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NORTH AYRSHIRE 

Health and Social Care 
Partnership 



Integration Joint Board 
24 October 2019 

Subject: 

Enhanced Intermediate Care and Rehabilitation 
Services 

Purpose: 

This paper provides update to the Integration Joint board on the 
progress made in North Ayrshire, in Implementing the enhanced 
model for Intermediate Care and Rehabilitation. It seeks support for 
continued funding and development of the model, in support of 
North Ayrshire Health and Social Care Partnership’s strategic 
ambitions. 

Recommendation: 

The Integration Joint Board is asked to : 

* Note the progress made in implementing the enhanced model for 
Intermediate Care and Rehabilitation in North Ayrshire; 

* Note the financial implications of funding the service for the 
remainder of 2019-2020; and 

* Consider the funding required to sustain the model on a longer 
term basis as part of the budget planning for next year. 


Glossary of Terms 

NHS AA 

NHS Ayrshire and Arran 

HSCP 

Health and Social Care Partnership 

IJB 

Integration Joint Board 

ICT 

Intermediate Care Team 

SPOG 

Strategic Planning Operations Group 


1. 

EXECUTIVE SUMMARY 

1.1 

The Enhanced Intermediate Care and Rehabilitation Services went live on 19 
November 2018 following approval of a business case by NHS Ayrshire and Arran 
and the three Ayrshire IJBs. The impact of the service has been monitored regularly 
through the Strategic Planning Operations Group (SPOG) to ensure it delivers in line 
with the business case. The outputs of the Pan-Ayrshire Enhanced Intermediate 
Care and Rehabilitation model demonstrates the impact the service is making in 
terms of avoiding hospital admission, and providing a positive experience for the 
people of North Ayrshire. 

1.2 

The investment was not fully funded with part-year funding of £316k allocated during 
2018-19, the additional cost to continue investment for the full year during 2019-20 is 
£260k, this would require to be incorporated into the IJB financial position for this 
year. The funding required to sustain the model on a longer-term basis from 2020- 
21 will be included as part of the budget planning for next year. 


















2 . 


BACKGROUND 


2.1 PAN AYRSHIRE ENHANCED INTERMEDIATE CARE AND REHABILITATION 

2.1.1 A paper was brought to the Integration Joint Board (IJB) in North Ayrshire in 
September 2018, to provide an overview of the work being undertaken to meet the 
Pan -Ayrshire Enhanced model for intermediate care and rehabilitation as part of 
the New models of care for older people and people with complex care needs. 

2.1.2 The Pan-Ayrshire Enhanced Intermediate Care and Rehabilitation model was 
developed around Enhanced Intermediate Care and Rehabilitation Hubs which 
provide a single point of access, with screening and clinical triage, ensuring the 
person is seen by the right service, first time and includes 7 day working. The model 
supports people at different stages of their recovery journey and links up and builds 
on existing intermediate care and rehabilitation services reducing duplication and 
fragmentation of services across Ayrshire and Arran and offering better outcomes for 
people. 

2.1.3 The Enhanced Intermediate Care and Rehabilitation Services went live on 19 
November 2018 after approval of the business case by NHS Ayrshire and Arran and 
the three Ayrshire IJBs. This has been monitored regularly through the Strategic 
Planning Operations Group (SPOG) to ensure it delivers in line with the business 
case. 

2.1.4 The impacts described within the original business case reflected the cumulative 
impact of all aspects of the model working together to ensure the reduction in 
occupied bed days, drawing on sound local and national evidence. The business 
case proposed a 30% increase to 2335 referrals (1295 from Partnership plus 1040 
from ACE Practitioners) to Enhanced Intermediate Care and Rehabilitation, which 
would result in cost avoidance of £4,052,014 for a required investment of £2,516,175 
to employ an additional 51.4 WTE staff across Ayrshire and Arran. 

This equates to 24,860 Bed days avoided, which is the equivalent of the closure of 
28 beds in University Hospital Ayr and 39 beds in University Hospital Crosshouse. 

