Segment Key Line of Enquiry Organisation response Supported by: NHS Vale of York Clinical Commissioning Group

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1 Strategic Plan Key Lines of Enquiry Submission details Which organisation(s) are completing this submission? In case of enquiry, please provide a contact name and contact details NHS Vale of York Clinical Commissioning Group Rachel Potts, Chief Operating Officer rachel.potts@nhs.net Lynette Smith, Head of Integrated Governance lynette.smith4@nhs.net a) HospSystem vision What is the vision for the system in five years time? NHS Vale of York CCG aims to achieve the best health and wellbeing for everyone in our community. To ensure we can continue to provide safe and effective care for all those who need it, we will change the structure of the healthcare system over the coming five years to meet the changing needs and demands of our population. We are committed to delivering this change in partnership with the Local Authorities, provider organisations and the wider health economy within our area. Significant investment in time and energy has been spent to ensure we have an agreed and common vision across the principal partners. The plan on a page Draft Strategic Plan The people within our community have told us that they want well-coordinated, local provision of care services. They want to go to hospital only where there is an absolute need to, and when they do for them to be and feel safe, well cared for and having access to the best clinical support. Our vision for the system responds to this challenge, and is one in which health 1

2 and social care services are easy for individuals to access, available in a timely manner that meets the needs of the individuals and are delivered in a community setting. Vale of York CCG and its partners have a five year vision for health and care, which is expected to be delivered through the Care Hubs initiatives. Care Hubs combine all resources of public sector, independent sector and community assets for populations of around 100,000 in designing services that meet the needs of individuals, supporting them to stay in their own homes where possible. Through this approach the NHS and Local Authorities aim to improve health and care outcomes, user experience and efficient use of public sector funding. Care Hubs are an important part of the drive towards integrated health and care across the Vale of York, with dedicated resources applied through the Better Care Fund and other investments dedicated to improving services for our residents, such as use of winter pressures funds and additional GP funds for improving access. The new model of the system will prioritise the quality and safety of patient care. We will change the way in which services are delivered so that they fit around the needs of the patient and offer a single point of access to both primary and secondary care services within their local community. 2

3 Care Hubs The ambition is high by desire and necessity. It builds on good experience locally and draws on evidence from national and international exemplars: for example: the Canterbury experience in New Zealand, Caremore and Extensivists in California, Polysystems in London and Microsystems in Sweden. The long term aim is to create consistent and wide spread co-ordination of services that meet the needs of individuals across the catchment of the Care Hub : effectively to identify risk early and quickly put in place the care and support necessary to actively avoid further deterioration and facilitate fast recovery through: Simple access to services, information and advice. 3

4 Fast access to assessment and diagnosis Increasing the choices for individuals and reducing unnecessary hospitalisation, nursing home and residential care Releasing resources to reinvest and spread further improvements to wider patient cohorts. We recognise that this is likely to expose areas of unmet need, which test sites will need to make arrangements for within the resources for their community. We hope that the number of incidences of crisis will be reduces through the shift to proactive care management. Over the next year the CCG intends to concentrate on older people who are frail and have complex long term conditions that lead to heavy intensive use of health and social care services. This is estimated initially as 2% of a total community population, growing to 5% where it will include those at high risk of intensive use unless early interventions, care and support are in place. This model will be rapidly expanded to cover the whole population. The anticipated impact of this model of approach is a reduction in hospital emergency admissions, re-admissions and avoidable admissions, with a corresponding increase in primary and community activity; decreases in the potential years of life lost and increases in patient satisfaction across the system as the models for accessing health and social care services are re-aligned. The impact will allow for significant re-configuration of the acute service provision. This model will improve the quality and safety of non-urgent care services, and also those delivered in an urgent care environment by relieving some of the pressure in the system and reducing the variation in the level of and access to care provision. This model of provision will ensure that services are able to 4

5 respond rapidly to the needs of the patients, allowing them to experience seamless care that meets all their needs. What is more, this will drive efficiencies in the system and result in improved clinical pathways for all secondary care services. This is supported through the implementation of standardised processes and clinical support in the Referral Support Service. The outcomes of the Care Hub will be interdependent on the transformations in the delivery of urgent care and mental health services. In addition to a reduction in demand for urgent care services through the Care hub model, reforms to urgent care services will further reduce the number of avoidable admissions. This will be delivered through a range of new models and pathways, which will look to provide more emergency and ambulatory care expertise in the community. For more detail please see the Improvement Interventions section of the strategic plan for NHS Vale of York CCG. Reforms to mental health services will improve early access to psychological therapies and dementia care support, which is expected to reduce the incidence of crisis requiring interventions. The provision of mental health services within the acute care services will be reformed to provide improved support and signposting to mental health services. We are currently reviewing the appropriateness of our mental health estate with a view to establishing an estate that is fit for purpose in the future. In addition, we are working closely with out mental health provider to reduce the number of patients placed out of the Vale of York area for their mental health treatment. 5

