IJB029 Budget Scrutiny: Integration Authorities · 2016-11-17 · IJB029 1 Budget Scrutiny: Integration Authorities The Committee has chosen to consider the integration of health

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Budget Scrutiny: Integration Authorities

The Committee has chosen to consider the integration of health and social care as part of its consideration of the Scottish Government‟s budget. The following questions are designed to explore the budget setting process for 2016-17 and how budget allocation reflects the priorities set out in the performance framework.

1. Which integration authority are you responding on behalf of? South Ayrshire Integration Joint Board

2. Please provide details of your 2016-17 budget:

£m

Health board 94.6

Local authority 66.6

Set aside budget 21.6

Total 182.8

3. Please provide a broad breakdown of how your integration authority budget has been allocated across services, compared with the equivalent budgets for 2015-16.

£m 2015-16 2016-17

Hospital 27.2 27.4

Community healthcare 32.7 33.2

Family health services & prescribing 37.4 38.7

Social care 83.0 83.5

Total 180.3 182.8

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4. The 2016-17 budget allocated £250m for social care. Please provide details of the amount allocated to your integration authority and how this money has been utilised.

South Ayrshire IJB‟s share of the £250m investment for social care is £5.83m. The additional SG funding will be used to meet pay and inflationary uplifts in 2016/17; the cost of the living wage from 1st October 2016 and the shortfalls in funding base for services in place prior to 31 March 2016.

Budget setting process

5. Please describe any particular challenges you faced in agreeing your budget for 2016-17 The delegated budget from NHS Ayrshire and Arran was not formally approved until 21 June 2016.

6. In respect of any challenges detailed above, can you describe the measures you have put in place to address these challenges in subsequent years? We are reviewing our experience in setting the 2016/17 budget with work being undertaken on a pan-Ayrshire basis through groups (Strategic Planning and Operational Group, Integration Finance Leads, Directors of Finance Group, Chief Executives Group) and will report to the Chief Executive Group. The timing and coordination of budget settings in the IJB is dependent on clarity of funding to the Council and NHS Board and subsequent delegation.

7. When was your budget for 2016-17 finalised? This remains under discussion in respect of certain aspects. The element of the budget that has been applied to social care services is finalised along with plans for the utilisation of additional monies. However, because of the late approval of the health budget an indicative contribution to the integrated budget was provided by NHS Ayrshire and Arran. This will require further adjustment before a full, final base budget can be confirmed.

8. When would you anticipate finalising your budget for 2017-18?

March 2017.

Integration outcomes

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9. Please provide up to three examples of how you would intend to shift resources as a result of integration over the period of your Strategic Plan:

By enhancing anticipatory care there should be fewer admissions to hospital with a consequential reduction in acute in-patient stays.

Increasing the multi-disciplinary rehabilitation teams should reduce the length of stay in a hospital setting and assist older people to maintain independent living.

Intervention by rehabilitation teams at A&E should identify alternative solution rather than admission to hospital resulting in a reduction in admissions.

Development of third sector services to assist with support to older people on discharge should allow discharges to be effected at an earlier stage.

10. What efficiency savings do you plan to deliver in 2016-17?

The following efficiency savings are planned:

Service Area Outstanding

Requirements

£ M

Chalmers Road Respite Facility 0.107

Learning Disability Services 0.082

Call Monitoring System 0.105

Community Transport 0.045

Day Care contract savings 0.100

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Rebalancing of Nursing/Residential Care placements

0.100

Review of Management Costs 0.050

Respite - close monitoring of usage 0.250

Sleepovers 0.150

Mental Health Care Packages 0.120

LD Care Packages 0.200

PD Care Packages 0.100

Meals on Wheels 0.100

General Contract Efficiencies 0.270

AHP management post 0.080

Dietetic supplies 0.020

Addiction post 0.062

Reduction in Agency costs 0.050

Management of enhanced services 0.080

Vacancy management 1.250

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The following budgets were released as a result of a review of the budget provision:

Service Area Outstanding

Requirements

£ M

Self Directed Support Underspend 0.200

Day care meals income review 0.012

Resource Transfer income review 0.134

Care at Home – OP 0.315

11. Do you anticipate any further delegation of functions to the integration authority? (If so, please provide details of which services and anticipated timescales)

In setting up the IJB, South Ayrshire Council and NHS Ayrshire and Arran agreed to include Children‟s Community Health Services and Social Work Services for Children and Young People and Criminal Justice within the Integration Scheme.

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Performance framework

12. (a) Please provide details of the indicators that you will use to monitor performance and show how these link to the nine national outcomes

The HSCP is finalising the performance framework for inclusion in the first Annual Report to be considered by the IJB in September 2016. This work is still in development. Performance reports have been submitted to the IJB Performance and Audit Committee. A copy of a recent report from June 2016 is attached below.

(b) If possible, also show how your budget links to these outcomes

National Outcome Indicators 2016-17 budget

People are able to look after and improve their own health and wellbeing and live in good health for longer.

We are will be using the Core Suite of Integration Indicators published by the Scottish Government. See:

http://www.gov.scot/Resource/0047/00473516.pdf

N/A

People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community.

N/A

People who use health and social care services have positive experiences of those services, and have their dignity respected.

N/A

Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services.

N/A

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National Outcome Indicators 2016-17 budget

Health and social care services contribute to reducing health inequalities.

N/A

People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing.

N/A

People who use health and social care services are safe from harm.

N/A

People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide.

N/A

Resources are used effectively and efficiently in the provision of health and social care services.

N/A

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SOUTH AYRSHIRE HEALTH AND SOCIAL CARE PARTNERSHIP

PERFORMANCE AND AUDIT COMMITTEE 17th June, 2016

Report by Director of Health & Social Care

1. PURPOSE OF REPORT 1.1 The purpose of this report is to submit for consideration the second Partnership Performance Report for aspects of service

for Adults and Older people and the initial report for Children‟s Health Care and Criminal Justice, comprising both baseline information and in some cases information for the period to 31st March 2016.

2. RECOMMENDATION 2.1 That the Performance & Audit Committee considers and notes the performance data detailed in Appendix 1 and

Appendix 2. 3. BACKGROUND INFORMATION 3.1 At the December 2015 meeting of the Performance and Audit Committee the initial Partnership Performance Report for Adult

and Older People‟s Services for the period to 30th September 2015 was submitted for consideration.. It was agreed that updates would be submitted to the Committee on a six monthly basis for its consideration and that the next reporting cycle would include the Children‟s Health and Criminal Justice Performance Report. Information is provided up to the 31st March 2016, where available, or alternatively the most recently published data is provided. It should be noted that some data for Children‟s Health and Care is not available for 2015/16, or the latest quarters, due to the reporting schedule being aligned to the Educational year i.e. from August to July each year rather than the financial year of April to March.

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3.2 The range of the performance data being presented is still fairly limited in that it does not cover all of the functions delegated to the Partnership, particularly in relation to the areas noted below at 3.3. The construction of the performance framework will continue to develop and evolve within this strategic planning period as services are reviewed and change in accordance with the programme of activity that has begun.

3.3 At the last meeting of the Committee it was acknowledged that there are areas where further development is required in

terms of measures to reflect all of the activity within the Partnership, including those noted below:

District Nursing

Learning Disabilities

Mental Health

Corporate Performance measures

Work has been undertaken since the last report to incorporate a range of Health Promotion indicators and these are now included in both performance reports. Discussions have also taken place with Allied Health Professional Leads who are currently in the process of mapping available data to the Strategic Objectives to allow for future reporting of performance in this service area. Further work is planned as part of the reviews around Mental Health and Learning Disabilities to establish key performance indicators which will incorporated into future reports.