In order to avoid any double counting, only the Enhanced Intermediate Care Teams 
(EICT) referrals were used in the business case. 

2.2 FINANCE 

2.2.1 The business case was predicated on acute hospital savings offsetting the 
investment and during 2018-19 the investment was funded by the Health Board on a 
part-year basis. However, with the approach taken in the 2019-20 budget to pass 
through the funding uplift to the partnership there is an expectation that the IJBs will 
fund the full year impact of the investment. The 2019-20 approved IJB budget did 
not include provision to fund the full year impact of the service and it was noted as 
an unfunded pressure. The intention was to review the impact of the investment 
during 2019-20 to determine future funding alongside the work to progress the 
formal commissioning of acute services. 

2.2.2 Part year funding of £982,370 was provided by NHS Ayrshire and Arran in 2018-19 
to fund the model, this has now been incorporated into the overall financial allocation 
to the IJBs. If all posts identified through the business case are filled, this leaves a 
Pan Ayrshire shortfall of £1,533,805 to sustain the model. 




The North element of this is: 

• Full Year Budget £807,534 

• Part Year Funding £316,000 

• Recurring Shortfall (assuming all posts are appointed to) £491,534 
Note the projected shortfall in 2019-20 is only £260,000 due to vacant posts. 

2.2.3 The ongoing pan-Ayrshire work to progress Directions and the acute set aside has 
not progressed to the stage of having confidence that an approach to accessing 
acute resources to fund the investment will be possible in the short to medium term. 
The service has been established with a permanent staff group in place, the 
unfunded element of the cost of the service for 2019-20 is £260k. The IJB are asked 
to note that the continuation of the service will add an unfunded pressure of £260k to 
the overall projected outturn for the IJB. 

The funding required to sustain the model on a longer term basis from 2020-21 will 
be included as part of the budget planning for next year. This includes the ongoing 
Pan Ayrshire work on the set aside budget and directions. 

2.3 ENHANCED INTERMEDIATE CARE AND REHABILITATION IN NORTH 
AYRSHIRE HEALTH AND SOCIAL CARE PARTNERSHIP 

2.3.1 The investment of £807k in North Ayrshire was to provide an additional 16 WTE staff 
across a range of disciplines including: 

• Allied Health Professions 

• Pharmacy 

• Nursing 

• Business support 

• General Practitioner sessions 

All posts, with the exception of the GP sessions were recruited to as part of a wide 
ranging successful recruitment campaign. 

Further, the investment provided funding required to deliver service across 7 days 
per week. 

2.3.2 As described in the original business case, and earlier paper brought to the 
Integration Joint Board, investment into intermediate care and rehabilitation in North 
Ayrshire was across three main components: 

• Hub - To support right service, right time approach by increasing business 
support capacity, to allow effective referral management, and reduce the 
duplication experienced associated with multiple referrals 

• Enhanced intermediate care and rehabilitation - to increase the capacity 
within the team, to progress the skill mix of the team, and to allow appropriate 
level of workforce availability so as to provide service across seven days per 
week 

• Community rehabilitation - to increase capacity within the less urgent, more 
goal orientated community rehabilitation options, which protect enhanced 
intermediate care and rehabilitation for the fast response, admission 
avoidance work. 

3. IMPACT 

3.1 Referrals for the full range of intermediate care and rehabilitation options in North 




Ayrshire now all stream through the Intermediate Care and Rehabilitation hub taking 
around 1,000 referrals per month. 

3.2 Intermediate Care and Rehabilitation Service is now provided seven days per week, 
with a focus on activity which provides alternatives to acute hospital admission. 
Relationships with key referral stakeholders continue to develop, with regular 
referrals, to avoid admissions, received from: 

• Primary care 

• Ayrshire Unscheduled Care Service 

• Scottish Ambulance Service 

• Emergency department at University Hospital Crosshouse 


3.3 At any one time, the enhanced Intermediate Care Team (ICT) are supporting around 
130 individuals at home in North Ayrshire, as an alternative to acute hospital care. 

