Agenda item

Anne Marie Lubanski, Strategic Director for Adult Care, Housing and Public Health gave the following powerpoint presentation, recapping the information provided previously and focusing on how the work would be taken forward.  This included how it would link in with the service redesign in Adult Social Care, which would see a 30% reduction in its workforce, maximising the front door, reablement and the preventative offer.

 

The pathways would be joint integrated working pathways with health rather than structural changes, although these could follow at a later stage.  This was a significant piece of work and a testimony to partnership working and the maturity of it in Rotherham, as health and social care were two very different systems, especially regarding contributions and charging.  The pathways were based on best practice, on the 12-week recovery model seen in mental health principles and two proof of concept initiatives would run with the reablement team to test things.  The trusted assessment role would also be looked at so that people would not have to wait to see someone else to get something they might need. 

 

From a commissioning perspective across the CCG and RMBC the view was that this would become a more cost-effective model, not immediately as some of it would be iterative going through the process.  In Year 2 it would be a question of looking at where things could be done differently and whether it was about efficiencies or reinvestment would be considered later on.  

 

Heading into winter was part of the challenge of how to double run and test things, at a time when it was also critical for the Trust not to impact on flows in and out of the hospital. 

 

Communication and engagement were key areas to get staff on board and to understand the cultural changes and potential professional changes necessary.  Work would also be needed with the GP Federation following the introduction of Primary Care Networks (PCNs).

 

Why Change?

·         People have told us

They would like to be at home wherever possible

They would like to regain their independence

Current services were disjointed and could be hard to navigate

·         Care Quality

Evidence shows people did better at home

We know that a large number of people received care in a community bed when they could have gone home with the right support

Rotherham had significantly more community beds than other similar areas

Current services were focussed on older people and their physical needs

Through changing the way we worked, more people were going home and our community beds were not fully utilised

 

Current Services

·         Community-based Services

Integrated Rapid Response (TRFT)

Community Locality Therapy – urgent (TRFT)

Independent and Active at Home Team (TRFT and RMBC)

Reablement (RMBC)

·         Bed-based Services

     Intermediate care at Davies Court and Lordy Hardy Court (RMBC    and TRFT)

     Oakwood Community Unit (TRFT)

     Waterside Grange (Independent Sector)

·         Services currently provided by a range of teams and bed-based sites

·         In addition, several teams of Social Workers and therapists working into the bed-based provision

·         People moved through multiple services rather than an integrated pathway

·         Significant duplication and some capacity issues in a number of services

 

Project Aim

                            Referrals

                                    ê

                          Co-ordination

                                    ê

Integrated Intermediate Care and Reablement Service

àPathway 1:  Integrated Urgent Response

àPathway 2: Integrated Home-based Rehab/Reablement

àPathway 3: Integrated Bed-based Rehab/Reablement

 

·         To simplify current provision to provide an integrated, multi-disciplinary approach to support individual needs across Health and Social Care

·         To re-align resource to increase support at home, reducing reliance on bed-based care

 

Future Services

·         3 core integrated pathways

·         Services aligned to work as a single team to provide the 3 pathways

·         Increase in community capacity to meet the demand to support people at home (urgent response or rehabilitation/reablement)

·         Reduction in community bed-base (phased and double-running for a period with increased community capacity)

·         Integrating processes for triage and co-ordination to ensure people get the right support

·         Reduction in duplication

 

Community-based Pathways	Bed-based Pathway
1. Urgent response (integrated team)	3.  Community bed-base – rehabilitation and reablement without nursing (integrated team)
2.  Home-based reablement and rehabilitation (integrated team)	3.  Community bed-base rehabilitation and reablement with nursing (integrated team)

 

Benefits

Patients and Carers	Commissioners (CCG and RMBC)	RMBC (Service delivery)	TRFT
Improved experience of services Telling story once Reduced duplication and hand-offs Improved outcomes More people able to be supported at home	Supports Rotherham Plan for ‘Home First’ and integration of Service delivery Reduces over reliance on bed base where Rotherham was an outlier More cost effective model	Supports delivery of the Council’s target operating model and future sustainability Improving flow through the Social Care system	Supports the Trust’s wider plans for bed configuration/estate moves Improving flow through the Hospital and Community Services

 

Taking the work forward

	Pathway Redesign & Implementation

 

                                                            àWorkforce: HR and OD

                                                            àIT, IG and Analytics – system inter-

                                                                operability and sharing information

                                                            àAccommodation

Off-site Community Unit Implementation

                                                            àCommunications and engagement

                                                            àFinance, contracting & commissioning

                                                               (including winter beds and flows)

 

Proposed Timeline/Phasing

Integrated Model

Home-based pathways 1&2                                   From 1 April 2020

Reduced intermediate Care Bed Base                From June 2020

 

Therapy Led Community Unit with Nursing

Phase 1 off-site - Open off-site Unit                     November 2019

Phase 2 on-site                                                        November 2020

 

Discussion ensued with the following issues raised and clarified:-

 

·         The staffing side was of interest because of the known recruitment difficulties in the Health Service and it would be helpful to see a profile as this evolved and if any patterns emerged on difficulties.