3.4 At the last Performance and Audit Committee, members were advised of the Scottish Health and Care Experience Survey.

The full results for each Partnership were made available at the end of May 2016. The initial results from the latest survey are included in the attached Adults and Older People performance report against the measures which were previously reported. A more detailed analysis on the full results from the Survey will be presented to the next Performance and Audit Committee.

4. REPORT 4.1 A summary position is provided in the table below to show the numbers of indicators highlighted with red, amber or green

status across the 97 indicators within the report. 70% of indicators present no concerns, 20% present some concerns, and 9% present a higher level of concern.

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Indicator Status Number of Indicators at each Status level

No concerns 68

Some concerns

19

Major concerns

9

N/A Not Applicable

1

4.2 Adult and Older People Exception Reporting

The following indicators show a performance of amber or red for which there are areas of concern when comparing against the Scotland position, the previous year‟s performance, or lower than expected performance.

Status Indicator Description Indicator No.

Emergency hospital admission rates per 100,000 population ( all ages)

2

Bed Day Rates per 100,000 population of all emergency admissions for people aged 65+

3

Rate of drug related hospital stays 6

Rate of alcohol related mortality 8

Number of drug related deaths 10

Delayed Discharges of more than 2 weeks 46

SDS Uptake across options 1-4 47

SDS spend on Direct Payments 48

Adults aged 65+ requiring intensive care (10+ hours) receiving it at home

26

Deaths by Cancer by age standardised mortality rate 28

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per 100,000 population.

Psychological Therapy treatment within 18 weeks of referral

33

% of adults who are overweight 34 &35

% of adults meeting physical activity guidelines 36 &37

% of adults who smoke 38

Rate of falls emergency admissions per 1,000 population (For 65+ age group)

40

% AP Inquiries completed within target timescale 50

% AP Investigations completed within target timescale 51

4.3 Areas of Improvement

The table below shows the indicators which were previously highlighted within the exception report for Adults and Older People and have since demonstrated improved performance and no longer present under areas of concern in the current report.

Indicator Description Indicator No.

Adults who agree they had a say in how their support is provided.

17

Adults who rate their care as excellent or good 18

Adults supported at home who agree that services have improved or maintained their quality of life

19

Adults who agree they feel safe 20

Adults in receipt of basic Telecare ( Community Alarm) 41

4.4 Children’s Health Care and Criminal Justice Exception Reporting

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The following indicators show a performance of amber or red for which there are areas of concern when comparing against the Scotland position, the previous year‟s performance, or lower than expected performance.

Status Indicator Description Indicator No.

Percentage of new Children‟s Hearing Reports completed on time

1

Percentage of High Risk Pregnancy initial risk assessments completed by week 24 of pregnancy

5

Percentage of Looked After Children who are seen by a supervising officer within 15 days

6

LGBF The gross cost of "children looked after" in a community setting per child per week £

15

% of P1 Children at Risk of obesity 21

% of P1 children with no obvious tooth decay 22

Percentage of staff within Children‟s Health who have received an e-KSF in the last 12 months

25

Percentage of Home Background/Home Leave Reports submitted within timescales

3

Percentage of case reviews held within timescales 7

4.5 It should be noted that where there are no local or nationally prescribed targets, the Scottish average figure has been

selected as a target, where such figures are available. Further work around target setting will take place as the reports evolve.

5 RESOURCE IMPLICATIONS 5.1 Financial Implications 5.1.1 There are no financial implications arising from the consideration of this report.

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5.2 Human Resource Implications 5.2.1 There are no human resource implications arising from the consideration of this report. 5.3 Legal Implications 5.3.1 There are no legal implications arising from the consideration of this report. 6 CONSULTATION AND PARTNERSHIP WORKING 6.1 There has been no consultation on the preparation of this report. The preparation of the report has been supported by staff

in the Policy & Performance Team of South Ayrshire Council. Senior Partnership Managers participate in Pan-Ayrshire sponsored work in this area with colleagues from the Health Service and the other two Ayrshire Partnerships through the Planning & Performance Leads Group.

7 EQUALITIES IMPLICATIONS 7.1 There are no equalities issues arising from any decisions made on this report. 8 SUSTAINABILITY IMPLICATIONS 8.1 There are no sustainability issues arising from any decisions made on this report. 9 CONCLUSIONS 9.1 This report recommends that the Performance and Audit Committee considers the latest performance information for the

Partnership.

BACKGROUND PAPERS Public Bodies (Joint Working) (Scotland) Act, 2014

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National Outcomes for Health & Social Care Health and Care Experience Survey 2015/16 Date: 08.06.16

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D Delayed Discharges: South Ayrshire

In relation to delayed discharge the Committee is interested in three areas. The extent to which the IJB is able to direct spending, how much money is available to tackle delayed discharge and how well it is being spent to eradicate the problem.

1. As an Integrated Authority what responsibility do you have for tackling the issue of delayed discharges?

The Integration Joint Board has full delegated responsibility for utilising funding for the achievement of the 9 National Outcomes and outcomes associated with both Children‟s and Criminal Justice Services. This delegation includes responsibility for the achievement of outcomes associated with delayed discharges.

2. What responsibility do you have for allocating expenditure including additional sums allocated by the Scottish Government to tackle delayed discharges?

The IJB has full delegated authority for allocating resources including additional resources to tackle delayed discharges. The total budget for the HSCP in 2015/16 was as outlined in the table below:

£m

Health board 94.6

Local authority 66.6

Set aside budget 21.6

Total 182.8

This resource can be broken down in a number of ways:

£m 2015-16 2016-17

Hospital 27.2 27.4

Community healthcare 32.7 33.2

Family health services & prescribing 37.4 38.7

Social care 83.0 83.5

Total 180.3 182.8

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By client group the breakdown is as follows:

3. How much was spent in 2015-16 on tackling delayed discharges? If necessary this answer can be based on your shadow budget for 2015-16.

The total spend to tackle delayed discharges in 2015/16 was £3,204,831. This sum is detailed in the table below:

2015/16 2015/16 2015/16 2016/17 2016/17 2016/17

Social Care Health Care Total Social Care Health Care Total

Budget Budget Budget Budget Budget Budget

£'000 £'000 £'000 £'000 £'000 £'000

Learning Diabiliites 15,608 477 16,085 17,200 493 17,693

Mental Health Services 4,199 3,208 7,407 4,422 3,371 7,793

Criminal Justice 223 0 223 114 0 114

Older People 40,389 48,011 88,400 41,866 50,548 92,414

Hosted Services 0 21,584 21,584 0 22,208 22,208

Children's Services 18,851 1,769 20,620 20,530 1,925 22,455

Support Services 3,691 712 4,403 (646) (826) (1,472)

Set Aside 21,600 21,600 21,600 21,600

Partnership Total 82,961 97,361 180,322 83,486 99,319 182,805

82,961 97,361 180,322 83,486 99,319 182,805

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This funding directed to delayed discharges comes from a number of sources and includes the recent Scottish Government allocation as well as other sources including the Integrated Care Fund and funding redirected from base budgets to tackle the issue. As the table in section 2 highlights, the budgets for older people‟s services amounted to £88.4m in 2015/16. In summary, therefore, while the £702,000 delayed discharges funding does provide additionality to the overall budget it is a relatively small component. The HSCP seeks to use all of this resource in a way which provides best outcomes for older people including particularly minimising the risk of delayed discharges.

