Local Care Plan. Date: July Patient focused, providing quality, improving outcomes

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1 Local Care Plan Date: July 2017 Patient focused, providing quality, improving outcomes

2 Document Version Control Document Title Local Care Plan Version Version 1.5 Author Alison Burchell, Programme Director - Local Care Date 31 July 2017 File Location S: WK CCG\Primary Care\Local Care Revisions (1.3.1) Revisions (1.4) Revisions (1.5) Various section updates Amendments following feedback from executives and governing body members. Final infographics inserted. Minor amendments to narrative in various sections. Final minor amendments in various sections following Governing Body meeting. Page 2 of 86

3 Contents 1 Introduction and purpose Background Kent and Medway Case for Change and Local Care Vision The Patient perspective Our Population Population forecasts Population demographics Deprivation and wider determinants Children and Young People Older people Urgent Care West Kent Health Profile Highlights Life Expectancy Trends in Mortality Trends in Morbidity Diabetes Asthma Chronic Obstructive Pulmonary Disease (COPD) Coronary Heart Disease (CHD) Cancer Learning Disability Mental Health Dementia Falls West Kent Local Care Model General Practice Extending access in general practice Clusters Local Care Hubs West Kent wide services Community Beds Prevention Lifestyle factors affecting health in West Kent: Alcohol Obesity, physical inactivity and diet Smoking Page 3 of 86

4 8.2 Working with our District Councils West Kent Councils North Kent Councils Self-care Quality Pathways and interventions Medical, Long Terms Conditions and Frailty Commissioning Medical and Long Term Conditions End of Life Care Frailty Care Homes Falls Multi-disciplinary Teams (MDT) Children & Maternity Children Maternity Mental Health Planned Care Enablers to delivering the local care model Estates Workforce, Education and Training Primary Care Wider local care workforce Patient and carer workforce Digital infrastructure Care Plan Management System (CPMS) Electronic Prescription System (EPS) Vision DocMan Roll out of HSCN Patient Communication Wifi access in practices Desktop devices, PCs and Printers (and mobile devices) E-consultations in general practice E-referrals (ERS) Advice and Guidance Communication and Engagement Page 4 of 86

5 14 Summary of Impact of local care plan Developing the financial model Paying for enablers that will support the delivery of the model In West Kent Workforce requirements Digital requirements Estates Investment in general practice to incentivise change in ways of working including: MCP Development Governance Context The New West Kent Governance Next Steps Appendices Page Appendix 1 West Kent CCG General Practice Forward View Plan 61 Appendix 2 Glossary 86 Page 5 of 86

6 1 Introduction and purpose The purpose of this document is to set out NHS West Kent Clinical Commissioning Group s Local Care Plan. Local care is care not in a main hospital, providing better access to care and support in people s own communities. In this document we describe the local clinical model of care, the infrastructure required to deliver this and what will change for people who live in west Kent. We detail our progress to date and the key elements that we need to further develop and talk to local people about. 2 Background The Local Care Plan in west Kent is not new; it has its roots in the Mapping the Future (MTF) programme of work undertaken during Mapping the Future produced an initial picture of the modern, efficient health and care services that need to be provided to meet the changing needs of the 480,000 people who live in west Kent. Mapping the Future set out a whole system approach for west Kent where all health and wellbeing system partners use their individual and collective efforts to tackle the root causes of health and well-being problems, and where people are encouraged and supported to take greater responsibility for their own health to make healthy choices. Our Primary Care Strategy was developed through our Mapping the Future programme and it is this that forms the basis for our local care plan. The collaboration and engagement with stakeholders through Mapping the Future has provided the firm foundation for our local care plan which is part of delivering the Kent and Medway Health and Social Care Sustainability and Transformation Plan (STP). Our local care plan aligns with the NHS Five Year Forward View (FYFV) and General Practice Forward View (GPFV). Information regarding Mapping the Future and our Primary Care Strategy can be found on the Mapping the Future website. The NHS Next Steps on Five Year Forward View (March 2017) sets out the NHS main national service priorities and practical action that will be taken over the next two years. These include ensuring that GP practices have the support they need to deliver the quality of care they want to provide, that people with less severe conditions can access urgent care without attending A&E, and improving prevention and care for patients mental and physical health through better integration of GP, community health, mental health and hospital services and more joined up working with home care and care homes. Our local care plan responds to this. 3 Kent and Medway Case for Change and Local Care Vision We all want health and social care services that can meet our needs now and in the future. However, we face new challenges that mean we need to change the way we work to improve care and get better value for the money we have available. As our population grows, and more people live with long-term conditions, the demands on our services are changing and increasing. Services are not necessarily designed for today s or future needs, and it is becoming harder to keep up with rising costs. What is more, we are not making the most of opportunities to improve health and wellbeing, prevent illness and support people to manage existing conditions and stay independent. Page 6 of 86

7 The Kent and Medway case for change describes the current situation and why change is necessary. Our challenges in Kent and Medway The Kent and Medway case for change identifies that There is not enough focus on prevention across the whole Kent and Medway system (including health, social care and the wider public sector) There are challenges in primary care provision, which is extremely fragile in some areas this may contribute to the increasing number of A&E attendances which are rising at twice the national average Page 7 of 86

8 There are gaps in service and poor outcomes for those with long term health conditions Many people are in hospital who could be cared for elsewhere - every day over 1,000 people are in local hospitals when they could be elsewhere if services were available Local hospitals find it difficult to deliver services for seriously ill people - there are also issues with services outside hospital, making it difficult for people to go home when they are able Planned care is not delivered as efficiently and effectively as it could be - in Kent and Medway, the level of referrals from GPs to hospital specialists is higher than other places with a similar population There are particular challenges in the provision of cancer care - late diagnosis of cancers is a particular issue in Kent and Medway People with mental ill-health have poor health outcomes and may not always be able to access services The local care model needs to Support the long-term provision of primary care services by scaling up practices to larger federations Educate the population in monitoring and improving their own health, making it easy for them to do so, and promote self-care Engage with the patient and provide the education and basic skills needed to allow them to manage their own care Coordinate and integrate health and social care services so that they provide care around a centrally held care plan in an efficient and holistic way Provide an easy to access service that patients can contact from their home, or via their GP to provide an alternative to what would otherwise be an A&E attendance Work across acute and primary care services to ensure a patient has the correct holistic care package in place and that this process begins upon their admission Provide the short term level of care needed immediately upon discharge to allow a patient to live independently in their place of residence Make it easier for a GP to get an opinion from a specialist in the community to avoid referral Position mental health staff consistently in all care settings to support and direct care for patients with mental health issues and reduce the risk of mental health issues developing especially among those with long-term physical health conditions The vision for local care in Kent and Medway Our aim is to develop holistic, patient-centered community and home-based care across Kent and Medway resulting in: Wide ranging proactive self-care and self-management measures that reduce lifestyle risks and their causes Local people being given the tools and information, services and support needed to be accountable and responsible for their own care Page 8 of 86

9 Connected care services, including integrated health and social care, resulting in patients being able to access services quickly and efficiently in a community setting where their needs are fully understood People only attending hospital when essential Our first priority is to develop more and better local care services, which bring together all the services people currently get from their GP, as well as a range of additional services. Bringing together primary, community, mental health and social care services will mean we can offer joined-up care in people s homes and local communities. We recognise we will need to increase our capacity in these areas in order to achieve this. Having high-quality local care services with greater capacity will relieve some of the pressure on our hospitals. It will reduce the need for people to go to hospital for treatment and services that in the future will be provided more locally. In order to deliver our plan, there are three foundation areas that must be working well. Section 12 of our plan describes what we are doing in west Kent. Summary The Kent and Medway STP case for change reflects the key issues and priorities that we identified through our Mapping the Future work in west Kent. Local multi-stakeholder collaboration and engagement has been at the heart of our work to date and will continue as we develop and implement the local care plan, ensuring that we design local solutions with local ownership. Our local care plan therefore responds to the Kent and Medway Sustainability and Transformation Plan and NHS Five Year Forward View. Page 9 of 86

10 4 The Patient perspective As a patient, through the new way of delivering services you can expect to see: joined-up services to treat and care for you at home and support you to leave hospital as soon as you re medically fit to leave your own bed, is the best bed with the right care and support in place health and social care professionals coming together to work as a single team for your local area, able to access your records 24 hours a day (with your consent) a modern approach to health and social care services using the best technology, from booking your appointment online to virtual (but secure) consultations, online assessment and diagnostic systems, and advice on apps to monitor your health timely appointments with the right professional care for you as a whole, for both your physical and mental health regular monitoring if you have complex health conditions affecting your physical or mental health, or both more support from voluntary and charitable organisations who have great expertise and local knowledge and already play such an important part in our communities better access to health improvement advice and services to help you improve and manage your own health and so reduce your risk of serious illness social prescribing information to help you access relevant support from voluntary, charitable and local community groups or services quality hospital care when you need it and more care, treatment and support out of hospital when you don t. The diagram below details what this looks like from a patient perspective as part of our local care model: Page 10 of 86

11 Between October 2016 and December 2016 the STP Programme Board ran a survey of residents across Kent and Medway to help gather the views of service users and local people. The survey asked questions about keeping people well and various aspects of local care. The Kent and Medway survey results provide us with lots of helpful feedback to inform our work going forward. In summary the Kent and Medway local care survey shows that people: in general are keen to improve their own health, particularly in losing weight and taking more exercise. The three main barriers they gave were will-power, lack of time and preexisting medical conditions. Many people wanted more support from health professionals to help them make changes in their lifestyles are concerned about health and social care in Kent: mainly about insufficient staff or other resources, but also about management and delivery. In particular, there was frustration about mental health provision, and social care. There was, however, praise for specific services and for the professionalism and dedication of staff are clear about the need to bring health and social care closer together. There was widespread support for hubs and other ways to integrate GP, social care and other services. The main concerns were about time and distance to travel, particularly for those reliant on public transport. They also wanted services to be better integrated so that they received the right care for them as individuals see beds based in the community (e.g. community hospitals) as crucial in reducing bedblocking and providing a bridge between specialist hospitals and care at home, and again a means to integrate health and social care. are seeking extended opening times for GPs and other services, particularly after work during the week and during the day at weekends; overnight access was less of a priority generally open to the idea of new technology in supporting enhanced health and social care. Some options, such as telephone advice lines, were more popular than others, such as mobile phone apps. Though there were concerns about security, most participants who expressed a view did not think this should stop innovations such as electronic patient records. Participants also felt that technology should augment and not replace face-toface contact supportive of social prescribing and other innovations, although also some doubt as to available resources and concern that this should not distract from getting the basics right More widely, there was qualified support for the STP process: while most respondents wanted more resources committed to health and social care, they also accepted that improvements could be achieved within existing constraints. 5 Our Population The CCG has a registered patient population of 484,460 1 and is made up of the 60 general practices (doctors surgeries) in the west Kent area and the majority of patients registered with west Kent practices live in the districts of Maidstone, Sevenoaks, Tonbridge & Malling, and Tunbridge Wells. The exception being Swanley (Sevenoaks district area) whose residents are predominantly registered with practices in the Dartford Gravesham and Swanley CCG area. The population figures for Sevenoaks below are based on 59.4% of the Sevenoaks population being registered in the West Kent CCG area. 1 As at 31 December 2016 Page 11 of 86

12 5.1 Population forecasts Population forecasts tell us that we should expect the resident population to grow from 476,497 to 562,040 between 2015 and 2035 this is an increase of 85,543 people (18.0% 2 ). The graph below details the population forecasts for each of the four district and borough council areas in west Kent. 5.2 Population demographics Population demographics will change significantly over the next 20 years, with an increasing ageing population, but also in diversity, particularly in town centre areas. The age profile of the West Kent CCG resident population is broadly similar to that of Kent; however, it has slightly lower proportions of people aged 20 to 29 years, and marginally higher proportions of people aged between 5 to 9 and 40 to 54 years (Source: ONS, 2015). Using resident populations for the districts of Maidstone, Sevenoaks, Tonbridge & Malling and Tunbridge Wells, the following changes are predicted between 2015 and 2035: 2 Z1: 2012-based Subnational Population Projections. Local Authorities in England, mid-2012 to mid-2037 Page 12 of 86

