VALUE PROPOSITION. Encompass MCP. Value Proposition

Transcription

1 Encmpass MCP Value Prpsitin 1

2 Table f Cntents Value prpsitin 2016/ Encmpass MCP (Frmerly Whitstable, Faversham and Canterbury Cmmunity MCP) Intrductin Scpe f the MCP Lcal case fr change Develping Impactful Opprtunities fr Change Hw the MCP prgramme will generate value... 6 Overarching MCP prgramme bjectives during 2016/ Overarching MCP prgramme bjectives up t Encmpass MCP s prgress t date a brief utline f 2015/16 wrk prgramme Year 2 Investment and sustainability verview Year Activity Prjectins f New Care Mdel Impact Encmpass MCP s Aim, visin and values Aim Visin Values Encmpass MCP s transfrmatin prgramme Develping Primary Care The prpsed integrated mdel (Nursing and Beynd Health) Schematic f the Mdel f Care Cmmunity Hub Operating Centres (CHOCs) Develping Nursing Integratin Beynd Health Prmting Wellbeing Prmting Independence Supprting and Maintaining Independence Develping estate infrastructure Wrkfrce redesign including educatin and training Innvatin and IT Enablers - using technlgy t make infrmed decisins n accessing health care Research, Evaluatin and Replicability Research and evaluatin Replicability Outcme measures Activity, Finance and Evaluatin Detailed Prfile Develping Primary Care Extended Wrking Investment Paramedic Practitiners Investment, Resurce Sustainability and Evaluatin

3 Paramedic practitiner investment and savings table A&E and Unscheduled care activity and finance ver 5 years table GPwSI Services Investment, Resurce Sustainability and Evaluatin End f Life Clinics Investment, Resurce Sustainability and Evaluatin Develping Nursing Integratin and the Integratin f Services Beynd Health Integratin Investment and Savings Table Develping Nursing Integratin and the Integratin f Services Beynd Health Investment Investment in mre detail Mental Health Nursing Integratin Investment Scial Care Integratin Investment Single Patient Access fr Scial Prescribing Investment Health Trainer Investment Develping Nursing Integratin and the Integratin f Services Beynd Health Resurce Sustainability and Evaluatin Develping Estate Infrastructure Investment fr infrastructure Crprate Csts Prgramme Management and Gvernance Cmmunicatins and Engagement Strategy fr the MCP Annex A Value Hypthesis Generatin Assessments Annex B Encmpass MCP Partnership Steering Grup Terms f Reference Purpse f the Steering Grup Scpe f the MCP Wrk Prgramme Rle f the MCP Partnership Steering Grup Timescale Membership f the Steering Grup Gvernance Meetings

4 Value prpsitin 2016/2017 Encmpass MCP (Frmerly Whitstable, Faversham and Canterbury Cmmunity MCP) 1. Intrductin The encmpass MCP seeks t deliver an integrated health and scial care mdel that fcuses n delivering high quality, utcme fcused, persn centred, crdinated care that is easy t access and that enables peple t stay well and live independently fr as lng as pssible in their hme setting. Mre than that, it seeks t transfrm lcal services t deliver practive care and supprt, fcused n prmting health and wellness, rather than care and supprt that is slely reactive t ill health. Cre t the mdel f care is the philsphy f health and care services wrking tgether t prmte and supprt independence, utilising statutry, vluntary and, where apprpriate, independent sectr services t deliver the right care, in the right place at the right time. The Value Prpsitin als sets ut an ambitius visin fr whle system redesign at an rganisatinal level, seeking t wrk in cllabratin acrss the health and care landscape t build and implement an innvative wrkfrce redesign mdel that will enable the lcal ecnmy t develp and deply a wrkfrce fit fr the future f integrated health and care delivery acrss current prfessinal bundaries. The MCP will be lking t draw n supprt frm the Natinal Team, as well as lcal educatin and evaluatin leaders, as it prgresses with this prgramme. The MCP cre team has engaged with its delivery partners and with service users (via the lcal Cmmunity Netwrk infrastructure) in develping its wrk prgramme and in develpment f the Value Prpsitin. This prcess f engagement and c-design will cntinue as the wrk prgramme is develped and as services becme peratinal. 4