Delayed Discharge spend

Expenditure

2015/16

£

Original SG allocation 691,000

Integrated Care Fund 298,831

Delayed Discharge Funding 702,000

NHS Recurring 157,000

NHS Non-recurring 50,000

South Ayrshire Council

Non-recurring 604,000

Recurring demography 562,000

Technology Enabled Care SAC 140,000

Total 3,204,831

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4. What is the total funding (in 2016-17) you are directing to address the issue of delayed discharges? Please provide a breakdown of how much money has been received from each of the following for this purpose:

The funding available to tackle delayed discharges in 2016/17 is detailed in the table below:

As with 2015/16, the resources identified as being for delayed discharge need to be viewed within the wider context of the funding for older people‟s services and the partnership in general. In 2016/17 it is anticipated that £92.4m will be committed to older people‟s services.

Delayed Discharge spend

Funding

2016/17

£

Original SG allocation 691,000

Integrated Care Fund 715,410

Delayed Discharge Funding 702,000

South Ayrshire Council

Recurring demography 1,384,000

Technology Enabled Care SAC 33,000

Total 3,525,410

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5. How was the additional funding allocated by the Scottish Government to tackle delayed discharges spent in 2015-16? How will the additional funding be spent in the current and next financial years?

The table below outlines the way in which the delayed discharges resources have been used in 2015/16 and the intended spend for 2016/17. The proposed spend profile for 2017/18 has not yet been developed. Decisions on how to allocate this resource will depend on key priorities and pressures as they emerge over 2016/17.

DELAYED DISCHARGE FUNDING

Partner Plan Actual Plan Projection Plan

2015/16 2015/16 2016/17 2016/17 2017/18

£ £ £ £ £Social Workers (Biggart) SAC 90,000 48,102 90,000 90,000

Additional Homecare: SAC 250,000 400,000 200,000

: Mobile Attendants 821

: Weekend working 10,000

: Homecare tender for Winter Capacity 30,000

: Uncommitted

Rapid Response SAC 200,000

Physio and OT capacity NHS 75,000 37,500 130,000 114,757

Advanced Nurse Practitioner NHS 45,000 0 45,000 30,000

Worker re code 9 and guardianship SAC 40,000

Power of Attorney Campaign SAC 10,000

Care Home Fees SAC 430,000 267,243

Offset Care at Home OP Care packages overspend 135,577

Increased costs Biggart NHS 10,000

Uncomitted 2,000 27,000

TOTAL 702,000 702,000 702,000 702,000 0

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In the table there is a difference between the planned expenditure and the planned or projected expenditure for each of the years. This reflects emerging priorities and pressures in each of the two financial years. For 2015/16 the plan was largely associated with increasing capacity to support the timeous management of demand both for assessment and for home care discharge from hospital. As the year progressed it became clear that funds would be needed to support the rise in demand for care home placements.

For 2016/17 a similar pattern has emerged. Later in this paper we refer to the review and redesign of care at home services which are critical to the ambition to look after more people in their own homes. The elements of the redesign requiring investment have progressed a little slower than anticipated; this coupled with other efficiencies being found within the service mean that funds are available to be diverted to fund care home placements.

6. What impacts has the additional money had on reducing delayed discharges in your area?

The investment of the delayed discharges £702K in 2015/16 was used as follows

Additional Social Work assessment capacity:

Two additional social worker posts were appointed to help reduce the delays in assessment for patients identified as having complex care needs.

During the winter period social workers were deployed at the acute hospital at weekends to assist with discharge planning.

Additional Biggart AHP capacity

The HSCP used additional capacity to support a test of change in hospital based rehabilitation. At its peak 8 beds within the Biggart Hospital were identified for AHP led rehabilitation. The test of change has resulted in a decrease in the length of stay from from 50 to 21 days. This work is now a key element of our future planning.

Additional Care at home capacity

Private sector capacity was secured during the winter period to offer additional rapid access to support to effect discharge.

Care Home Placements

As the table shows a significant proportion of the funding was used to support care home placements. The funding equates to the cost of approximately 24 placements on a full year basis.

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7. What do you identify as the main causes of delayed discharges in your area?

The most significant issue within South Ayrshire is that there has been insufficient funding to enable the placement of people requiring care home support to leave hospital.

The following graph shows the net change in the numbers of people funded by South Ayrshire in care home placements.

The graph shows that throughout 2014 and into 2015 the overall number of placements was either stable or falling. In the spring and summer of 2015 the number of placements rose significantly. In total the net rise in placements beyond the average of 820 was approximately 80 places. The cost of a care home placement varies depending on the type of placement and assets available to the resident. However, on average, the cost is approximately £18,000 to the local authority. An increase of 80 places in such as

Number of funded care home placements in South Ayrshire April 2014 to July 2016

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short space of time creates a full year budget pressure of approximately £1.4m. The downward curve in the graph from October 2015 reflects a decision by the IJB to reduce care home placements to contain costs within the budget available. At the IJB meeting on 21 August the Board considered the spend projections emerging from period 3 in the financial year. At that relatively early stage in the financial year the projected overspend for social work services was estimated to be £0.6m. Significant pressures were emerging at that stage within older people‟s services (£1.08m overspend projection) and in children‟s services (£0.79m overspend projection). These were in part offset by other underspends including vacancy management. In the period following the August meeting the Chief Officer considered the range of options to achieve financial balance based on emerging financial information. At the IJB meeting held on 28 October a paper was presented which indicated that the projected overpsend against social work budgets had increased to £0.7m from the £0.6m reported in August. The most significant pressures were identified as follows:

Area of Service

Position reported Aug

2015

Temporary adjustments

agreed August 2015

Position reported Oct

2015

£m £m £m

Older people‟s care packages

(0.76) 0.40 (0.50)

Older people‟s care home fees

(0.60) 0.58 (0.10)

Adult care packages (0.38) - (0.50)

Placements for Children (0.79) - (1.00)

Slippage in the Integrated Care Fund, Delayed Discharges Funding, over achievement of payroll management and smaller underspends from other sources to a total of £1.4m were used to mitigate in part the over commitment in older people‟s budgets. Taking into account all of the available resources there remained a projected shortfall of approximately £0.7m on the social work budget. The recovery plan presented to the IJB included a range of measures designed to achieve financial balance. The recovery plan included a number of cost reductions including a target of £0.14m in reductions in care home fees. The IJB accepted a proposal that the number of new placements be limited to two for every three discharges.

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The graph below illustrates the reasons for delayed discharges over the period since April 2015. The impact of the decision to reduce the funding available for placements has increased the number of people delayed as a consequence of awaiting funding since November 2015.

Prior to the autumn of 2015 the pattern for South Ayrshire had been a steady and reducing number of delayed discharges as illustrated in the graph below. It is also noteworthy that the number of code 9s has reduced over the early part of 2016 despite the rise in overall numbers.

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In addition to the primary reason for delay being the pressure on budgets to fund care home places there are a range of other system issues across the unscheduled care pathway which we are aware can result in delayed discharges. The work described later in this paper is designed to reduce the impact of these:

The main causes of delayed discharge can include:

Inadequate focus anticipatory and preventative work

Lack of alternatives to conveyancing to hospital

Lack of capacity in acute services to provide timeous frailty assessment pre-admission

Lack of timeous access to Step Up alternatives to hospital.

Lack of confidence and knowledge in acute staff re community services leading to risk averse clinical decisions

Lack of Care of Elderly Medical capacity leading to delayed decision making

Lack of integrated approach between acute and community teams

Limitations in speed of Social Work assessment

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Limitations in out of hours and weekend clinical and social work capacity

Lack of Step Down alternatives including dealing with those with delirium

Lack of capacity and range of community services adequate to deal with increasing discharge

With Adults with Incapacity issues

Lack of availability of Care Home placements

Lack of availability of Care at Home capacity

8. What do you identify as the main barriers to tackling delayed discharges in your area?

As indicated earlier the primary issue for 2015/16 contributing to delayed discharges was the financial pressure created by a steep rise in the number of people identified as needing a care home place as identified at question 7 above.