13 5.3 Deprivation and wider determinants Each district within west Kent has areas with poor health outcomes that are also the areas with high deprivation, poor levels of educational attainment, high in fuel poverty, poor air quality and high crime rates. This provides challenges as well as the opportunities for partner organisations to develop collaborative commissioning plans to address wider determinants that affect health outcomes. Nationally funded programmes are often available through districts to address the wider determinants, such as Warm Homes for energy efficiency, or Troubled Families programme for families with multiple problems. These programmes, if used effectively can reduce cost to the entire system, in financial and human terms. 5.4 Children and Young People Childhood indicators such as infant mortality and low birth weight babies are similar to the Kent average, although there is variation between wards. (Source:PCMD, PHBF, NHS Digital) Breastfeeding at six weeks is higher and smoking in pregnancy is lower than the Kent average (Source: KCHT, 2016/17 Q2-Q3). Snodland West ward is in the highest quintile of teenage conceptions in Kent. More children are placed in Kent County Council Foster care in west Kent rather than being placed into an independent fostering agency. Maidstone has two wards with high numbers of Gypsy and Traveller pupils; Marden & Yalding and Headcorn (Source: KCC MIU, Jan 2015). The gap in school achievement between those entitled and not entitled to free school meals is greater in west Kent than the Kent average, with those in poorer households achieving less in the education system. 5.5 Older people The highest rates of home care services for people aged over 65 are currently provided in Snodland East, Shepway South and Shepway North wards (Source: KCC Adult Social Care, ). With an expected increase above the Kent average of people over age 85 in Maidstone and Tonbridge and Malling, this picture could change, but will certainly place higher demand on services for both health and social care. 5.6 Urgent Care Locally there have been increases in the use of emergency services. Between 2013/14 and 2015/16: the number of A&E attendances at Maidstone and Tunbridge Wells NHS Trust has increased by 11.4% emergency admissions have increased by 4.9% ambulance conveyances have risen by 4.3% the average length of stay for an emergency admission has increased by 0.6 days to 7.4 days During this same period: the resident population in west Kent increased by 2.0% and Page 13 of 86

14 the number of people registered with a GP increased by just under 1.8%. Last year, the King s Fund 3 undertook the most comprehensive analysis 4 to date of demand and activity in general practice. This found that GP workload had grown both in volume and complexity, with the sample showing a 15 per cent increase in the number of consultations between 2010/11 and 2014/15. The system is seeing a significant rise in delayed transfers of care. This is where patients remain in hospital unnecessarily for a range of reasons, including delays in agreeing packages of care in order for a patient to return home, lack of suitable residential care, or limited provision of community hospital beds. The total number of bed days lost due to delayed transfers of care where: Maidstone and Tunbridge Wells NHS Trust was responsible for the delay has increased by 18.8% (+1,327) in 2014/2015 and by a further 1.4% (+114) in 2015/2016. Social Care was the reason for delay has increased by 398% (+1,030) in 2014/2015 and by a further 379% (+4,884) in 2015/2016. Patients that are delayed in hospital, particularly within the acute setting, remain in a place that is not appropriate for rehabilitation and where they risk catching hospital related infections, becoming institutionalised and increasingly dependent. Though the increase in emergency department attendances in west Kent is not as significant as the national picture there is still considerable pressure on the system due to: The fact society has changed, we have a right now society with very different expectations and that is able to use technology to access a variety of other services. Our sizeable frail and elderly population who often have multiple and complex health problems. It is estimated that the population over 85 years of age will increase by 22% (2,803) between 2015 and 2020 and by a total of 144% (18,048) between 2015 and In addition a high number of people are estimated to be living with undiagnosed conditions such as hypertension, diabetes, COPD, depression and dementia. This is likely to put significant pressure on the urgent care system and highlights why we must further develop our local care model - we are aiming to achieve not just more years but more years of quality life. 6 West Kent Health Profile Highlights 6.1 Life Expectancy In west Kent life expectancy is higher than the Kent average (82.9 and 81.8 years respectively) (Source:PCMD, ONS, SEPHO, 2011/15 pooled years) Over the last five years whilst the life expectancy has increased across the whole CCG area, it has increased marginally faster in the most deprived quintile 5 compared to least deprived quintile but there is still a gap of 11.9 years, between the poorest and most affluent areas within the CCG. 3 The King's Fund - Understanding pressures in general practice (May 2016) 4 Analysis of 30 million patient contacts from 177 practices 5 Five equal groups into which a population can be divided Page 14 of 86

15 6.2 Trends in Mortality The overall trend in premature mortality rates for cancer, circulatory and liver disease in west Kent is decreasing., but not so respiratory disease (Source: West Kent CCG Population Health and Wellbeing profile, KPHO, ) Of the Districts in west Kent, Sevenoaks had the highest excess winter deaths (Source: ONS, 2014/15). Fuel poverty is highest in Tunbridge Wells (Source: PHOF 2014). Venn diagram of mortality by cause Source: PCMD, ONS, prepared by: KPHO (LLY), 04/17 Based on 2011/15 pooled data. Numbers on diagram correspond to the ward numbers on the below map. Page 15 of 86

16 6.3 Trends in Morbidity Diabetes Recorded prevalence of diabetes in west Kent is 5.6% (2015/16); this is an increase from 5.51% in 2013/14. Prevalence in west Kent is lower than the Kent average of 6.4% but varies between practices. There is a moderate association between recorded diabetes and obesity. Additional risks of complications among people with diabetes are higher in west Kent than England and Wales, in particular heart failure, stroke, major and minor amputations and renal replacement therapy Asthma Prevalence of asthma in west Kent is the same as Kent at 5.5% (2015/16) but there is variation between practices ranging between 3.6% and 8.0%. Prevalence has however decreased slightly from 5.6% in 2012/13. There is no strong correlation between prevalence of asthma and hospital admissions Chronic Obstructive Pulmonary Disease (COPD) The prevalence of COPD in west Kent is 1.6% (2015/16) and is below the Kent average of 2%. Prevalence has increased from 1.4% in 2012/13. Modelling estimates large numbers of undiagnosed cases Coronary Heart Disease (CHD) Prevalence of coronary heart disease in west Kent is 2.7% (2015/16). This is lower than England (3.2%) and Kent (3.1%). Reported prevalence has reduced from 2.9% in 202/13 and modelling estimates that prevalence is significantly higher. There is an estimated undiagnosed hypertension prevalence of around 12% for West Kent CCG. (Source: PHE disease and risk factor prevalence) Cancer The recorded cancer prevalence in west Kent is 2.8%, an increase of 0.7% since 2012/13 (Source: QOF, 2015/2016). Recorded cancer prevalence ranges from 1.2% to 4.4% across west Kent general practices. Recorded prevalence is higher than England (2.4%) but similar to Kent (2.7%). Incidence in west Kent is similar to the national figure which would indicate that that more people are surviving cancer or being recorded as having cancer. The CCG had a local incentive scheme in 2015/6 for practices to audit their cancer cases and this may have supported the improved recording of cancer. Under 75 years mortality rate from preventable cancers in west Kent is significantly better than the national average (74.7 per 100,000 compared to national figure of 81.1). Past analysis has suggested that more than half of lung cancer hospital admissions in west Kent are emergencies, whilst only around a quarter of cases are diagnosed at an early stage (1 or 2) (Source Cancer Equity Audit - KPHO). West Kent is on par with national figures on 1 year survival rates for lung cancer and also for the percentage diagnosed at a late stage. Page 16 of 86

17 Right Care indicates that non-elective spend on lung cancer is better than England average. Lung cancer prevalence is among the best in England and incidence is relatively low. This may indicate that survival rates are improving in west Kent The FYFV update indicates that each cancer alliance will have a diagnostic hub for cancer within 2 years and the CCG is working with the Kent & Medway Alliance to develop a bid for funding such a hub. This will increase the number of people diagnosed at an earlier stage of cancer. There are more than 13,000 people in west Kent on cancer disease registers with their GP (Source: QOF, 2015/2016). The number of people who will survive cancer will significantly improve by 2030 and we can expect a continued rise in the number of people on cancer disease registers. Survivorship Initiatives for cancer care (e.g. annual reviews, self-management and community cancer nurse) are part of the CCG plan Learning Disability The prevalence of patients with learning disabilities was recorded as 0.36% for West Kent CCG for 2015/16 (Source: QOF, 2015/16). Recorded prevalence in 2013/14 was 0.37%. Mental health learning disability contact rates for those aged between 16 and 64 are highest in Harrietsham & Lenham, Park and Bridge. (Source: KMPT 2015). Analysis also suggests low uptake of annual health checks for those with learning disabilities in some areas Mental Health The prevalence of serious mental illness, as recorded by GPs, is marginally lower in west Kent at 0.75% than Kent (0.8%) and England (0.9%). Recorded prevalence has been between 0.7% and 0.75% since 2012/13. Bridge and High Street have the highest mental health contact rates for those aged between 16 and 64 with a mental health condition, with contact rates varying considerably across the CCG (from 5.9% to 60.1%) (Source: KMPT, 2015). Hospital admissions for mental health conditions are lower than the Kent average (Source: ONS MYE, SUS, 2006/07 to 2015/16). The prevalence of depression recorded by GPs for west Kent was 8.2% for 2015/16, which is also lower than the Kent average (8.5%), although there is a variance of 3.1% to 17.1% between practices Dementia The dementia prevalence in west Kent is the same as for Kent and England (0.8%) (Source: QOF 2015/16). This has increased from 0.5% in 2012/13. Referrals into memory assessment clinics continue to increase by approximately 405 per year and emergency admissions amongst west Kent residents aged 65+ with dementia codes as primary or secondary diagnosis have increased by 33% between 2006/17 and 2015/16 (Source: ONS MYE, SUS, 2006/07 to 2015/16) Falls Hospital admissions relating to falls are marginally higher in west Kent (2943 per 100,000 population aged 65 years and over) than in Kent (2848) (Source, SUS, 2013/ /16 pooled). Page 17 of 86

18 Falls hospital admissions amongst those aged 65+ have stabilised in west Kent over the last 2-3 years. 7 West Kent Local Care Model In our local care model the system is organised at four different levels General Practice, cluster, local care hubs and west Kent wide services. Each setting will offer a different combination of accessibility and scale this is important because different types of services require different userpopulation sizes and workforce models. Two of the levels GP Practice and west Kent wide services are already actively used. However, to ensure that we can deliver our local care model and meet the needs of the population through more co-ordinated and integrated care our general practices have recently formed into clusters and we are developing plans for local care hubs. We recognise that we need to work with the Clinical Commissioning Groups that border west Kent to understand interfaces and opportunities. Specifically this will relate to services provided through local care hubs and CCG wide services in other areas that may be closer geographically to people that live on the borders of west Kent. These different levels of care are set out below in more detail. 7.1 General Practice General practitioners (GPs) are the first and most frequent point of contact with the National Health Service (NHS) for most people in England. They provide a range of primary medical care services to those who are registered with them and act as gatekeepers to most other NHS services, referring patients to specialist care where appropriate. The public relies on general practice services for their health and wellbeing and that of their families but services are under increasing pressure both locally and across the country due to increased demand. This isn t just about the numbers of patients; the population s needs are more complex and people are living longer. In 2016 the King s Fund undertook the most comprehensive analysis to date of demand and activity in general practice. This found that GP workload had grown both in volume and complexity, with the sample showing a 15 percent increase in the number of consultations between 2010/11 and 2014/15 6. The increase in people with multiple long term conditions, frailty and complex social, emotional, medical and psychological problems can only be addressed by harnessing the holistic skills unique to a primary care team. To meet these challenges, primary care has to change. GPs need to work more closely with other professionals, leading multidisciplinary teams, managing patients who are more unwell and fostering joined up care. Overview of general practice in west Kent 7 : The number of people registered with a GP in the west Kent area is 484,460 patients 6 Understanding pressures in general practice - The King's Fund (May 2016) 7 Source: PCIS as at 31 December 2016 unless otherwise stated Page 18 of 86

19 There are 60 general practices located in the CCG area General practices operate out of 86 separate premises including branch surgeries Across the CCG area there are 318 individual GPs 8 registered to practices, however a number work on a part time basis and therefore this equates to 228 full time equivalent GPs working in the CCG area supported by locum GPs (Source: Health Education England KSS Workforce Analysis March 2017). The practice list sizes range from the largest with 19,739 patients to the smallest, where there are 2056 patients registered In % of people in west Kent rated their overall experience of making appointment at their practice as very good or fairly good, representing a decline of 2% since Strong and resilient general practice is the bedrock upon which our local care plans are being built and these are essential to serve the majority of health needs in west Kent. We will support our general practices to co-operate, collaborate and combine by encouraging practices to work together to deliver services at scale, and will support practice mergers where this makes sense for the practices and population. We will prioritise and consider investment in new general practice premises: for existing practices where there is an identified population need for new practices where merger or population growth would support a new list of over 8000 patients Our vision for general practice as part of the local care model is set out below: 8 Individual GPs include Partners, Salaried and Registrars 9 GP Patient Survey 2016 (Ipsos MORI) Page 19 of 86