- It was agreed to come back and keep Members informed.

 

·         With the intention to reduce the number of points at which patients were triaged and having the three pathways, how would it work with GPs? Would there be a GP allocated to a pathway or would people still have their own GP, as not all GPs held the same view on things?

- People would have their own GPs. PCNs had only started in July 2019 and conversations would start to happen at the end of the year, including how they would work with Adult Care and the Trust as it was such an early stage. RMBC had six localities which would never match the PCN breakdown because a GP might have a practice in one part of the borough but a satellite in other localities as well.  The key was to ensure everybody understood the benefits of the pathway, including primary care.  Dr Muthoo, leader of the Federation, was a member of the group co-chaired by the Strategic Director and Chris Preston, The Rotherham Foundation Trust (TRFT) and was very engaged and supportive of this way forward.

 

·         Although the overall head count seemed ok, was there a possibility that when people were asked to move or to take on new skills and to adopt new ways of working that some might decide they wanted to work for someone else?

- There was always that risk but as seen with the Occupational Therapists (OTs) moving into the Single Point of Access, after initial resistance in the restructure. They could see the benefits of being in the same building and talking to one another.  This was effective partnership working and was always different at the front line with a lot of work to do there, but both TRFT and RMBC had taken it down multiple layers into both organisations and could see the advantages of joint working. 

 

·         Two information management systems were used in Liquid logic and SYSTM1, with people likely to have records in both databases and fields in both with effectively the same information. If the information was not in fact identical, was there a risk things could go awry? Were protocols in place to ensure that when people copied or cut and pasted information that it was identical?

- RMBC was contracted to have Liquid Logic for a number of years but much of the database was already shared across the Cloud.  People at the hospital could see SYSTM1 and the other systems used at the hospital and the Integrated Discharge Team could see Liquid Logic at a certain level.

 

This had been discussed within the steering group as part of the pathway work and the key was the same decision points to sit in both systems, consistent and agreed, to remove any confusion. Mental health had manual input as they used two systems, which was time consuming and there were other issues in addition, thus it was a case of being pragmatic.    

 

Information Governance was important in terms of people only seeing the information they wanted or needed to see but the main issue was correct sign offs and staff not being stuck by the system.

 

·         The worst possibility would be with some text that was supposed to be identical in both systems and in one system it included the word not and in the other it did not.

- In a project of this size it would be disingenuous to say all human error could be eliminated. People had different styles of writing and there was a need for coherence in how people recorded what they did, which was about professional judgement.  In RMBC, people talked all the time about positive recording and being aware of third party information and data access requests in the context of having to return and remember something six years after writing it.  The pathways would be very clear in terms of what should be recorded, for intermediate care and reablement and when. TRFT concurred that they too held similar conversations with their staff.

 

·         What would the future measures of success be in terms of introducing this particular extensive change, other than the financial ones already included? 

- A very easy one would be hospital admissions went down absolutely. 

- Another was not having the revolving door of some people in the community who fell back from where they were, had to go back into hospital and deteriorated each time, because it was quite traumatic every time someone had to go into hospital.

- The other measure of success was that Adult Care needed this to work, i.e. self-management for longer so people did not come in to long term care and support needs, including looking from a budgetary viewpoint, so that people were staying at home and maximising their independence. 

- Drawing parallels with mental capacity, where under the law people were assumed to have capacity, the assumption should be that someone would recover.  Intervention at the right time and in the right way was needed and would include digital and equipment so people would not need ongoing health and social care support, or if they did, at an absolute minimum.  The service would look to build confidence in terms of assistive technology as much of the direct support provided could be replaced by a technological offer.

- An old KPI in social care that would still be used was whether someone was still at home 91 days after a reablement intervention as an indicative measure that people were not going into hospital or elsewhere.  It allowed you to see where people were at that point in either system.  The best outcome would be a healthier resident population.

 

·         Were we at the vanguard of this particular approach or were there other areas where this had taken place?