Demographic pressures are also significant in the way in which they are driving up demand for unscheduled care and wider service responses. The graph below illustrates the significant rises in the population of older people, particularly those aged over 75 in South Ayrshire over the next 20 years. It should be noted that while the numbers are less than the rise for Scotland as a whole the baseline for South Ayrshire is higher.

Population projections (2012-based) projected change (2012-2037)

-2% -7%

-18%

15%

79%

9% 5%

-4%

37%

86%

-0.4

-0.2

0

0.2

0.4

0.6

0.8

1

All Persons Age 0-15 Age 16-64 Age 65-74 Age 75+

% C

ha

ng

e

Population Projections (2012-Based) Projected Change (2012-2037)

South Ayrshire Scotland

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We are seeing a rise in the number of people requiring unscheduled care. The graph below illustrates the rise in the number of people attending Accident and Emergency at the University Hospital Ayr over the last 5 years. Attendances in 2015 were 13.8% higher than in 2011.

In addition to the rise in demand there are a number of other issues which can contribute to delays. These can include

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Risk Management

There are at times differences in the assessment or risk between professionals which impact on decisions around return home for example. It is overly simplistic to characterise these as being between acute and community but at times it is clear that hospital staff have anxieties around discharge home where they have less confidence in the ability of community services to adequately support someone.

Structural/Process Issues

There are limitations in the whole sequence of work from pre-admission assessment, decisions to admit, internal processes, out of hours working, medical decision making, through to decisions to discharge

Workforce Pressures

There have been some limitations in the availability of staff including vacancies for Care of the Elderly Consultants. There are also difficulties in the recruitment and retention of staff at a range of other levels including qualified nurses and care at home staff.

9. How will these barriers to delayed discharges be tackled by you?

At its most basic the delayed discharges in South Ayrshire are a consequence of the non-availability of funding to make placements.

9.1. Funding of Care Home Placements

The financial position reported to the IJB in August 2016 provides a degree of reassurance that demand management and efficiencies are progressing largely in line with expectations. As a consequence it has been possible to release funding to support the placement of people in care homes. In the first instance funding has been released for a further 30 placements of which approximately 19 have been from the Biggart Hospital. As at Thursday 18 August there were a further 11 people awaiting funding from Biggart. The financial position will be monitored closely over the coming weeks and where possible funding will be made available to make placements.

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The funding agreed to date is some £300,000 from slippage within a number of projects. These are one-off funding sources. The funding provides for 30 places for approximately 6 months. These placements will be likely to create a budget pressure for the HSCP of approximately £600,000 from 1 April 2017. The work associated with the modernisation of services described later in this paper is in part designed to support approaches which will see a greater proportion of people looked after at home rather than in a care setting.

9.2. Care at Home Capacity

For the most part the delivery of care at home has not been a major factor in delaying discharges. However as the numbers of people potentially needing a service increase it has been necessary to ensure that best use is being made of the available resources. The provision of timeous access to care at home services is a critical to the timely discharge of people from hospital back to their own homes. The HSCP has embarked on an ambitious process of redesign of key aspects of the service. At the IJB in May 2016 a paper outlining the outcome of a service review were presented and the ongoing programme of redesign approved. Work to implement the approved changes is currently underway. A key element of the redesign is to develop a “re-ablement” service which will be designed to ensure people are supported to enable them to perform as many activities of daily living as possible for themselves. The overall aim being to make best use of the available resources, particularly the staff capacity.

9.3. Pan-Ayrshire Modernisation of Services

South Ayrshire HSCP is working collaboratively with the partnerships in East and North Ayrshire and Acute Services to develop proposals aimed at modernising approaches to care for older people and those with complex needs. The governance for these workstreams rests with the four operational directors in Ayrshire from the 3 HSCPs and Acute Services. The work to develop proposals for new models of service for older people is being led by North Ayrshire HSCP and is at a relatively advanced stage. It is expected that recommendations will emerge over the next few months. The work undertaken by the Programme is underpinned by the Scottish Government's 2020 Vision: where by 2020 everyone is able to live longer healthier lives at home, or in a homely setting and, that we will have a healthcare system where:

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We have integrated health and social care

There is a focus on prevention, anticipation and supported self-management

Hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm

Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all

decisions

There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate,

with minimal risk of readmission

The future Models of Care work being undertaken is has focussed on five key components of care:

Supporting people to stay at home or a homely environment (including care at Home, GP and community services),

Supporting older people with mental health issues

Supporting people to regain independent living through rehabilitation

Supporting people with hospital care, when appropriate

Supporting people towards the end of their life

At Appendix 1 the New Models of Care for Older People and People with Complex Needs Interim Report is attached. This paper provides a summary of the work to date and proposed approach to the care of older people is attached.

This work is progressing in conjunction with workstreams focussed on both unscheduled care and primary care. There has been an ongoing focus on the response to the pressure to respond to the needs of people presenting at hospital on an unplanned basis. During the winter of 2015/16 the NHS Chief Executive was directly involved in overseeing the work of the “Improving Patient Experience Programme” (IPEP) which sought to bring together all key stakeholders from acute services and the HSCPs to manage unscheduled care including discharge management. The learning from that work and the Winter Plan from 2015/16 are being used to inform the wider programme of service modernisation.

9.4. South Ayrshire Service Modernisation

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As part of the Ayrshire wide programme of service modernisation, South Ayrshire HSCP has been progressing with the planning and implementation of a range of activity designed to better respond to the needs of older people in particular. The changes are happening at a number of levels involving the wider community and service delivery across the statutory, independent and third sector. In our localities we are supporting local people and stakeholders to identify those priorities which are important to them which will improve the opportunities to meet our collective ambitions. This has led to locality groups identifying priorities for future work such as tackling social isolation and transport accessibility as key to enabling people to remain at home Our objectives include the desire to respond appropriately to the outcomes which people identify as important to them wherever we encounter them. We are keen to identify people in the community whose ability to support themselves is at risk through the use of anticipatory care. Where needs are identified our ambition is to engage timeously and where appropriate provide or arrange support necessary for people to remain in or return to their home or somewhere homely. A key operational objective is to develop an approach which maximises early multi-disciplinary team assessment, both at presentation and immediately following admission. Some examples of local work include: Community Led Support Programme South Ayrshire HSCP is working in partnership with the National Development Team for Inclusion (NDTi) on a new „Community Led Support‟ programme.

This programme will develop better community based alternatives for service users and patients, including using their own, their family and their local community‟s assets to support better outcomes. It is premised upon better front end outcome-focused conversations focused on „What matters to you?‟ rather than „What is the matter with you?‟ Currently the early part of the programme is geared towards fairly extensive staff and community engagement that will set the context for the improvement activity that will take place over the next 18 months. Anticipatory Care Planning within GP practices We are implementing plans across GP practices in the partnership to introduce Anticipatory Care planning meetings involving GPs and the wider multi-disciplinary team. A successful pilot in one practice has demonstrated the value of the approach in tackling the needs of individuals in a planned way which seeks to respond prior to crisis and to plan pro-actively to manage a crisis should one occur in the future.