20 7.1.1 Extending access in general practice The Next Steps on the NHS Five Year Forward View (5YFV) detailed Urgent and Emergency Care (UEC) as one of the NHS main national service improvement priorities. The NHS England Urgent and Emergency Care Delivery Plan (April 2017) provided more detail regarding the elements which will deliver transformation of urgent and emergency care. One of the priorities is extended urgent care access in general practice. The national plans for extended access expect that by March 2019 the public will have access to pre-bookable and same day, evening & weekend appointments within general practice; with coverage reaching 50% of England by March 2018 and 100% by March This means that urgent care appointments within general practice will be available 8am 8pm and on a Saturday and Sunday to meet population need (therefore no specific time set out). Extended access is not just about more appointments at different times of the day it must meet locally determined demand and support the wider transformation in general practice including a step change in our use of digital technologies and integrated service delivery as part of our local care model. General practices in west Kent currently offer appointments in hours (8am 6.30pm, Monday to Friday) with 54 out of 60 practices already offering some extended hours outside of core hours, including 11 practices offering appointments at the weekend. We will develop our extended access plans working with our seven general practice clusters and will learn from early adopter areas. We will seek to expand to include aspects of appropriate routine primary care provision and, utilising transformational funding, explore robust clinical governance processes to underpin at scale routine primary care provision. These schemes will exploit the use of a single clinical system and enable full implementation of 7 day urgent and routine primary care provision from October 2018 for the whole registered population (to mitigate potential inequalities of care). This 7 day primary care service will also integrate with the new OOHs and 111 services. Page 20 of 86

21 Our plans for general practice respond to the NHS England General Practice Forward View ((GPFV) April 2016). Our West Kent GPFV plan ( ) is provided in Appendix 1 and details our plans for investment, workforce, workload, infrastructure, care re-design, primary care quality, quality improvement and medicines optimisation. These plans are core to developing a strong and resilient general practice as part of our local care plans and feature throughout our local care plan. 7.2 Clusters Clusters are groupings of general practices that are working together to co-operate, collaborate or combine regarding delivery of services for their registered populations. Clusters are critical to the integration of out of hospital care - forming a bridge between the services available at an individual GP practice and those available in local care hubs or secondary care. As detailed in the NHS England General Practice Forward View it is becoming increasingly normal for general practices to work together at scale through networks or federations of practices. In west Kent we continue to support greater opportunities for practices to work collaboratively in larger groupings for the benefit of more sizeable populations, importantly though this allows practices to still maintain their unique identity and relationship with their own patients. Clusters will: Offer the opportunity to realise extended hours, more GP appointments, and enhanced primary care offer integrating teams of nurses and allied health professionals. Play a central role providing co-ordinated care and ensuring that primary care can realise the benefits of scale. Utilise and share the skills and expertise of their member practices to offer a wider range of services than single practices. Achieve efficiencies in back office functions Support estates efficiencies both in terms of better utilisation and cost Support a sustainable and resilient general practice There are seven clusters in west Kent covering populations of between 46,000 and 82,500. The table below provides a population breakdown by cluster. Page 21 of 86

22 7.3 Local Care Hubs A local care hub will be a building in the community enabling the delivery of a range of health and care services that: Don t need to be delivered in a hospital setting but need to be delivered to a population bigger than cluster level. Deliver services around frailty and other pathways which need a physical building. Depending on the exact services to be delivered from a hub and after appropriate modelling has been undertaken we will determine a minimum population size for a hub. This is to ensure a critical mass of services, with interdependency, can be co-located and that services can be delivered on a safe, cost effective and sustainable basis. Local care hubs will both deliver services and be used by clinicians and other professionals to deliver services in the community. Whist there may be some core services that are consistent across all hubs we don t anticipate that each hub will be exactly the same as the population need will determine the service model that s required. In the first instance we have worked with the key health providers that we currently commission services from and have undertaken an initial piece of work to define the characteristics, culture and environment and the potential range of services that could be delivered from a hub. As part of the next steps we will be working with a wider range of stakeholders, including progressing work with the county council and district and borough councils to further understand and identify shared opportunities between health, social care and public health. We will undertake detailed modelling using the potential range of services to understand the requirements and impacts and help inform where the hubs should be located. Where possible these hubs should utilise our Page 22 of 86

23 existing estate and provide ease of access for our population. The estates section (12.1) of our plan provides more detail regarding our approach to developing local care hubs. Some of the key principles informing our hub development are: enable delivery of a range of services in addition to the ones delivered at the cluster level and those that need not be delivered in a hospital setting. complement services delivered at practice and cluster level in delivering clinical pathways for different population segments. Co-location of accessible health, social care and voluntary sector Services designed around pathways for vulnerable groups (frail, mental illness, long term conditions, dementia) as part of a patient pathway continuum from clusters into secondary care. An eventual shift in patient expectation, viewing the hub as the place to attend for their first line health needs, not always secondary care. Infrastructure utilisation for non-core hours to maximise use of the assets. Measurable shift and impact on Secondary care (i.e. reduced outpatients taking place inside a hospital ) 7.4 West Kent wide services There are some services that form part of local care but that will continue to be delivered at scale across the west Kent area as a whole two key services are community beds and integrated urgent care services. Both of these services need to be delivered on a larger population basis to ensure a critical mass of safe and high quality services can be delivered round the clock on a cost effective and sustainable basis, specifically from a workforce perspective Community Beds A range of bed audits and assessments of patients whose discharge has been delayed indicates that implementing the new care model in west Kent will require a number of beds outside of a hospital at today s level of activity. To absorb growth over the next 10 years we will need to plan for additional beds. There is strong evidence to show that a patient should not be assessed for long term health needs in an acute hospital. There is also evidence that the provision of a short period of more intense rehabilitation after some hospital admissions can significantly reduce the ongoing needs of a patient, and sometimes the right place to assess and care for a patient is in their own home with a suitable package of care to support them. These community beds could therefore be in a step up / step down facility, a rehabilitation facility or the patient s own home supported by the care they need. The following beds are currently in the community: Hawkhurst Community Hospital (22 beds) - Unlikely to change in this period Page 23 of 86

24 Tonbridge Cottage Hospital (14 beds, with an additional 8 therapy led beds currently being piloted) - The current lease for the building expires in We plan to commence a programme of engagement and consultation around its future. Sevenoaks Community Hospital (18 beds) - A recent utilisation study has told us that the space in the buildings on the wider Sevenoaks Hospital site is only 34% utilised. We will look at options for beds at the Sevenoaks site as part of the process set out in section 12 of our plan. Edenbridge Community Hospital (14 beds) - A consultation process has been recently completed with recommendations being made to our Governing Body in the summer of As set out in section 12.1 of our plan we will undertake further work to model and define the requirements for community beds as part of the wider local care model Integrated Urgent Care The NHS Five Year Forward View (5YFV) explains the need to redesign health systems, including the urgent and emergency care services in England for people of all ages. It states that across the NHS, urgent and emergency care services will be redesigned to integrate between Emergency Departments (ED), GP out-of-hours services (OOH), urgent treatment centres (UTC), NHS 111, and ambulance services; highlighting the fact that services need to be integrated around the patient. Under this model, organisations would collaborate to deliver high quality clinical assessment, advice and treatment and work to shared standards and processes, with clear accountability and leadership. Currently the urgent care system in west Kent is complex, often fragmented with limited integration between the different sectors; acute, community, primary care and social care, and the services within those sectors. The ability of services to work together is one of the most important features of an effective healthcare system. When systems fail or patient safety is compromised, the inability of services to safely and appropriately transfer patients, or share important information, is often a key factor. It is vital to support clinicians to work together to ensure best care is delivered both within and across organisational boundaries. Once patients have been assessed as urgent we need to ensure there is an integrated approach to their care, particularly emergency medical admissions to hospital, involving hospitals, community, primary and ambulance services through joint service planning and sharing of clinical information across different agencies. Emergency departments also see significant numbers of patients who could be treated in a primary care setting. Patients are frequently admitted to hospital when this is not clinically justified because of a lack of alternative options. Poor sharing of information as patients move between different providers is also a cause of significant failures of care. Section 5.6 of our plan details some of the key facts and figures around use of and pressures on urgent care services. Emergency and urgent care need to be developed in primary care-led integrated pathways. This must be based on more extensive access to primary care through integrated in-hours and out-ofhours services, including multi-disciplinary UTCs. In summary, we need to change the urgent care system so that: The system is intuitive and helps people make the right decision; There are alternatives offered to emergency departments that provide timely clinical access for urgent care services close to people s homes Page 24 of 86

25 We focus our skilled resources in hospitals on the sickest patients and those with serious or life-threatening needs We reduce the pressure on our hard-working staff enabling them to provide higher quality care There is a much greater emphasis on patient education, self-care and signposting Technological solutions are fully exploited to facilitate an integrated delivery of care The diagram below sets out the future integrated urgent care services. As part of the local care model primary care will need to play an important role in meeting the urgent care needs of the population, both in terms of ease of access and treatment. There will be a renewed integration between in-hours and out-of-hours primary care services. This will improve the current fragmentation, allow a greater continuity of care and reduce unnecessary contact with emergency services, thus aiming to reduce hospital admissions. In addition the cluster level multi-disciplinary teams will be working to proactively manage and support patients at home and in the community to reduce how many times they are attending A&E or being admitted to hospital. However, if a stay in hospital is required a process from admission to discharge will be in place to minimise the length of time a patient stays in hospital and supports quicker patient recovery. The integrated urgent care service will be a key interface to the local care model ensuring that patients are directed to and supported by the most appropriate service. 8 Prevention A number of the health problems people face in Kent and Medway are preventable, and sometimes small changes can make a big difference. As part of the Kent and Medway STP we are Page 25 of 86

26 working together in improving health and wellbeing so people stay well, look after themselves, each other, and use services only when they need to. Our prevention programme will: effectively treat both physical and mental health issues at the same time concentrate prevention activities on key areas obesity and physical activity, reducing alcohol-related harm, preventing and stopping smoking deliver workplace health initiatives, aimed at improving the health of staff delivering services focus on making every contact count (MECC) utilising the day to day interactions that organisations and people have with other people to encourage changes in behaviour that have a positive effect on the health and wellbeing of individuals, communities and populations. 8.1 Lifestyle factors affecting health in West Kent: Alcohol Alcohol misuse contributes to stroke and hypertension, as well as rising rates of mortality related to liver disease. There are a number of alcohol related chronic conditions such as alcohol-induced pancreatitis, chronic liver disease and stomach cancer which all lead to reduced health and wellbeing and at worst, loss of life. Across England, 31% of men and 16% of women drink over the current low-risk guideline of 14 units per week (Source: Health Survey for England, 2015). The highest numbers of licensed premises in west Kent are restaurants and cafes, most densely found in town centres. Although there appears to be higher admissions for obesity or alcohol related conditions from these areas, this is more likely to be due to deprivation as analysis shows no correlation Obesity, physical inactivity and diet Obesity can contribute to a range of health conditions such as hypertension, type 2 diabetes and heart disease. An estimated 63.4% of adults in the West Kent CCG area have excess weight (Source: Active People Survey, Sport England). In west Kent 8.4% of reception year pupils and 15.7% of year 6 pupils are obese (22.4% and 29.0% respectively have excess weight) (Source: NCMP, 2015/16). People who have a physically active lifestyle have a 20-35% lower risk of cardiovascular disease, coronary heart disease and stroke compared to those who have a sedentary lifestyle. Regular physical activity is also associated with a reduced risk of diabetes, obesity, osteoporosis and colon/breast cancer and with improved mental health. Inactive people are at the highest risk of developing disease conditions as a result of their low levels of physical activity. Levels of physical inactivity in west Kent have improved since 2012 (previous range from 20 27%) and remain below the county and national average level of physical inactivity. The levels of physical inactivity are reported as 10 : o Maidstone 24.2% o Sevenoaks 19.6% 10 Public Health Outcomes Framework, 2.13ii - The percentage of adults classified as "inactive" Page 26 of 86