6 How does the vision include the six characteristics of a high quality and sustainable system and transformational service models highlighted in the guidance? Specifically: 1. Ensuring that citizens will be fully included in all aspects of service design and change, and that patients will be fully empowered in their own care 2. Wider primary care, provided at scale 3. A modern model of integrated care 4. Access to the highest quality urgent and We are committed to ensuring that patients are at the centre of all care planning, both at an individual and strategic level. Through every proposed improvement intervention we are seeking to promote patient empowerment, self-management and patient choice. Patient-led planning is at the heart of the Care Hub approach, working together across the system to provide a holistic package of care within local areas and reducing the need for patients to navigate around a complex system. This is detailed in our Person Centred Care Improvement Intervention We will continue to engage our population at each stage of the system planning process, through our engagement and consultation events. Adapting and amending our plans and priorities in line with their feedback. Triangulation of patient feedback with the available comparative and quality data has allowed us to prioritise our plans (please see appendix A). General Practices will be working together, through the Care Hub approach, across populations of around 100,000 to provide an enhanced and integrated care service. We want to move away from traditional definitions of primary, secondary, community and social care to an integrated model of care. This requires working closely with pharmacy, dental services and community based services, and workforce reform to enable a 7 day service within the community Practices will develop a more centralised role around proactively co-ordinating care for elderly/complex patients across a range of wrap around services including community nursing, mental health, social/domicilary care, pharmacies and the voluntary sector. Care Hubs will also work closely with Hospital consultants to bring more specialised services closer to the patient with the aim of reducing avoidable Hospital admissions, and actively engaging in discharge planning to reduce Hospital lengths of stay and delayed transfers. It is Better Care Fund Submission You said, w did framework Stakeholder feedback framework 6

7 emergency care 5. A step-change in the productivity of elective care 6. Specialised services concentrated in centres of excellence (as relevant to the locality) envisioned that non-acute mental health and dementia services will provide a key supporting role in the Care Hub approach as it develops, in line with the drive to ensure parity of esteem for mental health conditions. The collaborative approach will also enable groups of GP s and practices to develop, deliver and bid for enhanced community-based services at scale under a Primary Care Plus model. This approach, working closely with pharmacies, dental and GPs will ensure the delivery of enhanced primary care primary care plus at scale and provide a modern model of integrated care. The above will be supported through efficient communication, co-ordination of care services, standardised working practices and interoperability of IT systems - delivered through our Primary Care Strategy, and changes in funding/payment structures initiated through the Better Care Fund. In addition, the CCG is providing additional support to Primary Care organisational development through action learning sets. The Care Hub model will be tested at three sites across the Vale of York, two in Primary Care led by GP practices as detailed in the Better Care Fund submissions these will be continually evaluated, modified as required and rolled out at scale. The Care Hubs will initially focus on the frail elderly and people with Long Term Conditions (see Better Care Fund submissions), and subject to rigorous evaluation and lessons learned, will be extended across the range of local health and social care provision. On-going public and patient engagement events across our geographic area have helped form the detailed design of these test sites. We intend to deliver the highest quality urgent and emergency care for the future 7

8 system. The Urgent Care Working Group has worked closely across organisations, including the voluntary and community sector, to develop and test approaches to managing demand through the winter pressures fund, including funding to enhance mental health and social work support within A&E, and the creation of step-down beds to reduce delayed discharges of care. The Urgent Care Working Group is testing the impact of innovative schemes such as embedding of a hostel-employed homelessness link-worker within A&E, extended rapid assessment and treatment services, hospice at home and increasing the number of Emergency Care Practitioners. The focus within the plan for years 1 and 2 is to work with the local community and providers to manage the demand and reduce activity through appropriate community responses, targeting those who are most vulnerable to multiple emergency admissions, close working with Care Homes to reduce admission rates and to ensure patients can move out of hospital as soon as they are ready. This will be enabled through the review of our out-of-hours services; the expansion of alternative workforce approaches e.g. Emergency Care Practitioners and the transition to 24/7 working arrangements. These approaches work in conjunction with the Care Hub model, enhancing services to prevent emergency admissions and re-admissions. This will support the system transformation to achieve a hospital base focussing on A&E and urgent care services and as a centre for elective excellence. We are committed to transforming the productivity of elective care, initially through driving efficiency by redesigning pathways, such as neurology and diabetes and supporting research to improve recovery and re-admission rates. We plan to build on the success of the outpatient follow-up work and look to redesign outpatient pathways. Through our Referral Support Service and the creation of a single point of access within the Care Hub, we aim to reduce the variability of service provision. The projects we have prioritised in our strategy 8

