Meeting documents

Purpose:

In February 2017, the Committee received a presentation on the Buckinghamshire, Oxfordshire and Berkshire West (BOBW) Sustainability and Transformation Plans.  Buckinghamshire is one of the first waves of Accountable Care Systems, now known as Integrated Care Systems. 

This item is an opportunity for the Committee to review the progress being made on the work of the BOBW STP, as well as reviewing the work which is being carried out locally as part of the Integrated Care System.

Attendees:

Lin Hazell, Cabinet Member for Health & Wellbeing

Ms L Patten, Accountable Officer, Bucks Clinical Commissioning Groups

Ms L Watson, Managing Director, Bucks Integrated Care System

Ms G Quinton, Executive Director, Communities, Health and Adult Social Care, Bucks County Council

Mr N Macdonald, Chief Executive, Bucks Healthcare Trust

Papers:

Power point presentation attached

Intended outcomes:

For Members to seek assurance that progress is being made in delivering the plans set-out in the BOBW STP as well as the progress of the Integrated Care System in delivering the local plans.

The Chairman welcomed Lin Hazell, Cabinet Member for Health and Wellbeing; Ms L Patten, Accountable Officer, Bucks Clinical Commissioning Groups (CCGs); Ms L Watson, Managing Director, Bucks Integrated Care System; Ms G Quinton, Executive Director, Communities, Health and Adult Social Care, Bucks County Council (BCC) and Mr N Macdonald, Chief Executive, BHT to provide an update on the Buckinghamshire, Oxfordshire and Berkshire West (BOBW) Sustainability and Transformation Plans (STP).

Ms Patten referred to the presentation in the agenda pack and made the following main points:

• Anything that made sense to do at scale in terms of commissioning would be undertaken at scale and the following facts and figures were provided as an example of how it was working:

v  Total population of 1.8 million

v  £2.5 billion place-based allocation

v  Three Clinical Commissioning Groups

v  Six Foundation Trust and NHS Trust providers

v  14 Local Authorities

• Ms Patten was now Interim Chief Executive Officer of Oxfordshire CCG as well as leading the Buckinghamshire CCGs.
• Fiona Wise was the STP Executive Lead from 5 March 18.
• The programmes led by the STP included cancer alliance, prevention, population health management, estates and workforce.
• Best practice was being shared in urgent and emergency care, mental health, primary care and maternity.

Ms Watson said she had been in post for 3 months to support the Buckinghamshire Integrated Care System and emphasised that she was not aligned to any particular organisation; her post was to support and challenge the system to ensure the best outcomes for the population of Buckinghamshire. 

Ms Watson then highlighted the following points with regard to the Buckinghamshire Integrated Care System:

• The vision and objectives of the Integrated Care System.
• The transformation journey so far.
• The work with BCC on the emerging care model to target services for those most at need and make the best use of resources.
• The significant amount of engagement with the public and stakeholders over the last year and highlighted that engagement would continue during 2018.

Ms Quinton mentioned the following points concerning the  integration and transformation of social care:

• Adult Social Care had recently launched its new strategy called The Better Lives Strategy and within this was the context of the transformation programme.

• The aims – to help people live independently; to help people regain control of their independence; help for people to live with support but as independently as possible.
• The Strategy was underpinned by a new social work approach model which focussed on what people could do rather than what they could not do.
• £161m was spent on adult social care; it was a very complex system supporting over 8,000 clients with a myriad of providers.
• There were approximately 10,000 new contacts into adult social care each year, of which 2281 resulted in an ongoing care package i.e. 22%, a ratio of 5:1; best practice was 22:1. 
• At the moment, 59% of people were helped to live independently but this should be much higher at approximately 80%.
• The average length of stay in residential care was approximately 2.6 years; best practice was 1.8 years.
• Different types of provision of care and support were needed to allow people to live independently.
• There would be better commissioning of services, reduced duplication, focus on evidence and prevention, early health and tele-health.
• There were three tiers – living independently, regaining independence, living with support.

In response to a question on whether the STP would be able to support the huge growing older population in Buckinghamshire and reduce the ratio of people needing a care package to 22:1, the following points were made:

• Ms L Patten said the majority of the care will happen locally in Buckinghamshire but it meant that, where possible, it made sense to commission at scale with linkage between Buckinghamshire and Oxfordshire.
• Ms Quinton said the ratio would involve building more community capacity and would need investment.  It could be achieved by redistributing resources already in the system e.g. if the average length of stay in residential care was reduced by six months there would be a net saving of £2 m. 
• The following demographic figures were provided:  33% of ASC clients were less than 65 years old, 54% were between 65-85, 13% were over 85.  It was acknowledged that the number of people aged over 85 would increase and that Adult Social Care needed to be prepared.
• Ms L Watson clarified that they were looking at what made sense in the whole of Buckinghamshire and said that the providers in Buckinghamshire had signed a provider collaborative agreement.  It would mean looking at developing integrated teams and involving social care professionals to integrate the resource into a multi-disciplinary team.  It would need to be planned very carefully with a realistic timescale.
• In response to a question regarding the difficulty in getting a primary care appointment; the pressure moving to a different place and taking people out of the GP service; Mr Macdonald said providers could not work in isolation and that there was a shortage of GPs and nurses.  GP surgeries could offer more services if district nurses, reablement services and other support services were provided which would prevent people from going to hospital.  Mr Macdonald added that BHT was one of eight pilot sites and was learning from best practice and co-designing collectively to provide more services via GP clusters than individually. 