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Early MDT assessment on admission to hospital We have put in place arrangements to further develop capacity to support discharge from hospital as soon as possible. Evidence suggests that the likelihood of a successful return home is highest when the MDT assesses needs quickly and is able to provide supports to enable a return home. The longer people remain in hospital at that early stage the higher the risk of them losing confidence and the ability to return home. Focus on Rehabilitation We are looking to use the Integrated Care Fund to invest further in rehabilitation services. Our aim is to develop services which are flexible enough to deliver rehabilitation at home or in hospital. Evidence from a small test of change at the Biggart with an Allied Health Professional (AHP) managed beds suggests there is significant benefit to operating in this way to reduce lengths of stay and facilitate successful discharge. We are also looking to maximise further the opportunities for rehabilitation at home. Telecare and Telehealthcare Ayrshire and Arran Health Board has been at the forefront of the move to utilise new assistive technologies to help support people remain in their own homes. South Ayrshire HSCP has been particularly pro-active in the use of Home Health Monitoring to support people with long term conditions to manage their health, with support, in order to reduce the need to use hospital services. The 3 HSCPs have benefitted from additional short term funding to support this work from the national Technology Enabled Care Programme. Reablement Service Development A key element of the redesign of home care is to develop an Occupational Therapy (OT) supported re-ablement service. The aim is to have all new service user‟s needs related to activities of daily living assessed by an OT who will then be able to support the home carers to help an individual re-learn skills they may have lost while in hospital for example. The aim is to maximise a person‟s ability to care for themselves. Red Cross Hospital to Home Service The three Ayrshire partnerships have secured a service provided by the Red Cross which supports people to return home. This service is particularly focussed on the out of hours period and has been successful in enabling a significant number of people to return home who otherwise may have been admitted to hospital.

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Combined Assessment Unit As part of a major programme of capital investment a Combined Assessment Unit is to be opened at University Hospital Ayr in the spring of 2017. This new unit and associated care pathways is intended to bring together hospital assessment and diagnostics with community based capacity. The intention is to be able to support more people to return home quickly when they present at hospital.

10. Does your area use interim care facilities for patients deemed ready for discharge?

The HSCP does not purchase interim care placements. The HSCP does have delegated responsibility for two community hospitals, Biggart Hospital Prestwick and Girvan Community Hospital. These facilities are used for patients that are medically stable enough to transfer down and where there is more need for nursing and rehabilitation support. The majority of the reported delayed discharges are in the Biggart Hospital.

11. If you answered yes to question 10, of those discharged from acute services to an interim care facility what is their average length of stay in an interim care facility? N/A

12. Some categories of delayed discharges are not captured by the integration indicator for delayed discharges as they are classed as ‘complex’ reflecting the fact that there are legal processes which are either causing the delay (e.g. application for guardianship orders) or where there are no suitable facilities available in the NHS board area. Please provide the total cost for code 9 delayed discharges for 2015-16? What is your estimate of cost in this area in the current and next financial years?

There were 3,196 lost bed days due to Code 9 delays in 2015/16. At a cost per night estimated to be £170, the annual cost was £665,000. The estimated cost in 2016/17 and in 2017/18 is approximately £489,000 each year. This reflects the emerging reduction in the number of Code 9 delays.

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Appendix 1

New Models of Care for Older People and People with Complex Needs

Interim Report

Introduction

Health and social care services provide a vast range of high quality services that improve the quality of life for many older people and people with complex needs within Ayrshire and Arran. However, these services are under considerable strain as resources are squeezed, people live longer with multiple and complex conditions and demographic changes increase. This report hopes to outline the next steps required for transforming health and social care for older people and people with complex needs. There is mounting evidence that this requires a fundamental shift towards care that is co-ordinated around the full range of an individual‟s needs (rather than condition centred) and care that prioritises prevention and support for maintaining independence, otherwise by 2035 we will need an additional 398 acute hospital beds. It is clear that current arrangements are not sustainable and often fail to provide the holistic service that people require. In addition, it should be noted that incremental or small scale change will not be enough to meet the continued pressures outlined above and therefore large scale, whole system change is required at considerable pace to meet the on-going needs of the residents of Ayrshire and Arran. Background

The work undertake by the Programme is underpinned by the Scottish Government's 2020 Vision –where by 2020 everyone is able to live longer healthier lives at home, or in a homely setting and, that we will have a healthcare system where:

We have integrated health and social care

There is a focus on prevention, anticipation and supported self-management

Hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm

Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions

There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of readmission

In addition, the programme builds on Ayrshire and Arran‟s Reshaping Care for Older People - Ten Year Vision for Joint Services. This set out a high level vision and future direction of travel for older peoples services for the next 5-10 years. Over the next 20 years the number of people aged over 70 years within in Ayrshire and Arran is predicted to increase by over 55%. (Appendix 1) and the 75 years and over group by 86%. At the same time the number of working age adults is reducing suggesting that there will be fewer family carers. Life expectancy at birth has been increasing over many decades in Scotland and has increased by 6.7 years for males and 5.3 years for females in Ayrshire and Arran. However, we cannot ignore the considerable inequalities in life expectancy which exist in different parts of Ayrshire and Arran. There is an 8.4 years difference between men living in the most and least deprived areas of Ayrshire and Arran and a 5.4 years difference for females. However,

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although people are living longer, they are also spending more years in ill health. In Ayrshire and Arran it estimated that on average 17.5 years would be spent in a “not healthy” status. However, as people age, they are progressively more likely to live with complex co-morbidities, disability and frailty. Within Ayrshire and Arran by the age of 65, nearly two-thirds of people will have developed a long term condition. It should be noted that 42% of older people discharged from Ayrshire and Arran hospitals have six conditions recorded (average 3.6). This is in line with national statistics which note that people with long term conditions are twice as likely to be admitted to hospital, will stay in hospital disproportionately longer, and account for over 60 per cent of hospital bed days used. This increase in demographics will have a significant effect on current and future prescribing. The numbers of drugs people are prescribed rises after age 50, and many people over 75 are taking four drugs or more. Overall 24 per cent of the population in Scotland are taking four or more different drugs, 60% of which are aged over 50. These people have an increased risk of side effects from their drugs, and the combination of drugs could have an adverse effect on their quality of life. Older people are most likely to attend Accident and Emergency (A&E), and are most likely to arrive by ambulance In terms of acute care only 22% of A&E attendances were for people aged over 65 years and 11% for those aged over 75, however, older people are more often admitted. In 2014/15, people aged over 65 accounted for 48% of Ayrshire and Arran acute inpatient activity, 46% of day cases, 58% of elective activity. For those aged over 75 years this was 30% of acute inpatient activity, 23% of day cases, 35% of elective activity. In 2013/14, 6.3% of over 64s in Ayrshire and Arran were admitted to hospital as opposed to the national average of 5.6%. However, a 25% increase was noted in geriatric admissions (Medicine for the Elderly) from 09/10 to 14/15, alarmingly this was more than twice the rate of the national figures. From 2010/11 the mean Length of Stay in Ayrshire and Arran for Medicine for the Elderly - fell by 7% to 18 days compared to a 25% national reduction to mean of 14 days. In addition, a 35% increase in Ayrshire and Arran Medicine for the Elderly throughput 04/05 - 13/14 is just half the national increase (72%). The 8% increase in throughput since 2010 is well below the national average increase of 34%. Medicine for the Elderly acute/rehab beds reduced by 6 beds since 2009/10. In 2015 there were approximately 4643 deaths in Ayrshire and Arran. Just under half of deaths in Ayrshire & Arran take place in hospital and between 4-5% in hospice. In a National Audit Office (NAO) study, at least 40 per cent of people who died in hospital did not have medical needs that required them to be treated in hospital, and nearly a quarter of them had been in hospital for over a month (National Audit Office 2008). In addition, an estimated 50 per cent of residents admitted to hospital who died could have been cared for in their care home with better proactive management (National Audit Office 2008). Advances in technology provide opportunities to support and care for people at home. A specific programme for Technology Enabled Care within Ayrshire and Arran will provide great opportunities for local people. These tools will help people stay healthier for longer and to self-manage their own conditions better and become more involved in decisions about their own care.