9 and QIPP are designed to drive efficiencies in elective care. This will create a more productive environment that reduces patient waiting times and the proportion of cancelled procedures. This will build upon our experience of treatment centres, for example through the private sector for orthopaedics, to enhance elective productivity. We will be working closely with our colleagues in specialist commissioning to understand the impact of the specialist services review and work with the local community and providers to support any changes. Our local Specialised Commissioning Team is currently undertaking consultation to establish their five year plan which is due to be published by the end of spring. Within the priorities being consulted on there is focus on the following: Complex Cardiology Services, with the view to full scale reconfiguration Morbid obesity surgery where there is a need for CCGs to commissioning Tier 3 weight management services to support this priority And in line with the national requirements Vascular Surgery We are working closely with the specialist commissioning to ensure that our plans are aligned through: Proactive engagement with specialised commissioners to secure and align local commissioning responsibilities national commissioning responsibilities. Proactive engagement with Operational Delivery Networks (e.g. Vascular and Major Trauma) regarding securing local pathways and those which interface with specialised services and performance monitoring. 9

10 Where changes to pathways and sites of service delivery are concerned, working with national commissioners to support the clinical and business case for the proposed changes (including understanding the impact on local service provision and potential risks to local services. Proactively contribute to the evidence base and input to local consultation processes. Ensuring that there are effective links to specialised commissioners/ agendas so that local practitioners are informed and can support their patients accordingly. Working alongside specialised commissioners to develop and support a jointly agreed work programme (with realistic timescales). Taking a collaborative approach with our commissioning neighbours utilising existing CCG collaborative agreements where possible. How does the five year vision address the following aims: a) Delivering a sustainable NHS for future generations? b) Improving health outcomes in alignment with the seven a) A sustainable NHS and social care system is at the heart of our ambition. The Care Hub model and urgent care pathway reforms are designed to reduce pressure on the acute services within the NHS system and support social care. The focus on community management, greater use of the voluntary and community sector, self-care and health promotion are integral to delivering the vision for the Vale of York. This has wide-ranging support from our key stakeholders. The move to more local provision through Care Hubs will also support the environmental and community sustainability of our communities. Enabling people to access greater levels of service without traveling to major urban centres will contribute to our NHS commitment to environmental sustainability Plan on a page Draft Strategic Plan Financial submission Better Care Fund Submission 10

11 ambitions c) Reducing health inequalities? and support local communities, particularly in our rural areas to maintain local services. NHS Vale of York CCG has agreed financial values that underpin all plans: Value for money Effectiveness Efficiency Financial resilience The draft Financial Plan for the Vale of York incorporates all business rules and inflation assumptions. Non-Recurrent expenditure will be targeted to test areas of innovation and transformation aligned to the strategic plan, for example in piloting Care Hub models and rigorous evaluation integration models. The Better Care Funding streams have been identified and ring-fenced within the budget profile. The position has been risk assessed and the draft plan contains a number of risks, primarily around the assumptions in the main acute provider contract and the delivery of the QIPP. The contract negotiation with the main provider is a key mitigation of these risks. Additional risks with supporting mitigations that are factored into the planning include the return of the surplus for , the impact of pressures within specialist services provision, Continuing Health Care retrospective payments and increases in prescribing costs. See the financial submission for details. b) The strategic plan addresses the transformational programmes of work we are undertaking to deliver the levels of ambition. The Care Hub model and Better 11

