Integrated Medium Term Plan 2015/ /18 Summary Document

Transcription

1 Integrated Medium Term Plan 2015/ /18 Summary Document Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board 1

2 The Integrated Medium Term Plan 1. Introduction This Integrated Medium Term Plan (IMTP) provides the Health Board with a process and vehicle to review and articulate the organisation s values, future strategy, key priorities and delivery actions for the period 2015/16 to 2017/18. It reiterates and reflects our values and commitment to engage and collaborate with partners, patients, communities and staff to deliver safe and high quality services. The plan reflects current pressures and priorities and outlines the service and system change required to deliver the strategic future we set out in our Clinical Futures Strategy. The plan highlights key priorities, actions and outcomes for delivering more patient centred services within local communities wherever possible. Those priorities have to be set within a financial framework that is affordable and supported by workforce strategies for delivery and improvement. Priorities have been developed through engagement processes with key partners and Divisions to provide the foundation for achieving delivery and also reflect national strategies and policy requirements. The plan has focused on clarifying key priorities supported by actions, likely timescales and the expected benefits. This reflects significant progress compared to the 2014/15 IMTP and we will continue to strengthen these through the delivery process. Effective alignment and connecting the outcomes of individual plans is critical to achieve more ambitious service and system change. There will be particular focus on developing services which have a greater primary care focus to provide alternatives which are more accessible for patients. This will require developing the necessary infrastructure and investment to support this shift to local delivery. The development of more appropriate services will require the Health Board to adapt and modernise processes and health systems to make sure services are effective, safe, accessible and timely. This requires greater integration of services within primary, community and secondary care services and with Social Care and third sector organisations. The IMTP provides a comprehensive overview of Health Board plans. This document provides a synopsis of the planning process, service priorities, workforce implications and financial plans and is supported by a detailed technical document. The technical document complies with Welsh Government Planning guidance. We will robustly monitor and scrutinise the delivery of our plans, ensuring that benefits are realised by our citizens and key enablers to support change are optimised. 2

3 2. Health Board s Values and Mission The Health Board strives for excellence in our collective efforts to deliver effective health care and encourages a culture of support, respect, integrity and teamwork. This is balanced with always assessing and challenging services to strive for improvement to match and exceed national standards, learning from success and identifying where improvements are required. This ambition must be driven by a commitment to work collaboratively and effective engagement with patients, communities, staff, partner organisations and government. We believe in putting the patient first, staff taking personal responsibility to safeguard patients, fostering a strong passion for improvement in delivery of services, and making sure that promoting pride in service delivery promotes improvements in patient experience. Our mission and ambition is that by 2019: Everyone is able to live longer healthier lives at home or in a homely setting. The will be an integrated health and social care system, which includes housing and the third sector, built around Neighbourhood Care Networks focusing on prevention, anticipation and supported self management delivering reductions in health inequalities in the most deprived communities. Development of cohesive services for children, older and vulnerable people will be available to all the distinct communities served including an agreed suite of care pathways delivering care which is safe, local, citizen centred, clinically and cost effective. Sustainable 24/7 primary care services are in place to ensure that urgent and planned primary care is locally accessible to enable patients to receive their care close to home. A more equal relationship between patients and professionals (using co-production approaches), based on openness and sharing information ensuring that the intensity of testing and treatment is consistent with the seriousness of the illness and the individual patient goals. Shift the balance of services to primary care by increasing the number of specialist services currently provided in hospitals to primary care settings with more seamless collaboration between practitioners across the whole system. This will necessitate some services working very differently to support patients in primary care, through direct patient contact, indirect support to practice teams and remote monitoring of patients. Technological opportunities will be maximised with an integrated electronic health and social care record system that allows clinicians and social care practitioners to share information about patients that enables new workflows (for example virtual clinics, booking systems, advice lines) across the health and social care system, which will also enable patients and carers to access appropriate, timely and relevant information. All our independent contractors will be part of the NHS network so that patients will have a single record that will facilitate shared care and patient management across all settings. 3

4 All local services will be configured within the 12 Neighbourhood Care Networks and designed to meet the health and social care needs of their communities. This will require a professional and managerial accountability structure to ensure the delivery of safe, effective, efficient services to meet the health and social care needs of the communities they serve. When hospital treatment is required, and cannot be provided in a community setting, day case and ambulatory care treatment will be the norm. There will be 24/7 access to consultant led hyper-acute and specialist care, facilitated by consolidating these service in the newly opened Specialist and Critical Care Centre at Llanfrechfa Grange in Whatever the setting, care will be provided to the highest standards of quality and safety, with the citizen at the centre of all decisions. At all times, in every part of the system, we will strive to be best in class, pushing the boundaries of efficiency, effectiveness and proportional interventions in accordance with prudent healthcare. There will be a focus on ensuring that people are supported in their home or community environment as soon as appropriate. This will be supported by a reduction in health inequalities in the most deprived communities and a reduction in premature deaths in key conditions such as cancers, heart attacks and strokes. Our health service will be regarded as a caring and improving health system built on a model where integration, partnership working, prudence and public participation are all paramount. The delivery of these challenging and ambitious aspirations will require a significant refocusing on achieving major changes to align investment and improvements in public health, facilitating more patient services being delivered within primary care and community services closer to patients homes, and sustainable secondary care services which provide timely access for appropriate patients. Our values and plans have always had a strong focus on delivering safe and high quality services and national targets in spite of challenges associated with increasing demands on health services, capacity pressures and the impact of challenges associated with financial austerity. There is a collective determination to ensure that the values developed over recent years are sustained and that leadership continues to be based on fundamental standards, openness and transparency, candour with patients, effective engagement with communities, patients, staff, and partners in planning and delivery of services in an effective manner. 4

5 3. Key Drivers Feedback from Engagement Our commitment to improving service quality, patient safety and experience and the delivery of timely services for patients, not only focuses on delivery of key targets but also ensuring that we are developing effective plans with communities and partner organisations to reduce the impact of health inequalities and promoting people to take more responsibility for their own health. The engagement process has identified key issues where we must develop improved service: Timely access to primary care, in particular General Practice Reliability and responsiveness of ambulance services Delays and queues in emergency departments Knowledge of locally available services, understanding when and how to use them Concern that the Specialist and Critical Care Centre has not yet opened Sustainability of the current system of care Increasing and persistent pressure on the health system Maintaining focus on quality and patient care The necessity for change within healthcare systems and delivering key improvements Health Needs Assessment The Health Board covers diverse geographical areas and covers a mix of rural, urban and valley communities. Many of these areas experience high levels of social deprivation, including low incomes, poor housing stock and high unemployment resulting in many challenges: Smoking is a major risk factor for heart disease and remains a significant public health concern with 24 per cent of the adult population being active smokers with the subsequent impact on quality of health and life expectancy. A quarter of adults are obese (BMI 30) with rates in Blaenau Gwent, Torfaen and Caerphilly significantly higher than the Wales average. Low participation of local residents undertaking physical exercise on a regular basis. Poor dietary habits illustrated with a survey in 2009/10 demonstrating the proportion of adults in the Health Board who had consumed at least five portions of fruit and vegetable in the previous day was 32 per cent. Alcohol misuse with around 43 per cent of adults reported drinking above recommended limits in the previous week. In relation to patterns of alcohol misuse around 131,118 residents report binge drinking. Deprivation is higher than the Welsh average, ill health more prevalent and life expectancy is 10 years lower for residents in the most deprived areas of Gwent then in the least deprived areas. Four of the Local Authority areas a high percentage of children are living in poverty Children living in a deprived area in Gwent are less likely to be breast fed and more likely to have dental caries which is an indicator of a poor diet. The latest projections indicate that if current trends continue, the number of persons aged 65 and over will increase from one in five residents in 2015 (108,500 people) to one in four by 2030 (153,000 people). The proportion aged 75 and over is projected to increase from 10% to 19%, the sharpest increases being in Monmouthshire and Torfaen. By % of our citizens will be 85, more than double the proportion in 5

6 2015. The increase in the number of older people is likely to be associated with a rise in long-term conditions whose prevalence is strongly age-related, such as circulatory and respiratory diseases, cancers and dementia. We face major challenges linked to health inequalities and the consequent impact in demand for services particularly associated with cancers, cardio vascular diseases and dementia. Working collaboratively with partners to support people to adjust lifestyles improves health status, reduce or delay the onset chronic conditions and improve life expectancy and quality of life in older years is of a critical component of any strategy to deliver a sustainable health care system. Legacy Issues from the 2014/15 Plan Significant progress has been made in improving performance on many issues during the past 12 months including: Major improvement in the care of Stroke patients with the ring fencing beds improving performance against Bundle 2 of the Stroke pathway. Sustaining improvements in reducing C Diff rates and numbers with a reduction of 46% on the previous year. Sustaining the lowest level of MRSA rates in Wales for several years. Significant reduction in the backlog of Outpatient follow up patients and plans in place to deliver further improvement. Reduction in the Health Board s RAMI to 94 (lowest in Wales) in June 14 compared to the Welsh average of 103. Sustaining good compliance with patient safety solutions for alerts and rapid response notices together with comparatively low number of serious incidents. Continued to ensure good access for patients to GP and Dental services. Major changes to the Minor Oral Surgery and Glaucoma pathways to reduce demand to secondary care and develop more sustainable services. Progress achieved in improving outpatient services in Neurology, Diabetes, Orthopaedics and Nephrology. Published the second Annual Quality Statement outlining the positive progress being actioned. Positive progress with the digitisation of medical records with over 60,000 patients now having their records available in a digitised format. Progress achieved in recovering cancer performance during late Developed plans for delivery of the Prudent Healthcare agenda. Developed an approach for convergence of WCP and the local Health Board clinical portal to further promote the National IT Programme. Good progress in implementing Nursing Principles although recruitment difficulties may be a risk to delivery. Investment in Public Health to target improvements in population health prioritising smoking cessation, immunisations and obesity. Agreed plans and investment to improve compliance with the Mental Health Measure requirements without losing the well regarded service model. Achieving more progress in integrating services in primary, secondary and community care, including care of the elderly and frail and development of integrated pathways for minor oral surgery and ophthalmology. Increasing healthcare improvement and R&D activity reflecting the benefits of University Health Board status and building our partnership with Cardiff University on pioneering applied mathematical modelling in UK health care through our ABCi. Rolled out the Values and Behaviour framework across the Health Board. 6

