.

Mental Health bed based-inpatients

● 44% of total CCG MH spend on bed-based inpatients. 5

● On average, 10,495 occupied bed days for MH inpatients in GM per 100, 000 population

( higher than the 7,199 national average).

£176m CCG spend on bed based-inpatients. 5

(£21m uncategorised by CCGs).

Suicides ● 277 suicides registered in Greater Manchester (2014). 6 £2.9m in direct costs to the NHS and policing

£442.7m wider costs due to lost waged and non-waged output, as well as intangible human costs .

Based on total cost per suicide of £1.6m 6

Homelessness ● 25-35% of all those accessing homelessness services present with mental health as their main need.

£2.8m cost to Local Authorities

Based on total GM spend on homelessness of £9.45m per year7

Source: (1) GMCA Mat Ainsworth Working Well: Supporting long term ESA claimants into sustained employment. http://stats.cesi.org.uk/events_presentations/SeminarSeries2014/Tacklingemployment/MatAinsworth.pdf

(2) a) http://www.hscic.gov.uk/catalogue/PUB06116; b) http://www.nice.org.uk/guidance/qs59/documents/qs59-antisocial-behaviour-and-conduct-disorders-in-children-and-young-people-support-for-commissioning2

(3) http://www.alcoholconcern.org.uk/training/alcohol-harm-map/

(4) a) ‘ITEM 6 - Substance Misuse in Greater Manchester’, GMCA; b) http://www.nta.nhs.uk/uploads/whyinvest2final.pdf

(5) a) CCG programme budget returns; b) Mental Health Benchmarking 2012to13 vs 2013to14 v4.

(6) a) ONS, Suicides in England and Wales by local authority, 2016; b) Scottish Executive, Evaluation of Choose Life, 2006

(7) Local authority outturn returns 2014/15

http://stats.cesi.org.uk/events_presentations/SeminarSeries2014/Tacklingemployment/MatAinsworth.pdf

http://www.hscic.gov.uk/catalogue/PUB06116


































http://www.nta.nhs.uk/uploads/whyinvest2final.pdf

25

Summary: Investment Case and the Potential Benefits The following sets out a summary of the impact of some of the strategic initiatives within the strategy across GM. These figures relate to opportunities and based on publically available information and published studies. All figures are given on an annual basis. Further detail including assumptions and referencing are provided on the next four pages. Detailed financials relating the actual activity to be delivered will be developed as part of the implementation planning for the strategy.

Scheme

Cost

Fiscal Benefits1

Additional Public Value Benefits2

Early years £15.1m £15.8m £28.1m

Education: School based social and emotional learning £5.8m £44.4m Unknown

Troubled families £22.8m £33.4m £75.2m

Alcohol Misuse: Screening and brief early intervention £1.3m £5.9m Unknown

Suicide Prevention: Suicide awareness training and intervention £0.4m £0.3m £48.0m

Working well £3.0m £5.1m £13.0m

Workplace screening for depression and anxiety £1.2m £0.7m £2.2m

Promoting wellbeing in the workplace £0.04m £0.0m £0.5m

Housing step down support facility £0.5m £5.2m Unknown

RAID - Psychiatric Liaison £1.5m £2.4m £0.2m

Intermediate Care for patients with delirium £9.6m £12.7m Unknown

Crisis prevention through IAPT £6.9m £11.6m Unknown

Assertive Outreach for individuals with complex dependency £1.0m £1.5m £1.4m

Total of above schemes £69.3m £139.0m £168.4m

1 the financial or ‘fiscal’ impacts to government agencies

2 the overall public value created by a project including economic benefits to individuals and society; and wider social welfare/wellbeing benefits

26

Assumptions



Note: (1) New Economy – Early Years Cost/Benefit Analysis (2015) (2) Mental health promotion and mental illness prevention: The economic case. LSE/PSSRU, Institute of Psychiatry, Kings college London (April 2011). (3) New Economy – Troubled Families Cost/Benefit Analysis (2014)

Early Years: Children & family

Early Years Programme1

● Though investment in parenting support, maternal/postnatal health, and early childhood education yields major, long-term social and economic growth, and also help prevent children develop anti-social personality disorders as adults. Based on a cohort of 38,000 children across GM.

● Costs and benefits of the Early Years programme were modelled over 25 years, with returns increasing annually. Some benefits, e.g. reduced A&E attendances/improved school readiness, to be accrued in the short term. Others e.g. increased employment when children leave school to be accrued long-term.

● Division of fiscal benefits between agencies: DWP 53%; Schools 17%; Local Authority 14%; NHS 10%; Police 3%; Other CJS 3%; Housing Providers < 1%.