The following points were made with regard to how the move would be made from "aspiration" to "delivery" and how the objectives would be measured.

• Ms Quinton provided the example that in December 2017 there was a significant waiting list for occupational services.  There was now a triage service which prioritised calls and adopted a process called "trusted assessor models" which meant the health professionals were trusted to make those decisions on Adult Social Care’s behalf for relatively low cost equipment that could transform people's lives resulting in people obtaining equipment much faster than they would have done otherwise.  There was no need for expensive assessments and as a consequence the waiting list, which was approximately 900 clients, was now down to about 90 and would be zero by May 2018.

A Member asked to see performance metrics to demonstrate direction of travel at a future  Committee meeting.

Action: Ms Quinton

In response to a query asking for clarification on the statistic of 22:1 receiving a care package and the strength based approach to social care, Ms Quinton made the following points:

• The strength based approach to social care was not new; it was part of the principles and values of social work practice but had not been adopted in Buckinghamshire before. 
• The new model involved healthcare professionals having a different type of conversation with people on how they could regain their independence rather than saving money. 
• The ratio was indicative of the dependency model created, which is not  what people want. 
• More telecare and digital assistance could be provided in people’s homes so they could stay at home for longer and by providing different types of environments such as supported living and extra care rather than residential care.
• Fewer people would get high end care packages, resulting in dependency and worse outcomes.  More people would receive other types of care, that focused on enabling independence.
• It was confirmed that there was eligibility criteria for care.
• BCC was sharing best practice with colleagues from other local authorities via the Association of Directors of Adult Social Care and Social Services (ADASS).
• Best practice nationally was confirmed as 22:1; regional data was not yet available but Ms Quinton agreed to provide the figures to the Committee.

Action:  Ms Quinton

• Part of the care model being developed was heavily reliant on local pharmacists in towns and villages to provide diagnoses of minor illnesses and ailments and the immunisation programme. 
• Ms Patten said the work of pharmacists in care homes was incredible and would provide more detail to the Committee at a later date.

Action:  Ms Patten

• In response to a query over whether Ms Patten had the capacity to cover both CCGs; Ms Patten said she had been covering the two roles since January 2018 and that the funds that would have funded the other Accountable Officer in Oxfordshire had gone into the team to help provide the backfill.  It was not to save money; the most important thing was her personal experience and it made it much easier to see what could be done across the two CCG areas as there were masses of similarities across Buckinghamshire and Oxfordshire and opportunities existed to reduce overlap.
• Ms Patten clarified that the whole of the Thames Valley area was looking at their diagnostic capacity in cancer so it could be mapped across the demographic growth in the next ten years. 
• The GPs were independently contracted to the NHS but were encouraged to work together in clusters across the County in order to expand opening hours and reduce costs and provide a comprehensive service for patients; however, this was still in development.
• Ms Quinton confirmed that the figure of 33% of under 65 year olds requiring adult social care was in line with the demographic profile of other areas.
• A green paper on the future funding of health and social care was expected to be published in the summer of 2018. 
• In response to a question on where public health education would play a part; Ms Watson explained the following: 

• A Committee Member asked when people would see a change as it was hard to understand in detail what progress had been made so far and the level of public and stakeholder engagement.  Ms Patten offered to respond to Ms Jervis’ points outside of the meeting and thought it best if Ms Wise attended the next meeting.

Action:  Ms Patten and Ms Wheaton

• Not all the provider contracts were managed by BCC and Ms Quinton confirmed that there was a large team of commissioners monitoring the contracts.
• Ms Watson clarified that she had set objectives for 2018 and that the first one was the creation of the delivery plan with measurable outcomes.  There would also be a gateway review process at the end of September 2018 which would look at the indicators set alongside the financial reporting elements.   Ms Watson would be looking at a shared system reporting mechanism and operating model for the ICS.
• Mr Macdonald reported that since December 2017 patients could access a GP at Stoke Mandeville hospital via a triage system.  On 3 April 2018 the MIIU service in High Wycombe was brought back in to the ICS under BHT so it would now be possible to link up 111, A & E, the out of hours service and the district nursing team to make it easier to navigate for people.  There would be more changes in the future and Ms Watson confirmed the situation would be monitored.

The Committee NOTED the progress made in delivering the plans set out in the BOBW STP as well as the progress of the ICS in delivering the local plans.