APPENDIX A
CAMBRIDGESHIRE INTEGRATION TRANSFORMATION FUND VISION AND PRINCIPLES – FOR CONSULTATION
Issued by:
Cambridgeshire County Council
Cambridgeshire and Peterborough Clinical Commissioning Group
November 2013
Version 0.5
Contact
Simon Willson, Head of Performance Management and Quality Assurance,
CFA, Cambridgeshire County Council
xxxxx.xxxxxxx@xxxxxxxxxxxxxx.xxx.xx Tel: 01223 699162
VERSION CONTROL
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Tom Barden, CCC
13/11/13
First draft
0.2
Matthew Smith, CCG
15/11/13
Amendments and
addition of CCG
OP Programme
information
0.3
Geoff Hinkins, CCC
15/11/13
Editing, additional
strategy
information
0.4
Geoff Hinkins, CCC
20/11/13
Adding draft
consultation
questions, more
clearly highlighting
the vision
0.5
Simon Willson
25/11/13
Adding changes
following CFA MT,
CCC
1
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
1
Introduction
1.1
Nationally, the health and social care system in the UK is under
enormous pressure. Demand for services is increasing at a time when
funding is decreasing. This is most obvious in the case of emergency
admissions to hospital, which rose by 27 per cent in England in the
period 2000-01 to 2011-12.1 This increase has come about because
more people are attending A&E than before, and more of those people
are being admitted to hospital than before.
1.2
The National Audit Office believes that this increase in people attending
A&E is a symptom of health and social care services not working
effectively. Patients who could be using primary care, community care
or social services turn up in A&E because it is the most visible and
easily accessible place to turn to for help. The additional pressures this
places on A&E departments has a knock-on effect to other services,
leading to cancellation of planned operations, longer waiting times, and
increased costs. Simply increasing funding to expand capacity in the
system is not an option because the Department of Health expects the
NHS to make very large savings over the coming years.
1.3
The social care system is also under pressure nationally. It faces a
‘complex mix of changing demography, rising need and increased
public expectations,’2 and has been described by former Minister for
Care, Paul Burstow, as ‘unsustainable… leaving increasing numbers of
people struggling to cope.’ These issues are sharpened by the fact
that councils are having to make unprecedented savings from their
budgets due to reductions in funding from central Government.
1.4
In order to start to address these problems, the Government
announced in the June 2013 Spending Round the creation of the
Integration Transformation Fund (ITF), a change to the way that some
NHS budget is allocated with the explicit intention of integrating health
and social care systems at a local level. Local councils and health
services are expected to submit plans to Government explaining how
they will use this fund to improve local services.
1.5
The County Council and the Clinical Commissioning Group have set
out in this paper a shared vision and principles for the use of ITF. It is
intended to start a conversation between local people, service
providers and local authorities about our ambitions for the health and
social care system in Cambridgeshire to meet the challenges of an
ageing population, disparate local services and severely restricted
funding, and to explore how we might use the resources in ITF to
realise those ambitions.
1 See
Emergency admissions to hospital: managing the demand National Audit Office
October 2013.
2 Glasby, J
et. al ‘Turning the welfare state upside down? Developing a new adult social care
offer’ Health Services Management Centre, University of Birmingham 2013
2
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
2
About ITF
2.1
The Integration Transformation Fund (ITF) was announced in June
2013 as part of the Treasury Spending Round. The Spending Round
statement was as follows:
[The Government will] put £3.8 billion into a pooled budget for health and
social care services to work more closely together in local areas, in order to
deliver better services to older and disabled people, keeping them out of
hospital and avoiding long hospital stays; and £200 million for local
authorities from the NHS in 2014-15 to ensure change can start immediately
through investment in new systems and ways of working3
2.2
It is important to note that this is not ‘new’ investment from Government
but a re-allocation of money that is currently in health services’
budgets. It is estimated by NHS England that for the average CCG,
shifting money into the fund will effectively reduce spending that is
directly controlled by the CCG by 3%.
