To approve the proposed content of the better care and integration plan 2017-19 for Herefordshire and to note the assurance and final sign off arrangements for national submission.

The director for adults and wellbeing introduced this item and reminded board members that the better care fund (BCF) plan was a developing situation.

The better care fund manager talked through the proposed plan as set out in the appendices and highlighted that the guidance for production of the plan for the two years 2017/18 and 2018/19 had not been received until July so it had been difficult to get papers prepared within timescale. During the presentation the following key points were made:

·           In terms of background context of the BCF, it was explained that the system was utilising existing money as single pooled budget with no additional funding available, and over the last two years closer working had led to the development of a unified contract with the care home market.

·           The plan was for the two years 2017/18 and 2018/19 and how to achieve integration between health and social care by 2020 whilst maintaining protection of adult social care (PASC).  It was not intended to include a risk sharing agreement at this time.

·           There were national requirements for approving the BCF plan within a timeline: Following submission to NHS England on 11 September, the proposed plan would undergo regional moderation. Those plans which were identified through moderation as requiring modification would be required to be resubmitted by 31 October. As a precaution, an additional meeting of the board could be scheduled in case it were necessary to reconsider the plan. A review of performance of metrics would be included in the November meeting.

·           The BCF plan was aligned to One Herefordshire and set out how it would be supported. There was a shared strategic vision between the Clinical Commissioning Group and the Council and a constructive relationship supported a shared direction and understanding of successful outcomes for the population of Herefordshire.

·           The four national conditions were: jointly agreed plans; maintenance of social care; investment on NHS commissioned out of hospital services; and management of transfers of care. Locally, this included key lines of enquiry reflected in the plan, such as how to utilise the disabled facilities grant (DFG), how the inflationary uplift would be used for transformational change, and agreed investment in hospital services with contribution from Wye Valley NHS Trust.  For managing transfers of care, there was a detailed plan involving providers, with a focus on some innovative projects.

·           National metrics included: reduction in non-elective admissions to hospital; reduction in permanent placements into residential and nursing homes; increasing access to reablement services; reducing delayed transfers of care.

·           Looking at these metrics in more detail, diagnostics were being carried out to better understand a recent unseasonal spike in non-elective admissions and ensuring people accessed the right care in the right place.  For reducing placements, from a number of schemes and initiatives, the focus was on the third recommendation, which was based on average admission rates over the past 3 years and accounting for local demographics, as a more reliable metric. To support reablement, a new model, known as ‘home first’ would be in place from November and brought in-house. As part of this, and the existing in-house rapid response would be expanded by 50% in order to support an increased county-wide service, working closely with WVT for therapeutic input. Figures for delayed transfers of care (DToC) were being revised for the plan, based on an expectation to reach a target of 7.2 days per 100k of population, or no more than 11 people in hospital at any one time who should not be there. It was emphasised that the figures in the BCF plan for DToC were evolving during the approach to the plan’s submission date and had been updated further since the report was published for this meeting, and it was intended to provide updated information in November following a review.

·           All of the schemes included within the plan had system-wide impact and contributed to admissions and DToC.

·           In terms of finance, contributions included protection of adult social care and elements of implementation of the care act, the disabled facilities grant and iBCF.  There was also a locally agreed pool for the care home market and the associated unified contract and how this was commissioned. In relation to inflationary uplift, this would be utilised for community redesign, informed by engagement.

·           A small number of key issues were identified, which had largely been resolved constructively with some support from an external critical friend provided through the BCF national team.

·           iBCF was subject to Section 31 grant conditions and required local agreement on its use, which was identified as for rapid response services and additional resources to work on transformational change. 

·           High level risks had been identified but these were mitigated through agreement and working together. 

Board members responded to the presentation with the following comments and observations:

·         With regard to DToC and whether demand growth was automatically accounted for, in the modelling, placements in residential care were running below expected and above expected in nursing care. The plan was focused on helping people to stay in their own homes but it was becoming more likely that people who were no longer able to remain at home would require nursing care due to frailty. A level of care was needed due to dementia but it was anticipated that in general someone could stay at home till end of life. The large majority of need was from people in the over 75s group.  DToC was a complex issue but essentially related to people in hospital beds who were best cared for in another way.  Research highlighted the adverse impact of staying in hospital longer than necessary on a person’s wellbeing as being, for someone aged over 85, equivalent to 10 years loss of capability for every additional 10 days in hospital.

·         The chairman commented that wellbeing needed to be put to the fore of everything and from the council’s point of view it was not acceptable for the national guidance be delayed and for there to be imposed conditional targets with the threat of funding being withdrawn if those targets were not met. This did not seem to be a rational approach when there was an expectation to achieve transformation, but it was testament to local effort that both the council and the CCG believed the plan would be deliverable.

·         There were significant reductions in the acceptable figures for DToC achievement, although for social care the target appeared achievable and there was a joint plan which had been in place within the system for some time overseen by the A&E delivery board and supported through the BCF manager’s work.  The health target was more challenging but it was also believed to be achievable, although it should be noted that there was impact from out of county admissions to A&E to be taken into account.

·         The plan represented improved outcomes supported by limited resources. The planning process was used to produce a plan intended to deliver real benefits for the county, to support efficient delivery and constructive and productive conversations with partners, and was to be commended for adoption.

·         It was important to recognise the needs of Herefordshire’s residents and to ensure that at the heart of this, the most vulnerable people get the best care and for the plan to be right. 

RESOLVED

That:

(a)       the proposed content of the Better Care Fund (BCF) plan and pooled budget for 2017-19 be approved; and

(b)       that officers of Herefordshire Council and of the Clinical Commissioning Group be authorised to finalise the BCF 2017/19 plan for submission to NHS England (NHSE) by 11 September 2017.