Agenda item

Report attached to be presented by Jean Kielty

The Board received an update report on national conditions within the BCF which haven’t yet been fully met and which set out the reasons why this was the case and the planned steps towards progressing these areas of work.

National Condition 4 (ii) – Are you pursuing Open APIs (ie systems that speak to each other)

The long term next steps are in the further development of the Great North Care Record.  This is being developed at a regional level with significant input from health and social care organisations from Newcastle and Gateshead.  It is anticipated that we will soon be able to make use of open APIs from Primary Care clinical systems as part of the national GP Connect Programme.  Health and Social Care Network connectivity is being explored and an initial fact finding meeting has taken place, led by the Council’s ICT services.  This is as a result of the proposed co-location of the 0-19 public health nursing service and the Council’s children’s services.

National Condition 4 (iv) – Have you ensured that people have clarity about how data about them is uses, who may have access and how they can exercise their legal rights.

This is an ongoing piece of work which will need to be a regular feature of communications to the people of Newcastle Gateshead.  We are currently seeking case studies to help us explain messages about data and technology in way which are relevant to our populations and professionals.

The next step is to develop a clearer plan in relation to communications which will happen at a local level to complement communications from the regional Great North Care Record level.

National Condition 6 – Agreement on the consequential impact of the changes on the providers that are predicted to be substantially affected by the plans.

As a Care Home Vanguard Programme, we are currently identifying what developments will be completed and what will be progressed further at the end of the Vanguard period.  In particular, we are focusing on taking the learning from providing enhanced care to older people living with family in care homes to their own homes.  This already involves much of our BCF initiatives and will continue to be improved upon wherever necessary.

National Condition 7 – Agreement to invest in NHS commissioned out-of-hospital services.

As with the frailty developments identified, this will involve many of our BCF initiatve and will continue to be improved upon whenever necessary.  This includes a whole system integrated approach that ensures the voluntary care sector is also appropriately involved.

The quarter 4 BCF return either reported ‘no improvement in performance’ or ‘on track for improved performance, but not to meet full target for the following metrics:

Estimated diagnosis rate for people with dementia

It is understood, however, from a clinical audit completed as part of the Care Home Vanguard Programme that around 7% of care home residents are likely to have dementia but are not yet formally diagnosed.  As a result of bespoke diagnosis pathway has been developed in order to address this.

Delayed Transfer of Care (DTOC)

Work has been undertaken between the Council and the Trust to ensure that there is a coordinated and agreed approach to DTOC (as analysis identified that there had been some changes to recording, which had not been agreed across the system).

The CCG, LA and Trust worked together during the winter period to develop a different approach to facilitating home care packages from hospital.  This was piloted as the “bridging service”, and is in the process of being evaluated.  The high level feedback, however, was positive and we are looking to develop a longer term model, through the improved Better Care Fund.

Patient/Service User Experience metric

In 2017, NG CCG in partnership with their key stakeholders have developed a Long Term Condition Strategy which seeks to improve care delivery and self-management of LTCs right across disease progression from diagnosis to end of life, including a specific focus on frailty.

Reablement

Going forward, where there is a requirement to provide urgent support (eg to support discharge from hospital or end of life care) and only the reablement service can provide this, we will look to make sure that such referrals are not recorded as reablement, as they are not truly reflective of the service and therefore should not be counted as such.  From the analysis of those people who were admitted to reablement in order to prevent a hospital admission but subsequently deteriorated and were then admitted to hospital, we will ensure that the lessons learned from the analysis are developed into an action plan.  Within any changes, we need to balance our approach in order to prevent a situation occurring whereby the system becomes risk averse and does not accept referrals from those people with higher level needs.

The Board were advised that in September there will be the new re-iteration of the plan which the Board will have an opportunity to comment on.

RESOLVED - that the information contained within the report be noted.