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Programme Governance Within Ayrshire the integration of health and social care and the formation of East, North and South Ayrshire Health and Social Care Partnerships in April 2015, have provided the opportunity to work with Acute colleagues to review a number of wider systems and structures within the NHS Ayrshire and Arran area. Each Partner is leading on a number of pan-Ayrshire projects. The Strategic Alliance maintains an oversight of this work, with the overall direction being co-ordinated through the Strategic Planning and Operational Group on a monthly basis. In addition, reporting has been undertaken through CMT and the Integrated Joint Boards, as appropriate who have all agreed the programme vision: Older people and those with complex care needs will be supported to proactively access and direct the high quality care and services they require to live a long, safe, active and healthy life at home or in a homely setting, drawing on support from informal networks and services available in their local community. The Review of Services for Older People and Those with Complex Care Needs sits with North Ayrshire Health and Social Care Partnership, led by Iona Colvin, Director North Ayrshire health and Social Care Partnership. This programme is directed by a Programme Board with involvement of partners in Acute Services, Primary Care, Health and Social Care Partnerships, service users and carers and the Third and Independent Sectors. The Programme Board agreed the programme would be developed to provide the three Ayrshire Partnerships and Acute the chance to develop a framework to ensure consistency of approach but would enable local application in order to reflect the needs and ambitions and management arrangements of the different partners accordingly. The programme has four key workstreams: 1. Future Models of Care – to review and co-design new models of care and support across

all care settings and stages 2. Data and Analysis – to review where services and support are provided, understand their

impact and help us project future needs 3. Workforce Planning – to review our teams and their skills and development, including

education and training 4. Financial Planning – to see how much money we have and how we can use resources

better

At this stage of the programme significant work has already been undertaken by the Data and Analysis Workstream to inform the background information. However the largest piece of work has been undertaken around the Future Models of Care Workstream in order to develop the overarching frameworks. In all, over a hundred individuals from the range of partners, worked across the five subgroups to develop the work so far. Future Models of Models of Care The future models of Care Sub-groups (figure 1) were divided across five key components of care:

Supporting people to stay at home or a homely environment (including care at Home, GP and community services),

Supporting older people with mental health issues

Supporting people to regain independent living through rehabilitation

Supporting people with hospital care, when appropriate

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Supporting people towards the end of their life In order to draw out key areas of work we have focused on components of care focused around the needs of older people and people with complex needs rather than service structures. This has enabled us to design a framework that can be further developed depending on the structures and needs of each partnership. However, of most importance when designing these structures is „walking the journey of care‟ from prevention right through to the end of life to ensure a person centred holistic approach.

Figure 1

It is worth noting that there are multiple interdependencies and transitions between these components as well as other pan-Ayrshire Programmes. In addition, there are a number of opportunities for innovation pan-Ayrshire developments to meet the specific needs of groups of individuals e.g. people with Alcohol Related Brain Disorder. Supporting people to stay at home (or a homely environment) Within Ayrshire and Arran we are keen to ensure that older people and people with complex needs should be able to enjoy long and healthy lives whilst living safely at home and connected to their community. As a first step we need to ensure a range of options to enable people to remain in their own homes as they get older. This could include:

Developing a range of housing options that support individuals through life transitions and working in partnership with housing and the third sector to ensure Housing Strategies reflects the needs of the local ageing population, with sufficient extra care, sheltered and age-friendly housing available. In addition, continue to develop activities offered within units and expand the provision of local hubs to reduce loneliness and social isolation

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To ensure older people and people with complex needs within Ayrshire and Arran are enabled to stay in their own homes for as long as possible we will work with partners in the third and independent sectors to secure a range of tailored services and targeted interventions aimed at supporting individuals to live full and active lives within their local communities

Further enhancing the use of Telecare and Telehealth to support individuals to maximise their independence to remain safely at home, support self-management of their own health and prevent hospital admissions. This will include preventative work with individuals with a diagnosis of dementia, reducing the impact of falls and providing more person centred intelligence around trends and usage.

Work in partnership to develop a Pan Ayrshire Equipment Service to ensure equity of services and increase efficiencies. There is already considerable evidence that equipment and adaptions can support older people and people with complex needs to remain in their own homes, promote recovery after a hospital stay, prevent hospital admissions and reduce the costs of long term care.

This should be supported by the development of fully Integrated Complex Care Teams with geographical relationships to GP clusters which include:

Multi-disciplinary approach including Social Workers, Community Nursing, Community Psychiatric Nurses and Allied Health Professionals in order to support individuals locally and prevent hospital admissions. This will require further development as part of the wider workforce redesign

Supporting individuals with prescribed multiple medications by ensuring clinical teams are fully aware of the interactions between drugs aging and disease, the older person‟s ability to adhere to medication regimes and the individual‟s personal goals for their health and treatment.

Regular medication reviews and poly pharmacy management as well as the role of more specialist advice and support from the new integrated community based team.

To develop a professionals Single Point of Contact within each partnership area to ensure seamless access to services.

Promotion of anticipatory and self-management approaches to maximise independence and prevent hospital admissions.

To develop the use of Community Connectors linked to GP Surgeries to undertake health promotion, early intervention and prevention and facilitate alternative community supports to individuals.

To continue to develop information and signposting systems to support and signpost the person and their carers to local support groups and networks.

To provide a range of flexible high-quality, person-centred care services that reflect the changing needs of older people and people with complex needs in Ayrshire and Arran which include:

The continued promotion of self-directed support to ensure social care provision for older people and people with complex needs will be more flexible, creative and focused on personal outcomes

Care at Home Services that offer a 24 hour flexible and responsive service to support timely discharge and prevent unscheduled care. In addition they will promote a step-up approach to support hospital at home and end of life care and offer short-term re-ablement interventions in a targeted and tailored way

To review the current model of day-care provision and provide a more flexible service across seven days and in the evening and provide a re-ablement approach with short-term interventions

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Ensuring Care Homes are active partners in localities and are engaged in planning of future specialised residential care to meet the needs of those with most complex conditions and those at the end of life. In doing so we will develop the skills competencies and confidence of care home staff through enhanced care home liaison teams, provision of specialist interventions and promoting initiatives such as My Home Life to develop and maintain Standards of Care.

Creating more seamless community based Dementia Services, such as the Dementia Support Services in North Ayrshire, dementia friendly communities with more flexible interventions to meet the needs of individuals and their carers

Providing a range of financial guidance, assessment and benefits advice to service users and carers to ensure they are in receipt of their full entitlement of benefits and maximise their income

In addition we need to ensure we provide on-going support and education for family and carers to undertake their caring role. This will include:

Promoting the uptake and accessibility of Carer‟s Assessments

Review and update of Carer‟s Strategies in order to meet the changes in legislation

Ensuring carers are established as partners in individuals care and provided with support and education.