5 2. Scpe f the MCP When the MCP was awarded vanguard status in April it represented a ppulatin base f apprximately 53,000. The NHS England New Mdels f Care Team recmmended that the MCP shuld lk t scale up its size, as set ut in the feedback frm the site visit n 5 th and 6 th May. Subsequently the vanguard clinical leads have held bilateral meetings with a number f neighburing practices, and have als held a GP briefing sessin with all CCG practices. This resulted in a further 13 practices frmally signing up t the MCP Memrandum f Understanding. The MCP nw represents a ppulatin base f 169,806 patients acrss Whitstable, Canterbury, Faversham, Sandwich, Ash and the surrunding rural lcatins. 3. Lcal case fr change In line with the natinal trend, the MCP ppulatin faces challenges in respect f its ageing ppulatin prfile. It als faces challenges in terms f meeting the cmplex needs f peple living with lng term cnditins. T help infrm the MCP s future planning, the MCP has requested that the Kent Cunty Cuncil s Public Health Team develps an MCP specific Needs Assessment that fcuses n the 16 GP practices that incrprate the MCP. In additin t this very lcalised Needs Assessment, we have drawn n the Canterbury and Castal CCG wide Demgraphic Prfile. 4. Develping Impactful Opprtunities fr Change The MCP will draw n bth the methdlgy and learning frm the CCG s Cmmissining fr Value prgramme, and Kent Cunty Cuncil s methdlgy fr identifying impactful change. The MCP s Value Prpsitin and assciated mdel f care seeks t supprt health and scial care cmmissining pririties acrss the lcality. The MCP will utilise the methdlgy and learning frm the Cmmissining fr Value wrk prgramme which riginated during 2013/14 in respnse t requests frm clinical cmmissining grups (CCGs) that they wuld like supprt t help them identify the mst impactful pprtunities fr change. It is a partnership between NHS England, Public Health England and NHS Right Care and the initial wrk was an integral part f the planning apprach fr CCGs. Cmmissining fr Value is abut identifying pririty prgrammes which ffer the best pprtunities t imprve healthcare fr ppulatins; imprving the value that patients receive frm their healthcare and imprving the value that ppulatins receive frm investment in their lcal health system. By prviding the cmmissining system with data, evidence, tls and practical supprt arund spend, utcmes and quality, the Cmmissining fr Value prgramme can help clinicians and cmmissiners transfrm the way care is delivered fr their patients and ppulatins. The MCP will supprt delivery f future CCG pririties as these develp fr 16/17. 5

6 5. Hw the MCP prgramme will generate value Encmpass MCP s Value Generatin Hypthesis Tree is included n Page 7. It seeks t describe the key elements f the prgramme, the utcmes it will deliver, metrics and targets that will measure its success, the resurce investment required and the resurce sustainability evidence. The Value Generatin Hypthesis Tree is backed up with a full set f Value Generatin Assessments, detailing the assertins and evidence base that supprts the assertins. The full set f Assessments, can be fund at Annex A f this paper. Overarching MCP prgramme bjectives during 2016/17 Encmpass MCP will seek t build Cmmunity Hub Operating Centres (CHOCs) that represent a fully integrated health and scial care team, ffering hub-level services, inclusive f primary, cmmunity and scial care prvisin ver the perid until 2017/18. It is planned that the integratin f services at a hub level, cupled with the cntinuatin f the alignment f paramedic practitiners at a practice level t supprt hme visiting, will: Cntribute t a reductin in A&E demand and nward admissin in the shrt term; and Reduce pressure n acute services and lng term care hme placements in the lnger term. Once prven, the MCP will negtiate fr funding t be remved frm the acute cntract t supprt these schemes n a recurrent basis. It is expected that this wuld ccur during the 17/18 cntracting perid. Prving that the MCP has the ability t deliver these schemes will be key t building the trust between parties that will enable the clsure f existing bed capacity in 17/18. By building integrated cmmunity teams we will endeavur t increase effectiveness within the current system and release capacity thrugh enabling an integrated wrkfrce t perate mre efficiently. We will mnitr the impact n the existing services and als mnitr the ptential fr the creatin f new demand that is ften missed frm the evaluatin f prjects. Overarching MCP prgramme bjectives up t 2021 The lng term bjectives fr Encmpass MCP is t supprt system sustainability thrugh the creatin f a hlistic cmmunity based mdel f integrated service delivery, reaching acrss the health and scial care landscape t deliver seamless care and supprt t lcal residents. 2015/16 has fcused n early bjectives that seek t build capacity and re-design existing pathways t cmmence the jurney twards preventative, persn-centred, jined up care (see the fllwing sectin n prgress t date). As we prgress int 2016/17 (see sectin abve) the fcus will shift t scping, designing and develping the integrated service mdel described in Sectin 9 f this paper. The fcus fr 2016/17 will necessarily be ne f transfrmatin, rganisatinal develpment and wrkfrce re-design. There will als be a fcus during 2016/17 n addressing the Infrmatin Management and Technlgy challenges related t develping a shared patient recrd that will supprt ptimum delivery f an integrated service delivery mdel. This will be underpinned by a strng 6