3.4 Referrals 

In order to ascertain if progress is being made against the outputs of the business 
case, the target for North Ayrshire investment of £807,534, for an extra 16 staff was 
for an additional 407 referrals, giving an annual target of 1672 referrals 

3.4.1 North Ayrshire Enhanced ICT saw a decrease of referrals to 1,207 in 2018-19 when 
compared to the previous year. This represents a 20% decrease on 2017-18 
referrals. However, the 2018-19 figure still represents an 8% increase on the 
baseline year used in the business case. For North the performance from the 12- 
month business case target is 1,762. Based on current performance the trajectory 
would be 1,609. This is a projected shortfall of 153. 

3.4.2 The reduction in referrals to the enhanced intermediate care team in North Ayrshire 
is likely due to the more mature triaging being undertaken in the North Ayrshire Hub 
ensuring right person to the right place, first time - with less urgent referrals now 
being streamed to community rehabilitation options, for example the Health and 
Therapy Team, or domiciliary physiotherapy teams. 

3.5 Hospital Bed Days Saved 

The business case attributed 10 bed days to an avoided admission, in addition, it 
attributed 3 days for supported discharge by EICT staff. 

3.6 Using the above metrics, for the 9-month period from 19 November 2018 to July 
2019 (254 days), the North Ayrshire Enhanced Intermediate Care and Rehabilitation 
Teams avoided the following bed days: 

• North - 7,116 

This equates to an additional 28 people, not requiring acute hospital care every day. 

3.7 Benefits for Service Users 

The independent evaluation of impacts for service users by the Scottish Health 
Council produced some helpful feedback as well as areas for further improvement. 
In order to give an indication of how well/able individuals were before and after 
receiving support from the services, to give a sense of distance travelled, the 
following scores out of ten were given. 

• North - 3.7 and 6.7. 




3.8 In addition, individuals were asked to score the overall services out of five, with the 
following results observed; 

• North - 4.9. 

Whilst individuals provided some key areas for improvement around the 
quality/speed of assessments and the resource available, feedback received was 
overwhelmingly complimentary and evidenced real benefits for individuals. 

4. PROPOSALS 

4.1 The Enhanced Intermediate Care and Rehabilitation model in North Ayrshire is 
demonstrating positive early outcomes, supporting a significant number of people to 
remain at home and independent, and providing a seven day alternative to hospital 
admission. 

4.2 As the model develops further, and the workforce matures, there will be opportunity 
to consider how the various components of intermediate care and rehabilitation in 
North Ayrshire - Intermediate Care team. Health and Therapy Team, Community 
rehabilitation Allied Health professional Services - align further with the developing 
model around locality based multi disciplinary teams. 

4.3 The current financial arrangements create an uncertainty around the future of the 
enhanced model, with a number of associated risks. 

It is proposed that funding is factored into the IJB financial position for 2019-20, and 
consideration be given around funding on a longer term basis from 2020-21 as part 
of the budget planning for next year. 

This will create a welcomed stability for the model which will in turn support ongoing 
development and strategic alignment with the other partnership priorities. 

4.4 Anticipated Outcomes 

The model ensured a reconfiguration of existing services to improve service user 
experience, increase the capacity of intermediate care and rehabilitation, and 
improve interface with acute care in Ayrshire. The model supports the strategic 
ambitions around promoting independence, self management, and supporting 
people to live at home or in a homely setting. 

4.5 Measuring Impact 

The impact of the enhanced intermediate care and rehabilitation model continues to 
be monitored as described, with regular updates provided to the Strategic Planning 
Operations Group (SPOG) and NHS Ayrshire and Arran Corporate Management 
Team. 


5. IMPLICATIONS 


Financial: 

Part of the funding (£982,370) has been provided by NHS Ayrshire 
and Arran on a Pan Ayrshire basis. 


This recurring shortfall for North is £491,534 for North Ayrshire on a 
full year basis. 




The 2019-20 impact is a shortfall of £260,000 as not all posts were 
appointed, and some have subsequently become vacant. 