2.3
Policy on ITF is being set out jointly by NHS England and the LGA.
Policy information is available from
http://goo.gl/2MJsSq. At the time of
writing, the most recent update was 17 October 2013.
2.4
Government, NHS England and the LGA expect that this funding will be
used to significantly affect the pattern of local services, shifting
resource and demand away from acute services focused on treatment
and towards community based services, focused on prevention.
2.4
Some information has been released by Government about the NHS
budgets that will be affected by ITF. It will be funded from £1.9bn that
is already allocated to joint arrangements and £1.9bn from other NHS
allocations. The existing joint funding part is made up of:
£130m Carers’ Breaks funding
£300m CCG reablement funding
c£350m capital grant funding (including £220m Disabled Facilities
Grant)
£1.1bn existing transfer from health to social care (the existing
sustainability fund transfer)4
No information is available at the time of writing about which budgets
the Government envisages CCGs will divert to create the other half of
ITF.
3
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/209036/spendi
ng-round-2013-complete.pdf
4 For Cambridgeshire arrangements see item 3, Health and Wellbeing Board meeting 17 Oct
2013,
http://www.cambridgeshire.gov.uk/CMSWebsite/Apps/Committees/Meeting.aspx?meetingID=
636
3
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
2.5
Some of the money will be awarded based on performance in 2014/15
and 2015/16. Performance targets may be set in the following areas:
Delayed transfers of care
Emergency admissions
Effectiveness of reablement
Admissions to residential and nursing care
Patient and service user experience
2.6
No specific information is available at the time of writing about the
amount of funding the Government envisages Cambridgeshire and
Peterborough CCG will need to divert to ITF. The advice that the CCG
has received so far suggests that the TFI is set at 3% of the CCGs
base allocation. This means that Cambridgeshire could expect £25m to
transfer in 15/16.
3
The situation locally
3.1
Cambridgeshire is a county of around 620,000 people. It was the
fastest growing shire county in England in the period 2001-2011,
growing by 12%.5 It is set to continue to grow at about the same rate
over the next 10 years. Overall health and life expectancy are well
above national averages for Cambridgeshire as a whole, although
there are significant differences between our communities, which are
closely linked to socio-economic differences.
3.2
More information about the health of people in the county can be found
in the Health and Wellbeing Strategy, available at
http://www.cambridgeshire.gov.uk/council/partnerships/health-
wellbeing-board.htm and the Cambridgeshire JSNA, available at
http://www.cambridgeshirejsna.org.uk/.
3.3
People over 65 make up a significant proportion of the county’s
population. Furthermore, in common with similar areas around the
country, the number of people over 65 in the county has been
increasing more quickly than the overall rate of growth. Older people
are more at risk of needing to use health and social care services.
Work done as part of the JSNA showed that nearly half of resources
(45%) used in hospital care (which itself is the largest single area of
spend in Cambridgeshire on health services) are used helping people
over 65. Over two-fifths of the adult social care budget (43%) was
used supporting people over 65. Much of these resources are used to
support people who fall into the most elderly and frail age groups, over
80 or over 85. People who are over 80 make up the majority of users
of home care packages and residential or nursing care, and resources
used for unplanned hospital admissions were highest amongst the very
5
Census 2011: Cambridgeshire Snapshot Research and Performance, Cambridgeshire
County Council, 2012
http://www.cambridgeshire.gov.uk/NR/rdonlyres/80EA41E7-C981-
452E-8861-1D2F2A61783C/0/Cambridgeshire_snapshotV2.pdf
4
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
oldest age group (over 85). The high rate of growth in the number of
older people in Cambridgeshire is putting very heavy pressure on these
budgets.