School-based social and emotional learning2

● Programmes to help children and young people recognise and manage emotions, and to set and achieve positive goals. Based on a cohort of 38,000 children, as per Early Years. ● Costs of intervention include teacher training, programme coordinator and materials. ● Cumulative benefits taken as an annual average from across ten years of operation. Recognition is given to the build-up in benefit over time. ● Division of fiscal benefits between agencies: Criminal Justice System 58%; NHS 36%; Education 6%; Social Services 1%; Voluntary Sector <1%.

Education

Troubled Families

Troubled Families Programme3

● Interventions to support such families characterised by there being no adult in the family working, children not being in school and family members being involved in crime and anti-social behaviour. These problems are associated with mental health issues and wider determinants of mental health such as domestic violence, relationship breakdown, mental and physical health problems. Assumptions based on cohort of 13,561 troubled families (out of total of 27,200 troubled families across GM).

● All figures are an annual average based on a ten-year intervention. The average reflects the fact that costs are only incurred in the first six years, whereas benefits are accrued for all ten. Significant lead-in time for benefits, with increases from £4.4m in the first year to £41m in the fifth.

● Division of fiscal benefits between agencies : Local Authority 44%; NHS 17%; Housing Providers 11%; CJS (exc. police) 10%; DWP 9%; Police 9%; HMRC/Schools/Department for Education < 1%.

Alcohol Misuse Intervention

Alcohol screening and advice2

● An inexpensive intervention in primary care which combines screening by GPs, followed by a 5 minute advice session for those who screen positive. ● Brief interventions in primary care settings achieve an average 12.3% reduction in alcohol consumption per individual. ● Based on approximately 30% of 66,000 patients screened registering as positive. ● Division of fiscal benefits between agencies: Criminal Justice System (including police) 73%; NHS 27%.

Suicide Prevention

Population-level suicide awareness training and intervention2

● Suicide prevention education for GPs can have an impact as a population level intervention to prevent suicide through greater identification of those at risk. Individuals can receive cognitive behavioural therapy (CBT), followed by ongoing pharmaceutical and psychological support to help manage underlying depressive disorders. The cost of this type of intervention includes ten sessions of CBT in the first year with further ongoing pharmaceutical and psychological therapy together with suicide prevention training for GPs. By applying the England-wide economic model to the GM context, this amounts to approximately 30 potential suicides.

● Division of fiscal benefits between agencies: NHS 63%; police 37%. ● Public value benefits include the prevention of lost wages and non-waged output as well as associated intangible human costs.

27

Assumptions



Note: (1) New Economy – Working Well Cost/Benefit Analysis (2015) (2) Mental health promotion and mental illness prevention: The economic case. LSE/PSSRU, Institute of Psychiatry, Kings college London (April 2011). (3) Health and housing: worlds apart?:Housing care and support solutions to health challenges. National Housing Federation 2009.

Employment Support

Working Well Programme1

● This includes expansion of the Working Well programme across GM to help people with MH conditions who are on Employment and Support Allowance (ESA) to overcome their barriers to work. The benefits provide a prudent estimate related to a cohort of people (1,500) directly identified as having a MH condition. However, the number of people within the overall programme is greater and may also include those be impacted by mental health issues.

● Each person taking part in the scheme will receive individually-tailored packages of support ensuring, through careful co-ordination, that the issues which are holding them back from work are tackled at the right time and in the right order.

● Division of benefits between agencies: DWP 64%; NHS 30%; Police 2%; Prisons 1%; Courts/Legal Aid 1%; Other CJS 1%.

Employment Support

Workplace screening for depression and anxiety2

● Work place based enhanced depression care consists of completion by employees of a screening questionnaire, followed by care management for those found to be suffering from, or at risk of developing, depression and/or anxiety disorders. Those identified as being at risk of depression or anxiety disorders are offered a course of cognitive behavioural therapy (CBT) delivered in six sessions over 12 weeks. The assumption is made that 25,000 employees will be screened. The cost of intervention covers the cost of facilitating the completion of the screening questionnaire, follow up assessment to confirm depression, and care management costs. This also includes six sessions of CBT for those identified as being at risk.

● Figures are based on a benefit which includes a one-year lead in. Benefits to the HSC system only accrued in the second year. Therefore numbers are annual averages from a five year programme.

● 100% of fiscal benefits are attributable to the health sector, and accrued in the year following the intervention. Further potential fiscal benefits to the exchequer through reductions in unemployment, but these have not been quantified. Public value benefits relate to increased productivity through reduced absenteeism and presenteeism.