27 o Tonbridge and Malling 24.2% o Tunbridge Wells 24.4% Around three-fifths of adults in west Kent meet the recommended 5-a-day fruit and vegetable consumption on a usual day, which is higher than the Kent average. (Source: Active People Survey, Sport England) Smoking Smoking is a major cause of lung cancer, cardiovascular disease and chronic obstructive pulmonary disease (COPD). Smoking also contributes to many other cancers and conditions, such as high blood pressure. It is estimated that around 15% of adults in the west Kent area smoke ranging from 13.2% in Maidstone to 15.6% in Sevenoaks. The west Kent prevalence is below the current Kent wide estimated prevalence of 17% and has reduced from an estimated 17.5% in 2012.(Source: Public Health Outcomes Framework, Smoking prevalence in Adults (current smokers, Annual Population Survey 2015) Despite a service provider success quit rate of 54% (3% above the national average) in Kent, fewer people are accessing stop smoking services. 8.2 Working with our District Councils We work in partnership with the District and Borough Councils, Kent County Council and Health and Wellbeing Boards to improve the health and wellbeing of the local population. District and Borough Councils are in a unique position to help Kent County Council s Public Health team to deliver the health agenda. They are close enough to their communities to understand how they work and how best to reach and support them. The recent Kings Fund report outlines opportunities for District and County Councils, working together holistically with health services, to deliver the public health agenda. It states District Councils are in a good position to influence many factors of good health through their key functions. We work closely with four district and borough councils. Three of the councils are working in partnership as the West Kent Councils Sevenoaks District Council, Tunbridge Wells Borough Council, Tonbridge and Malling Borough Council. Maidstone Borough Council is working in partnership as part of the North Kent Councils with Swale Borough Council, Dartford Borough Council and Gravesham Borough Council West Kent Councils Using a coordinated partnership agreement, West Kent Councils have developed a ten point enhancement plan as part of a West Kent District Health Deal. The Deal recognises councils can provide vital components which make significant contributions to improving and sustaining the health and wellbeing of local people. This demonstrates the need to invest in prevention now in order to generate considerable savings for health commissioners in the future and uses their extensive partner and community infrastructures to achieve this through a single point of access to services in the local area. Page 27 of 86

28 Through a coordinated partnership and a range of district council core services such as housing, planning, environmental health, leisure and community safety, this work not only supports local people to make healthier lifestyle choices such as stopping smoking, being a heathier weight, they will also receive a holistic assessment to support them to tackle the root causes of complex issues including debt, housing, unemployment and social isolation, many of which may be contributing to unhealthy behaviours. This work demonstrates effective partnership working to address issues relating to wider lifestyle, social, environmental and economic factors can make a significant contribution to the wider health agenda and improving health longer term North Kent Councils Maidstone Borough Council, as part of the North Kent Councils, are working with Kent County Council Public Health to systematically integrate health including through all policies and wider service provision aligning itself to the prevention strand of the STP. This Partnership approach is looking at promoting the following outcomes and priorities: - Reducing Health inequalities - Increasing health lifestyle choices - Creating Healthy communities - Embedding health in all policies approach The North Kent District Health Deal will see a range of activities developed to deliver each of the above outcomes. Examples of activities that will form part of the model include social prescribing, holistic assessment, provision of indoor and outdoor leisure facilities, neighbourhood action plans, green open space in new developments, workplace health initiatives, and increasing the integration with general practice and other health professionals. We will work closely with Maidstone Borough Council to support the development of the model and the activities that are core to supporting the local care model. 9 Self-care The ability to live with my condition in my own way, with the best possible support and information so I can make my own medical and lifestyle choices: my life, in my hands, with the best possible support to help me Page 28 of 86

29 Self and community supported care includes key components of prevention and self-care which are imperative for successful implementation of our local care plan. Through patient participation and engagement with our local communities we have developed a Self-Care and Self- Management Strategic Delivery Plan with self-care at the heart of the new system, with more people and their families being supported to manage their own care and long term conditions. Our strategy considers all three categories of prevention namely primary, secondary and tertiary prevention and at the heart of it will be self-care and self management and including more personalized, preventative services delivering the best outcomes. Primary prevention - This is aimed at people who have no symptoms of illness or particular social care needs. The focus is on maintaining good health, independence and promoting wellbeing. Secondary prevention - This aims to identify people at risk of disease and to halt or slow down any progression or promote an intervention to seek to improve their condition or situation. Tertiary prevention - This is aimed at minimising disability or deterioration from established health conditions or complex social care needs. We firmly believe that to achieve the necessary transformational change local populations need to be involved in decisions relating to their health whenever possible with clinicians seeking to understand patient agendas and desired outcomes. People must be supported in taking more responsibility for their health and in caring for themselves and their families, and also in using services appropriately. We have worked with local residents and developed a local definition of self-care (detailed at the start of this section). Social prescribing (sometimes known as community referral) is a way of linking primary care clients with psycho-social issues, with sources of appropriate, non-medical support in the community and has been described as having the potential to improve mental health outcomes, reduce demand on statutory services, improve community wellbeing and resilience and reduce social exclusion. Social prescribing can be for such risk groups as; people with mild to moderate depression and anxiety, low income single parents, recently bereaved older people, people with long term conditions and frequent attendees in primary and secondary care. A variety of activities are offered within the community for people to attend such as arts and creativity, physical activity, learning and volunteering, mutual aid, befriending and self-help, as well as support with benefits, housing, debt employment, legal advice or parenting. We will use education events to promote and explore both social prescribing and application of making every contact count by all health professionals. We need to ensure we tackle the barriers that prevent self-care, such as social isolation, housing, energy costs, by engaging with districts, voluntary sector and supporting agencies that are often able to offer advice, guidance and often practical support. As already described in section 8, we will continue to work with district councils, Kent County Council, Citizens Advice Bureau, voluntary and community sector and social care to improve services and service integration and to align health improvement services with clinical and care services to ensure pathways are fit for purpose and cover prevention, early intervention together with secondary and tertiary prevention. We will continue to identify community assets (i.e. buildings), and work with the voluntary sector to build Page 29 of 86

30 capacity, using groups and initiatives such as dementia friends to build awareness and support for vulnerable and isolated people living with long term conditions. 10 Quality Improving the quality and safety of services, providing better health outcomes for our patients and a more positive patient and carer experience underpins all of our work. Quality is the thread that runs through the design and delivery of all aspects of healthcare activity and will remain so as we develop and deliver the local care model. We will use a robust and consistent process to ensure that all commissioned services are high quality and safe; are accessible to all patients and deliver excellent outcomes and experience. The process will involve the gathering and interpretation of intelligence to inform routine, targeted or supportive quality assurance visits to services. These will lead to the sharing of best practice and innovation across providers, commissioners, the local authority and other stakeholders. Where it is identified that improvements are required we will support and monitor progress. We will continue to work closely with patients, families and carers to co-design and co-produce services that are sustainable, innovative, reflect best practice and incorporate learning. Our approach to improving quality, innovation, productivity and outcomes is to utilise the clinical microsystems framework. This quality improvement programme is offered to healthcare providers within our CCG area. Each clinical microsystem is facilitated by an improvement coach who holds a recognised qualification from the Microsystem Academy. Coaches use a range of tools and techniques targeted at delivering improvements in an area chosen by the provider. The framework includes the use of well recognised and tested tools such as lean, and PDSA plus measurement tools to improve both services and outcomes. The inclusion of patients in co-designing these outputs is an essential ingredient. Microsystems will be used to drive improvement during the transformation of services to deliver the local care plan. 11 Pathways and interventions We have set out above how our local care system is organised at the four different levels General Practice, cluster, local care hubs and west Kent wide services. The services delivered will comprise of physical and mental health services, integrated urgent care, specialist medical services and community beds. The care delivered within our model will be either proactive care - preventing and actively managing or reactive care - responding to a new or existing healthcare issue. It is not our intention to detail all pathways and interventions in this local care plan as the detail is set out in our operating plan and is being developed as part of individual strategies and plans. Set out below is a summary of our key commissioning programme areas that will form part of the local care model (in addition to prevention, self-care and urgent care already described in earlier sections). As we continue to develop these individual plans we will be clear about how they fit into the local care model along with the outcomes and benefits and seek inputs and feedback from patients, carers, public and our wider stakeholders. Page 30 of 86

31 Through the local care work stream of the STP we have a picture of how different groups or segments of our population interact with the healthcare system we have this information at both a west Kent and cluster level. The population has been segmented, stratifying the population by age and condition, based on the Kent Integrated Data (KID). This information provides us with a framework to support our discussions as we develop our local care model and allows us to explore how people interact with the system today and where the biggest opportunities lie to improve care and use resources more efficiently. The table 11 below details how many people are within each segment, the total spend and spend per head. From the table above we can see that: 153,000 people with 1 3 chronic conditions access services equating to million of our total spend, this ranges from 953 per head (0-15 age group) to 1512 per head (over 70 year age group) 53,000 people with 4 or more chronic conditions access services equating to million of our total spend. This ranges from 2,785 per head (16-64 age group) to 4,422 per head (over 70 year age group) This segmentation analysis has driven the initial focus of the emerging Local Care model across Kent and Medway to consider how to improve services for adults with complex conditions Medical, Long Terms Conditions and Frailty Commissioning Medical and Long Term Conditions The Five Year Forward (5YFV) notes that long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the longer term rather than providing single, unconnected episodes of care. 11 Notes:KID data covers 54% of population and 30% of spend for scope area. Populations have been scaled to account for population registered to practices not flowing data into the KID. Spend has been scaled to match CCG data returns to account for data not included in the KID (e.g. non-pbr acute activity). Children s social care, CAMHS, prescribing costs and continuing care costs are not included. People registered to GP surgeries which flow into KID but had no activity in 2015/16 have been added to mostly healthy segments. KID data quality issues cause some people with long term conditions (incl. physical disability and SEMI) to be categorised erroneously as mostly healthy, artificially raising those segments spend and populations. Source: Kent Integrated Dataset; Carnall Farrar analysis; latest version as of 31/03/2017 Page 31 of 86

32 This is particularly important in supporting the increasing numbers of people with more than one long term condition, helping people with long term conditions to live well, age well and die well. Through our medical and long term conditions programme we are working collaboratively with our local community and hospital providers to focus on clinical pathways in specific conditions as well as utilising the cluster multidisciplinary teams around the patient for delivery of proactive, coordinated care. An area of particular focus is diabetes, where we are pursuing a whole system approach that sees reconfiguration of currently hospital based level 3 diabetes services to include local primary care services under a single integrated level 2 and 3 service model. This new hub and spoke model is to be provided by current local secondary and primary care providers in order to maximise local knowledge, ensure access to the complete patient record and minimise any delay in implementation End of Life Care End of life care affects us all, at all ages, the living, the dying and the bereaved. Adults, young people and children with advanced life limiting illnesses and their families should expect good end of life care whatever the causes of their condition. The vision for care of these people draws upon the wishes of those with bereavement experience and seeks to ensure a personal experience of end of life that is as good as possible. Deaths in usual place of residence (which combines people s own homes and care homes) are recognised as one of the main markers of quality in end of life care. Survey data suggests that many people would, given a choice, prefer to die at home and few wish to die in hospital. I can make the last stage of my life as good as possible because everyone works together confidently, honestly and consistently to help me and the people who are important to me, including my carer(s). The above statement was created with extensive input from the widest range of individuals and organisations. It is based on existing literature, bespoke research and the engagement of people with experience and reflects our ambition in the end of life programme. In 2008 the Department of Health published The National End of Life Care Strategy 12, and since then there have been annual reports on activity around the country. Our local strategy is aligned to this well-researched document. Various threads of the national strategy are reflected in our local strategy. When the end of life is in sight everyone should have the care and support to enable them to live to the end in the best way that they can. To realise this vision we have adopted the eight foundations set out in the Ambitions for Palliative and End of Life Care: A National Framework for local action produced by the National Palliative and End of Life Care Partnership. These foundations are the pre-conditions for delivering the rapid and focused improvement that 12 End of Life Care Strategy: Promoting high quality care for all adults at the end of life Page 32 of 86

33 we seek and include individualised care planning, shared records, Involving, supporting and caring for those important to the dying person, education and training and 24/7 access Frailty The aims of our frailty programme are to provide the best possible quality and experience of care for people who are frail and their carers, enhance quality of life, optimise independence and reduce unscheduled care episodes. We are working collaboratively with other commissioners to ensure that the system becomes more reliable, responsive and integrated, able to provide robust care for the frail in the most appropriate setting. Plans are in place to develop and deliver a coherent, integrated, multi-disciplinary service designed to deliver care across traditional organisational boundaries. This will support and add value to patient care and experience using primary, secondary, community and social care provision to ensure needs are managed in a holistic and integrated way Care Homes In line with our frailty strategy we are undertaking a significant programme of work in relation to our local care homes. NHS England: New Care Models The framework for enhanced health in care homes (2016) was co-developed with six vanguards and illustrates evidence based interventions designed to be delivered in a coordinated manner to make the biggest difference to residents. Principles of a successful enhanced health in care homes care model include: Person centred change Co-production Quality Leadership Page 33 of 86