3.4
At the same time, locally the County Council and the Clinical
Commissioning Group, in common with other publicly funded bodies
providing services in the county, are trying to make savings to their
budgets and cope with an anticipated increase in demand. The County
Council must make the following savings to its adult social care budget:
Cambridgeshire County Council Adult Social Care Budget 2013-186
Year
2013-14 2014-15 2015-16 2016-17 2017-18
Budget (£m)
195
188
187
187
190
Savings required (£m)
12
18
15
14
10
% of budget
6
9
8
7
5
3.5
There is therefore a twin pressure on the health and social care
system. Much of the resources that go into it are used to support older
people. The number of older people is rising much faster than the
number of people generally, generating rising levels of demand for
health and social care services. Regardless of the financial situation,
this would create difficulties for local services. However, the bodies
which commission and fund those services are receiving less money
from the Government and must reduce their spending.
3.6
There are numerous shortcomings in current service provision. There is
evidence of a lack of ‘joined up working’ between acute – community –
primary care and social care organisations. The way in which services
are organised is reactive to illness rather than proactive to prevent
crises and maintain independence. This results in known current
service issues – pressure on Emergency Departments, high occupancy
in hospital beds, delayed transfers of care, extended lengths of stay in
hospital, and pressure on limited resources in community and primary
care services. In addition, there are issues with information sharing,
financial incentives not being aligned to support effective care, and
short term contracts.
3.7
We are already seeing some of the effects of this situation. Generally,
Cambridgeshire is in a similar situation to its statistical neighbours. It is
difficult getting people out of hospital, too many of them are unable to
get the care they need at home. Emergency admissions have been
going up, with consequent impacts on planned operations. Admissions
to nursing care, the most expensive form of social care support, are
increasing. The effects on the system go beyond impacts on services
6 Source: Cambridgeshire County Council Business Plans
5
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
for older people only – cancellation of elective surgery could affect
anyone.
3.7
Without change in the system there is a significant risk that the current
trends in the performance of the system will continue and be
exacerbated by the pressure on spending. Waiting times for planned
operations and health services could rise; it may become more difficult
to find social care for people who need it (potentially increasing the
pressures on A&E and emergency health services); service quality
might fall as staff have to see more and more people in the day.
3.8
This description of the situation has not discussed many other services
that people rely upon that have an impact on their health and wellbeing,
such as housing, community safety, transport, leisure or education.
The economic situation, household income and employment are also
recognised to have a major impact on health and wellbeing, as noted
by the Health and Wellbeing Strategy. Taken together, all of these
factors have an effect on demand for health and social care services,
and of the effectiveness of those services in terms of the outcomes
people experience following support. For example, it is much harder to
recover from a hip operation if your house cannot be adapted so you
can live there without needing to go up and down stairs. We recognise
that it is crucial to get all of these elements working together in order to
prevent people needing the most intensive types of health and social
care service as much as possible.
4
Proposed vision and principles for ITF in Cambridgeshire
4.1
Reforming the system – our vision
Our long-term shared vision is to bring together all of the public
agencies that provide health and social care support, especially for
older people, to co-ordinate services such as health, social care and
housing, to maximise individuals’ access to information, advice and
support in their communities, helping them to live as independently as
possible in the most appropriate setting.7 We believe this
transformation will also require the input of a range of health and social
care providers as well the greater involvement of the community and
voluntary sectors.
4.2
The County Council and the CCG believe that ITF offers an important
opportunity to transform the system in Cambridgeshire to meet the
needs of a rapidly ageing population better, and by doing so, ease the
pressure on the system more generally, enabling it to provide better
services to the whole population of the county. In the current financial
7 Adapted from ‘Older People Community Budgeting: Principles and project ideas’ available
from notes of item 3 of Health and Wellbeing Board 17 October 2013, at
http://www.cambridgeshire.gov.uk/CMSWebsite/Apps/Committees/Meeting.aspx?meetingID=
636
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CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
climate, this is also likely to be a unique opportunity to re-think how
significant chunks of money are spent.