12 Care Fund proposals will contribute to reducing time spent avoidably in hospital, increasing the proportion of older people living independently and increasing the health related quality of life for people with Long Term Conditions. The proposals to transform community and mental health services through the Care Hub model will contribute to patients experience out of hospital, and reducing pressure on the hospital is designed to improve patient satisfaction and avoidable deaths. c) Preventing ill health and targeting health inequalities is a critical enabler of the vision for the Vale of York. We know that across the Vale of York there are significant differences in life expectancy for men (and women to a lesser extent) depending on where they live, and that for certain groups access to services can be more challenging and outcomes are lower than the comparators, for example children emergency admissions for lower respiratory tract infections and tooth decay in the under 3 s. The Health and Wellbeing Boards are committed to reducing these health inequalities, and the CCG will work closely with public health and local authorities to target interventions for greatest impact on health inequalities. Examples of this include alcohol and substance misuse strategies, healthy eating and weight management programmes for children and families and a review of asthma prevalence and pathways. We will also be taking forward a review of cancer pathways to enhance preventative measures, diagnosis and waiting times. Transforming mental health services is a major focus to tackle health inequalities. A mental health problem increases the risk of physical ill health. Currently, men with a severe mental illness die on average 20 years earlier than other people; women 15 years earlier. They have higher rates of cancer, heart disease, respiratory disease and diabetes. People with mental health problems have higher levels of alcohol misuse and obesity than the population as a whole, 12

13 and do less physical activity. Some 42% of all tobacco smoked is by people with mental health problems. In addition to transforming our services, we are currently reviewing the appropriateness of our mental health estate with a view to establishing an estate that is fit for purpose in the future. We are working closely with out mental health provider to improve access to services in our local community and reduce the number of patients placed out of the Vale of York area for their mental health treatment. The CCG works closely with the Health and Wellbeing Boards to address to the wider determinants of health, including promoting mental health, economic wellbeing and housing reforms to reduce the health impact of poor quality housing. The Care Hub model is a key enabler to reduce health inequalities, bringing together health and social care colleagues to assess and support an individual s needs holistically and provide a consistent single point of access for care. The strategic plan incorporates our equalities strategy. It identifies the need for greater equalities analysis to reduce health inequalities, and the equalities implementation plan will drive this work forward. Who has signed up to the strategic vision? How have the health and wellbeing boards been involved in developing and signing off the plan? NHS Vale of York CCG has taken a robust partnership approach to the development of the strategic plan. During the Autumn all local public engagement events were analysed to develop key themes. The themes were triangulated against the available comparative data and quality information to identify areas for priority. These initial areas were then shared and discussed with: CCG Governing Body (October, December, February) North Yorkshire Health and Wellbeing Board (5 th Feb 2014) City of York Health and Wellbeing Board (29 th Jan 2014) Board papers are available on the associated Council Websites and the Vale of York website. Better Care 13

14 East Riding Health and Wellbeing Board (30 th January 2014) Weekly Executive to Executive meetings with York Hospitals Foundation Trust and a Board to Board session. Board to Board meetings with Leeds and York Partnership Trust Better Care Fund development sessions with City of York Council A Stakeholder Planning Event was held on January 22nd to share the details underpinning the priorities and to challenge the CCG on the level of ambition with the plan. This was attended by 49 attendees from 35 organisations, including our providers, local authorities, Healthwatch and local voluntary groups. Council of Representatives session on the vision and challenges (Jan 23 rd ) Submission. Stakeholder Feedback framework You said, we did framework Through these meetings, the vision and approach has been endorsed by all key stakeholders. The detail is being developed in collaboration with our stakeholder and sign up is anticipated at the following meetings: CCG Governing Body: North Yorkshire Health and Well-Being Board: City of York Health and Well-being Board: East Riding Health and Well-Being Board York Teaching Hospitals Foundation Trust Board: Leeds and York Partnership Board: Yorkshire Ambulance Service Board: Additional public consultation was conducted following on from the first draft submission. This feedback has helped us finalise the plan: 14

15 Public Engagement events: 3 March 2014 Selby Strategic Plan 4 March 2014 York Strategic Plan 6 March 2014 Easingwold Strategic Plan 10 March 2014 Better Care Fund - joint event held with City of York Council 24 March 27 April Online survey, available on our website How does your plan for the Better Care Fund align/fit with your 5 year strategic vision? The Better Care Fund is an integral enabler to the Vale of York s vision for future services. The initial two year plans are targeted on testing approaches and models in line with the recommended system characteristics to enhance an integrated Care Hub model and reduce the pressure on acute admissions. (See BCF Submission) As well as the specific outcome described in the vision, providers and commissioners aim to demonstrate the following outcomes for the wider system through the Better Care Fund: Detailed, whole pathway, outcome based specifications for each of the service dimensions Sustainable approach to risk stratification and service user identification, either locally or on a more regional footing Create the engagement, procurement and contracting framework that secures sustainable delivery of improved services Restructure the balance of investment towards increases in personal care and community based care and support, along with relative reductions in hospital and residential based care. (Commissioning and Decommissioning strategies) Leadership and delivery demonstrates person-centred approach to innovations, and whole system approach to securing benefits and managing risks: crossing organisational boundaries. Better Care Fund Submission. 15