34 Our local strategy is aligned to this well-researched document. Various threads of the care models are reflected in our local strategy. The vision is to develop a sustainable framework for care home support in west Kent, which provides high quality, person centred care appropriate to the needs of the resident. This will be achieved with enhanced primary care support, reablement and rehabilitation services and multidisciplinary support including coordinated health and social care. The key enablers to achieving this will be a trained and competent workforce, joined up commissioning and collaboration between health and social care and enhanced use of data, IT and assistive care technology Falls Falls and fall-related injuries are a common and serious problem for older people, which require evidence based rehabilitation and preventative strategies. Delivery of an integrated and holistic falls prevention model is essential for the successful management of those who have fallen and/or are at risk of falling. We intend to achieve this with a suitable community falls prevention service that has a joined up pathway between primary, secondary and community care. The successful management of falls prevention requires a whole system approach to have an impact on outcomes across all care settings. We are working to develop a model that it will improve patient outcomes, quality of care and make better use of resources. We intend to achieve the following objectives through developing a model in 2017/18: An integrated falls prevention model with a range of stakeholders that supports the identification, management and prevention of falls; A seamless falls prevention pathway for patients in west Kent in accordance with clinical best practice; Single point of referral for health and social care professionals; Comprehensive, multidisciplinary falls prevention assessment and access to wide ranging interventions, appropriate to the needs of the patient (incl. home hazard assessment and strength and balance training); Improved access to at risk groups (housebound and care homes) with tailored falls prevention interventions and care planning; Improved patient engagement and adherence to falls prevention interventions to ensure best possible outcomes; Supported patient education to reduce risk and fear of falling (ongoing strength and balance programmes, education and care planning) Improved patient and stakeholder awareness of intrinsic and extrinsic risk factors associated with falls; Improved collaboration with stakeholders to ensure high quality referrals, effective care and discharge planning; Page 34 of 86

35 Provision of post discharge care planning for prevention of reoccurring falls, quality improvement and effective service monitoring; A commissioned service which delivers improved patient outcomes and experience Multi-disciplinary Teams (MDT) A key component and way of working for local care in west Kent is the establishment of new multi-disciplinary teams at cluster level. A multidisciplinary team (MDT) approach provides individuals with care and support needs with access to the right care when they need it. The MDT improves the care of complex conditions by making full use of the knowledge and skills of team members from multiple disciplines and service providers, including primary care, community health services, acute care, social care, and other specialist advice. The MDT approach also ensures that people with complex needs have access to expert advice. The principal function of a west Kent MDT will be to provide preventive care and reactive support to patients by developing a comprehensive care plan and coordinating the right care for the individual. The above diagram illustrates the proposed composition of the multi-disciplinary team, which will comprise of core disciplines including a health and social care coordinator, community nurses, complex care nurses, social services, GPs and mental health / dementia workers as needed. Research demonstrates that the most successful examples of integrated care and the facilitation of multi-disciplinary teams have been those that identified a designated care co-ordinator. The King s Fund identify the role of the care co-ordinator as being fundamental to the successful delivery of integrated care and better long term outcomes for patients and users of services 14. The creation of cluster MDT teams in west Kent is being undertaken in two phases. Phase one was the collaborative development and implementation of the service specification for a core cluster 14NHS England, MDT Development working toward and effective multidisciplinary/multiagency team, 2014 Page 35 of 86

36 level team in west Kent focussing on prevention and planned care covering five main areas: frailty, long term conditions, end of Life, dementia and mental health. Phase two will be the development of a supra-core service specification including pharmacy, therapy and other services. During 2016 we developed, through a collaborative approach with commissioners and providers, a service specification that we are now implementing. Through our collaborative approach we are starting a programme of rolling out the new way of cluster working on a cluster by cluster basis throughout We will continually review and receive feedback and learning on the new way of working from staff and patients to ensure that we evolve and enhance the model to meet the needs of our patients. Our progress to date includes: Standardised evidenced based, IT enabled MDT process for clusters, roll out beginning July 2017 Training for all west Kent community nurses and rapid response teams to detect frailty and undertake a comprehensive assessment with other MDT members Dementia pilot in one cluster with early data demonstrating 50% of new dementia diagnosed and managed in community instead of secondary care Clinical Microsystem coaching for cluster teams will support all parties in this integrated working model Our cluster team model aligns to the Kent & Medway clinical model for adults with complex needs. This model has eight interventions that all form part of our local care model and are at various stages of development or implementation locally. The eight interventions are: Page 36 of 86

37 11.2 Children & Maternity Children The Five Year Forward View sets out the key aim of ensuring that children get the best start in life. This ambition is shaping our transformation programme for children and maternity services, underpinned by the Kent Health and Wellbeing Strategy priority areas to: Tackle key health issues where Kent is performing worse than the England average Tackle health inequalities Tackle the gaps in provision Transform services to improve outcomes, patient experience and value for money Underpinning the principles of the Five Year Forward View is a legislative framework, with supporting regional strategies, which define the statutory requirements placed on Local Authority and CCGs. These include the Health and Social Care Act 2012 placing a duty on CCGs to ensure that health services are provided in an integrated way and the Children and Families Act 2014 introducing new duties for children and young people with special educational needs/disability up to the age of 25. Locally a significant proportion of healthcare for children is currently provided within an acute setting and this is demonstrated in the steady increase in referrals across all points of delivery within the paediatric speciality. Many of these children and young people do not need to be seen within costly secondary care structures and can be effectively and safely looked after in a primary care setting with appropriate community services managed through clusters and local care hubs. The implementation of new pathways accompanied by a robust infrastructure can help facilitate care within a local setting. The Children s Delivery Plan outlines our commissioning intentions. We are working with Kent County Council to explore opportunities for joint commissioning across health, education and social care to address the needs of the child and their family in an integrated and holistic way with a view to developing an integrated commissioning plan Maternity The National Maternity Review, Better Births (2016) sets out a clear vision for maternity services over the next 5 years across England to become; safer, more personalised, kinder, professional, more family friendly, where every woman has access to information to enable her to make decisions about her care and where she and her baby can access support that is centred on their individual needs and circumstances. There is a focus within this to halve the number of stillbirths, neonatal death and brain injuries by Providers, commissioners, public health and other stakeholders of maternity services have formed a Kent & Medway Local Maternity System (LMS) which will plan, design and deliver local services as a way of reducing variation between services and improve outcomes. This will be based on the vision of the Maternity Transformation Programme in which there are five key drivers for safer maternity care: Focus on strong leadership for maternity systems at every level. Page 37 of 86

38 Focus on learning and best practice. Focus on teams including promoting multi-professional team working. Focus on data-improving, data collection and linkages between maternity data and other clinical data sets. Focus on innovation. As part of the Local Maternity System work, one of the aims will be to enable more women to give birth in a midwifery led setting based out of hospital as a way of improving outcomes and bringing care closer to home. The Kent and Medway Local Maternity System are currently working on a draft transformation plan which is due to be submitted to NHS England in October Mental Health Mental Health is a specific work stream formed as part of the Kent & Medway STP. The new model of care promotes prevention, self-care and early intervention and integrates physical and mental health services to treat the whole person and aligns with NHS Forward View 5 year planning requirements. We are working to review and refresh our community mental health team model within as part of the cluster model. The vast majority of mental health care is currently provided within secondary care. Many patients do not need to be within costly secondary care structures and can be effectively and safely looked after wholly in primary care. The redesign of mental health (MH) provision within local care and improvements within liaison services for urgent care provides both considerable challenges alongside opportunities including improved outcomes and better value for money. New pathways are required to facilitate and deliver mental health provision and the emerging teams within local care and meet the agreed specifications. Collaborative engagement is ongoing to facilitate the development of local care MH clinical teams. The Mental Health Crisis Concordat sets out the case for change, the four principles and four domains around which outcomes should be designed and measured. These are: access to support before crisis point; urgent and emergency access to crisis care; quality of treatment and care when in crisis and recovery and staying well/preventing future crisis, these care principles form part of the new cluster model. Considerable redesign is also required of urgent and crisis services to meet the requirements of Five Year Forward View. This includes the formation of Crisis Resolution Teams (CRT) and Home Treatment Teams (HTT) that will function in local care enabling more patients to stay at home when unwell. People facing a crisis should have access to mental health care 7 days a week and 24 hours a day in the same way that they are able to get access to urgent physical health care. Good liaison mental health care is also needed in acute hospitals across the country, including Maidstone and Tunbridge Wells NHS Trust (MTW) in west Kent, providing a 24/7 urgent and emergency mental health response for people attending A&E or admitted as inpatients to acute hospitals. We commission KMPT to provide Liaison Services at the two MTW sites. As a system we have recently bid to increase the service at Tunbridge Wells Hospital to a 24-hour service. Page 38 of 86

39 West Kent experiences significant levels of demand for mental health services in excess of current capacity. This is often manifested in the need to send service users significant distances from home when they need treatment in a crisis. This is not a sustainable position. We must change our model of care and deliver services that promote wellbeing and enable people with a mental health problem to live in their own community with access to care closer to home. We must operate across organisational boundaries, to deliver care in a more effective manner and to work more collaboratively in partnership with community and voluntary bodies and to work in a more integrated way with primary and community health services. To be sustainable, mental health services need to consider future function outside the current MH delivery structures and in particular ensure MH and associated professionals can care for patients within local care footprint accessing supervision and specialist advice Planned Care As set out in the NHS England Five Year Forward View one of the greatest opportunities for increasing efficiencies in the NHS is the reduction of unwarranted variation in care. Across the NHS there are very large variations in the number of people seeing a GP, being referred to hospital and receiving operations that are not explained by clinical need alone. In a financially constrained system, unnecessary care given to one patient results in needed care being denied to another. Through our planned care programme we are already working collaboratively with our local community and hospital providers and will be increasing our work to reduce this variation through a focus on clinical pathways and better use of technology. Optimising outpatient and elective pathways is identified as a priority area for the local care model in Kent and Medway. One of our priority areas is MSK (Musculoskeletal) related conditions. We know that approximately 7.5% of our budget is spent on MSK related conditions and that the rate of referrals to orthopaedics is much higher than the national average; we have therefore developed a strategy for MSK to support the delivery of an integrated MSK service. Through a multi-disciplinary Clinical Decision and Management Unit (CDMU) a single point of access for clinical triage and navigation will exist for all MSK referrals ensuring that patients are seen in the right place, at the right time, by the right person. Patients with MSK conditions will routinely be managed in a community setting wherever possible as part of the local care model with referral to secondary care only when appropriate. Pilot projects have been carried out for patients with hip, knee and back pain where a patient is assessed by a team of skilled professionals. The learning from this has informed the further development of the MSK strategy. As a single point of access for patients with MSK conditions, the CDMU will be able to identify those requiring additional, non-medicalised support from Health and Wellbeing services locally (including weight management, smoking cessation and support with adaptations in the patient s home). This provides a more holistic patient pathway, addressing the whole needs of the patient. As part of our collaborative approach to transforming outpatients we will continue to work with community and hospital providers to identify further opportunities for improvements to clinical pathways. We will fully utilise available benchmarking tools, such as Rightcare, as part of this work. Our focus on clinical pathways will also allow us to identify where it may be more Page 39 of 86