- Different approaches had been taken, for example some areas had set up Care Trusts with all the staff together, going for structure rather than pathways. Visits to other areas such as Northumberland had been undertaken and people tended to default to thinking new structures were needed but Rotherham had chosen integrated working rather than integration.  We were not a trailblazer but in terms of the maturity of our approach many places would not have this.

 

·         Would the decrease in community beds impact on any of the providers in a serious way? 

- The context in Rotherham was too many residential care homes, coupled with the national shortage of nursing homes due to nursing recruitment challenges, plus too many care homes which created issues with regard to safeguarding.

 

In terms of the bed base in intermediate care, people sometimes ended up in a bed base rather than being helped to stay at home longer. People being helped to live at home was not new as it came in from 2000 as part of the direct payments statutes and social care had overly relied on bed-based activity for far too long. It might have an impact on how the market changed but was still too early to say how that would come through. The best quality providers were wanted for remaining placements and part of the Strategic Director’s statutory role was to market shape, building quality and making no aspersions in terms of any providers.  A tender process for the new care and support contract jointly with the CCG was under way because we wanted that to be the best it possibly could be and it sat alongside this piece of work. 

 

·         Services were encouraged to undertake market shaping in a proactive way rather than a reactive way when a problem arose. 

 

·         Clarification was sought on the monetary split between TRFT, RMBC and RCCG and whether any large transfers of money from one partner to another had taken place with the shift from a bed base to a community base? Where were savings accrued?

- For both RMBC and the Trust the offer was staffing, with no money moving across because it was integrated pathways, not structures, although changes to roles and what people did were being worked on.  As a system across health and social care, the Better Care Fund and winter pressures money would continue to be used, together with the additional monies from the Improved Better Care Fund, which had helped fund the parallel running that had been agreed.  No virement of funds took place other than in an agreed way to deliver the projects and that was part of the bridge to reach the next stage being implemented in October 2020.

 

·         Were staff flowing either way?

- RMBC have said to staff that if for example health or a GP practice had a building in Maltby and space it might make sense practically given the work was on a locality basis, but it would be a considered rather than a reactive view. Going back to trusted assessors, if an OT was going to see someone needing ongoing support an hour-a-week to do something, on that part of the pathway would be those decision points on what could be agreed and tolerances. Financially this had to work based around people coming into the system and the type of intervention because the money had to last for people who needed ongoing care and support.  In 12 to 18 months those discussions would happen but at that time the offer in terms of front line enablement officers had not reduced.  Based on the information around activity it could have done but we wanted to make sure this had the best opportunity to happen and with the right workforce.  OTs based in the Single Point of Access team were not RMBC employees but sat with us and worked with us, which was the whole principle.

 

·         Reassurance was sought that although short term money was used for some aspects this would not be reliant in the long term on short term money?

- Things were not reliant on the short term money; this was about building our workforce in a different way, in RMBC and the Trust.

 

·         No-one doubted that most people would rather be treated at home or to recover at home, but could you assure me given that there would be a reduction in beds that people would not be pushed out too early?  What checks would be put in place to make sure that people were ready to go home and would receive the care and support they needed?

- This was not only people coming out of hospital; it might be someone who had been bereaved or lost their partner and their skills were not where they should be.  Work was happening in the community.

 

Creation of the Integrated Discharge Team brought hospital and social work teams together in one room and was a positive case of partnership work between RMBC and TRFT.  A single referral funnelled through the team who would say whether a person needed an intermediate care bed, or if they needed a bit more time but were medically fit for discharge, if they could possibly go back home to reablement and another intermediate care offer.   The three  pathways included the hospital discharge pathway but that was not the only pathway, so people would come in and out at different times.  Everything was about making sure of people's safety with best outcomes at the heart of any changes made.

 

The Chief Nurse concurred that the two organisations had worked very closely to ensure that the Integrated Discharge Team worked really well for the hospital, for the community, for the patients and would not push people out there.  They were referred and had a full assessment before leaving hospital.  The team won a national award a few months ago at the HSJ Awards.

 

·         If this is done right the Trust would save money but where would the Council save money with pressure on Adult Care because people’s stay in hospital would be much shorter and the number of people supported in the community theoretically would grow?  Rotherham had an unhealthy and ageing population and there would be an age where people would be unable to be looked after at home, for example because their carer or partner had died. How in the longer term would we be able to reduce care home spaces because people would not be available to help us to be independent, whether due to age or disability?