Employment Support

Promoting wellbeing in the workplace2

● A multi component health promotion intervention consisting of personalised health and wellbeing information and advice; a health risk appraisal questionnaire; access to a tailored health improvement web portal; wellness literature; and seminars and workshops focused on identified wellness issues.

● Evaluation of this type of programme has reported significantly reduced stress levels among workers, as well as reduced absenteeism. All benefits derived are therefore attributable to employers, not health or necessarily even other public services. As such, benefits are expressed of public value rather than fiscal in nature.

Housing Support

Supported housing step down facility3

● A step-down facility to enable prompt discharges from psychiatric hospitals into the community. The provision of four weeks of floating support to clients immediately after they move on provides vital continuity of support during transition. This helps to reduce the revolving door scenario where people relapse during stressful changes in circumstances and need more intensive support again.

● Based on a cohort of 200 clients per annum. brings net saving of approximately £25,900 per client, per year. ● All figures are annual. Costs within reference material are not divided between agencies more deeply than a broad attribution to the 'wider health and social care system‘.

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Assumptions



Note: (1) New Economy – Hospital-based Liaison Care Cost/Benefit analysis (2012). (2) Frontier Economics – Evidencing Pennine Care’s Impact (2015) GM NHS Provider Trusts Federation – A standardised offer for community Care (2015).


(RAID)

RAID: Psychiatric Liaison1

● RAID teams working in wards and A&E depending on the focus of their team (including A &E, Older people, Alcohol Addiction). Includes reduced hospital admissions/readmissions, reduced bed days, and reduced residential care admissions,

● Division of benefits between agencies: CCGs 61%; Acute Trusts 25%; Local Authorities 14%; DWP < 1%.


(MH Intermediate Care)

Intermediate Care for patients with delirium2

● Based on a scaling of Saffron Ward , an intermediate care ward, across ten GM boroughs. Delirium appropriately identified and treated by a trained multidisciplinary team able to identify and design targeted appropriate packages of care for the patient. Additional benefit from new appropriate onward referrals. Intermediate care is cheaper than standard ward care, and more likely to prevent escalation into residential care. 90% of total occupied bed days in standard ward care are reduced from Saffron ward for patients with delirium. Costs are mainly derived from workforce figures.

● 100% of fiscal benefits are accrued by the NHS, although there are potential further unquantified savings to the social care system as the result of prevented entry into residential care.

Crisis prevention through IAPT

Using IAPT to reduce patients in crisis in A&E3

● Analysis disperses the prevalence of incidents proportionately across the national population, equating to 9,321 A&E attendance due to self-harm in GM per year. ● Early intervention, including the use of IAPT services earlier on, results in a lower acuity of treatment. Assumes that GM meets the target of a 50% success rate, which it

regularly exceeds. This reduces the cost of more intense treatment and the number of A & E attendances, generating net savings. ● Division of benefits across agencies: HMRC (tax gains) 40%; Health and Social Care 39%; DWP 21%.

Reduction in police call outs for MH

(S.136)

Assertive Outreach and problem solving for individuals with complex dependency4

● Section 136 is used by the police to remove a person (who appears to be suffering from a mental health disorder) from a public place to a place of safety. In Trafford, a system has been piloted which involves embedding a specialist nurse practitioner within response teams to provide assertive outreach support for individuals who present with need on a repeated basis. Through intensive problem solving, the long-term demand which these individuals present on services has been curtailed.

● Division of benefits across agencies: CCGs 79%; GMP 11%; NWAS 10%; Other CJS/Housing Providers/Local Authorities <1%.

(3) Department of Health – Impact Assessment of the expansion of talking therapies services as set out in the Mental Health Strategy (2011)

(4) New Economy – Home Office Innovation Fund Specialist Mental Health Practitioner Pilot (2015)


Prevention

Access

Integration

Sustainability

Golden Threads

1

2

3

4

5

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Prevention

Targeted Mental Health Campaign A targeted public mental health and wellbeing campaign to raise awareness of mental health issues, reducing stigma and discrimination and helping the public in understanding their role in own wellbeing and how they can support others to deal with such issues. Campaigns will also enable improved access to appropriate support.

1.6

Supporting those most vulnerable in society to help reduce the risk of developing poor mental health, or from any existing mental health conditions in deteriorating further. Aims to address inequalities in access, experience and outcomes for vulnerable people including looked after children, child sexual exploitation and learning disabilities. Interventions include ‘wrap around’ services for those with complex needs such as housing support, drug/alcohol counselling, education programmes. Better targeted case management and outreach support for frequent attenders.