40 appropriate for care to be provided outside of a hospital setting and closer to home, for example in a local care hub. In line with the Kent and Medway local care model for adults with complex needs we will ensure that primary care professionals can access a specialist opinion in the community setting and rapid access to diagnostic services (diagnostic test and result). This will enable clinical decisions to be taken with the patient regarding their ongoing management in the community thereby avoiding un-necessary outpatient appointments and admissions to hospital. Technology is a key enabler and the digital section of our plan (Section 12.3) provides information on e-referrals and advice and guidance services that support this outpatient transformation programme and local care model. We will continue to work with providers to identify further opportunities to embrace information technology tools and techniques to support improvements in clinical pathways and where appropriate a reduction in face to face appointments. 12 Enablers to delivering the local care model Accommodating the local care model (out of hospital services) through an increased volume of activity in primary and community settings and ensuring the primary and community care estate meets quality standards and enables new ways of working is a complex task. It will require major change in three main areas - workforce, extended use of technology (digital) and estate. This section of our plan looks at the detail of these areas and what we need to consider and do Estates Background The existing healthcare estate in west Kent exists at the two main acute hospital sites at Maidstone and Pembury, four community hospital sites at Sevenoaks, Edenbridge, Tonbridge and Hawkhurst, a number of other sites owned or leased by community health providers and 86 separate general practice premises. A range of services are delivered from these sites although services are mainly delivered in silos and not as part of a co-ordinated, integrated and co-located model. The CCG already meets the costs of running much of the healthcare estate in the west Kent area, either directly at the CCG offices, or indirectly through commissioned service contracts. Estates running costs represent the third largest cost to the NHS after staff costs and medicines. Better use of the estate will enable significant savings for potential reinvestment in patient care. We know that west Kent population forecasts estimate an increase of 85,500 (18%) people between 2015 and This would mean an estimated resident population of around 562,000 by These forecasts are informed by the overall housing requirements of each of the district and borough councils and the overall requirements are informed by the objectively assessed need (OAN). Page 40 of 86

41 We are working closely with the district and borough councils to ensure existing Section (S106) planning contribution commitments linked to new housing developments support the healthcare infrastructure. It should be noted that S106 is currently being replaced by Community Infrastructure Levy 16 (CIL) as the means to fund community infrastructure. S106 / CIL funding could be used to upgrade or extend general practice premises to ensure the practice can meet the demands in population growth, funding towards local care hubs as a strategic healthcare facility for a population or the provision of land to build a new healthcare premises/hub. Our plan Estate is an enabler, not a driver of service delivery. Our local care model requires local estate infrastructure that enables: High quality sustainable estate meeting the needs of the growth in population Safe, appropriate and value for money settings for the provision of care New ways of working, including Integration and co-location - primary, secondary, community, mental health, social care, broader public sector and voluntary sector, improving patient care and outcomes Flexibility to adapt to changing demand and models of provision Use of technology to support wider service transformation Supports and aligns to the Kent and Medway STP and One Public Estate In addition, the key principle implicit to developing our estates options is that existing sites, and those sites currently agreed for building, will be assessed for suitability before building any new sites. The three areas that we will focus on in our estates plan are general practice premises, community beds and local care hubs. Existing general practice premises are variable in terms of condition and suitability for longer term provision. We have already supported five practices to take forward building projects to ensure they can deliver sustainable services for the growing population. We will continue to work with individual general practices and clusters to develop sustainable premises solutions for longer term delivery; this will also include working with other healthcare providers and district and borough councils to identify shared opportunities such as co-locating general practices with other services (health and non-health) within a local community. 15 Section 106: planning obligations tied to a legal agreement, which are site-specific or within a defined area. 16 Community Infrastructure Levy: flat rate charge that developers pay, in line with a Local Authority s Charging Schedule Page 41 of 86

42 Community beds - As detailed in section we believe that there is a requirement for a number of beds outside of hospital at today s level of activity and these could be provided in a step up / step down facility, a rehabilitation facility or the patient s own home supported by the care they need. Local care hubs (as described in our local care model) do not currently exist. As detailed in section 7.3 depending on the exact services to be delivered from a hub and after appropriate modelling has been undertaken we will determine a minimum population size for a hub. Whist there may be some core services that are consistent across all hubs we don t anticipate that each hub will be exactly the same as the population need will determine the service model that s required. To respond to these requirements we have started a collaborative process to define the services that might be provided in a local care hub, supported by existing pathway redesign and commissioning plans. We will undertake detailed modelling (including service activity and population need) to help us define the service model and determine the space requirements. In parallel we are undertaking a baseline review of existing estate in order to understand current service utilisation, condition and suitability of estate and to ensure that it complies with all healthcare standards and codes of practice. This includes using information that already exists or undertaking surveys to provide the baseline. We expect the baseline review to be complete by autumn Alongside developing a clear plan for general practice premises, the work described above will enable us to articulate specific options for local care hubs and community beds using existing or new estate. This will enable us to also make a clear case for targeting strategic investment and disinvestment in new or existing estate across west Kent. As part of this process we will need to consider the following: How many hubs can be supported economically? What number of hubs makes sense for the number services and appointments? Which configuration of hubs covers an area that is easily accessible to patients? How many hubs can be safely staffed? Which location can we use pragmatically? Without estate transformation, it will be difficult to deliver a successful model of local care. In some cases local estate may be enhanced, moved or rebuilt, but for this to be considered a viable option the estate in question must meet our estate requirements, be able to meet standards and facilitate delivery of our new model of care. Investment in new estate will be considered where suitable existing premises cannot be identified. We know that significant capital investment will be required to get what we need and we will need to produce a business case that shows that we have undertaken a full options appraisal. To guide the estate transformation process and investment/disinvestment strategy we are in the process of developing a set of strategic criteria against which all estates options will be assessed. We don t yet have a reliable estimate of the exact size of estate we will need over the next 10 years to deliver our new model of care, but we can apply rigorous modelling techniques and clear methodology to existing data and estimates of predicted activity, to understand how significant Page 42 of 86

43 our estate transformation needs are and what might be the most appropriate way to meet these needs. The next step is to develop a detailed estate plan that covers general practice, community beds and local care hubs, the modelling and baseline estates exercises and the strategic criteria against which we will assess options. This will be developed and supported through the whole system West Kent Local Estates Forum Workforce, Education and Training The workforce is the means of delivery of all aspects of service in the NHS. The workforce is the NHS s greatest asset and at its best is able to deliver world class exemplary care. The current financial challenges are paralleled by shortages of clinicians and other staff in most areas of the health and social care system who commonly describe fishing from the same pond as they compete for staff. Workforce is as a key enabler for delivery of the transformation plans and requires a collaborative system wide approach through the K&M STP. The objectives of the K&M wide work are: Develop a fit for purpose infrastructure for workforce scheduling and planning assurance across K&M, particularly to support new care models Undertake an Organisational Design (OD) programme of work to ensure system leadership and talent management is in place to support the STP Analyse demand and projection of supply to support potential safe service and rota arrangements in K&M Develop a K&M Medical School for both undergraduate and post-graduate education Increase supply and develop specific roles in K&M proactively e.g. paramedic practitioners; dementia care workforce; pharmacy in community and primary care, physicians assistants Primary Care There has been an awareness of the escalating recruitment and retention challenges and the ageing workforce in general practice for several years and recognition that without alternative ways of addressing increasing workload, capacity for meeting demand will come under increasing strain as is already occurring in many parts of the country. This has led to a renewed focus on how to address access issues, to new strategies for smarter working by individual practices and to exploration of how to bring other disciplines into the general practice workforce. West Kent is still in a relatively strong position compared with other areas of the county where recruitment is proving extremely difficult. Standards of general practice have been traditionally high and up until the recent past there have been few vacancies although numbers of applicants for GP and practice nurse posts have been rapidly diminishing. Increasingly practices are reporting clinical vacancies with practice nursing capacity being a greater risk. The local GP training schemes have been full although this is a reflection of proximity to London and many trainees return to their homes in the London area once qualified. We need to find a way of supporting people who want to come and work in west Kent. Page 43 of 86

44 Health Education England (HEE) is responsible for workforce planning and aspects of staff training. They have sought to respond to the current primary care workforce context in several ways. The HEE Ten Point Plan (Building the Workforce the New Deal for General Practice) described the creation of a system of learning hubs. Within London & Kent Surrey and Sussex (KSS) regions these have been alternatively called Community Education Provider Networks (CEPNs). These can be thought of the community equivalent of hospital postgraduate medical centres and have responsibility for an overview of the primary care workforce and its development and education. Kent and Medway is organised in CEPNs, West Kent ( West Kent Education Network WKEN), East Kent & North Kent (Dartford, Medway & Swale). These CEPNs will effectively become the education and workforce strategy groups for each of the three regions and will have their own boards. Health Education England Kent Surrey and Sussex (HEEKSS) also commission a workforce tool. This is an online system for practices to inform HEEKSS of practice data related to numbers of staff, their age and levels of qualification. Over 90% of west Kent practices have returned data for their staff which has enabled a picture of the current workforce to be described. This and other data will inform the strategy when predicting likely shortfalls in staffing. Estimations are complicated by several factors such as population growth, GPs and others choosing to work fewer sessions per week and best guess estimates of challenges in recruitment to the west Kent area. From the HEEKSS workforce data 17 we know 18 : We have taken a strategic approach to workforce planning and development with four key areas - Recruit, Train, Refresh, Retain. Within our strategy each of these four functions is described for GPs, practice nurses, practice managers and administrative staff. The HEE Ten Point Plan contains similar heading areas recruit, retain and return, the WKEN operating plan adds and describes training but also contains the concept of refreshing. The latter has to do with staff wellbeing, something that is often neglected but represents one of the overall WKEN objectives of making west Kent a great place to work. It will enhance recruitment and retention and will help to create a fulfilled workforce who feel supported and valued thus motivated to provide the best standard of care for west Kent residents. 17 HEEKSS workforce data April GP workforce excludes locums, Direct Patient Care group includes Healthcare Assistants, Phlebotomists, Dispenser, Pharmacist (clinical) and Paramedics. Page 44 of 86

45 The Education and Workforce Strategy will be introduced in phases, developed by the WKEN. The Education and Workforce Strategy will need to underpin the 5YFV aim of movement of care nearer to the patient and to greater community leadership and provision. There will also be a greater emphasis on self-care through patient education (making every contact count) and more systematic provision of patient education addressing patient educational needs ( PENs ) Greater consultant colleague involvement in community education is likely but as team member not necessarily team leader. Learning will thus be joint and mutual in multi-professional format. In line with the NHS England General Practice Forward View there will also be changes to the primary care team composition with addition of paramedic practitioners, clinical pharmacists, physician s associates and physiotherapists; this is necessary to meet the demand and changing needs of the population. Members of these disciplines are already working within several west Kent practices with positive feedback from their employing practices. We are developing a Cluster Protected Learning Time (PLT) approach to nurture and develop relationship between cluster practices and their staff, share best practice and innovate together to optimise patient care, provide opportunities for mutual support which can develop and sustain the workforce and allow the development of units of service delivery fit for the delivery of future models of care Wider local care workforce As well as our proposals for transforming primary care, our model of local care will have wideranging implications for the workforce. It will require the development of new roles, the development of new skills and the development of new ways of working to deliver the transformation required. Integrating care will require professional teams to come together around the needs of patients, rather than organisational silos. To do this there must be removal of walls between secondary and local care with common teams working across both sectors. This will have implications for how health and care professionals work together. It is not simply a case of doing more of the same; it must be about working differently around patient needs and will only be possible within an environment of inter-professional trust and respect. Professionals will require an understanding of each other s roles in delivering care along the patient pathway, Page 45 of 86

46 and trust they that will deliver that care effectively. Building this trust will mean breaking down barriers between current organisations, within healthcare as well as between health and social care. Effective communication within multi-disciplinary teams will be critical but we need to recognise that our starting point is a different language across health and social care we need to work with and empower staff to develop a shared language to support a shared understanding of patient needs. We therefore need to consider development of a core education and training syllabus across the multi-disciplinary team. We will also need to ensure that health and care professionals have the skills, competencies and time to support and empower patients and carers in their new role, and that their interactions with patients reinforce, rather than undermine, patient empowerment. Staff will require training to enable and support service users to self-manage. While some staff will have these capabilities already there is a need to specify clear technical standards and train staff to them, specifically to delivery evidence-based self-management to support a successful local care model. During 2017/18 we will, in collaboration with providers, undertake a comprehensive review of current primary and community care nursing teams, including skills, competencies, and responsibilities. The cluster team multi-disciplinary model is a good example of where, through a collaborative approach with partner organisations, we are re-aligning the workforce around clusters and addressing any education and training needs to enable the new way of working. Workforce considerations and impacts for the local care model will continue to be developed as part of a workforce strategy through a collaborative approach with our partners across health and care and through engagement with patients and public Patient and carer workforce We have already set out how self-care and involvement of patients and carers is core to the local care model and what we are doing to support this. As care is transformed and co-production becomes a reality, patients and carers become effectively part of the workforce. The ability to empower people to become or remain highly engaged regarding their own health and wellbeing is important. We will need to support this through provision of advice, up to date and easily accessible digital and paper information and tools, accessible and user friendly directory of community resources, peer support, education programmes and in some cases formal training Digital infrastructure The use of technology is as a key enabler for delivery of the transformation plans and requires a collaborative system wide approach through the K&M STP. The Digital programme will: Facilitate improvement of health and care of residents Join up health, social care & other providers of care services by transforming the way care professionals record information, transact and communicate with patients and staff. Support self-care and support carers. Enable more informed decision making. Page 46 of 86