Supporting Older People and Mental Health Issues Recognising that as the number of people experience of mental health problems in older age increases over time there is a need to ensure our specialist services are configured to work with wider health and social care professionals to adopt a holistic approach to the assessment of individual need and the delivery of care and support to meet that. To do this we will:

enhance the Elderly Liaison service to provide for a seven days a week service as part of fully integrated teams supporting the Combined Assessment Units and Emergency Departments in supporting early effective screening and in-reach into University Hospital Ayr and University Hospital Crosshouse (UHC/UHA).

further enhance the Care Home Liaison service to increase availability and physical health care competencies of Care Home Liaison nurses to allow individuals to be better supported in the care home setting, moving towards the development of Advanced Nurse Practitioner competencies.

work with fully Integrated Complex Care Teams with geographical relationships to GP clusters, to provide a seamless service for the individual/carer, that avoids duplication of effort and bridges general medicine and old age psychiatry removing service barriers and enabling services to wrap around individuals.

Supporting people to regain independent living through rehabilitation Intermediate Care & Rehabilitation (IC&R) Services will be Community Based, co-located and accessed by a Single Point of Contact, enabling people to remain as well and as independent as possible at home/homely setting. This will include:

Providing a safe alternative to Acute Hospital Admission, further developing ICES, Hospital @ Home and in reach to Combined Assessment Units.

Designing the service to allow people to return home as early as possible if they do require Acute Hospital Admission

Services will be developed with the person who has experienced and acute episode including those who have had a stroke, returning home becomes the norm. For those unable to do so,

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Intermediate Care/Rehabilitation will be provided as an inpatient before returning home or to a homely setting Working in partnership with a range of providers and services are required, this will include:

the Independent Sector moving to more Specialist Services targeting Dementia, Step Up, Rehab and Palliative Care.

third Sector will be intrinsically part of IC&R Service‟s reconnecting people to communities pulling from locality clusters and inpatient areas.

Scottish Ambulance Services working closely with the SPOC to assess, treat and refer to IC&RS rather than convey to Acute Hospital.

Telehealth/Self-Management/Anticipatory Care being delivered as the norm.

To support this it is suggested that the each of the Health & Social Care Partnerships establish a Working Group to implement Proposals and ensure implementation of the recommendations from the Stroke MCN. In addition, an Ayrshire Wide Sub-Group to be set up to develop the Neuro/Under 65 Complex Care Model. Supporting people with hospital care, when appropriate It is recognised that the creation of the Combined Assessment Units offers an excellent opportunity to modernise and integrate how we collectively assess the needs of local people using the ethos of „assess to admit‟ rather than „admit to assess‟. To maximise the benefits from these units we will:

provide triage and rapid Multi-Disciplinary Team (MDT) assessment of frail / complex patients supported by senior MfE / MH liaison staff M-Fri 8am-8pm; Sat/Sun am, with a view to both CAUs being staffed by a full MDT seven days per week.

ensure staff in-reach to the CAU from the newly formed integrated community teams to help form the MDT support assessment and discharge planning.

fully integrate Information systems to ensure all of the relevant information is available to and accessed by all staff members involved in the assessment and care planning of individuals from their point of presentation to acute care.

The success of CAU will be dependent on rapid and timely supported discharge to a home, a homely setting or an appropriate in-patient bed either within an acute setting or within a rehab facility. To ensure these transitions are seamless we need to improve discharge planning across all care settings as follows:

create a Single Point of Contact in each Partnership area to ensure rapid access to those services required to support discharge home from the CAU, ensuring timely access to equipment, aids and adaptations based on need.

the MDT at each acute site, as a norm, ensures patients return home or are directed to an appropriate downstream bed to ensure a more appropriate balance of acute elderly assessment and community based beds. (not sure this is clear)

There will be a focus on a risk assessment for return home with all individuals with complex needs being case managed by the cross-sector discharge hub team and those requiring assessment for long-term care receiving this at home or in a downstream bed.

The Third sector will play an active role in supporting discharge planning by offering services aimed at easing the transition back to home life and reducing social isolation, with health and social care staff offering signposting to these services.

Supporting people towards the end of their life

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Our vision is that by 2021 everyone in Ayrshire and Arran who needs palliative care will have access to it. In order to do this we need to:

improve and increase the identification of people who would benefit from palliative care in order to discuss and plan for their care;

improve Anticipatory Care Planning, with regular reviews, to help people plan for expected and unexpected changes in their future needs;

equip health and social care professionals to discuss with people and their carers their unique wishes, preferences and goals;

enhance our approaches to support individuals and their families address legal and practical issues, such as under what circumstances their treatment should stop and should include discussion about Power of Attorney.

At the same time, we recognise that, towards the end of life, there is evidence that early involvement in end-of-life care planning can increase the likelihood of someone being able to die at home should they wish to do so. To support this we will:

develop a range of high quality end of life services including adequate provision of specialist palliative care services;

HSCPs will develop a small number of dedicated, specialist end of life care beds in each area to offer short-term respite and crisis intervention to individuals who have expressed a wish to die at home, as well as specialist support to those who have indicated they do not wish to die at home;

ensure adequate palliative care support across primary care, care at home, allied health professionals and specialist nursing services to enable people to die at home or a homely setting;

develop skills, competencies and confidence of staff within Care Homes;

encourage the use of highly trained volunteers, where appropriate, whilst recognising the importance of families and communities in supporting people and their carers end of life needs

To underpin all of this we will:

ensure there is a robust Anticipatory Care Plan in place for everyone who needs one, with staff supported in their development through training and awareness sessions to encourage greater use and completion of ACPs;

improve communication between primary and secondary care and with the independent and voluntary sector to avoid unnecessary admissions and manage discharge from hospital effectively;

enhance coordination, care management and communication for people, their families and carers who require palliative or end of life care; and

review how electronic systems will ensure that care planning conversations are effectively recorded and appropriately shared, with access for all staff and emergency services to the Key Information Summary to ensure all requirements for palliative and end of life care are delivered, where possible.

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Overarching Model of Care A high level depiction of the new model or care is set out below.

Figure 2 In addition, a high level plan of the actions to be achieved from years one to three can be found in appendix one. Engagement The development of these outline components of care have involved over 100 stakeholders from a range of partners across Ayrshire and Arran to help provide a framework on which to build the partnership business cases. However, in order to create a shared understanding and test our thinking to date, we have undertaken a number of engagement events both on a pan-Ayrshire basis and as individual partnerships and have been pleased to note overriding support for the models to date. After review and feedback by SPOG, this framework will be tested at the pan-Ayrshire wide stakeholder‟s event on the 8 June 2016, and Programme Board, before moving on to the business case development. Next Steps To develop three Partnership business cases that will build into an overarching Pan-Ayrshire Business Case for delivering the preferred way forward that were identified in the sub-group development period and evaluate all options in terms of their benefits, costs and risks. These business cases will then be compiled into an overarching consolidated pan-Ayrshire business case, to be presented to SPOG at the end of August 2016. Proposals

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It is proposed the Strategic Planning Operations Group supports the development of a Pan-Ayrshire Business Case.

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Appendix one

Strategic Service Change Programmes – Assessment of Anticipated Benefits

Programme Title: Review of Services for Older People and those with Complex Care Needs

Pan Ayrshire Context

East Ayrshire

Specific statistics

North Ayrshire

Specific statistics

South Ayrshire

Specific statistics

Pan-Ayrshire Population Projections

NHS Ayrshire and Arran 2015 2020 2025 2030 2035 % Change

Population 372,035 370,855 369,047 365,643 360,188 -3.18

Emergency Admissions 50,460 52,742 55,192 57,482 59,346 17.61

Emergency Bed Days 321,437 354,301 392,130 430,998 466,819 45.23

70+ Population 54,629 63,494 70,035 77,039 84,747 55.13

70+ Emergency Admissions 18,921 22,107 25,229 28,543 31,951 68.86

70+ Emergency Bed Days 205,941 241,445 280,008 321,829 364,692 77.09

Average Occupied Beds 880 970 1,074 1,180 1,278 Extra beds required 90 194 300 398

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Current State

Future State Year 1

Expected position demonstrating change from

current

Future State Year 2

Expected position demonstrating change from

year 1

Future State Year 3

Expected position demonstrating change from

year 2

Description of: Supporting People to stay at home

The infrastructure and co-ordination of community based services is not sufficiently well developed to provide sustainable, viable alternatives to acute hospital.