7 eths f c-design with prviders and service users. In 2017/18 the MCP envisages the ambitius estates prgramme will prgress, with the creatin f new facilities acrss the lcality, supprting the shift frm acute t cmmunity based bedded care. 2017/18 will als fcus n expanding the utilisatin f the newly created Cmmunity Hub Operating Centres acrss all lcalities as the whle system adapts t the presence f the Hubs. In the fllwing years, the MCP envisages the full psitive impact f the new mdel f care will be realised, bth in terms f its impact n care within a cmmunity setting, but als in terms f the delivery f its health preventin prgramme impacting n future demand fr services. Value generatin hypthesis tree Drivers Evidence Metrics T develp a new mdel f care that that delivers high quality, utcme fcused, persn centred, crdinated care that is easy t access and that prmtes wellness and enables peple t live independently fr as lng as pssible Develping Primary Care : - Scpe GP extended prvisin - Develp GPSIs - Increase PP utilisatin - EfL cmm. Clinics Integratin f practice, cmmunity and mental health wrkers with services beynd health including scial care and the vluntary sectr Develping Estate Infrastructure Transfrming the Wrkfrce Clinical utcmes will be imprved via integrated care hubs and specialist treatment in the cmmunity Shift activity frm secndary t primary and cmmunity setting resulting in: Reductin in secndary care activity Quicker diagnsis and treatment fr rutine care Integrated teams delivering reductin in verall caselad time per patient and ptimum patient utcmes. Reductin in cnditins linked t scial islatin (e.g. MH) Reduced sec. care activity. Decrease in delayed discharge Create lcal hubs and deliver patient care clser t hme C-lcatin f services Reductin in the use f secndary beds fr patients wh can be treated in the cmmunity Ensure patients receive the best level f care by the right prfessinal. Develp a flexible and respnsive wrkfrce wh want t deliver patient centred care Patient experience will be imprved thrugh a fcus n self-care & increased access t earlier cmmunity-based care Scpe extended access t GP services, drawing n Year 1 learning. Allw patients t be seen in the right envirnment fr their cnditin clser t hme. Reduce waiting times Reduce hand ffs between rganisatins. Mre cnsistent care delivered by fewer prfessinals Scial prescribing will imprve patients health and wellbeing thrugh imprved access t self care and self management Ensure patients are treated in the right care setting at the right time. Ensure a mtivated wrkfrce t deliver high quality care and supprt Safety/quality f the service will be safeguarded thrugh an IT system that integrates recrds acrss the cmmunity Allw patient recrds t be shared with ther health prfessinals imprving bth the quality and safety f care whilst a single patient recrd is develped. Cnsistent quality f care delivered by prfessinals in different wrkfrce areas. Crdinated planning and reductin in handffs result in better quality care. Deliver high quality, custm designed, energy efficient and fit fr purpse estate Build a wrkfrce that will have the capability t deliver high quality care in a sustainable way Resurce requirement f 3.9M is reasnable and the required wrkfrce can be put in place Allw the scping and develpment f an extended primary care service, integrated health and scial care cmmunity services delivered thrugh peratinal hubs, supprted by integrated IT c-lcated n 4 sites at a cst f 3.9m in 16/17. Resurce input frm the existing health and scial care ecnmy f 13.7m in 16/17. Require investment f 150k in 16/17 t further develp the case fr change in respect f bed utilisatin bth health and scial care. Likely requirement significant funding t duble run services. In 17/18 Create a wrkfrce willing and able t deliver sustainable efficiencies fr the abve level f investment Resurce sustainability will be driven thrugh increased efficiency and imprved staff retentin Reduced attendance, admissins and utpatient activity equating t 2.3m delivered in 17/18. Shifting mind-sets t embrace 7 day services and clser interactin between prfessinals. Use f linked care dataset t chrt match patients cmparing patient jurney nw t patient jurney in 17/18. Will allw c-lcatin f services and efficiency gain thrugh seamless transfer f patients thrugh the system Create a sustainable wrkfrce Develpment f a whle ppulatin budget and gain/lss share arrangements t incentivise sustainable changes in behaviur acrss the whle system. 7