16 Timely spread of learning and benefits to other groups such as Long Term Conditions, Adult Mental Health and Child and Family services. Pooled budget framework focussed in personal involvement in care and care planning. Risk sharing to assure integrity of the wider health and care system. What key themes arose from the Call to Action engagement programme that have been used to shape the vision? Is there a clear you said, we did framework in place to show those that engaged how their perspective and feedback has been included? See engagement information and vision above. A series of consultation events have been held across the Vale of York, and combined with existing feedback from the community gathered by City of York Council and North Yorkshire County Council. Analysis of this has identified key messages from the public: Fast access to care and support Locally available The right professional support when I need it I want to feel safe and trust my provider Good information to help me plan my care Care to be co-ordinated a through key link person These have been at the heart of developing the vision, which can be seen through the Care Hub approach. Please see attached document on the stakeholder and public feedback. The strategic plan outlines how we have listening to the community to develop our objectives and improvement interventions. You said, we did Framework 16

17 1. Current position Has an assessment of the current state been undertaken? Have opportunities and challenges been identified and agreed? Does this correlate to the Commissioning for Value packs and other benchmarking materials? A full assessment of our current position been carried out, both in terms of financial and performance information. The Commissioning for Value Packs, Outcomes Atlas and Levels of Ambition Atlas have all been utilised. This has been triangulated against the engagement feedback, NHS Constitution performance and activity levels. The challenges and opportunities are outlined in the about us section, but include: Higher spend and growth on emergency admissions than comparators and National Average Lower spend and number of GP referrals, but higher growth rate than comparators and national average Top 20% of 55 ONS comparators for spend on Circulation, Neurology Higher than average disease prevalence on Depression, Atrial Fibrillation, Dementia, Cancer, Hyperthyroidism, Stroke and Coronary Heart Failures Operating Plan submission Our operating plan is targeted on addressing these issues through relevant QIPP schemes, for example the Referral Support Service, pilots for the Care Hub to target reduced admissions, greater use of Emergency Care Practitioners and the Neurology pathway review. Expert modelling support has been contracted, which has enabled us to robustly model the impact of the Care Hub approach across health and social care Do the objectives and interventions identified below take into consideration the current state? Does the two year detailed operational Yes our planning has been based on the latest available data. Where data has not been available for or , trend data has been used to inform planning. Yes the operational plan is focussed on: a) testing approaches to deliver the vision Operating Plan Submission 17

18 plan submitted provide the necessary foundations to deliver the strategic vision described here? b) driving up performance and quality premium c) Delivering efficiency to enable the transformation activity QIPP schemes, quality premium measures and our CQUINS support the objectives and improvement interventions within our plan. These are outlined under each Improvement Intervention with the links to our objectives and levels of ambition. 2. Improving quality and outcomes At the Unit of Planning level, what are the five year local outcome ambitions i.e. the aggregation of individual organisations contribution to the outcome ambitions? How have the community and clinician views been considered when developing plans for We have calculated our five year ambitions based on benchmarking data available for all CCGs. Our ambition over the next five years is to work towards equally the results delivered by the highest performing among our peer group. Ambition area Metric Proposed attainment in 18/ to be developed n/a to be developed See above for the consultation and community engagement analysis We have developed good working relationships with our HealthWatch colleagues. Their presence and contribution at our stakeholder events have created an invaluable patient focus. 18

19 improving outcomes and quantifiable ambitions? The strong working relationships between the Vale of York and the three local authorities that work across the Vale of York boundaries has enhanced the shared understanding of the needs of the local community and the shared vision for the future of local health and social care. The programmes of work have been developed by clinical leads, from the transformational hub vision to the individual QIPP schemes, each have been led by clinical leaders. In addition this has been regularly discussed with clinicians on the Governing Body and at the Council of Representatives. A series of event have been held by the CCG engaging the public and stakeholders on our preliminary plans. These events have helped to form our shared vision for the health system. We are currently conducting an online consultation for all those who were unable to attend these events. The results of this consultation will help to amend our submission in time for the June deadline. What data, intelligence and local analysis was explored to support the development of plans for improving outcomes and quantifiable ambitions? How are the plans for improving outcomes See a) above. The planning has been informed by analysis of the national and comparative data provided through NHS England, analysis of local activity, quality outcomes and prevalence data through the Business Intelligence Team for the Vale of York and Public Health data through the Joint Strategic Needs Assessment. This has been combined with community feedback, analysis of national policy and NICE guidance and the financial position to develop the ambitions. The Anytown modelling system has been applied to aid our planning assumptions. NHS Vale of York CCG has worked closely with our council partners to discuss and prioritise schemes based on the local population needs. The JSNAs have 19