Detailed plans will be developed for infrastructure development while testing new ways of working and delivering services within individuals‟ homes and community facilities.

A programme of procurement and infrastructure development will commence while sharing learning from the testing of new ways of working and delivering services across Ayrshire and Arran.

As the new infrastructure is delivered new models of community service delivery will become embedded in all three Partnerships.

Description of: Supporting Older People who experience Mental Health Problems

While Woodland View and EACH offer modern, fit for purpose accommodation for specialist inpatient services, much of the remaining estate remains outmoded. At the same time, there is room for improvement in terms of co-ordinating care across the health and social care community-based teams and in providing support to the acute hospital, particularly in relation to CAU.

Develop service and workforce plans that will blend the skills and experience of the health and social care teams to best effect while working with the Crosshouse CAU Team to test new ways of working.

Test new community-based models of care that remove duplication and gaps while embedding integrated working with CAU at Ayr and Crosshouse.

Embed new community-based models of care while reconfiguring the Community Hospital estate to offer fit for purpose accommodation for specialist in-patient care.

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Description of: Supporting People with Hospital Care when appropriate

Joint working within the CAU at Crosshouse is at an early stage, with limited information sharing and use of ACPs to assess and plan care. Further, there are issues in accessing the support required to secure early discharge in terms of service provision and access to equipment.

Within Crosshouse CAU provide triage and rapid Multi-Disciplinary Team (MDT) assessment of frail / complex patients supported by senior MfE / MH liaison staff M-Fri 8am-8pm; Sat/Sun am who can co-ordinate community based services to support discharge and encourage the use of ACPs in care planning.

Embed this joint working within Ayr and Crosshouse CAUs, with use of ACPs becoming the norm and seamless transition back to community services.

Both CAUs staffed by a full MDT seven days per week.

Description of: Supporting people to regain independent living through rehabilitation

There is a lack of knowledge and understanding of the current community-based services available to support individuals home safely, with a traditional approach to rehabilitation being delivered within an in-patient setting.

Establish professional Single Point of Contact in North Ayrshire, with mutli-disciplinary triaging and allocation of cases to frontline teams, ensuring service users are supported to the right service based on their needs first time and reducing the workload of hospital teams.

Share learning from the North Ayrshire experience with colleagues in South and East with a view to replicating in other areas. At the same time, redesign Day Hospitals and Community Rehabilitation Services to create the capacity required to support home-based rehabilitation and Community Based outpatient Rehabilitation required to respond to frailty, falls and other specific pathways.

Share learning across all Partnership areas and continue to re-design the community services to reduce avoidable emergency admissions and reconfigure in-patient Rehabilitation beds to reflect services being developed with the person who has experienced an. acute episode including those who have had a stroke, returning home as the norm

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Description of: Supporting people towards the end of their life

There are deficiencies in the community-based support available which can result in individuals being admitted to acute care unnecessarily and against their stated wishes, with poor use of ACPs and information sharing to support this.

ensure adequate palliative care support across primary care, care at home, allied health professionals and specialist nursing services to enable people to die at home or a homely setting, with ACPs being promoted to support this care.

develop a range of high quality end of life services including adequate provision of specialist palliative care services with information sharing between those involved in the individual‟s care

HSCPs will develop a small number of dedicated, specialist end of life care beds in each area to offer short-term respite and crisis intervention to individuals who have expressed a wish to die at home, as well as specialist support to those who have indicated they do not wish to die at home

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Social and Community Care Workforce

In relation to the social and community care workforce the Committee is interested in the recruitment of suitable staff including commissioning from private providers and the quality of care provided.

1. As an Integrated Joint Board what are your responsibilities to ensure there are adequate levels of social and community care staff working with older people?

The Integrated Joint Board is responsible for the commissioning of services from the two statutory partners; The NHS and South Ayrshire Council. The Chief Officer working to the direction of the IJB and as Director of Health and Social Care accountable to the Chief Executives of the NHS and Council is responsible for the recruitment and retention of staff to delivery statutory services.

2. Are there adequate levels of these social and community care staff in your area to ensure the Scottish Government’s vision of a shift from hospital based care to community based care for older people is achieved? If not, please indicate in what areas a shortage exists.

Recruitment and retention of staff can at times be problematic both for statutory agencies and our third and independent partners. At present the filling of vacancies for front-line care at home staff has been difficult for independent providers. Clearly, if there is insufficient provision of care at home services then there remains a significant risk that the objectives associated with supporting people to remain at home will not be realised.

3. Other than social and community care workforce levels, are there other barriers to moving to a more community based care?

The impact of the need to manage increased demand for services with reduced resources is the single most significant factor in limiting a shift to community-based provision.

Growing sufficient capacity within our local communities by way of community based assets to jointly deliver community based support is a challenge that we have identified and is one that we are addressing through the use of ICF funding to support our locality planning initiative. This has successfully engaged local communities and professionals in identifying local needs and priorities and in considering how best support may be provided. This has entailed work on local

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signposting, has involved the local library service and has been considering how we might best make information easily available locally for people on the organisations, activities and support that is available in their communities.

4. What are the main barriers to recruitment and retention of social and community care staff working with older people in your area?

Pay and remuneration more generally (inc. sleepovers and travel) has to date been one of the most pressing issues in terms of barriers which should, in part, be addressed through the introduction of the living wage in October. People locally have been able to find better paid work in other sectors and work also which does not necessarily involve a requirement to study for an SVQ level qualification. Once recruited we have training and learning programmes in place to support and sustain employees in their roles. Aspects of the training are provided on a cross sectorial basis.

5. What mechanisms (in the commissioning process) are in place to ensure that plans for the living wage and career development for social care staff, are being progressed to ensure parity for those employed across local authority, independent and voluntary sectors?

The Council has established providers forums for its commissioned services which provide opportunities for Partnership and provider staff to meet and discuss matters of mutual concern, including service development and improvement. In 2016 this has included the introduction of the living wage. The Partnership made a proposal through these mechanisms in June of this year in terms of increases to hourly rates and in all appropriate contracts to assist providers to pay the living wage to social care staff. In the intervening period meetings have been taking place with provider organisations individually to discuss the proposal and understand more fully what it might mean for them by way of opportunities and challenges. The Partnership intends to meet again with providers in early September to finalise discussions with a view to having new contract rates in place for 1st October.

6. What proportion of the care for older people is provided by externally contracted social and community care staff?

In terms of hours of care provided the current ratio is 3:1 with three quarters approximately being provided by external providers to one quarter by in-house staff.

7. How are contracts monitored by you to ensure quality of care and compliance with other terms including remuneration?

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Following the creation of the Partnership current arrangements are under review although the contractual responsibility for the management of social care contracts sits with South Ayrshire Council. Our policy is for contract visits to providers to take place at least twice yearly and these are conducted jointly by staff from our Contracts and Commissioning Team and operational personnel. A range of quality and financial issues are discussed and recorded at these meetings. It is also our policy to obtain annual income and expenditure statements from providers. Care Inspectorate reports are discussed at inspection visits. We are currently reviewing a number of our service areas including Learning Disability and Mental Health. These reviews will result in new commissioning plans being produced which will include outcome based monitoring frameworks. Future contract monitoring will include whether providers are paying the living wage to social care staff.