8 6. Encmpass MCP s prgress t date a brief utline f 2015/16 wrk prgramme The MCP cmmenced building capacity and capability within primary and cmmunity services in Year 1 f its Wrk Prgramme. It peratinalised extended GP services and paramedic practitiner services in Nvember 2015, as sn as funding was secured via the NHS England Investment Cmmittee. The Scial Prescribing prgramme has als cmmenced, enabling the vluntary sectr umbrella rganisatin Red Zebra t start t build an MCP wide database f vluntary and cmmunity services that service users and practitiners will be able t access via the scial prescribing service team. An audit f cmmunity and practice nursing services has been undertaken t secure a rbust evidence base frm which t build the new mdel f care. This has prvided critical baseline activity data, a slid understanding f current practice and a rbust picture f the relatinship challenges that must be addressed as we prgress t building the integrated mdel f care. In additin, we have cmmenced wrk t integrate cmmunity and practice nursing services acrss specific service pathways related t cntinence care and wund care these were identified as service pathways that ffered clear pprtunities t cmmence jined up delivery acrss primary and cmmunity nursing teams, thrugh the utilisatin f existing services and establishment within the health ecnmy, ensuring that frnt line services t patients remain stable whilst the new mdel f care is develped. As set ut in the MCP s riginal Value Prpsitin, we are fcused n utilising the additinal cmmunity capacity t reduce demand in secndary care. We cntinue t wrk clsely with ur partners in the Cmmunity and Acute Trusts t mdel the planned shift in activity and t mitigate the risk f destabilising elements f the health ecnmy. As set ut in the Year 1 Value Prpsitin, the MCP has cmmenced the develpment f mdelling services arund hub lcalities based in Whitstable, Canterbury and Faversham, with a further hub in Sandwich t supprt the Sandwich and Ash practices. The hubs will deliver a brad range f integrated cmmunity services ranging frm primary care GP and practice nurse services, specialist nursing services, cmmunity nursing services, paramedic practitiner services, health preventin and prmtin services and vluntary and cmmunity services. The MCP is wrking with clleagues in Kent Cunty Cuncil t als integrate scial care services at a hub level. The MCP Executive Team and The Leader f the Cuncil meet regularly and wrk is in train t cmmence alignment at a single hub site within the MCP, t functin as a test bed fr further integratin f health and scial care services in 2016/17. Further dwn the line we intend t link these services via a single electrnic patient recrd t braden the effective use f IT acrss the Vanguard t supprt jined up high quality patient care, althugh recgnise the challenges that this presents in terms f current cntractual arrangements within partner rganisatins, infrmatin gvernance challenges and system inter-perability challenges. The MCP team has fully utilised the 150k management allwance received fr set up. Fr the 15/16 transfrmatin funding received the MCP team has established finance and gvernance prcedures within the existing CCG SBS system that will be in place until the rganisatinal frm fr the MCP is established. 8