47 By Encouraging service user empowerment through technology to support greater self-care, improvements in health and wellbeing, and access to services. the use of real-time and historic data to support predictive modelling and improvements in clinical service delivery at point of care, population health analysis and information management to support effective commissioning. the replacement of all paper based flows of information between care professionals with digital communications The key components of the STP Digital Work Stream are summarised in the diagram below. We have a comprehensive local programme of work that aligns to the STP work stream. Below is a summary of some of the key schemes and specifically the capability this enables within our local care model. 1. Care Plan Management System (CPMS) CPMS provides care professionals involved with the care of at risk patients with the ability to access care data from all organisations that are involved in the care of the patient. CPMS is based on the Orion Health Portal comprises a web based user interface, a clinical data repository and a data integration engine. The Orion system also includes functions such as triggers and notifications which can be used to support MDT working and other clinical management processes. The user front end can also be configured in windowlets to display data for specific use case. CPMS is currently able to retrieve and display patient clinical data from 54 practice, each practice has sign a data sharing agreement before the patient data from the practice s clinical system can be accessed from CPMS. Clinical data from the remaining 6 practices will be accessible, once data sharing agreements are in place. Clinical data for patients who have given explicit consent is accessible to care professionals who are involved with the care of the patient; clinical data for patients who haven t given consent is only accessible in a clinical emergency to a care professional through a process where the declaration to access is recorded and reported (known as breaking the glass ) and only granted for a limited period. South East Coast Ambulance NHS Foundation Trust and Heart of Kent Hospice clinical data is also available in CPMS and we are continuing to work with other providers to feed other Page 47 of 86

48 relevant clinical data, such as A&E data from Maidstone and Tunbridge Wells NHS Trust and encounter data from Kent Community Health Foundation Trust. CPMS will support the core cluster multi-disciplinary teams as part of our local care model and we will be working with the cluster teams to test and tailor the system. CPMS will also be used for other care pathways as part of the local care model. As part of a Kent and Medway STP ambition to have a single Kent Care Record, we are working collaboratively with all partners as part of the STP regarding this project and expect this to be our solution for the longer term. 2. Electronic Prescription System (EPS) EPS is a national system supported by NHS Digital. The Electronic Prescription Service (EPS) allows prescriptions to be sent direct to pharmacies through IT systems used in GP surgeries and will remove the need for most paper prescriptions. Building on the 2015/16 agreement, practices will be encouraged to transmit prescriptions electronically using Electronic Prescription Services (EPS) Release 2. It was agreed to aim for at least 80 per cent of repeat prescriptions to be transmitted electronically using EPS Release 2 by 31 March 2017, where appropriate. This will apply to repeat prescriptions only. We currently have 36 practices (59%) registered for EPS out of the 61 practices. The average use across all practices is 35% (March 17) and the average use in practices signed up is 56% (March 17). For dispensing doctors, this target would apply for non-dispensing patients only, until such time that a suitable EPS compliant dispensing system is available and sufficient time has been given to adopt this capability. This is suggested to be April 2018 which would allow 6-12 months preparation. It is clear that the issue of dispensing practices is limiting the sign up in west Kent therefore as part of the digital road map we need to review the current issues. 3. Vision 360 Vision 360 enables GP practices to access clinical records and the appointment book functionality from other practices where data sharing agreements exist between the practices. Clinicians are also able to write back into the clinical record at the home practice. Access to Vision 360 works across the two main clinical systems in west Kent Vision (27 practices) and EMIS (33 practices). The GP Federation in west Kent is leading this project and licences for Vision 360 have been purchased by the CCG on behalf of our practices. The Federation will need to create a data sharing agreement, based on the agreement already signed by practices in support of the diabetes pathway, and these will be sent to all practices for signing to enable Vision 360 to be used to support federated working in west Kent. 4. DocMan DocMan provides a digital storage for incoming correspondence that practices receive. Currently practices are either scanning letters as they arrive in the post or receiving them as Page 48 of 86

49 attachments. DocMan iworkflow and Intellisence adds capability to automatically scan incoming correspondence for clinical details and file it appropriately. DocMan is installed in 57 of our practices; the remaining three practices are using alternative document management solutions. Trusts are implementing DocMan hub which allows practices to download letters rather than having to scan them or save them from s this is something Kent Community NHS Foundation Trust are already doing for discharge letters and Maidstone and Tunbridge Wells are commencing a pilot in June 2017 for the transmission of discharge notes, outpatient letters, A&E summaries and other clinical documentation. Next steps: DocMan 10 moves a practices store of letters from local (practice) servers to cloud based storage, thus removing risk of hardware failure and improving performance at branch surgeries. We will be implementing DocMan 10 as part of our next steps. The DocMan 10 cloud storage can also be linked with CPMS thus making discharge letters available to clinicians from other organisations involved in the care of the patient. As part of our next steps we will be linking DocMan Vault to Orion Health portal to allow discharge letters to be accessed through the CPMS front end. 5. Roll out of HSCN Practices depend on the current N3 broadband connections access to clinical systems and other digital services. The capacity available under N3 is extremely limited and, given the expansion of digital services, additional band width is required. This will be delivered through HSCN (Health and Social Care Network) which is the national replacement for N3. The N3 contract ended on 31 st March 2017 meaning that no new N3 services can be commissioned. The N3 budget is being delegated from NHS Digital to CCGs with the expectation that HSCN will be commissioned and implemented during the financial year of 2017/18; it is also likely that the project will require access to GP IT capital funds. We will care providers across the county through the Kent & Medway Community of Interest (COIN) steering group to move towards a single approach to HSCN across the STP - this is a key component of the digital work stream to provide the facility for universal clinical access, meaning that all care professionals can access the systems that they need to from any location.. 6. Patient Communication Currently practices have access to basic patient communication using the EE SMS service. It is our intention to increase the capability of patient communication through the use of the iplato patient communications; this supports SMS messaging to patients where mobile phone numbers are held on the practices clinical system. This can reduce missed appointments and prompt patients to cancel appointments that are no longer needed. The iplato application can also support communication to practices thus reducing the cost of the service as it avoids SMS costs. iplato also supports health campaign messaging such as flu reminders. Page 49 of 86

50 This project is being funded from the GP IT budget. 7. Wifi access in practices Wifi access in practices will support greater flexibility of working and use of space, will allow care professionals to use mobile devices and will support network access for care professional from other organisations. Patient access to Wifi is mandated by the Secretary of State and will provide patients in waiting rooms controlled access to the Internet We are funding this programme from GP IT capital and Estates Transformation and Technology funds (ETTF) - equipment for first phase has been purchased and implementation into initial tranche of practices (23 sites from 21 practices) has commenced. Our next steps are to complete roll out to remaining sites, establishment of GovRoam or other roaming access protocol as the WiFi access method to support roaming access and to determine approach for WiFi access for patients. 8. Desktop devices, PCs and Printers (and mobile devices) The GP IT Capital budget, a rolling replacement programme to ensure that personal computers, printers and other devices remain in warranty has meant that all devices are in supported operating systems and within warranty. This means that no desktop PC is older than 5 years old. This reduces the risk of cyber security incidents as desktop devices are all covered by supplier hardware maintenance cover and will run operating system and other system software that is supported. This also reduces the down time and operating costs (printers). We will need to ensure that printers and other peripheral devices are the most cost effective devices for practices to operate. Another part of our programme is to provide mobile devices (at least one per practice) to support clinical access to clinical systems when the care professional is away from the practice. We will need to evaluate the effectiveness of mobile devices as they will typically have a 3 year warranty and have more limited upgrade potential 9. E-consultations in general practice The option for patients to access their primary care team via e-consultations can help reduce the administrative burden on incoming calls and patient visits to the practice by providing an alternative to face to face consultation. The use of e-consultations will also allow the patient s needs to be assessed and the most suitable professional selected to respond to them thus freeing up GP for the more complex patients. In practice, e-consultations should enable better management of the workload in general practice and offer more convenience for patients. E- consultations may also reduce the burden on urgent care services. We are currently in the process of scoping this project and reviewing the different systems available. Next steps will be developed between the CCG and practices. Page 50 of 86

51 10. E-referrals Service (ERS) In line with the ambition defined in The Forward View into Action: Planning for 2015/16 (March 2016), we will continue our work with all providers of secondary care services to ensure that all relevant services and appointment slots are published and meet regularly to review capacity and demand in ERS. We will work with practices to ensure the universal use of NHS E-Referrals as the mechanism for referring patients in to secondary care providers, including routine and 2 Week Wait referrals. This work stream will set a paperless deadline, whereby traditional paper routine referrals (including s and faxes) will no longer be accepted for specialties on a phased basis. This work is underway for suspected cancer two week wait referrals, and a review of this approach will inform roll out to the wider routine specialty clinics. Use of ERS supports patient choice, reduces patient DNA rates through patient enablement and engagement, and furthermore provides quicker access to first outpatient appointment dates than traditional paper referrals. For the GP referrer, referral trails are fully auditable, with referral progress trackable and transparent. Providers are able to manage demand and capacity through ERS, and can also implement more efficient administrative processes. In line with the Next Steps on the NHS Five Year Forward View (March 2017), practices will send 100% of secondary care referrals through ERS by October Advice and Guidance Through our Transforming Outpatients Programme, working with Maidstone & Tunbridge Wells NHS Trust, we will increase GP access to specialist advice and guidance from local secondary care clinicians on our Kinesis system. As outlined in Next Steps on the NHS Five Year Forward View (March 2017), employing advice and guidance techniques avoids the need to default to an outpatient referral for patients for whom supported management in primary care may be appropriate. We will build on the existing available specialists at Maidstone and Tunbridge Wells NHS Trust by continuing our specialty roll-out plan, culminating in all specialties being available to GPs by March There are clinical quality benefits to its use across the local healthcare system: Where a face to face clinical consultation in outpatients is determined as unrequired at this time, patients are saved a wasted trip in to hospital GPs are supported in primary care management of specialist conditions, and hospitals benefit from efficiencies in outpatients released by seeing more appropriate patients. When use of Kinesis results in advice to refer a patient, benefits can also be realised in the patient pathway: diagnostics can be requested in advance of a face to face appointment, reducing new to follow-up ratios and improving patient experience of care with fewer repeat visits to outpatients. Financial efficiencies are also seen across the system, with patients treated on more appropriate pathways resulting in a more efficient use of limited resources. Page 51 of 86

52 Overall advice and guidance should support a reduction in primary care referrals and associated reduction in first outpatient appointments. 13 Communication and Engagement We are committed to seeking every opportunity to involve local people in decisions about local services and building on our existing engagement activities in innovative and creative ways to ensure patients and carers from all areas and from diverse communities are involved and listened to in commissioning decisions. NHS England s Five Year Forward View outlines the challenges faced by the NHS and sets out how the health service needs to change, arguing for a new and more engaged relationship with patients, carers, citizens and communities in order to promote wellbeing, prevent ill-health, support people to be more in control of their own care and involving them directly in decisions about future health and care services. This changing health and care landscape means that communication and engagement is now even more critical to ensure that everyone in west Kent is aware of and can contribute to discussions and plans for local services. The patients and public voice needs to be at the heart of everything we do. Since our inception, we have developed infrastructure and processes for wide and deep engagement and wide-ranging communications with our population. We have carried out a range of initiatives to ensure that people s experiences, insights and feedback have informed commissioning intentions and decisions, and equip people to take decisions about their health care. Local care is made up of many different components - general practice, clusters, local care hubs and a wide range of pathways and interventions. We will ensure that when we engage and communicate on any of the components that we are clear how it fits as part of the local care model. Page 52 of 86