20 and quantifiable ambitions aligned to local JSNAs? been used as part of the analysis of need for the strategic plan document and are supporting documents to the plan. The objectives we have set are aligned to the local Health and Wellbeing Board s priorities and these are included in draft plan. We receive monthly Public Health Reports and are working closely with public health to refresh the JSNA in thematic areas, including mental health, gypsy and roma travellers and children s outcomes. How have the Health and well-being boards been involved in setting the plans for improving outcomes? 3. Sustainability Are the outcome ambitions included See above engagement. The Health and Wellbeing Strategies have informed the development of the proposals with the strategic plan and the Care Hub approach. We will be working with the Health and Wellbeing Boards to deliver their strategic priorities. These include: Improved care planning for people with long term conditions Integrated solutions for complex needs and end of life care Addressing social isolation and the impact of loneliness on all aspects of health Community based models of care, preventing unnecessary hospital admissions and reducing length of stay Managing the older population and associated increase in Dementia Workforce reform and promotion of the living wage Promoting healthy lifestyles Safeguarding children and young people Yes - All plans are being continuously reviewed to ensure their cost implication are accurately calculated to allow for unexpected events. This will enable us to Financial Submission 20

21 within the sustainability calculations? I.e. the cost of implementation has been evaluated and included in the resource plans moving forwards? Are assumptions made by the health economy consistent with the challenges identified in a Call to Action? Can the plan on a page elements be identified through examining the activity and financial projections covered in operational and financial templates? mitigate any risks that may emerge in our ability to deliver the planned outcomes. See financial submission Yes each programme of work has been tested against the Call to Action in the development of the strategic plan. The transformation of the system outlined in our vision is ambitious and targeted to address the longer term sustainability of health services for the Vale of York. Each QIPP scheme is aligned to the Improvement Intervention as detailed in the sections below. This can be cross-referenced to the financial and operational submissions 21

22 4. Improvement interventions Please list the material transformational interventions required to move from the current state and deliver the five year vision. For each transformational intervention, please describe the : Overall aims of the intervention and who is likely to be impacted by the intervention Expected outcome in quality, activity, cost and point of delivery terms e.g. the description of the large scale impact the project will have Investment costs (time, money, workforce) Implementation timeline Enablers required The investment costs provided are in addition to the core contract values with providers. Integration of Care Objectives: When people become ill, they are treated in a timely manner with access to expert medical support as locally as possible Where people have long-term conditions they are supported to manage those conditions to give them the best possible quality of life When people are terminally ill, the individual and their families and/or carers are supported to give them the best possible quality of life and choice in their end of life care. A move to Care Hubs, providing increased access to health promotion, care and support services, including GPs, pharmacies, diagnostics (e.g. scans/ blood tests), community services, mental health support and social care and community and voluntary services. Ambitions: Reduce the amount of time people spend avoidably in hospital by 14% through better and more integrated care in the community, outside of hospital. Increase the proportion of older people living independently at home following discharge from hospital from a baseline of 76.7 Improve the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions to equal the best amongst our peers The integration of care will be led through the implementation of the Care Hub See Financial planning templates for QIPP activity Plan on a page for additional interventions 22

23 for example medicines optimisation Barriers to success Confidence levels of implementation The planning teams may find it helpful to consider the reports recently published or to be published imminently including commissioning for prevention, Any town health system and the report following the NHS Futures Summit. approach. This will be supported by the Better Care Fund programme. This will initially be focussed on frail elderly individuals and those with Long Term Conditions, and then expanded to incorporate a wide range of care needs, including community mental health. Work programmes: Better Care Fund programme: - Implementation and Evaluation of Care Hubs - Mental Health Street Triage, creating a team of skilled mental health professionals to be deployed by the police to provide initial assessment and advice for individuals with mental health needs to help avoid unnecessary detentions - Hospice at Home to focus on clients who are approaching the end of their life and wish to die at home or their usual place of care - A dedicated Acute Liaison Psychiatry Service to the Emergency Department at York Teaching Hospital 24 hours a day, 7 days a week to support patients with mental health issues. - Single point of contact to enable patients to have one care record and a single point to contact health services. There will be a named care coordinator who will retain accountability for the individual and act as facilitator to access other services and interventions - Enhanced rapid assessment team and domiciliary support service to provide clinical management of patients who have urgent care needs as close to home as possible Community Services review to ensure our services are commissioned in line with the new approach and deliver high quality local services Community equipment review to ensure that people have timely access to high quality and safe equipment to support independence and care at home. Expected Outcomes: Increase in the proportion of older people living independently at home following discharge from hospital from a baseline of