7 Improved levels of medical appraisals with sustainable plans going forward. Progressed work to deliver the SCCC and participated fully in the ongoing work of the South Wales Programme. There have been major challenges in key delivery areas during 2014/15, particularly with waiting times for treatment; cancer waits in some specialties; and in keeping pace with unscheduled care demand. These pressures are not unique to Gwent, but experienced throughout the United Kingdom. Locally, much of this increased demand is generated by our system s inability to adequately care for the growing number of elderly frail patients. The impacts on our ability to manage flow for all our patients (planned and unscheduled care needs) across the system are significant. Some of the key areas to focus on in 2015/16 to recover a more timely access to services include: Reducing the number of patients waiting for long periods of time in Accident and Emergency departments. Working with ambulance services to make sure patients are directed to the best place to meet their needs to reduce delays for ambulances at hospitals. Reducing waiting times for patients requiring outpatient assessment, diagnostic investigation or planned surgery. Reducing variation in cancer waiting times by resolving some key workforce issues in Breast services. Reducing the number of patients waiting for outpatient follow up. These challenges illustrate that current service models need to evolve to meet changing needs for health services, particularly reviewing traditional systems and approaches. These changes range from using key skills available in the primary care contractor professions such as Pharmacists, Optometrists, Dentists and Podiatrists, bespoke community models of care for elderly and frail patients and the application of prudent principles in supporting patients in accessing effective treatment. It also illustrates the need to modernise some services to make sure that patients can be seen by staff with the skills to deal with their issues safely and in a timely manner. Key Challenges arising from Demographic Changes Health Services are facing unprecedented challenges from demographic changes which are already resulting in increased demands on services. There has been a significant increase in age and lifestyle related chronic conditions which require the development of more integrated service models across primary care and hospital services. Demands on community services which extends to nursing home provision and funded nursing care (FNC) are similarly increasing, resulting in major capacity and financial challenges. Community services play an important role by providing more appropriate services releasing hospitals to provide acute and rehabilitation services in a timelier manner. Risks to Service Sustainability Our services need to adapt and develop to reflect the wider requirements of the health service nationally and locally. In addition to demographic changes there are also regulatory pressures, including the changing arrangements for junior medical training which will require investment and different solutions impacting on services with the immediate challenge being in Paediatrics, Obstetrics and General Surgery. 7

8 4. The Health Board s Strategic Direction Our Clinical Futures Strategy sets out the strategic direction for modernising clinical services. A central theme is the creation of networks that bring care as close to the patient as possible through progressive working practices within Neighbourhood Care Networks (NCNs), a new relationship with patients as experts in their own health, the use of new technology, and our maturing NCNs as the vehicle through which local services are organised and delivered. They are already becoming the fundamental building blocks that bind together the work of all partners in health and care in a simple and practical way. NCNs will be supported through a streamlined hospital network, where routine hospital based services will be provided in Local General Hospitals, and all specialist, hyper- acute and critical care services consolidated in the Specialist and Critical Care Centre. Figure 4.1 Reduce health inequalities Direction of Travel Deliver most care closer to home, through co-ordinated and integrated health and social care teams build around NCN communities Provide integrated seamless services to patients, ensuring timely access to good quality specialist healthcare services that cannot be provided through NCN services. Local General Hospitals Specialist and hyper acute care- NCN Hub w/ specialist and enhanced services Primary care and NCN team Mobile Services Tele-medicine Home as the Hub Mobile Health Web Integrated CRTs, core and specialist community services, mental health delivered through shared assessment process and agreed responses based on individual s need 2 Diagram adapted from Kaiser Permanente model In this system the role of patients as co-producers in preserving, maintaining and improving their own health and well being is harnessed. Primary, community and care services are strengthened and integrated to create the capacity to support and treat patients in their homes and communities. Enhanced access to primary care services (urgent and planned) over seven days is a key component of the model. Importantly, the Strategy shows the quantum shift required to realise most care being delivered closer to home. Dependent on clinical need, patients will flow through the system to access hospital based services. The aim, at all times, is to minimise the time spent away from home and from local services. The new system relies on doctors and hospitals working together across different care settings, with high degrees of integration and coordination across agreed pathways of care. 8

9 The Welsh Government has set out the national strategic direction for Health Boards and Trusts within the overarching Programme for Government and the NHS Wales Strategy Together for Health, underpinned by more detailed strategies and delivery plans based on key service areas or population groups and linked to the seven strategic themes of Together for Health, namely: Service modernisation, including more care closer to home and specialist centres of excellence Addressing health inequalities Better IT systems and an information strategy ensuring improved care for patients Improving quality of care Workforce development Instigating a compact with the public and A changed financial regime We support these themes and feels that they are fully reflected in our local strategic plans. Our Clinical Futures Strategy has to make sure that the health system works effectively with partners to manage increasing demand for services, delivering effective, safe and sustainable services within the context of considerable workforce and social change. We will continue to work collaboratively with other Health organisations. The South Wales Programme focused on the optimum, sustainable configuration for some specialist hospital based services (consultant-led maternity and neo-natal care, paediatrics and emergency medicine). Specifically it considered those services where seriously ill and/or injured patients who need to be in hospital will have better and faster access to care from senior and expert doctors and their teams, which will have an immediate and direct effect on their recovery. The Acute Care Alliances (ACAs) were established in 2014 as the mechanism through which the outcome of the South Wales Programme (SWP) would be implemented, monitored and reviewed. For the UHB, the outcome was the reconfiguration of services in line with the Board s Clinical Futures Strategy, with the Specialist and Critical Care Centre (SCCC) an essential development in enabling change. We are part of the South East ACA, with the Clinical Futures Board the structure supporting local planning, with representation from Powys Health Board. We work closely with neighbouring ACAs and Health Boards on a number of service issues, notably where there are potential changes to patient flows e.g. with the Heads of the Valleys population. Our Board recognises its role as the decision making body of matters related to ACAs and retains full accountability. 9

10 5. Focusing on Quality and Patient Safety Delivering safe and high quality services lies at the heart of our mission. We have a strong focus on improving the quality and safety of care provided to our patients with the overall approach informed by the Institute of Healthcare Improvement guiding principles outlined below: Table 5.1 Aim Safe Effective Patient-Centred Timely Efficient Equitable This Means. Avoiding injuries to patients from the care that is intended to help them Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that the patient s values guide all clinical decisions Reducing waits and sometimes harmful delays for both those who receive and those who give care Avoiding waste, including waste of equipment, supplies, ideas, and energy Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. The aim to provide high quality care focused through addressing key risks and striving for excellence. This approach to improvement requires all staff to have two key roles which are to do their job and to improve their job, seeing patients as equal partners in their care. We learn about patient experience and outcomes through effective monitoring of complaints, incidents and mortality reviews. Assurance also comes from comparing performance against key standards including the Standards for Health Services (Doing Well, Doing Better) which helps to identify gaps, risks and areas for improvement. NICE guidance, Fundamentals of Care, standards and pathways lay out the evidence base for services, together with results of local and national audits. A range of external bodies, including the Community Health Council and Health Inspectorate Wales, also undertake formal, independent reviews of our systems, processes and practice, which also underpin our quality assurance processes and enable a triangulation of data. Our Quality Delivery Plan addresses the outcomes of the Francis, Keogh and Berwick reports (2013), with actions identified to address the challenges and priorities, covering values and behaviours, changes to the workforce, improving patient experience through listening to patients and staff. In 2014 Wales saw the publication of Trusted to Care, following a Minister-commissioned independent review of care provision, particularly for older people. An Assurance Framework has been produced describing the response to the report s recommendations. Priorities to deliver in 2015/16: implementing priorities from Trusted to Care particularly Nutrition, Hydration, Medicines and Continence Care improving dementia care which provides one of the greatest quality challenge reduction in hospital falls reducing the Risk Adjusted Mortality Index (RAMI) in our hospital sites reducing incidence and numbers of C Difficile and MRSA infections improving early recognition and treatment of Sepsis to reduce unnecessary death and harm preventing pressure damage in hospitals 10

11 Improving Patient Experience a good patient experience is at the heart of the quality in healthcare as it encompasses all the dimensions of quality. Services must be seen through the patient viewpoint to make sure clinical delivery meets patients needs and expectations. There are high expectations to improve the quality and care provided to patients following high profile problems in other health organisations. An important priority is working with communities to assess and design services seeing individuals as equal partners in treatment decisions allowing improved outcomes. The challenge is to develop a new relationship with the public as co-producers in their own care, empowering the patients to make informed decisions about the appropriate use of healthcare. A Framework for Patient and Family Engagement will be developed, embracing levels of engagement, consultation, involvement, partnership and shared leadership. Key approaches include: Figure 5.1 Patient Surveys All Wales Core Questions Fundamentals of Care Patient Experience survey Nutrition Reviews Observations of Care HIW reviews Dignity and Essential Care Inspectorate Community Health Council Spot Checks Patient Stories Complaints Analysis of Complaints, Comments and Compliments Participation Kings fund and Health Foundation and Family Centred Care Programmes Kafka Brigade Reviews Shadpwing Listening Events The Health Board will continue to collect and use patient stories to help to see our services through patients eyes. Carers stories will also be introduced as part of the Carers Measure implementation Safeguarding is central to all aspects of Health Board activity and the safety of service users and their families is a priority for us. The safeguarding agenda has increased in breadth and complexity in recent years and is concerned with children and young people; vulnerable adults, particularly the frail elderly; domestic abuse; sexual exploitation, human trafficking and slavery; female genital mutilation and counter terrorism. A safeguarding operational group delivers a plan of work to advance practice and enable healthcare staff to recognize and respond to any suspicion of abuse or neglect whether in the home, the community, residential or healthcare setting. This includes the development of a programme of training for frontline staff and the provision of supervision, and advice. 11

12 A Safeguarding Committee, chaired by an Independent Member, provides the strategic lead and reports to the Quality and Patient Safety Committee. Senior representation on the regional Children s Safeguarding Board, Adult Safeguarding Board and Multi- Agency Public Protection Strategic Management Board supports close inter-agency working and in the scrutiny of inter-agency practice to identify where improvements can be made. Over the coming year the Health Board will be working with partner agencies to further strengthen safeguarding processes and practice in meeting the requirements for the implementation of the Social Services and Wellbeing (Wales) Act 2014 and the Gender-based Violence, Domestic Abuse and Sexual Violence (Wales) bill, introduced in June

13 6. Mechanism to deliver our Strategic Direction and address challenges The previous sections identified some of the key challenges that need to be addressed if we are to advance our goals of improving access, quality and sustainability through an increasingly prudent healthcare system. If we are to realise our vision, as set out in our Clinical Futures Strategy, we must take action to: Increase focus on helping people and communities stay healthy Meet the needs of a growing ageing population and people with chronic disease Address disparities in low socioeconomic populations Provide care in the most appropriate setting and in a timely manner Improve access to a range of services delivered through Neighbourhood Care Network teams and improve patient flow across the system Develop a workforce that will meet future needs and provide a flexible, challenging, safe and satisfying work environment Realise the benefits of our integrated health system by adopting quality clinical practices including standardising pathways of care, anticipating needs, fostering innovation and promoting better outcomes. Improve information and measurement systems to support decision making and delivery. This list is not exhaustive but illustrates the multifaceted and co-ordinated work required to address current challenges and to truly transform the health system. Transformation is not an instant process and requires careful consideration of priorities, appropriately phased actions and appropriate alignment of resources to achieve the best outcomes, now and in the future. As we develop our service strategies, the UHB will organise these changes around two fundamentally important and interlinked relationships. These are: How services are shaped with communities and other partners to best improve health and prevent early onset of illness and injury. This requires focus on specific improvement goals tailored to these communities and groups, developing cross cutting public sector supports and enabling local ownership of this improvement. Figure Integrating Service Response How services are organised to meet the patients need for quality, accessibility and sustainable care, from initial assessment through to treatment and discharge or ongoing care. This means designing our system along key pathways of care describing the life events when health-care needs arise from birth to death and when treatment is needed. We will design these pathways based on best evidence, driven by prudent healthcare principles and quality and measure the improvement. 13