4.3
Fundamentally, we believe that ITF should be used for genuine
transformation of the health and social care system in Cambridgeshire,
not to plug a gap in the social care or health budgets brought about by
increasing demand and reducing budgets. This transformation is not
just about reducing admissions to hospital, but rather about changing
the whole system so that it is focused on supporting people wherever
possible with person-centered and professionally-led primary /
community / social care, with the goal of living as independently as
possible. This aligns with the principles set out by Government, NHS
England and LGA, is consistent with the priorities set out in
Cambridgeshire’s Health and Wellbeing Strategy 2012-17, and builds
upon the recent work of the Cambridgeshire Public Service Board on
Community Budgeting for Older People. It is also well-supported by
evidence that clinical and service integration delivers better outcomes
for people, particularly if groups of patients or service users are clearly
identified and services for them are joined up around their needs.8
4.4
Effects on services
We think it is important to be clear about what this will mean, especially
because this is not new investment in the system, but a re-organisation
of existing funding and services. There is likely to be an increase in the
support available for older and disabled people in primary / community
health and social care services, and by managing demand in this way,
a decrease in the need for support at acute level, with corresponding
changes in acute services. We will be working towards single health
and social care assessments that will require a much closer level of
integration between primary health (GPs), community health (e.g.
district nursing, physiotherapy) and social care (support to live
independently), so that these services can identify, support and
intervene much earlier to prevent a crisis occurring or someone feeling
they are unable to access the support they need. This will require a
different way of working from our service providers and will require us
to develop an infrastructure that will allow both the voluntary and
community sectors to play a greater role of supporting people more
effectively in their communities
If we are successful, funding for unplanned admissions to hospital,
particularly for people who are 80 and over, will be reduced because
people will not need to go to hospital in the same numbers as they do
at the moment, and lengths of stay will be shorter.
4.5
This is easy to say and hard to do. Recognising that the way that
change is done is as important as the change that is aimed at, the next
8 See ‘Clinical and service integration’ Curry, N and Ham, C; King’s Fund 2010; available from
http://www.kingsfund.org.uk/sites/files/kf/Clinical-and-service-integration-Natasha-Curry-
Chris-Ham-22-November-2010.pdf
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CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
four principles set out ‘rules’ we are proposing to govern what we do to
achieve this vision.
4.6
Measuring success
We will measure our success primarily by analysis of demand for acute
health services (such as emergency bed days) and formal social care
services (such as a paid agency carer supporting someone at home, or
someone moving into residential or nursing care home), using current
levels of demand as a baseline (and allowing for the impact of
demographic change so the ‘baseline’ keeps pace with population
change and growth). We will build on the Outcomes Framework which
has been developed to support the CCG Older People Programme and
procurement process. This has a major focus on patient and carer
experience, and triangulating data from several sources to measure
outcomes. The Outcomes Framework structure is shown in the
diagram below:
CCG Outcomes Framework: Domains
We will also use other measures that show us whether the system is
effective, such as delayed transfers of care, the effectiveness of short-
term recovery-focused services like reablement, and patient and user
experience of services. We will therefore seek to deliver services that
have a positive impact as measured by these measures.
4.7
Open, honest and evidence-based
It is recognised that the basis of the funding for ITF is money that is
already committed to health and social care services of many different
types. Some services will need to change to support the aim set out
above, others will need stability. Discussions should be open, honest
8
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
and evidence-based in order to make sure we use the money in the
best way.
4.8
Early intervention and supporting independence
The plans set out in the ITF should align with existing or developing
strategies, such as the CCG Older People’s Programme, the Older
People’s Strategy in development by the County Council, the
Cambridgeshire Health and Wellbeing Strategy 2012-17, and the work
on Community Budgeting for Older People. A key principle of all of
these strategies is that people experience the best outcomes when
they are able to live independently at home, and supporting them to do
so will be a theme throughout all proposals in the Integration Plan.
There will be other important themes also, including coherence and
integration of services, the importance of identifying vulnerability and
acting to prevent deterioration, ensuring professional judgement is
valued and free to be flexible, and that services are person-centred.
4.9
Support for everyone
It is recognised that health and social care services for older people
make up a major part of activity in health and social care generally; but
working age people with disabilities and people of all ages with mental
health issues also experience unnecessary hospital admissions and
institutional social care support. Proposals under ITF should not be
solely focused on supporting older people at the expense of others
such as those physical, sensory or learning disabilities or those with
mental health conditions.