9 9 VALUE PROPOSITION

10 7. Year 2 Investment and sustainability verview The table belw shws the summary request fr further transfrmatin funding in 16/17 f 3.9m. It als illustrates the prfile up t 201/21 excluding changes t estates infrastructure which will be wrked up in 16/17. In additin it illustrates existing resurce within the lcal health and scial care ecnmy that will be invested in MCP prgrammes ging frward. 16/17 Bid Summary in Grss Terms Q1-16/17 Q2-16/17 Q3-16/17 Q4-16/ / / / / /2021 Develping Primary Care Extended Primary Care and Cmmunity Services 12,590 12,590 12,590 12,590 50, Paramedic Practitiners 87,750 87,750 87,750 87, , , , , ,000 GPwSI Services 50,876 67,391 44,891 44, ,172 49,545 49,545 49,545 49,545 Palliative Care Clinics 22,957 22,957 22,957 22,957 91,828 91,828 91,828 91,828 91,828 Develping Nursing Integratin and the Integratin f Services Beynd Health Cntinuatin f Yr 1 Nursing Prjects 62,023 17,347 17,347 17, ,065 69,390 69,390 69,390 69,390 Cmmunity Hub Operatinal Centres 426, , , ,724 1,272, , , , ,580 Waitless App 40,000 40, , Develping Estate Infrastructure and Cmmunity Bed Develpment 37,500 37,500 37,500 37, ,000 TBC TBC TBC TBC Crprate Funding 416, , , ,607 1,666, , , , ,004 Grss Investment Requested frm Transfrmatin Fund 1,157,180 1,166, , ,367 3,933,554 2,068,347 2,068,347 2,068,347 2,068,347 Develping Primary Care Extended Primary Care and Cmmunity Services Paramedic Practitiners , , , ,814 GPwSI Services ,696-55,696-55,696-55,696 Palliative Care Clinics Develping Nursing Integratin and the Integratin f Services Beynd Health Cntinuatin f Yr 1 Nursing Prjects ,303-90,303-90,303-90,303 Cmmunity Hub Operatinal Centres ,693,561-1,693,561-1,693,561-1,693,561 Waitless App Develping Estate Infrastructure and Cmmunity Bed Develpment TBC TBC TBC TBC Crprate Funding Grss Savings Achievable ,321,192-2,330,825-2,507,680-2,520,374 Net Investment Requested frm Transfrmatin Fund 1,157,180 1,166, , ,367 3,933, , , , ,027 Ttal Investment t be Aligned frm Existing Resurces 1,691,273 1,691,273 5,151,767 5,151,767 13,686,080 13,686,080 13,686,080 13,686,080 13,686,080 Ttal Net Investment t MCP Prgramme 2,848,453 2,857,790 5,982,134 5,982,134 17,619,634 13,433,235 13,423,602 13,246,747 13,234,053 N.B. This table des nt include the expected csts r savings f develping estates infrastructure the case fr which will be wrked up in 16/17. In line with expectatin, this bid sets ut the expected impacts n bth activity and finance as a result f the develpment f the new mdel f care. Fr the main prjects a D Nthing ptin is cnsidered and shws the expected increases in activity as set ut by A Call t Actin ver the 5 years until 2020/

11 5 Year Activity Prjectins f New Care Mdel Impact 60,000 A&E attendances 55,000 50,000 D nthing Less Paramedic Practitiners Less Integrated Care 45,000 40, / / / / / / /21 23,000 Unscheduled admissins 21,000 19,000 D nthing Less Paramedic Practitiners Less Integrated Care 17,000 15, / / / / / / /21 Althugh the request fr transfrmatin funding in 2016/17 is accmpanied by rbust wrkings, there will remain sme ambiguity with regard t cst in future years and estimated ptential savings. Hwever, this will be cntinuusly reviewed thrughut the develpment f the MCP. The MCP develpment team have been careful t cnsider the financial landscape acrss the health ecnmy and hw recurrent funding will be generated within existing cmmissining resurce in future years. Hwever, sme f this cannt be defined until the prjects have had the pprtunity t run fr a perid f time and whilst sme may release savings t allw investment, thers may need t be reviewed and cease if fund t be ineffective, either in terms f financial efficiency r service imprvement in respect f patient pathways. As financial efficiency is ne f a number f key success factrs in the delivery f the new mdel f care, the success f prjects will be measured alngside ther clinical/service effectiveness, patient experience and quality utcmes. This is articulated within the Value Generatin Hypthesis Tree (see Sectin 6 abve) and assciated Value Generatin Assessments set ut in Annex A f the paper. 11

