The director for adults and wellbeing introduced these reports under a new standing agenda item to consider integration. The reports presented today were prepared jointly by the council and the clinical commissioning group.

Better Care Fund

It was a requirement to report to NHS England on the performance of the better care fund at required intervals. Board meetings had been aligned to the submission dates given by NHS England but changes to data templates had not made it possible to seek formal board approval of submissions and meet the timescale for submission. It was recognised that this was not ideal and retrospective approval was sought.

A key issue identified as regards financial implications was that of agreed risk sharing.  The total spending pool on residential, nursing and health care was in the region of £20m and had overspent by £1.3m which meant that the risk share was bulk-funded by the council. There would be considerable input to the new better care fund to address this issue.    

Board members confirmed that in terms of performance of the fund, they would be guided on significant issues and support would be given to officers in decision-making. 

In terms of quality of care, the quality monitoring team was working with contracted services, although board members were reminded that 70% of care was self-funded.  A new quality framework was in process of implementation with a balanced score-card approach for each home to use. This would enable closer involvement to maintain quality.

It was noted that care was provided for the most vulnerable people who were not always able to speak up about the quality of their care and the intention was to work across adults’ and children’s care to see the whole picture. 

In answer to a question regarding a new integrated framework regarding contracts, the director for adults and wellbeing reported that  the focus was on working towards a single contract with all residential and nursing homes.  There was close working with the CCG which allowed for streamlining of systems and better engagement with the market. For individuals placed or reviewed since April 2015, there was confidence that they were in right place with the right care package at the right price. The focus was on individuals who had not had a review and were not already on standard rates, to ensure proper and full review and risk sharing. 

It was noted that although it was possible to place people at standard rates, sometimes placement was not as close to home as wished. Whilst there was some pressure, this was not due to capacity, although it was noted that domiciliary care was more difficult, particularly for people with complex needs in more rural areas where it was less easy to establish cost effective visiting routes. To address this, reprocurement was intended, with active public consultation. 

The director of children’s wellbeing explained that there were also children and young people with complex needs and although numbers were small, a new approach was introduced to support a reduction in reliance on residential care, whilst providing a range of therapeutic provision which was value for money.  The director referred to the Narey report on the quality of care in children’s residential services which was driving an increase in the quality of care and local provision would need to meet this.

One Herefordshire / sustainability and transformation plan

The director of transformation for One Herefordshire introduced an update on the sustainability and transformation plan (STP) and how One Herefordshire would be realised within it.  The report summarised the work so far and how it addressed the triple aims gap. 

The director explained that One Herefordshire was a key element as a delivery mechanism for the health and wellbeing strategy and the children and young people’s strategy. The STP was submitted in June and NHS England had advised that this would be an interim submission with the final plans submitted for approval in September. A draft plan could be shared after that point. The priorities were to maximise efficiency and effectiveness across clinical pathways, with high value contact, and to reduce inefficiencies in front and back office.

The CCG and the council shared a strong vision of prevention. The NHS definition of prevention was evolving to be more about communities and resilience, and encouraging new ways of working.  The development of hospital care was under focus and in terms of local footprint for secondary care provision, this was wider than Herefordshire and Worcestershire.  It was also noted that there would be changes to the model which would raise the profile for children and young people through the children and young people’s plan. There would be a more place-based approach and a recognition that the workforce went beyond direct employees and this resource needed to be maximised.  Healthwatch and voluntary and charity services (VCS) were on the programme board, and VCS were involved in some of the work streams.  It was noted that there was a desire to focus more on engagement, although this had to follow the nationally mandated process, and more information would be shared as soon as possible. 

Discussion took place around a requirement for greater understanding of the plan in order to understand the next steps and although it was difficult to give people more information on the STP until the plans were made public, it was possible to say more about One Herefordshire.

The director for adults and wellbeing observed that there was high level engagement with the STP within the NHS and indications were that the local footprint was coherent. It was important to identify the best use of the £1.4bn budget that would be available by 2020 by addressing the triple aims gaps and providing high quality services.  One Herefordshire would be the focus for local provision in Herefordshire and in ensuring that the county’s view is seen in order for people to be able to relate to provision locally.

The director of children’s wellbeing reported that there had been good dialogue between Herefordshire and Worcestershire regarding key priorities, which included 0-5 years, healthy child programme and integration of services. The aim was to improve how all agencies worked together for children with special educational needs, unaccompanied asylum seekers, risky behaviour and mental health. For the latter, this included supporting parents with their mental health care needs. The chairman added that the key was to address the health of children as this was fundamental to the future health and wellbeing of the population of the county. 

Further discussion took place regarding promotion of knowledge of One Herefordshire and making it clearly understandable for everyone.  A communications and engagement group on One Herefordshire and the STP took the view that whilst co-ordinated engagement and formal consultation was essential, until there was more detail arising from the strategic level, there was insufficient information to share that would encourage engagement.  The chairman of Healthwatch confirmed an offer to assist with this at the appropriate time, noting that there was a range of forthcoming possibilities that could help to raise awareness. The role of councillors in passing on key messages was also noted.

The board was reminded that plans were still at a high level and guidance on integration was not expected until September at the earliest.   Plans for health and social care integration by 2020 would be prepared for signing off by the end of the financial year, and any delays meant that the plan may not materialise in tandem with the council’s 2017-18 plans and the NHS 2-year plan. 

Responding to a question from the vice-chairman, the director for adults and wellbeing added that there would be no shared budget implications arising from this.

Board members commented that the STP had raised the significance of One Herefordshire and was helping to move it forward. The STP was welcomed as a route to a balanced budget. Work streams were evolving and it was important that the board had ownership of the STP as custodians. Contributions from the board regarding the STP were welcomed by NHS England. 

(b)         the financial outturn report, attached at appendix 2, be noted;

(c)         board meeting dates be aligned to submission dates;

(d)         on such occasions when board meetings do not coincide with submission dates, authority be delegated to the director for adults and wellbeing, following consultation with the accountable officer of the clinical commissioning group, to sign-off that submission and to bring it to the next available board meeting to enable the board to review performance and make recommendations for improvement;

(e)         that a report on the quality of services and market shaping for adults and children be presented at a future meeting of the health and wellbeing board; and

(f)          the update on the sustainability and transformation plan and One Herefordshire be noted.