1.7 Supporting Vulnerable People

1.2

A GM wide system approach to helping people improve their wellbeing by using the principles of the ‘Five ways to wellbeing’ framework - Connect; Be Active, Take Notice, Give, Keep Learning (New Economics Foundation). This aims to improve physical and mental health, and protect people from loneliness and depression such as engaging in activities, building support networks within communities, and social prescribing.


Improving perinatal, child and parental mental health and wellbeing is key to the overall future health and wellbeing of our communities. We will look to direct activities towards the whole family and school life experiences including maternal mental health, family support (at all points during the whole life course), tackling domestic abuse; together with Community, Schools and Education programmes.

1.1 Early Years: Children and Family

1.3

Aims to build the individual’s capacity to better manage their own care and increase their resilience through providing self management resources, creating on-line communities and peer support. Also, raising awareness of the benefits of self care and the individual’s role in taking responsibility for their own health and wellbeing with support from the people involved in their care.

Building Capacity for Self Care

1.8

By focusing on wellbeing in the workplace, we will support working individuals in feeling happy at work and help achieve life satisfaction. We will sign up organisations across GM to a Best Employment Practice charter in relation to managing stress, mental health issues and drive wellbeing in the workplace. We will also ensure there is consistent support available across GM for those currently unemployed and seeking employment, including access to CV clinics, coaching and mentoring.. We will build on the Working Well Programme.

Workplace and Employment Support

1.5

Increase GM wide interventions to build good wellbeing and resilience including universal approaches for the general population and targeted wellbeing interventions for those facing particular risk factors, including mental illness to improving health and social outcomes, reducing prevalence of mental illness and supporting recovery. GM will also provide support on the wider determinants of mental health; addressing lower levels of mental distress earlier on helping to reduce the likelihood of a more chronic and debilitating illness.

Early Intervention

Suicide Prevention 1.4

Working with the GM Suicide Prevention Executive to reduce suicide risk by reflecting the main elements of the national strategy ie men’s mental health, mental health services, self-harm, young people, suicide hotspots, working with the media. Highlighting the features of MH services we have shown to be linked to lower suicide rates eg outreach, early follow-up on hospital discharge, adopting NICE guidance on depression and self harm. Supporting the development of real time data and information and workforce development to support suicide prevention.

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Access

2.1

Strengthen the role of the GP as an initial point of contact, and ensuring there is a consistent care co-ordinator role with the right skills and competencies across GM. This will bring together primary mental health care and social care support. Train practice nurses and other primary care workers in early intervention and ensure access to EIP, perinatal MH and IPT.

Identify single points of access across primary and secondary care and develop a

care co-ordination role

2.2

We will look at national best practice and aim to build our minimum standards around these interventions, taking into the account a need for local variations dependent on different demographics. We will work across the 10 Local Authorities to develop consistent approaches to social care for mental health. Introduce combined mental and physical enablement and group based practice.

IAPT services of consistent high quality across GM

2.3 Support services for parents at risk through home visits by professionals, GMs troubled families’ programmes and/or befriending initiatives by voluntary organisations. This will encompass the full range of community support in the NHS, Local councils and the Voluntary Sector. Improve police training and support services.

Improving support for carers and parents at risk

2.4 We will create 24/7 crisis care for children and provide 7 day access to Community mental health teams that are able to provide support across GM.

24/7 mental health services and 7 day community provision for children

2.5 We will ensure consistency is achieved in the delivery of 24/7 crisis care for adult service users and ensure consistent 7 day access to Community mental health teams that are able to provide support across GM including full implementation of the GM crisis care concordat

Ensure consistency of 24/7 mental health services and 7 day community provision for adults including crisis care concordat

2.6 We will work with clinicians, care managers, including the third sector to review the thresholds for access to all mental health services and ensure these are explicit within operational policies.

Standards and protocols for step up and step down (Inc. prisons)

2.7 Increase collaboration across providers to tackle current out of area provision, using GM capacity on GM residents, improving care and driving efficiency

Self Sufficiency in provision for GM (out of area placements)

2.8 Flexible specialist Children and Adolescent Eating Disorder (CAEDS) service model through Multidisciplinary community based teams

Eating disorders in CYP

2.9 Co-commissioned multi-agency care pathway for children and young people with ADHD across the lifespan into early adulthood and service expansion into adulthood.