14 As a further step toward this vision of integration and improvement, we are concentrating our change efforts into the delivery of preventative activities with neighbourhood care networks as the primary mechanism for delivering care, access to the right service, flow through the system and service sustainability. Our priority plans have been aligned and organised around 10 service change plans. These are: Table 6.1 SCP Title SCP Title 1 Reducing Health Inequalities 6 Continuing Health Care 2 Prevention and Improving Population Health 7 Service Sustainability 3 Primary Care and Provider Services 8 Mental Health and Learning Disability 4 Integration Bringing Care Closer to Home 9 Urgent and Emergency Care 5 Chronic Conditions Management 10 Planned Care Figure 6.2 below illustrates how these programmes align and the intended outcomes or contribution they make to deliver our vision. Figure 6.2 Improve Health and Prevent Early Onset of Illness/Injury Service Change Plans 1 and 2 Reduce health inequalities and lessen demand for healthcare Building a Neighbourhood Care Network Foundation for Delivery of Care Service Change Plans 3,4,5, and 8 Provide majority of care through integrated teams organised around our 12 NCN Communities Improving Access; Flow and Reducing Waits Service Change Plans 9 and 10 Robust needs assemments, demand/capacity alignment that minimises coversion from NCNs to secondary care and maximise timely provision of care when required Service Sustainability Service Change Plans 6 and 7 Ensuring services that are clinically or financially vulnerable are stablised and maintained for our citizens, and where relevant, across South Wales There will be a shift in the balance of services to Neighbourhood Care Networks, by increasing the range of hospital based services that will be delivered in primary and community care settings and there will be seamless collaboration between practitioners across the whole system. This will necessitate working very differently to focus on supporting patients in a primary care setting, through direct patient contact, indirect support to NCN teams and remote monitoring for patients. Significant enabling plans related to finance, infrastructure, workforce, delivery and information technology are being developed and aligned with the priorities and outcome targets identified in each of the Service Change Plans. Table x summarises plans that require additional investment, together with applicable funding streams. 14

15 Summary table No. UHB plans Funding stream 1 Living Well, Living Longer programme to reduce health inequalities in Pathfinders/Once for Wales most deprived areas 2 Increase access to Smoking cessation services in primary care to Primary Care reduce burden of disease 3 To reduce referrals to secondary care through introduction community Primary Care MSK & OA knee programme 4 To develop a multi-professional Primary Care support and improvement Primary Care team to support practices in difficulty, test out new service models and enable service improvement 6 To optimising GP access and agree health Board standards that build Primary Care on 5As for Access 7 To improve support to Care Homes through effective medicines Primary Care management and anticipatory care planning to reduce secondary care admissions 8 To realign district nursing services to NCNs and increase capacity to Primary Care meet primary and secondary care demand 9 To transform prison healthcare services Primary Care 10 To transform the minor oral surgery pathway Primary Care 11 To transform ophthalmic provision through development of a primary Primary Care care based Ophthalmology Diagnostic Treatment Centres 12 To support NCN development Primary Care 13 To implement a number of Local Authority schemes to Intermediate Care Fund 14 To strengthen community cardiac failure services to improve patient Primary Care care and reduce admissions 15 To transform the respiratory pathway Primary Care 16 To transform the diabetes pathway, transformation Primary Care 17 To strengthen patient support and education within Primary Care Primary Care 18 To improve outcomes and reduce length of stay through Primary Care implementation of a community neuro-rehabilitation service 19 To redesign the stroke service to improve outcomes Intermediate Care Fund 20 To strengthen CAMHS services to meet demand and improve access Primary Care 21 To strengthen Primary Care Mental Health Teams to improve access Primary Care and reduce waiting times 22 To use the RAID programme to improve patient care and reduce Intermediate Care Fund demand on secondary care 23 With the third sector, to extend care co-ordination across Gwent to Primary Care maintain independent living and reduce demand on secondary care 24 To improve pharmacy support to NCNs to improve both access and Primary Care patient care 25 To strengthen frailty services to maintain care of patients in the Primary Care community 26 To improve the care of elderly patients through the creation of Elderly Primary Care Frail Units 28 To implement patient flow technologies to improve patient flow Technologies fund 29 To improve access to physiotherapy and occupational therapy through Primary Care 7 day working 30 To expand telemedicine to provide support to primary care and shift Technologies fund balance of care 31 To extend the role of Community Resource Teams to support Out Of Hours GP services Primary Care 15

16 7. Improving Health and Preventing Early Onset of Illness and Injury The health of individuals and our population as a whole is affected by several factors; the socioeconomic environment; where we live and work; genetic makeup; the presence of risks to health; individual lifestyle choices; and access to health and supports. Taken together, these factors determine how healthy we are as individuals and as residents of Gwent. Major health disparities exist in Gwent that are differentially distributed among populations by gender, education, income and other indicators of disadvantage. Not only are the consequences of disparities avoidable, they are costly. Evidence suggests that, as well as the burden of ill health for individuals, health inequalities cost the economy around billion each year in loss of productivity and billion in lost taxes and welfare payments. Treatment of the disease outcomes of these health inequalities consumes 1/3 rd of the NHS budget, with direct treatment costs in England amounting to 5.5 billion per year. Reducing the current rate of heart disease, stroke, cancer, diabetes and liver disease for the most deprived fifth of the population to nearer the rate for the least deprived fifth would make a significant contribution towards the UHBs ability to create a sustainable healthcare system for Gwent. A co-ordinated effort is required to promote and protect the health of our citizens and to address health inequalities. Service Change Plan 1 Reducing Health Inequalities is a systematic, population scale programme, to increase the prevention, early identification and optimal primary care management of heart disease, stroke, diabetes, cancer and liver disease in our most deprived communities, where the rates of these diseases are highest. Reducing health inequalities across the UHB matters because, on average, there is nearly a 10 year difference in the average life expectancy at birth between men in the very least and very most deprived fifths of the population and around a 20 year difference in healthy life expectancy. A similar pattern is true for women too. Inequalities are particularly evident in cancer incidence, mortality and survival. Emergency hospital admissions rate is twice as high for people living in the most deprived areas compared with rates for the least. Of the patients living in the most deprived fifth areas of Wales, around 66% were registered within the catchment area of five of our Neighbourhood Care Networks. Graph % of patients living in most deprived fifth of areas in Wales, NCN clusters in ABUHB

17 The Living Well, Living Longer programme has been designed to have population impact on inequalities in health over a five year time period. The programme will address inequalities in access to primary care; develop a sustainable primary care system for identification and management of chronic cardiovascular disease and cancers in the highest areas of need. This programme is a core component of our delivery plans for heart disease, stroke, diabetes and liver disease. It focuses on: Identification and reduction of risk of cardiovascular disease. Reducing inequalities in cancer incidence and stage of presentation. Reducing inequalities in health expectancy due to lifestyle risk factors. The programme will co-produce with communities a network of support for people to make healthy changes to their lifestyle, building on local assets such as Communities First and developing sustainable approaches. Table 7.1 Vision Desired Outcome and Benefits Measurement Milestones Financial Implications Reduce health inequalities across the UHB area Reducing the current rate of heart disease, stroke, cancer, diabetes and liver disease for the most deprived 5 th to nearer the rate for the least deprived 5 th of our population Uptake of Living Well, Living Longer Programme (nos screened; lifestyle changes, nos on optimal primary care treatment programmes) Incidence of disease over three to five years Emergency admission rates for target populations Q1 2015/16 CVD risk assessment and management programmes offered to eligible adults in BG West NCN Q4 2015/16 CVD risk assessment and management programmes offered to eligible adults in BG East NCN and Caerphilly North NCN Q4 2016/17 CVD risk assessment and management programmes offered to eligible adults in Newport East and Newport West NCN Q4 2015/16 Community Health Champions rolled out in all 5 NCN areas Investment strategy (workforce and finance) in place to support the programme. Benefits in form of improved health status, and reduction in use of healthcare services will be realised in the medium term. Plans are also in place to reduce inequalities in child health focusing on low birth weight, maternal smoking cessation and reducing teenage conceptions. Plans are being progressed through the development of the UHBs Homeless and Vulnerable Groups Health Action Plan, to ensure that the Living Well, Living Longer Programme reaches these groups. Service Change Plan 2 Prevention and Improving Population Health aims to improve the health and well being of our entire population. As well as the burden of preventable disease for individuals, the current scale of preventable disease due to lifestyle risk factors is putting NHS treatment services under considerable strain and there is a high risk that the projected increase in lifestyle related disease will create an unsustainable strain on NHS services and finances. Reducing the proportion of the population who smoke, who are obese and who drink harmful amounts of alcohol 17

18 would have population impact on rates of heart attacks, stroke, diabetes, cancer and liver disease. The scale of our challenge facing Wales can be determined from the results of the 2013 Welsh Health Survey, summarised opposite. Gwent residents have even worse levels of poor lifestyle with marked differentials by area of residence between deprived and affluent areas. We aim to help large numbers of people to stay healthy and to reduce demand for treatment services for preventable conditions, thereby reducing system-wide costs and delivering best value from the NHS. Our plan builds on our Public Health Strategic Framework with the continued aspiration that: Babies are born healthy. Pre-school children are safe, healthy and develop their potential. Children and young people are safe, healthy and equipped for adulthood. Working age adults live healthy lives for longer. Older people age well into retirement. Frail people are happily independent. Figure 7.1 We have adopted the World Health Organisation Ottawa Charter framework (1986) for the organisation of partnership actions to address the social determinants of health; building healthy public policy; creating supportive environments; strengthening community action; development of personal skills; and re-orientation of health service moving beyond only providing clinical and curative services. Our focus is to: Make every contact count providing information and support to thousands of people to modify their lifestyles. Achieve high population immunisation levels one of the most cost effective interventions for improving health through prevention of serious infectious disease. Address the social determinants of health adopting a partnership approach, recognising the crucial role Local Authorities and other partners have to play in improving population health. Table 7.2 Vision Desired Outcome and Benefits Measurement Milestones Improve the health and wellbeing of our population To reduce the proportion of the population who smoke To reduce the proportion of the population who are obese To reduce the proportion of the population who consume harmful quantities of alcohol To achieve high population immunisation levels To minimise the burden on healthcare for preventable diseases Completed episodes of interventions and outcomes of interventions Q1 2015/16 expansion of Level 3 community pharmacy smoking cessation services from 20 to 50 pharmacies Q2 2015/16 dedicated smoking cessation services for pregnant women in all 18

19 Vision Improve the health and wellbeing of our population 5 Local Authority areas Q4 2015/16 Child Obesity Action Plan agreed by all agencies Q4 2016/17 achieve UNICEF Baby Friendly Accreditation and increase numbers of mothers breastfeeding at 6 weeks Q1 2015/16 Adult Weight Management Service extended to include routine referrals of patients presenting with knee pain who are obese Q1 2015/16 Child Weight Management Service Treatment Pathway agreed Q4 2015/16 Alcohol Harm Reduction Pathway develop and agreed with partners Q4 2015/16 delivery of immunisation and vaccination programmes The gestation time to delivering the benefits or our plans to improve health and prevent the early onset of illness is illustrated below. Graph Gestation time to impact of different interventions on population health 1 A B For example intervening to reduce risk of mortality in people with established disease such as CVD, cancer and diabetes For example intervening through lifestyle and behavioural change such as stopping smoking, reducing alcohol related harm and weight management to reduce mortality in the medium term C For example intervening to modify the social determinants of health such as worklessness, poor housing, poverty and poor education attainment to impact on mortality in the long term The case for focusing on wellness as a strategic response to ensuring our healthcare system is sustainable in the medium to longer term is irrefutable. The current trajectories of increasing demand for preventable conditions are overwhelming our system. Applying interventions that improve the health status of our population and stem the growth in demand for future health and social care services is paramount. 1 Adapted from Bentley, C and Leaman J: Health Inequalities National Support Team. Priority actions based upon best practice that could impact inequalities in mortality and life expectancy in the short term. [Online] London: DH. Available at [Accessed 18 January 2015] 19