53 We held some listening events in March 2017 and will be holding further local care focused listening events in the summer of 2017 to share our local care plan, talk about the key principles and outline the work we need to undertake to inform specific decisions we will have to make. We will be seeking feedback through these events to help inform the work we need to undertake. Through this work we will then identify key areas of the local care plan that we will need to undertake a formal consultation around. We will continue to work with our health and social care partners take a joined up approach to communications and engagement and so that wherever possible we avoid duplication. 14 Summary of Impact of local care plan 14.1 Developing the financial model Kent and Medway, like other parts of England, have a major challenge of balancing significantly increasing demand, the need to improve quality of care and improve access all within the financial constraints of taxpayer affordability over the next five years. It has been estimated that as a result of demand and cost increases rising more quickly than available funding, the financial deficit across Kent and Medway is expected to rise to 486m by 2020/21 if we do nothing. The west Kent system forms a component of this challenge. Securing financial sustainability in west Kent and meeting of future predicted increases in demand is predicated on implementing an integrated local care model that is significantly less reliant on acute bed-based care and the changes we are proposing will result in a significant reduction in acute activity in comparison to the Do Nothing scenario. As we change the model of care, reduced acute activity will release funding to help secure financial sustainability, and also provide resources to re-invest in further ambulatory care provision in primary, community and home based settings. We will continue to commission integrated pathways of care that shift the focus of care from a bed-based model to one that is primary and community care focused, and realign funding to enable this to happen. Work has been undertaken across Kent & Medway to assess the financial impact on acute care costs, together with the required level of investment in the Local Care model. It is anticipated that the establishment of the local care model will reduce costs for the health system compared to the Do Nothing scenario. This is being quantified in terms of a reduction in the number of admissions, attendances and appointments at acute hospitals, and a reduction in the length of stay that patients will experience in the acute care setting. It is important to recognise that these assumptions have been compiled at a Kent & Medway level, and now need to be tested now with partner organisations in west Kent. However, initial assumptions of the financial impact in west Kent are set out in the tables below: 17/18 18/19 19/20 20/ A&E ,833 2,946 Page 53 of 86

54 Non Elective admissions 0 3,251 6,734 10,451 Outpatient total 976 5,215 9,993 10,598 Elective admissions 759 4,000 7,569 7,938 Length of stay reduction NEL 1,869 5,608 9,346 14,954 Length of stay reduction EL Net system benefit 3,700 19,406 36,340 47,752 These anticipated system level savings include those relating to the population segment older people with complex needs, which represents some 47% of the overall opportunity expected for all population groups. 17/ / / / Older Complex Tier ,485 4,743 6,828 Older Complex Tier ,128 4,172 6,224 Older Complex Tier ,117 6,017 9,317 Remainder 2,577 11,676 21,408 25,383 Net system benefit 3,700 19,406 36,340 47,752 The current assumption of investment required for a Local Care model in west Kent is currently assessed at approximately 1.7m in 17/18, 5.2m in 18/19, 8.4m in 19/20 and 10.6m in 20/21. The tables below capture the required investment, including those services that will be established to focus upon the population segment older people with complex conditions and services that are directed towards the wider population: 17/ / / / Older complex 1,159 3,477 5,746 7,227 Other investment 558 1,675 2,620 3,403 Total expected investment 1,717 5,152 8,366 10,630 Once the model is implemented the reduction in activity in acute care has the potential to release cost in the health system that can be reinvested in the Local Care model. The reductions in acute care will build up over time and are not expected all at once, and some degree of parallel running of services will be required initially. The net position for the health system is set out below: 17/18 18/19 19/20 20/21 Page 54 of 86

55 Expected savings to system 3,700 19,405 36,340 47,752 Expected reinvestment 1,717 5,152 8,366 10,630 Net system benefit 1,983 14,253 27,974 37,122 As indicated above, the assumptions underpinning the financial impacts set out in the above tables need to be subjected to further testing and refinement, including reference to setting realistic trajectories for improvement (in terms of scale and timing), ensuring that the risk of double counting benefits are minimised, and the applicability of Kent & Medway assumptions to the west Kent context. The investment tables above do not include certain investment that may be required to underpin the Local Care model, and the CCG and wider health system will need to give consideration to the scale and funding sources for these items. In calculating the necessary investment, consideration will be given to the potential location and coverage of key services. The model suggests that each of the interventions making up the model can be provided at the level of either the patient s home, their general practice, cluster groupings covering 46,000-83,000 population, hubs covering a population larger than clusters, and west Kent wide services. That provision of care may also be split between different levels. The staff providing care will also need a team office base within these levels which may be combined with clinical space where appropriate. The gross and net opportunity, and activity opportunity, has been calculated by place of delivery taking into account existing, specific QIPP schemes. In addition, the workforce needed to deliver local care has been modelled on a 30-50k population basis and scaled to a west Kent level. A decrease in activity in hospitals allows for capacity to be released over time, which in turn means that hospital staff could be redeployed to deliver care in the community or in patients homes. A strategy for how staff could be redeployed to support enhanced professional and career development will need to be developed. Incentivising providers to adopt new ways of working by paying for care planning and coordination will be required and in order to deliver the benefits of the model recurrent and non-recurrent investments need to be made into the following areas: Care and support planning with care navigation and case management Self care and management Healthy living environment Multidisciplinary Team working Single Point of Access Rapid Response Service Discharge planning and reablement Access to expert opinion and timely access to diagnostics Page 55 of 86

56 14.2 Paying for enablers that will support the delivery of the model in west Kent There are infrastructure requirements needed for the model to proceed. This includes support for the enablers needed for successful delivery including organisational development, workforce education, training and recruitment, IT costs and any required investment in estates. CCGs in Kent & Medway are at different starting points in terms of infrastructure development with varying levels of current investment in these areas and strategies for further investment. There will also be some national monies available against certain criteria that may already be allotted or available to bid for e.g. national GP Forward View workforce funding; Health Education England / Community Education Provider Network resources. The Kent and Medway investment case for local care is being finalised and will be presented to the governing body of each CCG in the autumn, this will outline the expected capital requirements. There is an overarching risk that the required level of upfront investment (capital and revenue) is not available to support the required transformation of health and social care services set out in the local care plan. Without this investment ability to deliver the plan is severely constrained Workforce requirements As well as being able to identify the impact of the Local Care model on the numbers of additional staff that may be required, the training and development of our workforce will be a critical component in implementing the new ways of working in front line practice. Within the west Kent system, we will need to ensure not only the continued development of the workforce but also organisational development, succession planning, planning for recruitment and retention of staff and, importantly, the new roles required to deliver new, innovative approaches to local care. It will also be important to identify the skills and competencies required by existing staff for ways of working differently and to ensure that any generic competencies and skills are transferable across health and social care. For a model that has patients at its centre, the development of a shared approach to building coproduction capability for individuals, their carers and professionals, is essential Digital requirements We need to ensure that IT enables delivery of the Local Care model and improve the utilisation of existing systems and infrastructures to offer greater opportunities for joined up working. This will need to include: 1. A electronic pathway navigation system is needed to support care navigation, this links together the standardised care pathway with a directory of services and facilitates electronic referrals and links into the national E-Referrals Service; 2. Electronic care plans and shared care records are a pre-requisite, based in CPMS 3. Self-care needs to be supported by an appropriate digital platform, such as Health Help Now 4. Digital technology necessary to support MDTs Page 56 of 86

57 5. Single point of access must be supported by digital technology, as well as by a directory of services 6. Access to online expert advice Kinesis type model 7. Telecare and other intelligent monitoring 8. There may be infrastructure costs depending on the estates configuration The Kent Integrated Dataset (KID) enabled the segmentation analysis to be undertaken, providing meaningful insights into system activity and spend that has formed the basis of the development of the Local Care model. The KID has been instrumental in: Understanding the needs of the population and the costs per head Showing the flow of activity around the system Quantifying the opportunity It has been agreed that the KID is a critical asset to be continued to be developed for the benefit of Kent & Medway as a whole. Further investment and development in the KID front-end is required. A three-stage development process is anticipated: Stage 1 KID Dashboard with pseudonymised patients (June 2017) Development of dashboard that be accessed at the GP practice level Provides visibility of local segmentation and drill down into each of the segments Provides the top 100 patients (pseudonymised) in terms of resource utilisation Allows internal variation analysis at a segment level vs. other local GP practices Stage 2 Providing clinicians with the ability to linking back from the KID Dashboard to identifiable patients (2017/18) Stage 3 Development of a Shared Care Record across Kent and Medway (2019/20) Estates In order to implement the local care model in west Kent there is an expectation that there will need to be significant investment required in both existing and new estate, including our general practice premises. There will need to be space provided within local facilities for a range of services and office accommodation for locally based MDT staff. Our estates plan addresses the requirements of the Local Care model, including how best to ensure sufficient capacity within the one public estate, developing efficiencies for co-location and integration of services. An assessment of the impact of the Local Care model in terms of where future activity will be delivered (e.g. by setting for care navigation, case management, rapid response etc.) can be set alongside an assessment of the current public sector estate footprint to help to identify where any development may be needed. Section 12.1 of our plan sets out our approach to estates. Page 57 of 86

58 14.3 Investment in general practice to incentivise change in ways of working including: Coming together to work at scale Reducing activity/referrals to secondary care (currently no incentives for primary care to make savings) Better provision of urgent care to reduce A&E attendances Support for resilience and sustainability to make them fit for purpose to take on transformation role The nationally mandated 3 per head, required as part of the GP Forward View investment in primary care (non-recurrent for 17/18 and 18/19) will be directed at incentivising general practices to develop clinical leaders to lead the implementation of our cluster infrastructure, increased capacity for local care and developing primary care at scale. Our GP Forward View Plan is detailed in Appendix MCP Development To reflect the NHS England Five Year Forward view we believe that the appropriate vehicle for delivering local care is a multispecialty community provider (MCP) type arrangement and that building an MCP based on local care is a desirable outcome. We are therefore working with primary care to build on the bedrock of general practice and working with the GP Federation in west Kent to allow this environment to develop. 16 Governance 16.1 Context The establishment of a Kent and Medway wide Sustainability and Transformation Plan (STP) has coincided with a national steer to move towards a less transactional NHS, towards an NHS with more focus on partnership work and place-based budget management. This move was explicitly referenced in NHS England Next Steps NHS Five Year Forward View (5YFV), published in March The move is also encapsulated in the changing expectations of sustainability and transformation plans (STP), with the appointment of full-time STP senior responsible officers (SRO) and the proposal that STPs should have financial control totals. This move might be seen as an Page 58 of 86

59 acknowledgement that in an NHS that is so financial strained too much time spent on negotiations about where to land particular financial pressures is not appropriate. We have established new governance in west Kent aimed at developing much enhanced partnership working on the west Kent footprint, working on the premise that no significant increase in funding is to be expected and that partners must work together better to agree how to make best use of the resources. That agenda incorporates increased integration of provision and commissioning (also strongly signalled in the 5YFV refresh) and therefore it incorporates close partnership work on west Kent Local Care. We have put in place a new set of agreements and contracts with key partners that together serve to move partners away from transactional relationships and to enable and empower partnership working. These include aligned incentives contracts between the CCG and local Trusts and a new agreement between the CCG and the GPs Federation around Local Care development. Local Trusts have also put in place new forms of alliance The New West Kent Governance At the heart of the new west Kent governance is the West Kent Improvement Board, with representation from the most senior leaders of provider Trusts, the CCG, Kent County Council, the four district/borough councils and the GP Federation. The Vision of the Board is: To deliver through effective alliance and partnership work, continuous improvement in health care, health gain and wellbeing for the people of west Kent. Critically the Board will ensure a powerful and consistent contribution to the STP and delivery of transformational local care. It will develop a single west Kent view on which basis it will make shared investment decisions. The West Kent Improvement Board will sometimes form fixed-life sub-groups with multiorganisational membership to develop proposals or to ensure collective delivery of key projects. In addition, reporting to the Improvement Board are some permanent partnership groups that oversee key shared programmes: The Local Care Delivery Board The Elective Care Board The Local A&E Delivery Board (as a nationally mandated body this cannot formally report to but will report into the Improvement Board) Digital West Kent The Local care board will oversee delivery of all actions to realise the new local care model, including organisational development, infrastructure and governance through a shared work programme. Page 59 of 86

60 17 Next Steps Our plan outlines the different elements that come together as part of our local care model and the progress we have made but also highlights the areas where we need to do further work to develop our plans. We recognise that elements of the local care plan need further quantification specifically in relation to finance, buildings and staff. This will require further engagement with each of our communities, and potentially consultation, specifically in relation to the buildings and where community beds and services that form a local care hub will be located as part of the new local care model. Through a collaborative approach involving our main health providers, Kent County Council and district and borough councils our aim is to lead the modelling work identifying the system impact of rolling out this proposed model at scale in west Kent. We will articulate our aspirations for each of our communities and produce options for engagement and consideration, and where relevant consultation, during Page 60 of 86

61 Appendix 1 West Kent GP Forward View Plans

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