- From a social care perspective it was known from analysis over the last three years that many people came into services because they were unaware of what was out there.  This was illustrated by the abandoned contacts in the single point of access, as only around 20% went through into the next stage, because many people phoned the Council to ask for something it was not within their role to do and similarly with health.  For triage under the new model the service wanted really good qualified social workers at the front door, along with the other call advisers, to be giving the right information or signposting people appropriately, with OTs as mentioned giving resolution at that point.  If a grab rail was not fitted quickly for someone at risk of falls they could fall, need hospital admission and go back in that loop.

 

In relation to making savings, everything done at the moment was about cost avoidance for the Local Authority at that end because by not taking that kind of preventative, interventionist approach the money started to increase against every individual. 

 

Project Alcove was a pilot with about 40 people testing Alexa and some of the case studies were amazing. Dementia was an issue, as was a growing SEN children’s issue that from an Adult Care point of view was being watched. If the number of people who did not really need ongoing care and support was not minimised, the money for those people that did would not be there.  Residential care would always be needed but the issues were how it would be done and how to become more innovative. Reablement was a means of providing what people needed at the right time, in the right way and was why the recovery model was the way forward. From research and experience, after six weeks intervention, aside from their health, people's confidence might not be there but as soon as they went into localities they were in and it was forever ever money. Building the six weeks recovery to give them the confidence to be as independent as possible formed part of the interventionist approach because if not the money in Adult Care would increase exponentially. 

 

·         There might be carers who were unwilling to be carers, and older women especially could have other caring responsibilities and thus pressures. Carer assessments were undertaken for people in long term provision, but had there been consideration of and support for the carers of people in short-term interventions?

- Under the Care Act carers had parity of esteem and regardless of whether the person they were caring for wanted an assessment or not, carers had the right and entitlement to an assessment.  As part of the Adult Care restructure and new adult care pathway two roles had been identified specifically for carers, one operational and another for a strategic lead, which had been a gap and the caring role needed to be looked at.  From the 2011 census many people identified themselves as significant carers but probably only a couple of thousand came through the social care doorway. Carers identified themselves in different ways and might not see themselves as a carer but rather as the patient’s partner.

 

Aim 3 in the Health and Wellbeing Strategy focused on looking at the broader term carers to ensure that when talking about signposting that people were comfortable with that.  Increased use of GPS watches would enable carers to use phones to check the GPS if the cared for person tended to roam.  It was a case of looking at things in different ways with the new role to really start thinking of the narrative on what was done around carers.

 

The Strategic Director stated that she would like to come back in 12 months’ time to update the Commission about work in this area, both across the system and in social care.

 

·         How confident were you in having sufficient resources and skills to support people from a mental health or learning disability perspective within this particular area?

- Traditionally talk about reablement defaulted to older people as there was a tendency not to think that people with learning disability or mental health needs required a reablement approach and to think of it as being about personal care.

 

Through reablement, staff were able to get people up and dressed but if they had nothing to do or lacked the confidence to go anywhere then reablement failed. From an RMBC perspective the resource inputted i.e. staff was for people aged 18+ from one global pot. Cultural change regarding reablement was needed in both organisations for staff to feel comfortable, as it linked to perceptions around risk. Reablement was not necessarily about a physical change; it could be about confidence. It was about staff feeling empowered to walk to the shops with someone without worrying about exceeding their time slot. The present model was very much one of seeing people in defined time slots but as part of the proof of concept the reablement workers in the pilot were told these are the people you will be working with and you determine what to do.  Time was not an issue as it was non-chargeable. The managers struggled but front-line workers were overwhelmingly positive because they were seeing and doing things they knew would make a difference for individuals, which might be outside the comfort zone of previous practice.

 

Two six week pilots, the first with some initial problems, had taken place in preparation for implementation from the end of October.  Already good outcomes were resulting from one team operating differently.  Such a cultural shift would take time to cross over into mental health and learning disability but this was the aspiration and would happen.

 

·         Members were pleased to hear the focus would be on providing care and support to achieve outcomes rather than completion of time sheets.

 

·         The importance of continuing professional development and supervision and also having reporting structures were issues that emerged from the evaluation of the health village pilot.  How confident were you that we have learned from that model?

- As Reablement was a Care Quality Commission (CQC) registered service the supporting structures needed to be robust and would be looked at. It was also a question of helping the CQC to understand what partners wanted to achieve.  There was learning for health from the health village pilot, in a different vein to that for Adult Care.

 

Anne Marie was thanked for her detailed presentation by the Chair and would be invited to provide a future progress update.

 

Resolved:-

1)    That the Health Select Commission note the information provided.