24 Improve the health related quality of life for people with long term conditions to equal the best among our peers Reduced bed occupancy Reduced length of stay Reduction in delayed transfers of care Single point of access for clinicians End of life care plans Lead Partners: CCG, Local Authorities, Primary Care, Community Care, Acute and mental health providers Investment costs Non-recurrent funding: 2.2m for Better Care Fund preparatory schemes, 700k Carers breaks, 1.616m Reablement and 125k single point of access. Subsequent funding through the Better Care Fund. Non-Financial costs Officer time and partnership working arrangements. Clinical Leadership and dedicated senior project management team. Supporting data analysis, HR, financial, procurement and governance advice. Implementation timeline April 2014 onwards. Phased approach to enable evaluation of test models, with full rollout across York in Enablers required Strong partnership arrangements through the Better Care Fund. Community Services contract review Strong support from stakeholders 24

25 Barriers to success Procurement and funding arrangements Workforce re-modelling Confidence levels of implementation High three pilot sites identified and development plans in progress. Person Centred Care Objective: People will have more opportunities to influence and choose the healthcare they receive and shape future services. Ambition: Reduce the Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare by 21% in ( to ) Increase the number of people with mental and physical health conditions having a positive experience of hospital care by and care outside hospital in general practice and the community by 12% Patients, carers and the public are at the heart of health services and we are committed to the philosophy of no decision about me - without me. Delivering a sustainable and successful NHS in the local area is a collective challenge, and we will work with the public to put them at the centre of their care, help people stay healthy through informed lifestyle choices, support people to manage long term conditions and offer people choice through a range of providers. This also includes the move towards more personalised health care services and the roll-out of personal health budgets for people with complex needs and disabilities. 25

26 Work Programmes: Implementation of the local Public Health Strategies in collaboration with providers, public health and Public Health England. Cancer pathway review Encourage GPs and other health care workers to promote healthy lifestyle and provide access to support to stop smoking, increase physical activity levels and eat a balanced diet. Implementation of personal health budgets for people with complex health needs to extend their choice and influence over the care that they receive Refresh and implement our Communication, Engagement and Involvement Strategy to ensure that all stakeholders and members of the public can influence the shape of local health services Explore options of a health service directory to increase public knowledge of services and promote choice Self management strategy, including expanded use of technology to remotely support individuals (e.g. telecare solutions) and expert patient schemes Carers Support Strategy. As we support people to manage their conditions and live at home for longer, we recognise this can place different demands on the people who care for them. Expected Outcomes: Reduction in smoking prevalence Take up of vaccination and immunisation and screening programmes Increased take up of the friends and family test Increased opportunities for engagement across the Vale of York Increased access to personal health budgets Lead Partners CCG, Public Health, Healthwatch, Public Health England. 26

27 Investment costs Non-Financial costs Officer time and partnership working arrangements. Clinical Leadership and dedicated senior project management team. Supporting data analysis, HR, financial, procurement and governance advice. Implementation timeline April 2014 onwards. Enablers required Strong partnership arrangements through Partnership Commissioning Unit, CSU, Health and Wellbeing Boards, Healthwatch and community groups and the public Strong support from stakeholders Barriers to success The need to ensure clear roles and responsibilities for self-management and health promotion strategies Confidence levels of implementation Medium- High Urgent Care Reform Objective: When people become ill, they are treated in a timely manner with access to expert medical support as locally as possible We will implement revised delivery models and pathways to reduce avoidable attendances and admissions. This will be supported by the Integration of Care transformation detailed above, as well as specific funding from winter pressures support 27

28 which allows testing of new services and pathway change. This programme of work is led through the Urgent Care Working Group. Work Programmes: Demand and Capacity planning for winter resilience to ensure emergency services can cope under increased pressure at peak times Increased Emergency Care Practitioners across the area. These will help to respond quickly to crisis and urgent need, seeing and treating at the scene to reduce transfer to Emergency Departments, working with our Yorkshire Ambulance Service Under 5 s admissions review, to reduce the numbers of children experiencing a zero length of stay in hospital and ensuring children have swift access to high quality diagnosis in emergency departments Patient Transport Services review to improve access to healthcare services Out of hours services review, to enhance out of hours services aligned to the Care Hub approach and supporting the transition to 24hr/ 7 day working across the health system Provision of a geriatrician at the front door of ED to ensure the frail elderly have swift access to high quality diagnosis in emergency departments A revised Deep Vein Thrombosis Pathway to ensure people have timely access to diagnosis and treatment Expected Outcome Reduce unplanned emergency hospital admissions by 14% Compliance with NHS Constitution targets for urgent care services A more flexible and integrated service between OOH and GP provision Better provision for paediatric urgent care in the community as well as through hospital Better integrated support for frail elderly/care home urgent care 24 hour, 7 day working patterns across the Vale of York 28