20 8. Building a Neighbourhood Care Network Foundation for Delivery of Care Care at home, or in the patient s community, with the most appropriate person, with the right skills delivering care at the right time, is the unequivocal aim of our future vision. Strengthening Primary and Community Care services is therefore our top priority and the central tenet of our Clinical Futures Strategy and a key component of the Social Service and Wellbeing Act. Figure 8.1 In 2011 we established 12 Neighbourhood Care Networks (NCN), each comprising of primary care, health and social care, housing and third sector community providers operating within the boundaries of the neighbourhood. The original role was facilitative and enabling, responding to local need and national priorities across health and social care and has resulted in increased uptake of influenza immunisations, smoking cessation and the development of the Living Well, Living Longer programme. Our decision to actively adopt this broader integrated network approach (as opposed to clusters of General Practitioners) places our NCHs in a strong position to capitalise at pace, on the opportunities presented by the national Primary Care Plan and the Social Service and Wellbeing Act implementation and crucially the direction of travel set by the Health Board. Creating the capacity to deliver care closer to home will be achieved through the integration of treatment and care for our NCN communities. Our plans bind together the work of all partners in health and social care in a simple and practical way. Our twelve NCNs will become the focus for the communities they service, building multidisciplinary teams supporting local people with physical, psychological and social care needs. It is essential that the priorities for primary and community services as articulated through the five Single Integrated Plans, developed at a Local Authority level, are reflected and delivered through our NCNs. Over the next three years NCNs will become the main vehicle that drives the implementation of our key priorities, including our response to the Social Services and Wellbeing Act. Our clinically led NCNs create annual plans which are focused on discrete communities of 30 to 50,000 people. These plans reflect the needs of their neighbourhood population and underpin the key role that NCNs play in determining future models for integrated service design and delivery. NCNs are in a unique position to: Reduce Health inequalities through the Living Well, Living Longer programme and supporting lifestyle changes. Actively involve of the public, patients and their carers in decisions about their care and wellbeing. Deliver improvements in access and quality of care. Enable and support the provision of more care closer to home, where appropriate and reducing any unnecessary attendance in hospital settings. 20

21 Refocus the balance of care through adopting co-ordinated care models where generalists work closely with specialists and wider support in the community to prevent ill health, reduce dependency and effectively treat illness. Ensure all services and clinical pathways comply with prudent healthcare principles. Directly support the development of the Specialist and Critical Care Centre, and the Clinical Futures Hospital network ensuring that we deliver a truly integrated system of care. Our vision is to deliver most care closer to home (System change) by reengineering the whole pathway of care with the express intention of providing most of the pathway closer to home. These pathways will play a crucial role in simplifying our system of care and improving flow at the interface points to minimise fragmentation and avoidable delay in the patient journey. They will assist both health and social care staff and patients understand and achieve the best approaches for care which is safe, person centred, clinically and cost effective. We recognise that the combination of targeted action within primary care services and informing and empowering the individual with a condition will improve their sense of wellbeing and avoid repeated admission to hospital. Four separate but interconnected Service Change Plans - SCP 3 (Independent Contractor Services, 4 (Integration and NCN development), 5 (Chronic Conditions) and 8 (Mental Health) - have been developed to progress our ambition to create a Primary Care led NHS. They are designed strengthen universal primary care services, and to create the capacity to integrate care for frail older people and people with chronic conditions. Our ambition is to attain the scale of service transformation that has been achieved in mental health services over recent decades (i.e. reducing the need for hospital based care through developing pro-active, robust, integrated, multidisciplinary and multi-agency teams in our communities). Our plans for Mental Health and Learning Disability (SCP 8) services make a significant contribution to the delivery of care closer to home. Service Change Plan 3 Primary Care Services (Independent Contractors) sets out the unique role of primary care in co-ordinating care for people to the wide range of services delivered by our healthcare system. Primary Care is a crucial component of the strategic solution for sustainable healthcare. Whilst we have had success in using General Dental Practitioners and Community Optometrists to provide minor oral surgery and glaucoma assessment services in a primary care setting, which would have traditionally been provided in a hospital setting, we recognise the opportunities that exist in working collaboratively to provide more care closer to home. We have plans to develop Primary Care Ophthalmic Diagnostic and Treatment Centres to treat glaucoma initially with the potential to manage Wet AMD. There are significant challenges in recruitment and retention of GPs across the UK mirrored withnin the Health Board. Consequently, our plan is predicated on planning for a more sustainable GP workforce whose role will increasingly be to provide overarching leadership of a range of health care professionals. Improving Access to (Contractor) universal services by developing sustainable primary care services (urgent and planned care) over 7 days. This includes innovative service and staffing models to ensure that citizens have reliable access to primary 21

22 care clinicians that offer a better alternative than attending Emergency Departments or relying on Out of Hours Services such as 7 day minor illness centres. Optimising access to primary care also helps improve quality, patient experience and over reliance on secondary care services. Our focus is based on: Matching demand and capacity (for core and enhanced services). Reducing variation across contractor services that cannot be explained on the basis of illness, medical evidence or patient preference. Extending range of services provided through primary care contractor services (General Dental Services, Primary Care Eye Services and Community Pharmacies). Sustainable workforce (for core and 7 day General Medical Service provision). IM&T capability to provide timely access to shared information necessary to coordinate and manages care. Supporting the development of the general practice infrastructure of estate and I M & T. Table 8.1 Vision Desired Outcome and Benefits Measurement Milestones Vision Desired Outcome and Benefits Primary Care led NHS Health Board standards for access to GMS agreed. Citizens have timely access to 7 day primary care services that meet the majority of their healthcare needs. Primary Care workforce model will be robust and sustainable. A Multi Professional Support and Improvement Team will support practices in difficulty, promote quality improvements and test out new models of care. Unexplainable variation will be minimised and patients will receive as much care as possible closer to home with the result that the flow of patients to secondary care will be reduced End of Life Care Delivery Plan implemented Number of practices meeting local access standards Number of patients accessing Enhanced Primary Care Contractor services. Increase in immunisation rates. Service improvements in GP practices. Impact of enhanced roles in GP practices, such as Pharmacists and Nurse Practitioners. Referral rates for Emergency Medical Admissions and Out patients Patient flows across the system (e.g. primary care attendances; NCN team caseloads; attendances to ED, emergency admissions, referrals for planned care). Q3 2015/16 Board approval of local GP access standards Q1 2015/16 Expand minor oral surgery service Q4 2015/16 Implement phase 1 of ODTC Q2 2015/16 Scope mode clinical pharmacists to align with General Practices Q2 2015/16 NCN practice referral data/variation at practice level Q2 2015/16 PC Support and Improvement Team in place. Primary Care Ophthalmic Diagnostic and Treatment Centres (ODTCs) developed Primary Care ODTCs commissioned. More patients treated in primary care. Reduce reliance on hospital eye services. Improved RTT compliance 22

23 Measurement Milestones Vision Desired Outcome and Benefits Measurement Milestones Number of patients referred to ODTCs by condition Number of patients treated at ODTCs Number of patients meeting Wet AMD NICE guidance Patient satisfaction with service. Q4 2014/15 Glaucoma assessment LES commissioned to continue for 2015/16. Q4 2014/15 ODTC Task and Finish Group develop service specification and agree implementation plan Q1 2015/16 Commence tendering for ODTC sites Q3 2015/16 ODTCs become operational Patients access minor oral surgery in a primary care setting. Patients will have minor oral surgery in a primary care setting. Patients will be referred to the service directly from their General Dental Practitioner. Only patients at risk will be referred to the Hospital Dental Service. Number of patients referred by their GDP to the Primary Care Minor Oral Surgery Services Number of patients referred to the Hospital Dental Service. Number of patients referred to the Hospital Dental Service who are suitable to be treated in Primary Care. Patients satisfaction with the Primary Care Service Q1 2015/16 Review of Primary Care Service Contractors Q1 2015/16 Consider whether a contract should be offered to other practices. Q1 2015/16 Develop mechanisms to identify patients referred inappropriately and feedback to the originating General Dental Practitioner. Service Change Plan 4 Integration and NCN Development is a key principle throughout our plan. Specifically we aim to reduce the need for hospital based care through improving health and developing pro-active, robust, integrated health and social care, multi-disciplinary and multi-agency teams built around our NCN communities. Their role is to consistently provide care that is co-ordinated around people s needs and goals, delivering the right care, in the right place, and at the right time. This requires teams in physical and mental health, social care, public health and the wider public, independent and voluntary sectors to work together. The integration of care is not ultimately about where organisational lines are drawn and re-drawn. Care involves people working with people. As such, our vision of integration is on teams of people, with different expertise and experience, collaborating to meet health and care needs and improve outcomes for individuals, families and communities. The important next step is to simplify the patterns of community services, aligning them to create integrated health and social care teams for NCN communities. These teams will be the blueprint for progressively extending the range of care available to patients in their local communities. Improving and enhancing services for older people is one of the most significant actions that we can take, both to improve the quality and experience of care for our elderly, and ensure that care, whenever possible, is provided closer to home. We have adopted a whole system pathway approach from prevention & anticipation through to end of life care. This forms a significant component of our integration plan for 23

24 2015/16 and spans a wide trajectory from prevention and anticipatory care through to assessment, treatment, rehabilitation and end of life care. Prevention and Anticipation Assessment/ Treatment Rehabilitation/ End of Life Risk identification and management (including polypharmacy) Integrated services for NCNs rapid access to single assessment process and alignment of care responses with identified need (including CDM) End of Life Care Plan Anticipatory Care Planning Emergency Frailty Unit at EDs Graduated care model for community hospitals and step up facilities in localities Palliative Care Strategy Enhanced NCN services nursing home sector Clinical outcome measures and integrated pathways with CoTE Hospice at Home Developing NCNs to enable them to be the vehicle that drive change by planning, co-ordinating and delivering service that support people to receive the majority of their care, according to need, through integrated community based services. We recognise the scale of the organisational development agenda. We will begin by agreeing core leadership roles within the NCNs of GPs, District Nursing, Health Visitors, Social Workers, Mental Health Workers and Pharmacists. There will need to be some investment in District Nursing and Pharmacy services to support this. There will need to be a clear governance structure in place to ensure clear accountability both professionally and managerially. During 2015/16, NCNs will also consolidate and strengthen the management of patients in care homes and make progress in improving access to 7 day services. Vision Desired Outcome and Benefits Measurement Milestones Vision Desired Outcome and Benefits To Support Care Homes to provide high quality care for patients. All patients will have anticipatory care plans All patients will receive medicines management reviews Fewer patients will be transferred to a hospital setting when they could be managed in the care home Number of patients with anticipatory care plans in place Number of patients undergoing medicines management reviews Number patients transferred to a hospital setting Number of patients referred to the Out of Hours Services Number of patients who die in the care home. Q1 2015/16 Identify NCN pharmacists aligned to care homes and commence medication reviews. To explore 7 day working for all services aligned to NCNs. Patients will have access to all services every day. Increased number of discharges at weekends and bank holidays. Reduced number of patients being delayed in transfer from hospital to home. Improved rehabilitation outcomes due to continuity of service 24