12 Traditinally, it has been challenging t demnstrate the success f innvative prjects thrugh activity and finance reductins due t the number f influencing variables and cncurrent prjects. The MCP will nt be exempt frm this issue but will strive t cllate data in a way that enables rbust measurement f utcmes and the creatin f an evidence base, where ne desn t already exist. The MCP will seek t draw n the rbust and measurable evidence base that exists within partner rganisatins, including Kent Cunty Cuncil t supprt this. Sectin 11 f this paper utlines the evaluatin strategy that the MCP will perate. The MCP has already demnstrated its ability t achieve this thrugh the delivery f a cmmunity and practice nursing audit that has prvided an activity baseline, and quantitative and qualitative evidence abut the activities f nursing staff and evidence f the issues in respect f bth service delivery and relatinships, that the MCP will need t address in rder t make real and lng-term efficiencies within the health ecnmy. As a GP led team, the ability t access primary care data is felt t be f particular value. Similarly, the invlvement f partners acrss the prvider landscape will enable the MCP t access and cllate data acrss the whle system, in a way that has prved difficult t date. Kent has been a Year f Care Pineer site fr a number f years and the MCP is wrking clsely with the relevant prgramme team t develp capitated budgets frm the starter linked care datasets that are in place. The MCP will prvide bth technical supprt and leadership as the prgramme mves further twards capitated payment wrking with bth Clinical Cmmissining Grups and prviders. As the natinal lead fr develping new cntracting mdels, the MCP prgramme team feels that there is an intrinsic link between payment and cntracting, and therefre develpment f these shuld run cncurrently. Furthermre, the MCP is cmmitted nt nly t develping innvative service mdels but als innvative evaluatin. The linked care dataset will enable the MCP t set targets and evaluate prjects in a way that hasn t been achieved previusly and it is expected that sme chrt case matching will ccur prir and pst prject implementatin fr relevant prjects. Additinally, the MCP will be wrking with the University f Kent s Centre fr Health Service Studies t develp a rbust evaluatin arm t its prgramme, which encmpasses research, educatin and evaluatin. This will enable the MCP t wrk clsely with Prfessr Jenny Billings, wh is supprting the NHS England evaluatin prgramme natinally, in additin t linking int the Nuffield Trust which is lking at MCP mdels as a research basis fr prtfli research. The Research Directr is Dr Vanessa Shrt wh is a GP in ne f the Vanguard practices and has a part-time appintment as clinical research fellw in CHSS. She will direct the research ffice and line manage the staff as well as chairing the Vanguard Research Cmmittee made up f representatives frm the Vanguard, cnstituent practices and senir researchers frm CHSS. Sme supprt fr the central research csts have been agreed with the Kent Surrey and Sussex CRN. As set ut in the Year One Value Prpsitin, a Lgic Mdel has been develped (see belw). The MCP prgramme team will be prducing a separate mdel fr each service area and will use these as part f the package f cmmunicatin resurces that set ut the MCP s visin fr the utcmes that its mdel f care seeks t deliver. This will be f particular value in supprting rganisatinal and behaviural change management with key grups f staff aligned t the integrated health and scial care mdel. 12