5
Links to other local work
5.1
The CCG Older People programme
5.1.1 The CCG has been working closely with Cambridgeshire County
Council and other stakeholders on its Older People Programme, which
is very well aligned to the aims of the ITF. The vision and aims for the
CCG Older People Programme are:
1. For older people to be proactively supported to maintain their
health, well-being and independence for as long as possible,
receiving care in their home and local community wherever
possible;
2. For care to be provided in an integrated way with services
organised around the patient;
3. To ensure that services are designed and implemented locally,
building on best practice;
4. To provide the right contractual and financial incentives for good
care and outcomes
5. To work with patients and representative groups to design how we
commission services
5.1.2 The first part of the programme has focused on work to specify local
aims and outcomes for the future of services for older people. The
9
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
programme provides a clinical drive to organise care around the patient
by commissioning a joined up hospital and community service
specifically for older people, and using NHS funds in ways which
support staff to work better together. The CCG has embarked on a
major procurement for Integrated Older People Pathway and Adult
Community Services. The procurement is based on an outcome
specification, and is designed through a two stage competitive dialogue
process to select one or more Lead Providers which will take over
responsibility for community, acute and mental health services for older
people in summer 2014.
5.2
County Council Draft Older People’s Strategy
5.2.1 The County Council has developed a draft Older People’s Strategy,
which will be consulted on during Autumn and Winter 2013. The
County Council hopes to support older people to live independently, in
their own homes and communities for as long as possible. As with the
CCG’s older people programme, the strategy will emphasise how our
the Council can organise its services around the needs and wishes of
older people and make sure it works alongside carers, family, friends
and communities rather than operating in isolation; as well as
emphasising joint work across the health and social care system. The
draft strategy proposes the following outcomes:
1.
Older people remain living at home and in their own
communities for as long as possible into later life
2.
Older people are supported to retain or regain the skills and
confidence to look after themselves into older age
3.
Carers of older people are supported to cope with and sustain
their caring role
4.
The number of people requiring complex or intensive support
packages is minimised through successful early intervention
5.
Older people who need ongoing care and support feel in control
of their support plan and are able to choose the support which is
right for them
6.
Older people are supported to live with dignity throughout their
later lives
7.
Older people are protected from harm and isolation
5.2.2 Similar outcomes have been set for under 65 year olds with physical
and sensory disabilities as well as those with mental health conditions
that require the support of adult social care services. These clients
groups, along those with learning disabilities, are also included in the
scope of the ITF.
6
Government conditions
6.1
As well as the local strategic direction provided above, the Government
has imposed a number of conditions on the use of ITF, which will have
implications for what we include in our ITF action plan.
10
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
Plans must be jointly agreed by the County Council and the CCG and
signed off by the Health and Wellbeing Board. The development of
plans for ITF will take place in two phases – an initial phase, involving
stakeholders and the Health and Wellbeing Board, to develop this
vision and principles into an action plan that can be submitted to
Government, then a secondary phase, to be undertaken during 2014-
15 to develop the detail of implementation. Further consultation will be
undertaken surrounding each proposal.
Plans must protect social care services. Anybody’s support needs
currently met by social care will continue to be met under any new
arrangements for social care proposed under ITF. This does not mean
that services will remain the same – for example, a short-term intensive
recovery programme like reablement may mean that someone learns
how to live more independently. As a result their need for formal
support would be reduced, and their formal social care package might
be reduced appropriately. We may also wish to protect other services
– for example, equipment and adaptations available from the Disabled
Facilities Grant.
Plans must show how 7 day services will be introduced in health and
social care to support discharge from hospital and unnecessary
admissions to hospital. Success will mean that people will be able to
be discharged from hospital at the weekend, because the staff are
there to medically approve discharge, plan their discharge and link up
with a suitable provider if they need ongoing care. This will mean
service providers needing to change their staffing patterns to allow this,
which might mean changes in terms and conditions or working hours
for staff in hospitals, social services, housing or care providers.