25 Measurement Milestones No of patients accessing services at weekends and bank holidays No of discharges at weekends. Number of patients referred to out of hours with exacerbations of chronic conditions. Number of patients attending hospitals with exacerbations of chronic conditions. Q1 2015/16 Identify additional capacity required to enable 7 day working Q2 2015/16 Additional staff in place Prison healthcare we are responsible for healthcare provision at HMP Usk and Prescoed Prison, with a prisoner population of 520. Prisoners should be able to receive the same access to healthcare as the general population, this is currently compromised by a reliance on hospital based services, where the prison capacity to comply with prisoner escort arrangements cannot meet demand. Our plan sets out to develop and implement in-reach services, maximise virtual services and reduce inequalities in access to physical and mental healthcare services. Vision Desired Outcome and Benefits Measurement Milestones Prisoners in the secure estate will receive the same standard of care as people living in the community. Prisoners will be supported to make positive lifestyle changes Prisoners will be supported to stop smoking in preparation for the Prison Smoking ban being enforced. Prisoners will have access to a range of Independent Contractors. Prisoners will have as much care as possible within the secure setting. General medical Services Quality and Outcomes Framework data. Reductions in number of prisoners smoking Increase in immunisation uptake Increase in prisoners screened for Blood Bourne Viruses. Increase in number of in reach services for mental health support Increase in patients accessing General Dental Services and Optometry Services Q1 2015/16 Smoking cessation across both sites Q1 2015/16 All patients to undergo timely chronic conditions management reviews Q2 2015/16 Establish in reach sexual health clinics Q4 2015/16 Prepared for impact of Social Services and Well Being Act implementation Q4 2015/16 Improve uptake of blood bourne virus screening Service Change Plan 5 Chronic Conditions there is a strong link between deprivation and the numbers of people with poor health including chronic health conditions, for example the incidence of diabetes in Wales is almost doubled in areas of high deprivation compared to areas of least deprivation. The burden of chronic conditions for our population is significant as illustrated in Figure x. 25

26 Figure WHS results - ABUHB residents by LA, health board and Wales for selected conditions High Bp Arthritis Heart condition Respiratory Condition Diabetes Mental Illness Caer BG Tor Mon Npt ABUHB Wales While our plans to reduce the burden of ill-health through reducing health inequalities (SCP1) and prevention and improving population health (SCP2) will deliver benefits in the medium/long term, supporting our citizens who currently live with one or more long term conditions is a key priority. Managing patients with chronic conditions is a core component of General Medical Services and the plans set out in SCP 3 and 4 are fundamental to optimising outcomes for our citizens with chronic conditions. A holistic approach to care frames evidence based practice for each chronic condition, and we are adopting a whole system pathway approach for diabetes, chronic respiratory disease and arthritic knee. Co-production is central to all our interactions with patients. Patient activation and learning to self manage their condition has not been promoted and supported as extensively as it needs to be. This has led to a dependency relationship with health services, which needs to be altered and the balance of responsibility focused on enabling patients to be active and central participants in managing their condition. There are several education and rehabilitation programmes available, although these do not meet demand and are not always well attended, with only a small number of people completing the full programmes. We are working with Colleges of Further Education to develop modular programmes that are more accessible to patients and their carers. Our plans are based on the principle of prudent healthcare, supporting people to be full participants in their care, providing information, advice and support to make appropriate lifestyle choices and changes, maintaining psychological and emotional wellbeing, improving early detection and optimal management of their chronic conditions, predominantly in primary and community care settings. Our approach is illustrated through the work we are progressing on the management of diabetes. 26

27 The prevalence of Type 2 Diabetes in our local population is 27% higher than the UK average with 37,311 residents being cared for predominantly by local primary care (85%) supported by specialist secondary care diabetes services. 90% of patients have Type 2 diabetes, and the numbers of people who develop Type 2 diabetes is expected to rise sharply over the next 10 years. 30% of our adult population are at significant risk of developing the condition and any actions we can take to improve health and prevent the early onset of diabetes form a central plank of our approach to developing sustainable services. To deliver the highest possible level of care for the increasing number of citizens with diabetes we are moving from the current two stream service to one where we have a fully integrated diabetic pathway spanning patient education/participation, primary care and specialist inpatient and ambulatory care. Figure x below illustrates the integrated pathway and highlights the key changes that will be progressed through this service change plan. Figure Integrated pathway for diabetic care Key Changes Patient participation and support groups (NCNs) Learning and Activation capacity/ access to programmes Planned, robust interface with diabetes specialists and primary care to ensure equitable access to high quality generalist care Initiation of injectable therapy Integrated specialist nursing team directing delivery of care within community settings, in reach to hospital diabetic services Focus specialist care Super Six Improved and equitable access to diabetic care for patients admitted to hospital Table 8.3 Vision Desired Outcome and Benefits Measurement An integrated diabetes pathway, focused on supporting each person with diabetes to self manage by delivering care and support centred and coordinated around their needs. This integrated pathway ensures that all parts of the system work together to deliver all the components of the care pathway with clear protocols for who does what and what services are provided and where. Improved patient experience and competence to self manage Improved clinical outcomes Improved governance Increased capacity for delivery of care close to home Increased capacity to provide specialist diabetic care Reduction in referrals to outpatient specialist services Reduction in unplanned admissions Patient satisfaction surveys 27

28 Milestones Workforce Finance Numbers of newly diagnosed patients accessing education and training Compliance with annual review measures Numbers of diabetic population with poorly controlled diabetes Reduction in procedures resulting from diabetes (amputations, ophthalmology) Referrals to specialist services Admissions Q1 2015/16 establish integrated Diabetic Specialist Nursing service Q2 2015/16 eliminate specialist follow-up outpatient backlog Q4 2015/16 patient participation groups established in all NCNs Q4 2015/16 consultant mentoring and advice in primary care settings established Q4 2015/16 Insulin initiation and supervision enhanced primary care services Integrated DSN team 6 wte 2015/16-260,000 (integrated DSN team) 2015/16 -. (insulin initiation and supervision) Service Change Plan 8 Mental Health and Learning Disability around 100,000 people in Gwent experience mental health symptoms at any one time. Of our 240,000 children and young people, around 1 in 10 will have a mental health or behavioural disorder, and many of these go on to experience mental health problems in adulthood. Our older adult population is set to increase by 27% by 2030 with a predicted 39% increase in the numbers of older people with dementia. A predicted 2.3% increase in the prevalence of people with a learning disability by 2020 will impact on the capacity of our service to meet the increasingly complex physical and learning needs of this population. This may place additional pressure on demand for Continuing Healthcare Services. In order to meet future demand in a sustainable way mental health needs to become everybody s business, care should be delivered close to home, and efforts to reduce health inequalities that impact on emotional health and wellbeing. Our service change plan identifies the following service transformation priorities. Primary Care Mental Health Support Services improving access to assessment and therapeutic interventions in primacy care and community settings. 13 work streams testing a range of new and innovative approaches including the use of Super-Groups (large scale therapeutic group interventions to develop community capacity to enhance community resilience), computerised Cognitive Behaviour Therapy. Table 8.4 Vision Desired Outcome and Benefits Measurement Milestones To improve the emotional and psychological well-being and mental health of the population via the provision of enhanced Primary Care MH support Improved clinical outcomes and patient experience via timely access to mental health assessments and evidence based interventions within primary care. Achievement of PCMHSS Tier 1 targets. Further integration within Primary Care supporting the development of extended Primary Care teams. Monitoring of performance trajectory for Tier 1 targets for PCMHSS assessment and intervention. (Predicted to meet July 15). Service user, carer and GP satisfaction undertaken by CHC. Aggregation of patient clinical outcome measures. Nov 2014 Nov 2015: 12 month SCF programme implemented 28

29 Re-designing the Third Sector Service Model in order to ensure equity of access for patients and maximise the contribution of the third sector to the care pathway. Table 8.5 Vision Desired Outcome and Benefits Measurement All service users will have access to the same range of recovery focused services regardless of where they live in Gwent Equitable access to a range of third sector support across Gwent. Resource distribution across Gwent is in line with need. Outcome framework is in place and monitored for all third sector providers. Milestones Feb - April: Consultation on proposed service model April - May: Final service model agreed Feb - March: Further consideration of mechanism for commissioning final service model April: Commissioning plan and timescales agreed Older Adult Mental Health Liaison (RAID), early identification of patients, joint working and up skilling non-mental health professionals to care of patients in acute hospital settings. Table 8.6 Vision Desired Outcome and Benefits Measurement Milestones To improve outcomes and the experience of older people with mental health difficulties within secondary physical healthcare settings Improve clinical outcomes and patient experience. Improve patient flow and reduction in bed usage at RGH, STW and one other site Reduction in demand on social care via increased number of individual returning to original residence Improved integrated working and skill within physical and mental health workforce Length of stay Numbers of admissions Patient/Carer experience Staff experience Jan: Interim Pilot Evaluation Report March - April: Final Pilot Evaluation Report February - March: Pursue funding options to continue service for a further 12 months Plans are also being progressed to develop a Low Secure Unit to bring care closer to home and reduce reliance on independent sector providers. Collectively these service change plans will create capacity to deliver more care to patients in their homes, or through their local NCN team. 29

30 9. Improving Access, Flow and Reducing Waits Timely and appropriate access supports good clinical outcomes. Deterioration of health is reduced, unnecessary duplication of investigations is avoided and the burden to patients, families, communities and other support services is minimised as much as possible. Over the past 10 to 15 years access to planned and emergency services has becoming increasingly difficult due to a number of factors, including disease complexity, system expansion, ageing population, public expectation and workforce changes. We recognise the need to address each of those components in order to achieve optimal health outcomes for our patients. We need to make immediate improvements against locally and nationally agreed standards including the maintenance of the 95% 4 hour transit time ED target, elimination of 12 hour waits and achieving Referral to Treatment Time targets. To achieve this we need to reduce demand, improve patient flow across the system, reduce delayed discharges and increase direct and timely admissions for those who require inpatient care. SCP 9 and SCP 10 set out the significant actions that need to be progressed in the short to medium term for Urgent & Emergency Care and Planned Care respectively. These service change plans do not stand alone; they are integrally linked to areas for improvement in: Primary care assess Reduction in variation (including clear pathways and thresholds for accessing secondary care) Diabetes, Respiratory and Stroke Pathways Creating capacity in our neighbourhood care network teams to provide high quality, person centred, anticipatory, effective and efficient care to provide more care in the community Improving health and preventing early onset of illness and injury Collectively these programmes are designed to cool the system down, smooth demand, reduce inefficiencies and support the system to deliver optimal care for our patients. Service Change Plan 9 Urgent and Emergency Care there are significant pressures on urgent and emergency care services across the Health Board that require an improved whole system approach which maximises the contribution of every service with the aim of caring for patients in the right place, at the right time and by the right care team. This past winter has highlighted continuing capacity pressures on our current system resulting from a higher proportion of majors presenting at our Emergency Departments, stubbornly high ambulance conveyance rates (30% of patients arrive by ambulance) that results in ambulance clustering which further exacerbates our efforts to improve patient flow and an increasing ration of patients with complex care needs admitted to hospital. 30