29 Lead Partners CCG, Urgent Care Working Group Investment costs 1.737m non recurrent funding for emergency admission avoidance. Funding not planned for, but anticipated through winter pressure allocation Non-financial: Urgent Care Working Group partnership arrangements and commitments. Clinical Leadership and dedicated senior project management team. Supporting data analysis, HR, financial, procurement and governance advice. Implementation timeline Emergency Care Practitioners in place, with expansion through a phased approach Additional impact schemes from April 2014 with ongoing support via BCF Paediatric emergency admissions plans from October 2014 Enablers required Effective, Clinically led Urgent Care Working Group Robust monitoring of impact from Winter Pressures schemes Emerging pilots to test new approaches highlighted locally and nationally Barriers to success Inter-dependencies with the provision of enhanced community support Workforce remodelling (out of hours and seven day working) Confidence levels of implementation Medium. Several of the proposed interventions are in place as test projects and will be subject to impact review in March/April Interventions continued from April 2014 will have a proven record of impact. There is an inter-dependency on the Care Hub Model approach; reducing demand through enhanced community support, which has been factored in to the planning. 29

30 Equally support and close working from the Primary Care workstream is required to ensure effective implementation of the above schemes. Transforming mental health services Objective: High quality mental health services for the Vale of York, with increased awareness of mental health conditions, improved diagnosis and access to complex care within the local area. Ambition: Improve the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions to equal the best amongst our peers We plan to transform our mental health services in the local area to enable a greater parity of esteem between mental and physical health. Our mental health services currently have long waiting times and estate that is not fit for purpose in some areas. We intended to review the whole provision, and include a focus on dementia, access to psychological therapies and the physical health of people with mental health issues. Work Programmes Review of mental health provision, quality and contract monitoring including an estate plan that it is fit for purpose Active review to reduce out of contract placements Psychological therapies service, to provide a range of therapies from low level interventions to high intensity treatments within primary and community settings (IAPT) Work in partnership to develop Dementia Friendly Communities to reduce stigma and improve early diagnosis Work with primary care to increase the knowledge and skills of practice staff, increase efficiency of screening, coding and links to memory clinics and care 30

31 navigator. Support people with dementia who move from acute to community care to live independently. We will look at improving the standards of physical health care within mental health in-patient facilities to support earlier diagnosis and treatment of common illnesses. This is vital to our on-going goal of reducing premature mortality. Encourage people with mental health problems to access existing health and dental checks, and to understand the effects of medication and the need for screening and immunisation We will commission a comprehensive liaison service that is responsive to those within A&E and complex cases on wards for those with mental ill health in partnership with York Teaching Hospital Foundation Trust. Expected Outcomes: Increase the number of people with mental and physical health conditions having a positive experience of care by 12% A new model of mental health provision for the local area, which will deliver Reduction in waiting times across mental health provision Reduction in out of contract placements Increased dementia diagnosis rates Improved access to psychological therapies An Autism strategy and pathway Estate that is fit for purpose A reduction in delayed transfers of care Lead Partners: CCG, Partnership Commissioning Unit, Investment costs Financial costs 31

32 486k recurrent Continuing Health Care 322k recurrent Section 136 suite 9k non-recurrent for care packages and projects review The CCG is currently working with Leeds Yorks Partnership Foundation Trust on their Service Improvement Plan. This will impact on the proposed future investment from the CCG and this in the process of being modelled through the contract management board. Non-Financial costs Officer time and partnership working arrangements. Clinical Leadership and dedicated senior project management team. Supporting data analysis, HR, financial, procurement and governance advice. Implementation timeline The programmes of work will commence in April 2014, however expected timescales for the completion of the review of mental health services and a new service in place is anticipated in April Enablers required Dedicated resource for developing the specification Procurement support in place Strong community engagement Engagement from mental health providers Barriers to success Timescales and procurement processes Resources Confidence Levels for Implementation Medium. The mental health services review has commenced, including significant analysis of RAID. The IAPT improvement plan is in place and additional resource has been provided to support project management capacity within this workstream. 32