Human Resources: 

The new Model required an additional 51.4WTE staff across 

Ayrshire, 16 in North Ayrshire, on permanent contracts. This 
strengthened existing ICT and Community Rehab services. In 
addition. Organisational Development work was undertaken across 
Ayrshire to move from 5-7 day working for ICT teams. 

Legal: 

No issues 

Equality: 

No issues 

Children and Young 
People 

No issues 

Environmental & 
Sustainability: 

No Issues 

Key Priorities: 

The model ensured a reconfiguration of existing services and 
structures to increase access to Intermediate Care and 
Rehabilitation services, reduce system wide inefficiency, develop the 
interface with Acute Hospital Services, improve service user 
experience which helps to meet the increased demand for health 
and social care in Ayrshire and Arran. This is in line with our 
priorities for Prevention and Early Intervention and Bringing Services 
Together. 

Risk Impiications: 

There are a number of risks associated with lack of clarity around 
the financial sustainability of this model : 

Reputational 

Service planning 

Ability to further develop/ progress future improvements 

Workforce stability 

Community 

Benefits: 

This model aspires to keep people independent, safe, and at home 
or in a homely setting and provide alternative to acute hospital 
admission 


Direction Required to 

Direction to: 


Councii, Heaith Board or 

1. No Direction Required 


Both 

2. North Ayrshire Council 



3. NHS Ayrshire & Arran 

X 


4. North Ayrshire Council and NHS Ayrshire & Arran 



6. CONSULTATION 

6.1 There has been on-going consultation through the Models of Care work, and the 
Intermediate Care and Rehabilitation Network, as well as updates to Strategic 
Planning and Operations Group, Transformational Leadership Group, and NHS 
Ayrshire and Arran’s Corporate Management Team. 

This paper has been developed in consultation with the Senior Leadership team in 
Community Heath and Care, the AHP Leadership team, and the North Ayrshire 
HSCP Finance Leads 







7. 

CONCLUSiON 

7.1 

While still in early stages, the model is showing good evidence that it is making a 
difference for the people of North Ayrshire in terms of avoiding unnecessary acute 
hospital admission and is largely on target to meet the outputs outlined in the 
business case. 

However, uncertainty around future funding is causing understandable insecurity 
within the staff teams and making ongoing planning and alignment with wider 
partnership programmes of work challenging. 

It is recommended that the funding required to sustain the model is considered on a 
longer term basis from 2020-21 as part of the budget planning for next year. 


For more information please contact Alistair Reid, Lead Allied Health Professional on 
07825227834or Alistair.Reid@aapct.scot.nhs.uk 






DIRECTION 

From North Ayrshire Integration Joint Board 



NORTH AYRSHIRE 

Health and Social Care 
Partnership 


1. 

Reference Number 

24102019-Agenda No. 

2. 

Date Direction Issued by IJB 

24102019 

3. 

Date Direction takes effect 

24102019 

4. 

Direction to 

North Ayrshire Councii 


NHS Ayrshire & Arran 

X 

Both 


5. 

Does this direction supercede, 
amend or cancei a previous 
direction - if yes, inciude the 
reference numbers(s) 

Yes 


No 

X 

6. 

Functions covered by the direction 

Enhanced Intermediate Care and Rehabilitation Services 

7. 

Fuii text of direction 

NHS Ayrshire and Arran are to continue to deliver the investment in the Enhanced 
Intermediate Care and Rehabilitation Model for the remainder of 2019-20. The 
continued service delivery is based on the current recruited workforce. 

8. 

Budget aiiocated by Integration 

Joint Board to carry out direction 

The estimated cost of the service for 2019-20 is £576k, of which £316k is funded as 
part of the IJB baseline budget and the remaining £260k will be met from within the 
overall HSCP budget. The sustainability of the investment in the service will be 
included as part of the budget planning for 2020-21. 

9. 

Performance Monitoring 
Arrangements 

The impact of the service is monitored through SPOG (Strategic Planning Operations 
Group). 

10. 

Date of Review of Direction (if 
appiicabie) 

March 2020