31 Delivering sustainable urgent and emergency care services is and remains a priority for clinical and management action, we are focused on finding innovative solutions that deliver: A preventative approach which identifies those at risk of being admitted to hospital and seeks to intervene to avoid this where appropriate A proactive approach which identifies and manages those at risk of becoming delayed when in hospital Effective systems and processes to identify and manage those who experience a delay in their discharge or transfer to a more appropriate setting. We want Urgent and Emergency Care to become a coherent, co-ordinated, high quality system of care, that works seven days a week, and where possible 24 hours a day, in accordance with patient expectations, delivering the best clinical outcomes. To achieve this there must be senior clinical assessment prior to and on admission, integrated assessment for the frail elderly, and alternative pathways back to the community, supported by ambulatory care to prevent an unnecessary admission to hospital. Acute hospital care must meet the needs of all patients passing through the system, including those with complex co-morbidities. Services must provide adequate access to specialist input, minimise harm and ward moves and provide care that is compassionate and person centred. Discharge planning needs to start at first contact with the patient and be embedded in practice, with full patient and carer involvement. The UHB and Local Authority must work together to ensure that patients can access the most appropriate service and can leave hospital, once their clinical treatment is complete, with good discharge support to reduce the likelihood of possible readmission. Our delivery plan sets out the key components of the proposed system of care. Figure 9.1 Our experiences over the past year have informed the priority components of our SCP for 2015/16. Which are establishing sustainable urgent and emergency care services for frail older people, providing more urgent and emergency care assessments through Ambulatory Care, and achieving a sustainable nursing workforce. 31

32 In parallel, our plans to deliver care closer to home are being progressed through our joint work with: The Welsh Ambulance Services Trust on the Physicians Response Unit (PRU), the Falls Response Unit. Neighbourhood Care Networks, supporting the management of chronic conditions care (diabetes, respiratory disease) within communities, supported by specialist services. CRTs and primary care to strengthen anticipatory care planning and maximise flow through our work on improving supported discharge. Emergency Frailty Unit (EFU) over the past 5 years the age profile of patients seeking urgent and emergency care has changed. There has been an 18% increase in those aged 75 years and over, many of whom present with multiple and complex needs. These patients are more likely to arrive by ambulance (8 out of 10), over half will be admitted and have longer hospital stays. Older people are more likely to experience longer waits in our emergency departments and are disproportionately represented in 12 hour breaches, often reflecting the complexity of their healthcare needs. 70% of all medical inpatients are over 65 years. The majority of these patients present through ED or MAU. Getting the assessment of older people right at the earliest opportunity has the potential to improve outcomes, reduce inappropriate hospitalisation and identity those patients whose care needs can be best met and managed in their own homes. Meta-analysis of available data suggests that separation of elderly care from mainstream acute services (ED/MAU) delivers a 30% improvement in outcomes for patients. This has guided our decision to create a discrete 9 bedded Emergency Frailty Unit on Ward D4W at the Royal Gwent Hospital. Table 9.1 Vision EFU at Royal Gwent Hospital Desired Outcome and Benefits Measurement Demand/capacity/ flow To provide focused rapid multi-disciplinary assessment and management of older people meeting EFU criteria with episode of hospital based care competed within 48 hours. Early Comprehensive Geriatric Assessment Discharge to Assess Same day specialty consultant review Daily CoTE ward rounds Step up/step down capacity Patients have rapid access and transfer to most appropriate care Evaluation to determine impact on bed capacity initial modelling suggests 7280 bed days can be saved, equivalent to 19.9 beds Length of stay for EFU selected patients Volume of assessed out Discharge to home rates Transfer to other bed based care Occupied acute bed days for over 80 years (baseline ALOS 12 days) 9 beds Referrals from ED and GP (60/40 split) ALOS hours Discharge home 30 50% 32

33 The approach being adopted at NHH embraces a virtual EFU model, with an acute CoTE presence on a daily basis across the front door assessment units. Realignment of medical beds within the body of the hospital will see wards refocused to provide: Two dedicated CoTE wards One Stroke/CoTE combined ward One respiratory ward One acute/emergency medical ward One combined specialty ward (gastroenterology, cardiology and diabetes) Ambulatory Care as part of the on-going strategy to separate and stream ambulatory and non-ambulatory acute medical demand, Acute Care Physicians will take GP referral calls and stream patients according to agreed criteria. This will replace existing call handling arrangements. We need to test the perception that a sufficient number of the patients sent to MAU by GP s could possibly have been dealt with in a better way, specifically through emergency ambulatory services. We recognise that there are no simple ways for GP colleagues to get their patients seen in a timely manner, other than to send them in via the acute intake. This approach is designed to ensure that patients access the most appropriate service to meet their need. Whilst the pilot is aimed at reducing/managing acute medical GP demand at RGH, it will also be a proxy for assessing ambulatory care demand that could be safely streamed to YYF as part of the selected intake. Table 9.2 Desired Outcome and Benefits Measurement To trial consultant call handling for GP requests for urgent and emergency assessment Test fitness for purpose of deferred patient categories Divert patients from default hospital and smooth demand across the system Numbers of patients triaged and dispersed % needing admission, 30 days DNA rates Patient satisfaction GP satisfaction Sustainable Nursing Workforce the Welsh Government has supported the implementation of Nursing Principles to improve patient quality and safety. This has resulted in an increase in nurse to patient ratio both by day and night. Consequently for some areas this has meant a change in skill mix which has increased registered nursing posts and a decrease in Health Care Support Workers (the latter particularly affected NHH wards with HCSW were higher). Recruitment to additional registered nursing posts commenced last year without much success due to a limited nursing pool and the competition across South East Wales to fill the increased vacancies is high. At the start of the financial year there were wte registered nurses employed by Unscheduled Care Division, which has reduced to wte at December During this time there have been 36 new starters, but unfortunately 52 leavers across all the Directorates service resulting in a turnover rate of 8.93%. 33

34 Staff sickness and the prevailing registered nurse vacancy situation are driving up the use of variable pay, which represents poor value for money and increases the challenge of maintaining continuity of patient care. Concerted efforts are being made to manage down sickness levels in key hotspots. However, recruitment to existing vacancies, keeping ahead of turnover combined with reducing sickness absence should result in a reduction in variable pay, improved staffing levels and greater continuity of care for patients. Whilst a 3 year plan will inevitably take a longer term strategic and corporate view of how to address registered nurse staffing shortfalls, the following actions indicate our key priorities to address the immediate challenges for the next 12 months. Table 9.3 Vision Desired Outcome and Benefits Measurement Milestones Workforce Implications Financial Implications To ensure that the right number of staff, with the right skills are in employed by the service to provide high quality care to meet patients needs Wards staffed to All Wales Nursing Principle levels Robust staffing levels reducing reliance on bank and agency Delivery of high quality care maximised flow through the acute hospital component of the system Numbers of nurses recruited Turnover intervals Sickness and absence levels Compliance with fundamentals of care Completed episodes of care, including LoS Complaints and complements Untoward incidents Q1- Q4 2015/16 Recruitment Drive and Recruitment Strategy Q1 Q4 2015/16 alternative workforce plan (HCSW (enhanced skill mix), physicians assistants, enhanced clinical roles, speciality clinical roles) Q1 2015/16 Retention Drive and Strategy (including developing leaders for the future) wte Registered Nurses wte Health Care Support Workers Current expenditure to date (month 11) on nurse agency 2.8 million Service Change Plan 10 Planned Care encompasses scheduled services in primary care, community and hospitals services. Those related to the former are described in other SCPs, with this section focussing on the UHB s Planned Care Work Programme to improve Referral to Treatment waiting times (including sustainable orthopaedic services), diagnostic waiting times and cancer access. We have faced significant challenges in achieving improvements in elective access in 2014/15; nearly 2,000 patients will be waiting over 36 weeks for treatment at the end of March Table 9.4 Specialty Forecast no. of 52 weeks at end of March 2015 General Surgery Ophthalmology Orthopaedics Gynaecology 140 Total Forecast no of 36 weeks at end of March

35 Our aim is to deliver Best in Class performance for planned care, to improve timely access to elective services, and delivering RTT targets. Our system wide Planned Care Programme (see Figure x) essentially adopts a two prong approach, focusing on reducing demand across our population and optimising capacity. Demand and capacity assessment for key specialities has been undertaken, with details included in the supporting technical plan. The recurrent demand/capacity gap sets out the scale of the sustainability challenge where demand for service outstrips capacity to deliver care locally. This results in outpatient and treatment backlogs with the consequent delays for patients on some surgical pathways. Figure 9.2 Planned Care Programme Demand Prudent Healthcare Capacity Co-production Clinical thresholds Outpatient Transformation Theatre modernisation Lifestyle INNU Expand primary care services Best in Class & benchmarking Patient education Alternative interventions Pathway development Referral rate analysis 7 day services Separation of elective and Post Op Care Assessment Unit emergency streams Orthopaedic sustainability plan Our analysis of demand and capacity gaps has identified the need for specific actions in two specialities: Orthopaedics and Ophthalmology and these delivery plans are summarised below: Table 9.5 Vision Orthopaedic Services Demand/capa city/ flow Desired Outcome and Benefits Workforce and financial impacts Supporting information To provide a sustainable orthopaedic service by: Managing demand through prudent healthcare Optimising capacity Rebalancing activity between secondary and primary care Eliminating backlogs and providing sustainable services Treatment demand is calculated to be , which includes both the 52 week and 36 week backlogs. Treatment capacity is assessed at 10,319, which includes a contribution from prudent healthcare and the UHB will use external capacity to provide greater resilience in its delivery plan. The local plans include a range of initiatives including backfilling, weekend working, consultant expansion and high productivity lists. The protection of elective orthopaedic access, which has been compromised in recent years, is an essential. 52 week clearance by end of November 2015, with 478 breaches of 36 weeks at end of March Elimination of 36 week waits in 2016/17. The workforce and financial impacts of the orthopaedic delivery plan are included in the respective sections of the plan. Detailed delivery plans and supporting profiles are included in the supporting technical plan and annexes. 35

36 Table 9.6 Vision Ophthalmology Services Demand/capacity/ flow Desired Outcome and Benefits Workforce and financial impacts Supporting information To provide a sustainable ophthalmic service by: Managing demand through prudent healthcare Optimising capacity Rebalancing activity between secondary and primary care Eliminating backlogs and providing sustainable services Treatment demand is calculated to be 4,792, which includes the 52 week and 36 week backlogs. Capacity is assessed at 4,792, which includes a contribution from prudent healthcare (200 cases). The local plans include a range of initiatives including backfilling, application of INNU guidelines and the external commissioning of capacity. 52 week clearance by end of July 2015, and 36 weeks by the end of f March The workforce and financial impacts of the orthopaedic delivery plan are included in the respective sections of the plan. Detailed delivery plans and supporting profiles are included in the supporting technical plan and annexes. Based upon the above plans, our profile for improvement is described below, with the elimination of 36 week breaches and 91% 26 week compliance by March 2016, with reductions in the maximum outpatient wait for surgical specialties. Table 9.7 Parameter 2014/ / / /18 <26 weeks 85.5% 91% 93% 95% >36 weeks <2, >52 weeks Max OP wait for surgical specialties At the start of 2014/15, our comparative performance on diagnostic waiting times was relatively poor when viewed against the rest of Wales, with the main pressure points in non-obstetric ultrasound and MRI. Through non-recurrent capacity in year, the MRI waiting time has reduced successfully with ultrasound the remaining area of concern where it is anticipated that there will be approximately 1000 breaches in nonobstetric ultrasound. Performance against the 8 week standard remains high for other included diagnostic tests with significant improvements in Nuclear Medicine. Waiting times for cardiac diagnostics are longer than required to sustainably hit RTT targets and are being addressed through investment agreed by the Board. We have continued to make significant advances in improving waiting list management and reducing waiting times for symptomatic and surveillance endoscopy patients. Following the recent ministerial Task and Finish Group report on Endoscopy services we have reduced waiting times to achieve zero patients exceeding the operational standard in 2014/15 by the end of October 2014 for surveillance patients. Based upon detailed plans, our profile for improvement is described below, with the planned maintenance of diagnostic waiting times to a maximum of 8 weeks. Table 9.8 Diagnostics 2014/ / / /18 Radiology (all Patients>8 weeks) 1, Cardiac Diagnosis (>8weeks) Endoscopy (symptomatic patients >8 weeks) Endoscopy (Surveillance>target date)