Plans must show how better information sharing between the NHS and
the County Council will be introduced, including using people’s NHS
number as their primary identifier. 97% of social care records already
contain NHS numbers. People will be routinely asked for their consent
to share data between health and social care. More information will be
recorded about social care services in health systems, especially
SystmOne, the IT system used by the majority of GP practices locally,
and more information about health services will be available to social
workers. This will enable joint planning and support patients, service
users, clinicians and social care staff to make better decisions about
care and treatment based on a holistic consideration of individual
needs.
Plans must set out an approach to joint care assessment and planning
and show the proportion of the population who will receive such
support. Across Cambridgeshire, Local Commissioning Groups (made
up of groups of GP practices) are currently introducing multi-
disciplinary teams (MDTs) to provide better and more holistic support to
frail elderly or other vulnerable people. MDT assessments will become
11
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
the norm for people who fall into these categories. They bring together
social, medical and community care plans involving GPs, hospital
doctors, nurses, physiotherapy, social workers and voluntary or
community groups. If MDTs supported all social care service users,
they would be supporting around 9,000 people, around 1.5% of the
population. However, if they were also able to support everyone who is
80 or over for example, they would be supporting 30,000 people,
around 5% of the population, and the most important age group for the
intensive instutional services we are trying to reduce the need for.
Risk stratification will form a key component of the solutions being
worked on by bidders as part of the CCG procurement for Integrated
Older People Pathway and Adult Community Services. The illustration
below emphasises the need to ensure that proactive care approaches
extend beyond the most intensive service users at the top of the
pyramid, to cover those who are at moderate to high relative risk of
admission to hospital.
Plans must set out the impact of changes on the acute sector and show
they have been agreed. The intention is to reduce emergency bed
days which encompasses reducing unnecessary hospital admissions,
reducing length of stay, delay transfers of care and readmissions. The
CCG has undertaken detailed analysis and benchmarking to develop
trajectories for reduction in EBDs. These have been built into the
Outcomes Framework which forms the basis of the CCG procurement.
In the meantime, there are a range of projects in progress with acute
and community providers designed to reduce reliance on emergency
hospital care.
7
A proposed model
12
CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
7.1
In addressing the required areas below and local strategic priorities, it
is proposed that the model adopted in Cambridgeshire will have the
following characteristics:
7.1
A united approach to advice and information on community and
public sector services. This will include developing robust and
reliable sources of advice and support for older people before they
become frail or need to access the statutory system; and providing
universal information and advice about services from all partner
agencies, which should be quick to access, clear, friendly and
personalised;
7.2
Investment in community capacity to enable people to meet their
needs with support in their local community. This could include
extension of the community navigator system; and work to consider
people’s social capital alongside their other assets and support people
to be engaged in their families and communities. Further development
and investment in community capacity will prevent some people from
entering a crisis, potentially reducing long term care costs.
7.3
Coordinated and intelligence-led early identification and early
intervention. This might include professionals being proactive in
identifying need rather than waiting for it to be presented as a formal
referral; Ensuring that the workforce are able to feed back as much
intelligence as possible as to the needs of the service users they are
supporting and how service delivery and deployment of available
resources can be improved; further improving information sharing
between the range of organisations in contact with older people about
individuals at risk of requiring more support in future; Social Workers
having greater identification with a community and working with other
agencies to identify those at risk and commissioning interventions,
preferably through the voluntary and community sector for needs that
might be below the thresholds for statutory assessment; and giving
professional freedom to deliver a flexible response to need to avoid
escalation of cost.
7.4
An improved approach to crisis management and recovery. This
might include a process for rapid escalation and action when a crisis
occurs in the life of an older person; this is likely to involve a
coordinated response from all agencies working in multi-disciplinary
teams to provide intensive support in the short term and encompassing
services such as respite care. Support should focus on ensuring that
when the crisis is over older people and their carers remain as
independent as possible and avoid short term crises triggering a
deterioration which leads to long term health or social care need.