ADHD in CYP and service expansion for adults

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Integration

3.1

Simplify, consolidate and streamline the current commissioning landscape to create a robust and accountable commissioning function which removes duplication, creates economies of scale and provides consistency. Commissioning will be both place-based (as part of new care organisations) and across GM providers. Commissioners will have specialist competency training.

Integrated place-based commissioning and contracting

3.2 Design and implement appropriate MH services at suitable spatial levels -GM level and place-based settings. MH will be an assumed part of place-based commissioning and local care organisations will be a major contribution to parity of esteem with integrated leadership and collective accountability across the public sector.

Locality Care Organisations to integrate care both vertically and horizontally across

community, primary and acute settings

3.3 This involves 4 elements: all-age, integration between physical and mental health, integration across care settings and integration with the individual’s wider environment. This will engage the whole range of local services including housing, leisure and learning.

A whole person integrated vertical care pathway across a horizontal integration of

care providers

3.4 Building a stronger partnership with the voluntary sector will ensure the third sector is an integral part of each patient’s pathway and that the third sector can work in an integrated way to ensure appropriate care is provided in the right place. The service will operate on an outreach as well as responsive model to reduce inequalities.


3.5 Provide a GM environment that is appropriate for 21st Century mental health care by reviewing, assessing and managing all MH physical assets and facilities management across GM and ensure alignment with place-based working across the public sector. Make services available by telephone and over the internet.

Asset-based approach and devolution estate managed centrally for the benefit

of GM

3.6 Develop a consistent set of shared minimum standards and outcomes for GM with a set of standard KPIs that cover the whole range of mental health services that are involved in changing and promoting positive mental well being.


3.7 Improve information sharing between agencies to facilitate collaboration and drive integrated care, through integrated patient records and/or patient ownership of information.


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Sustainability

4.1 Systems leadership is necessary in driving new integrated care models, and it requires a real commitment across senior leadership to align their organisation’s goals with the goals of the wider system. ONE LEADER.

System leadership

4.2 Our vision for mental health is that it is led by wider primary care (including community pharmacies, schools and adult education), fully integrated with social care and supported by specialist interventions provided where necessary, based on an integrated, neighbourhood management model.

Improve SOCIAL CARE, community and primary care capacity

4.3 Changes to working practices and training to facilitate a culture of shared leadership accountability linking with the Academic Health Science Network and others to develop new curricula and qualifications.

Working practices

4.4 Establishing a consistent standard benchmark for programmes which must be implemented in all areas, and a more robust methodology for evaluating the success of a programme and the next steps.

Programme prioritisation

4.5 Pooling of budgets to enable joint decision making for the system as an integrated whole. Pooling of Mental Health budgets

4.6 A: Strengthen collaboration between providers, more substantially than integration of back office functions, to enable full needs based pathways.

B: Short-term solution for MMHSC unsustainability.


4.7 Recognising the value in alternative sources of investment, for example social impact bonds. Payment and incentives

4.8 Freedom to relax or reform regulation in areas where radical change to the system is proposed. Regulation reform

4.9 Recognising the value in alternative sources of investment, for example social impact bonds. New investment streams

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Cross-cutting Golden Threads

5.1 Initiatives to address this parity must address the multiple sources of this inequality – financial, attitudes and beliefs, both within and beyond health and social care and as MH accounts for 23% disease burden, need greater equality re resource through reducing unnecessary acute trust admissions, OPCs, investigations.

Ensure parity of esteem between mental and physical health

5.2 We will work in partnership with HInM and the Centre for Mental Health and Safety to ensure mental health research is sufficiently prioritised, drive better co-ordination, and that interventions which have been proven to be effective are swiftly rolled out.

Improve deployment of research to inform best practice care across GM

5.3 Staff must be enabled to become more adaptable in order to respond to systems-wide changes, and more multidisciplinary, in order to drive integrated care. This will require leadership, training and culture change.

Prepare a workforce to work as part of an integrated, joined-up system

5.4 Technology offers the opportunity to transform mental health and support self-care, but we need to ensure that all interventions are carefully assessed and evidence-based.

Utilise technology to provide new forms of support

5.5 These programmes must have access to the right mental health treatment, and they should be effectively integrated with other health and social care services. Target the 10% of people that generate 40% of activity and cost.

Leverage the success of existing programmes (e.g. Troubled Families,

Working Well) which prioritise the top 10% which account for 40% resources

through repeat admissions, detention and crises

GREATER MANCHESTER HEALTH AND SOCIAL CARE … · 2020. 2. 6. · Wigan Council Councillor Peter Smith (In the Chair) Donna Hall Wigan CCG Tim Dalton 01/16 WELCOME AND APOLOGIES Councillor

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