37 Maintenance of the cancer treatment time standards has been a significant challenge during 2014/15, due to a combination of increasing demand in a number of cancer tumour sites and reduced capacity due to key vacancies (notably in Breast radiology). As a consequence of these factors cancer performance deteriorated in the summer period, with performance slipping to 94% (31 day target) and 78% (62 day target) in August Action plans were put in place to recover performance which included commissioning additional outpatient breast cancer capacity. Whilst this delivered improvement, this has remained fragile. The current model for outpatient services is not fit for purpose or sustainable. Demographic changes require the UHB to support a growing elderly/chronically ill population who would benefit from receiving their care locally or for younger patients who require a more flexible accessible service, with technological advances are enabling innovative ways of providing care. Demand for outpatient services has grown over many years and contributed to increasingly long waiting times often resulting in inefficient and expensive initiatives to deliver waiting times targets. Operational and financial benchmarking across Wales shows that ABUHB is an outlier compared to other Health Boards, with excess referrals and costs of > 10m. In recognition of these challenges, the UHB has recognised the need for a transformational approach to its outpatient services (Figure below). Figure 9.3 Strategic Direction Vision All people are seen in the right place, at the right time by the right person Objectives Outpatient Transformation Plan on a Page No avoidable or unnecessary appointments Resources more efficiently and effectively used. More people assessed at home or in the community. Health Board s vision for outpatient transformation is enabled Goals and Targets Reduce DNAs from 9.9% to 6.5% Reduce referral demand by 12% 5% increase in capacity through improved core processes 10% reduction in follow ups. Reduce waste and improve patient experience. Enablers Leadership People Processes Clinically led service redesign Improved job planning Streamlined booking Agreed Vision More non consultant roles Improve flow and clear clinical profiles for each service Using the right measures More primary care/ interface services Informatics to support service redesign Key Initiatives Core Outpatient Processes Service redesign Rollout of Patient Reminder Services Implement/ reconfigure booking model Implement informatics plan for outpatients Increase virtual ways of working including advice only services, see on symptom approach Increase non consultant led healthcare and services outside hospital setting. Develop pathways, effective triage, one stop, integrated services. Tools Enhanced communic ation Business Intelligence Continuous Improvement support Enabling the Health Boards Visions Ongoing Programme Development and review of specific core outpatient areas. Enhanced clinical and patient engagement Enhanced support for key priority specialties in conjunction with ABCI Regular reporting of agreed metrics. Successful transformational change has been characterised by strong clinical and managerial leadership, the importance of engaging the whole clinical team and the use of robust diagnostic information to inform discussions. The right balance therefore needs to be struck at a corporative level to ensure there is the necessary level of rigour, structure and support in place whilst facilitating clinically led change, the ethos championed by ABCI. Whilst transformational change underpins the work programme, 2015/16 priorities 37

38 have been informed by an assessment of current performance (referral rates, long OP waits, costs, DNA rates, new: follow-up ratios, patient safety issues and reliance on non-recurrent solutions). Table 9.9 Year Specialities 2015/16 ENT, Oral Surgery, Orthopaedics, Ophthalmology, Respiratory, Cardiology, Paediatrics and Gynaecology in addition to infrastructure development (clinical, booking, information), workforce development and other associated processes and systems. 2016/17 General Surgery, Urology, Dermatology, Neurology, Obstetrics in addition to infrastructure development (clinical, booking, information), workforce development and other associated processes and systems. 2017/18 Specialties identified in Year Two that have been prioritised and assessed against the following parameters: Recurrent capacity and demand gap with no sustainable plan in place. Increased expenditure on additional clinics Increased use of Bank/Agency to cover core clinics, high sickness levels and wider recruitment/ workforce issues with no sustainable plan in place. Outlier in terms of benchmarking against quality, performance and financial parameters. Potential to integrate with Primary Care and alignment with Clinical Futures. Based upon detailed plans, the UHB s profile for improvement in outpatient services is described below: Table 9.10 Parameter 2014/ / / /18 Additions to New OPWL Projected if do nothing 141, , , ,225 Assumed impact of outpatient transformation programme 140, , ,221 Reduction in DNA to 6.5 % target 9.3% 8.5% 7.5% 6.5% Reduction in follow up backlog 41,000 31,000 15,

39 10. Service Sustainability Both human resource and financial requirements for the future necessitate a focus on sustainability for the coming three years and beyond. Service Sustainability was the key driver that resulted in the development of our Clinical Futures Strategy. This strategy was developed in partnership with the public, their representatives and key stakeholders (including all Local Authorities in the area). It was led by our senior clinicians, supported by senior managers, executives and independent members and set out to: Figure Clinical Futures, Strategic Direction (2006) At that time, in the light of foreseeable changes, our senior clinicians anticipated that service sustainability would becoming increasingly difficult to maintain, and by 2014/15 cause significant challenges if the proposed service model changes, including the SCCC, were not in place. The plan anticipated that the SCCC would be commissioned by 2014, and the healthcare system would be sustainable. The current timetable for the commissioning of the SCCC, and subject to Full Business Case approval by Welsh Government, will be SCP 7 sets out the service areas where sustainability challenges are most significant and require action in 2015/16. Demographic Pressures not least with growing numbers of older people living longer, many with multiple and complex care needs suggests that demand for Continuing Healthcare will continue to increase. Our most significant cost pressure relates to the increasing proportion of expenditure on Continuing Health Care, for adults and children with complex physical and/or mental health care needs. SCP 6 sets out our approach and emerging plans to contain costs and develop new solutions to meeting the continuing health care needs of our citizens. Service Change Plan 7 Service Sustainability the Specialist and Critical Care Centre remains an essential enabler to deliver services that cannot be sustained on multiple sites. The SCCC is a fixed point within the South Wales Plan, and subject to Full Business Case approval by Welsh Government in Autumn 2015, will be 39

40 commissioned in 2019 and see the consolidation of specialist, hyper-acute and critical care services. The service redesign set out in our Clinical Futures Strategy, and reaffirmed by the South Wales Programme, is critical to delivering a sustainable healthcare system for Gwent. The SCCC is a significant component of the model. Putting patient safety and achieving optimum clinical outcomes at the heart of our service model, means that we must improve access to specialist and critical care services for our most seriously ill residents. There is overwhelming evidence to support the consolidation of the most specialist services in fewer places to ensure that patients can access them at the time of need, irrespective of the time of day or day of week. Delays are inherent in the traditional District General Hospital model that has characterised healthcare provision in Gwent for the last four decades. It dilutes access to our most specialist clinicians as they are deployed across multiple hospital sites. This results in significant challenges in meeting clinical standards of care, organising our most senior clinical capacity to meet the needs of our most seriously ill patients (particularly in evenings and at weekends), and does not represent the most efficient use of scarce healthcare resources. Our plans to design a purpose built SCCC on a site that optimises access to the dispersed and diverse population we service that is spread over a vast geographical area resulted in a proposal to locate this hospital at Llanfrechfa Grange Site near Cwmbran. Between 2015 and 2019, we will as far as we practicably can, continue to sustain specialist and critical care services at our existing DGH sites. However, increasing challenges due to medical staffing concerns and our ability to meet Deanery training requirements may result in changes to sustain services in advance of the SCCC. Our focus for 2015/16 is sustainability plans for:- Women and Children s Services (paediatrics, neonates and O&G) Stroke Redesign Ysbyty Ystrad Fawr Child and Adolescent Mental Health Services Paediatrics, Neonates and Obstetrics & Gynaecology requires sustainable medical workforce plans in the short term to meet clinical standards and to comply with Welsh Deanery requirements to improve educational training. We experience difficulties in recruiting to middle grade posts at specialty doctor/clinical fellow grade due to a limited and dwindling workforce pool. Increasingly we are resorting to a medical workforce of Hybrid Consultants, consultants who offer residential middle grade cover as well as undertaking Consultant led work. These workforce difficulties could be alleviated and the Welsh Deanery requirements met if rosters could be consolidated and specialist acute services for women and children consolidated on one site. This would achieve the model set out in our Clinical Futures Strategy, with these services relocating to the SCCC in In the shorter term, safe services will be maintained on the two District General Hospitals sites through interim workforce solutions (shown below). We have carefully appraised and discounted the option to consolidate these services on a single site prior to the opening of the SCCC. 40

41 Our interim solution aligns with the South Wales Programme and is being implemented in agreement and collaboration with our Acute Care Alliance partners who are also experiencing similar challenges. The retention of services at Nevill Hall DGH will provide support to Cwm Taf University Health Board whilst it upgrades its facilities at Prince Charles Hospital in Merthyr, as part of its local solution to developing sustainable services. Table 10.1 Vision Desired Outcome and Benefits Measurement Milestones Workforce Implications Financial Implications To consolidate acute paediatrics, neonatology and obstetrics at the SCCC improving access and ensuring affordable and sustainable specialist clinical services. To deliver safe and sustainable services within acute paediatrics, neonatology and obstetrics that are equitable and accessible to the population we serve. Delivery of tier 1 targets Delivery of All Wales Neonatal Standards, Maternity Standards Compliance with tier 1 targets and clinical standards Recruitment to Hybrid Consultant and Specialty Medical and Nursing Posts. Finance, performance and quality indicators, e.g. spend, variable pay. Q4 2015/16 Continue recruitment of additional workforce Q4 2015/16 Continue collaboration with ACA to ensure sustainable regional services Q4 2016/17 Maintain workforce model monitor and evaluate Q4 2017/18 Develop and implement transition arrangements to SCCC. 6 Paediatric Hybrid Consultants, 4 Gynaecology Specialty Doctors, 4 Advances Midwifery Practitioners, 3 Neonatal Consultants 2015/16 1,015, /17-1,650, /18-1,650,000 The UHB s plans are being updated following confirmation from the Deanery that the requirement to achieve 1:1 rotas applies to Tier 1 posts in addition to the Tier 2 posts described above. This has potentially significant service, workforce and financial implications that will be clarified prior to submission of the plan at the end of March. Stroke is the leading cause of disability in Wales, and the third most common cause of death, after cancer and heart disease. Each year around 900 people who live in our area suffer a stroke or about 3 people each day. We are taking action to minimise the risk of our citizens having a stroke and, where a stroke occurs, to provide the best quality care and support to maximise survival and return to independence as quickly as possible. Many of the risk factors for stroke can be reduced through healthier lifestyle choices and/or through the use of primary and secondary stroke prevention interventions. Our focus on improving health and preventing early onset of illness (SCP 1 and 2) set out our approach to reducing risk factors across our population, the identification and management of people with Atrial Fibrillation is part of this programme. There is robust evidence that clinical outcomes for stroke survivors are improved by organised and specialist stroke services working in partnership with existing community services. Our local Stroke Pathway and service model spans primary prevention and pre-hospital care, through acute hospital care and rehabilitation to long term care, secondary prevention and end of life care. 41