8
What would this mean for people?
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CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
8.1
Patients and social care service users should expect their care plans
and support to be more joined up and sensible. Their GP would know
what support they get from social services, and they should expect
their social worker to know when they last went to the GP and what
they discussed. They should expect to be encouraged to go to
voluntary and community groups like lunch clubs, exercise classes, and
other positive social events, so that if there is a crisis they know people
they can rely on to help them through it. They should expect support to
be short-term, high quality, and appropriate to their situation; and help
them get back on their feet. When support ends, they should know that
it will be available for them again if they need it. They should know
who to contact if they think they might need help, and consequently
spend less time at A&E or in hospital.
8.2
GPs, community health workers, social workers, housing workers and
other professionals in the health and social care system should expect
to work more closely together with the express intention of supporting
the patient or service user to require as little support as possible to live
independently. This is likely to involve a single assessment process, a
joint care plan, and system-wide common ways of identifying risk and
measuring outcomes. They should trust each other to help the patient
or service user make good decisions about what support they need
next, and they should trust each others’ agencies to work co-
operatively and understand that getting things right for the patient or
service user is in everyone’s interests. They should have wide room
for professional judgement, and wherever possible make preventative
interventions to stop deterioration, even if that intervention is more
expensive in the short term. They should be able to access more
information about the patient or service user’s support from other
agencies, and they should make time for working together.
8.3
Hospital staff should expect to see fewer frail and elderly patients.
They should work closely with professionals who are based in
community services, whether that is medical, social, housing or
voluntary. They should have access to more information about
patients, including non-medical involvements by other services, and
they should use this information to help them make good decisions with
patients about the most appropriate care for them. Sometimes, this
might mean not treating people in hospital, but they should also expect
community based services to be easier to access and take on complex
cases.
9
Next steps
9.1
We have outlined a vision and a set of principles that we think are
important to how we will use ITF in Cambridgeshire. The King’s Fund
emphasises that it is important to find common cause with partners,
develop a shared narrative to explain why integrated care matters, and
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CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A
put together a persuasive vision to describe what integrated care will
achieve.9 We would like this paper to start this conversation.
9.2
We have not set out any specific projects in detail. The Public Health
Team in the County Council is currently doing a review of the evidence
of what works in integrated care, which is due to report at the end of
November. There are many other projects already up and running,
such as the introduction of multi-disciplinary teams in Local
Commissioning Groups, and existing integrated teams, upon which we
can build to achieve a more integrated system at a clinical and service
level.
9.3 This paper sets out a vision for use of the ITF, to bring together all of
the public agencies that provide health and social care support,
especially for older people, to co-ordinate services such as health,
social care and housing, to maximise individuals’ access to information,
advice and support in their communities, helping them to live as
independently as possible in the most appropriate setting.[1] We would
welcome your views on the following questions.
Q1 Do you agree with this vision as the overarching goal for our
ITF programme?
9.4 Section 4 sets out a number of principles for use of the ITF in
Cambridgeshire.
Q2 Do you agree that these principles will support us in achieving
the vision and making the most of the opportunity presented by
the ITF funding?
9.5 Section 7 sets out some features of a proposed model for use of the ITF.
Q3 Do you agree that using the ITF funding to support these
proposals is the right approach and will help achieve our vision?
9.6
Finally,
Q4. What other opportunities are there to join up the work of
agencies that provide health and social care and make our
arrangements more effective and efficient?
9 See
Making integrated care happen at scale and pace King’s Fund, 2013, available from
http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-integrated-care-
happen-kingsfund-mar13.pdf
[1] Adapted from ‘Older People Community Budgeting: Principles and project ideas’ available
from notes of item 3 of Health and Wellbeing Board 17 October 2013, at
http://www.cambridgeshire.gov.uk/CMSWebsite/Apps/Committees/Meeting.aspx?meetingID=
636
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CCG Governing Body – 3 December 2013
Agenda Item 3.3 – APPENDIX A