42 Figure Proposed New Model for Stroke Services Key Features of Model KEY Prevention Acute/Hyper-acute Stroke Prevention Management of Transient Ischaemic Attack (TIA) Increased focus on prevention Rehabilitation Life after stroke Pre-hospital Stroke Care Care setting Hyper-acute Stroke Care (= 3 days) Specialist stroke centre HOME Community Resource Teams Early Supported Discharge Community Rehabilitation (Frailty/Community/Neuro) Acute Stroke Care & Early Rehabilitation Rehabilitation +/- Complex Discharge HOSPITAL 3-7 days 7 days 6 weeks Fewer inpatient specialist stroke rehabilitation units Early Supported Community Discharge Ongoing general rehabilitation as close to home as possible Life After Stroke Multiagency support for life after stroke Our plan to redesign stroke services is driven by the need to achieve and sustain Tier 1 targets and improve our performance against the increasingly stringent standards set by the Royal College of Physicians Sentinel Stroke National Audit Programme (SSNAP). To achieve these we need to adopt the optimal configuration of services to minimise delays in flow of patients through the stroke pathway, ensuring timely access to key skills and expertise. During 2015/16 we will focus on: Delivering sustainable Community Neuro-Rehabilitation Services - early benefits identified from the CNRS pilot (supported by the Intermediate Care Fund) that provides early supported discharge (ESD) for eligible patients with a clinical diagnosis of a new stroke, are encouraging and show that: 11 out of 60 patients completed and were discharged from the pathway returning to independent living (better outcomes) ESD is initiated on day 3 post stroke and average reduction in length of stay is currently 4 days Patient experience and satisfaction with the services is high Current experience from the pilot suggests the improved flow resulting from the Community Neuro-Rehabilitation Services would release 730 bed days or 2 beds from the system Further evaluation of CNRS is required beyond the initial four months to determine the potential to achieve further benefits in terms of % of stroke patients leaving hospital early, length of stay and bed capacity. 42

43 Hyper-acute Stroke Unit (HASU) strong clinical evidence suggests that stroke patients have better outcomes when they are admitted to a specialist stroke unit and then returned home as quickly as possible. In August 2014, we ring fenced beds in RGH for acute strokes. This enabled the service to deliver and sustain delivery of Tier 1 stroke targets. The redesigned stroke service will need to deliver against more stringent targets that Welsh Government will introduce this year including shorter times to thrombolysis treatment and admission of all stroke patients to a stroke ward within 4 hours. Establishing a single Hyper Acute Stroke Unit for Gwent will improve timely access to stroke specialists. It will rely on efficient flow of patients to and from HASU as any patient in our catchment area with a suspected stroke will be directed to this unit. Extensive modelling using demand/capacity techniques with mathematical scenarios are being undertaken to ensure that the clinical and physical infrastructure required to support the stroke pathway is understood and in place. This will include consideration of the optimal configuration of inpatient based stroke rehabilitation. Table 10.2 Milestones Financial Implications Q4 2014/15 continued stakeholder engagement Q4 2014/15 Demand management analysis and initial evaluation of CNRS pilot Q1 2015/16 formal consultation on new model of stroke care Q1 2015/16 Blueprint for implementation Q2 2015/16 Implement centralised HASU; reconfigure acute stroke and rehabilitation services Q /16 Sustainable CNRS workforce model tbc Sustainable Clinical Model Ysbyty Ystrad Fawr Ysbyty Ystrad Fawr (YYF) opened in November 2011; it is the first of a new generation of enhanced Local Hospitals originally conceived in our Clinical Futures Strategy. It plays a pivotal role in providing hospital based healthcare (excluding high dependency services) to the local population as part of the local health and social care system. The site has 269 beds, 146 of which accommodate medical patients with a further 10 assessment trolleys in the Medical Assessment Unit. The hospital also provides excellent diagnostic services. In 2014 the Wales Postgraduate Deanery issued a directive in respect of Core Medical Training (CMT) Doctors, out of hours on call training has to be provided in a busier District General Hospital and seven day Consultant present at YYF is required to retain trainees on site between 9am and 9pm. This has presented two distinct and significant challenges, namely: Removal of 9 junior doctors (up to registrar level trainees) from on-call rota. 43

44 Insufficient consultant resource to sustain on-call rota, provide 7 day presence and develop/deliver new service models for ambulatory care and emergency frailty services. In order to maintain the safety of patients and deliver sustainable enhanced services at YYF, we are redesigning the overnight service model and investing in additional consultant cover. The Hospital at Night (H@N) approach is being adopted with two Advanced Nurse Practitioners and one Registrar level doctor on site overnight. The ANP and Registrar are the first responders to any cardiac arrest or acute incident (core skills for these roles include Advanced Life Support). This revised model will limit the role that YYF can play in our hospital network; specifically admissions will not be possible between 8pm and 8am. In addition the threshold for transferring a deteriorating patient to a DGH will be lowered, because the Registrar will not be available to accompany any patient transfer. Additional Consultant Capacity is also required to provide seven day consultant presence and develop ambulatory care and emergency frailty services as set out in table x. Table 10.3 Current Capacity Shortfall Sustain the on-call rota 6 consultants covering 1:8 rota 2 sessions 8am 8pm on site consultant presence 8 sessions Emergency Frailty Unit Ambulatory Care Service 13 consultant sessions 2 sessions 3 sessions Table 10.4 Vision Desired Outcome and Benefits Measurement Milestones Workforce Implications Financial Implications To develop a sustainable clinical model for patients with urgent and unscheduled care needs, optimising the provision of care closer to home Deliver safe and sustainable services at YYF Meet the requirements of the Deanery, ensuring the Health Board maintains its postgraduate medical training commitments Comprehensive 7 day Emergency Services for Frail Elderly improving flow and reducing the need for and length of hospital stays Robust emergency/urgent ambulatory care service Compliance with Tier 1 targets Number of patients assessed by EFU and their disposition (admitted, CRT, home) Number of patient transfers (deteriorating patient) Number and timeliness of repatriation of Caerphilly residents admitted overnight (RGH) back to YYF Deanery review of junior doctor training Q4 2014/15 Recruit and embed H@N model Q1 2015/16 Recruit consultants Q2 2015/16 Maintain workforce and service model monitor and evaluate 3 Consultants, 2.6 Advanced Nurse Practitioners, 2 Administration and Clerical 2014/15-70, /16 588,000 44

45 Child and Adolescent Mental Health Services (CAHMS) there are concerns about the sustainability of CAMHS across the United Kingdom, including Welsh Government and amongst the public. Meeting the psychological, emotional and mental health needs of our children and young people has been identified by the Minister for Health and Social Care as a priority. Locally demand for service had doubled over the past two years, and the proportion of referrals designated as urgent increased fourfold. We need to develop a sustainable and functioning secondary care CAHMS service, that reflects the changing demand and presentation of mental health difficulties and suggest models by which services can be provided. We need to capitalise on the opportunity offered to children and young people in primary care settings through Local Primary Care Mental Health Support Services, ensuring that early intervention and assessment services are accessible. Our focus is on developing sustainable NHS Specialist CAHMS services for children and young people who: misuse substances; are in the youth justice system; are looked after by Local Authorities; have sensory impairments; learning disabled children. An increasing number of children will have a formal Care & Treatment Plan (CTP) through the mental health measure, or statutory social care or education requirements. Involvement of social care staff in the care programme is a key component of the service. The model of care provided will provide a range of services, delivering a continuity of involvement, from specialist consultation through to intensive, evidence based, and direct therapy. The structural arrangement of these core specialist CAMHS services will be in the form of three multidisciplinary community teams equitably covering the ABUHB population, tier 3 services offering intense assessments and appropriate interventions, and a crisis outreach team who will work with emergency presentations and link closely with the nationally commissioned South Wales inpatient unit, in order to minimise length of admission and improve clinical outcomes. Within the specialist CAMHS directorate are specific resources for children and adolescents with learning disability (CALDS), youth offending services (YOTS) specialist nurses, young person s substance misuse services, virtual Tier 3 forensic service, and continuing care. Table 10.5 Vision Desired Outcome and Benefits Measurement To develop a sustainable and functioning secondary CAMHS Reduction of children admitted to adult MH wards Equitable CAMHS service in Gwent Patient receiving care in own homes / community where possible Service performance measures will be based on clear expectations of capacity and activity (based on benchmarking data and resource allocated) but primarily focus on achievement of patient outcomes and patient feedback, audit of governance performance (e.g. DNA rates, risk assessments, complaints, compliments, staff wellbeing, training and development) and regular multiagency, peer review of services. 45

46 Milestones Workforce Implications Financial Implications Q1 2015/16 CAHMS Crisis Outreach team Q4 2015/16 CAHMS liaison service (with acute paediatrics deliberate self harm reduction) Q4 2015/16 Neuro-developmental Service; Eating Disorders strategy; and Transition service Q4 2016/17 Bailey Review participation 2x Band 7s, 3x Band 6s, 1x Band 3s, 2x Consultant Sessions, 0.3 Dietician 2014/15-248k recurrent (assumed funding from WG as part of CAHMS review) Service Change Plan 6 Continuing Health Care costs are an increasing proportion of the UHB s expenditure, with growth of 9.3m in 2014/15. Forecast growth of 16m in 2015/16 is the most significant cost pressure, with savings plans of only 2.5m identified to mitigate the growth. Rising demographics in the older population and levels of chronic disease are key factors driving demand which call for a much more transformative approach to service delivery as it is apparent that the UHB s current CHC strategy and plans are no longer adequate to meet future forecasts. The CHC service is delivered through 3 divisional teams: Mental Health and Learning Disabilities Complex Healthcare Adult Community Complex Health Care Children s Continuing Care under the care of Specialist Child and Adolescent Mental Health Services (S-CAMHS) and Child and Adolescent Learning Disability Services (CALDS). The complex support needs of people with mental health and learning disabilities are diverse, requiring a multi-skilled workforce and range of services. The UHB currently commissions care with 76 providers, ranging from domiciliary care to Low Secure Units. The chart below shows the breakdowns of predicted Divisional CHC spend for 2015/16, which represents 31% of the overall divisional spend. The forecast overspend can be attributed to a number of factors; Low secure numbers are predicted to increase for both MH and LD, increasing numbers of transition cases and requests from Local Authority regarding eligibility, diminishing efficiency savings opportunities compared to the past three years, i.e. between 2012/ /15 8.2m saved, but for 2015/16 only 1.4m identified. Figure Predicted Divisional Spend 54.8 M 24.8M CHC Rest of Division The integrated medium term plan for MH/LD the next 3 years therefore focuses on redesigning and restructuring services across all tiers of MH/LD provision. This includes comprehensive education and training to change the culture of service delivery to ensure care is provided in the right place, at the right time by the right service/health professional. There are plans to deliver more services closer to home, e.g. in a new Low secure unit and via different service models. 46