13 Lgic Mdel Develp a new mdel f care that that delivers high quality, utcme fcused, persn centred, crdinated care that is easy t access and that prmtes wellness and enables peple t live independently fr as lng as pssible Challenges: Ageing ppulatin prfile Meeting cmplex needs f peple living with LTCs Financial challenges faced by lcal health ecnmy Traditinal divide between primary, secndary and scial care Opprtunities : T imprve identificatin and management f disease specific cnditins Health prfessinals t wrk in a practive and crdinated way Integratin with scial care t imprve discharge prcesses T be able t develp a mre sustainable mdel fr health and care Efficiencies and savings Inputs Activities Shrt-term utcmes Medium-term utcmes Impacts Financial: Initial start-up input f 150k received Allcatin f 1.636m fr 2015/16 nw received Value Prpsitin fr 2016/17 t be submitted by 8 February 2016 Nn-financial: MCP cre team Partnership Steering Bard and sub-grups CCG supprt Natinal CSU supprt NHSE supprt Develping Primary Care: Extended access t primary care thrugh extended wrking 8-8 seven days a week GPwSI and utpatient develpment Paramedic Practitiners Integratin f practice, cmmunity and mental health wrkers with services beynd health such as scial care and the vluntary sectr Develping Estate Infrastructure: Creatin f lcal hubs C-lcatin f services Bedded capacity Transfrming the Wrkfrce GPwSI training and educatin Wrkfrce redesign acrss nursing, scial care and dmiciliary care Shift f unscheduled activity frm secndary t primary care Quicker diagnstics and treatment fr rutine care Increased GP capacity Access t patient recrds Maximise use f existing nursing capacity Reductin in admissins and length f stay Less delayed discharges Reductin in care hme admissin East Kent wide bed mdelling wrk t aid prgramme f change Develp business case Maximise use f specialist clinical staff Effective referral demand management High quality triage Medium t lng-term imprvement in ppulatin health Larger step-change in shrt-term utcmes Imprved patient satisfactin with access t primary care Imprved management f patients Imprved quality f referral Larger reductin in secndary care activity Increased step up capacity Faster discharge frm acute setting Reductin in LOS Stable and cmmitted lcal wrkfrce T deliver an integrated health and scial care mdel f care that fcuses n delivering high quality, utcme fcused, persn centred, crdinated care that is easy t access and that enables peple t stay well and live independently fr as lng as pssible in their hme setting T transfrm lcal services s that we deliver practive care and supprt fcused n prmting health and wellness, rather than care and supprt that is slely reactive t ill health The MCP is wrking with and supprting the system in the develpment f the Sustainability and Transfrmatin Plan. In bth the shrt and lnger term the MCP will cntribute t supprt the wider health and scial care ecnmy in reaching financial balance. As the ecnmy appraches the end f the 15/16 financial year, the lcal acute trust is expected t have a deficit between 32m- 37m. Althugh bth the lcal CCG and cmmunity trust are intending t reach planned surplus targets in 15/16, ging frward all rganisatins will face significant financial challenge. Furthermre, KCC faces a particularly challenging budget fr 2016/17 and 2017/18. The draft budget and Medium Term Financial Plan published n 11th January 2016 shws that fr 2016/17 KCC face a net reductin in central gvernment grant f 48m and additinal estimated spending demands f 80m. Whilst KCC can increase the cuncil tax up t 2% withut requiring a referendum, plus levy a further 2% specifically fr scial care, this tgether with an increase in the tax base raises an additinal 34m. This means KCC need t find 94m f savings (10.3% f net spend) t balance the budget in 2016/ /18 will be equally tugh fr KCC with a further 42m reductin in central gvernment funding and 66m estimated additinal spending demands. KCC can raise an additinal 24m thrugh further cuncil tax increases but this will still leave 84m f savings t find (f which 56m is as yet is unidentified). 13

14 During 2016/17 Encmpass MCP will seek t build a fully integrated health and scial care team, ffering hublevel services, inclusive f primary, cmmunity and scial care prvisin ver the perid until 2017/18. It is planned that the integratin f services at a hub level, cupled with the cntinuatin f the alignment f paramedic practitiners at a practice level t supprt hme visiting, will cntribute t a reductin in A&E demand and nward admissin in the shrt term. In the lnger term, it will seek t reduce pressure n acute services and lng term care hme placements. These schemes are still in their early stages and will cntinue t be evaluated. Once prven, the MCP will negtiate fr funding t be remved frm the acute cntract t supprt these schemes n a recurrent basis. It is expected that this wuld ccur during the 17/18 cntracting perid. By building integrated teams in the cmmunity, admissin avidance (t hspital and lng term care) and mre rapid discharge will als relieve pressure n the acute Trust in the lnger-term. Prving that the MCP has the ability t deliver these schemes will be key t building the trust between parties that will enable the clsure f existing bed capacity in 17/18. By building integrated cmmunity teams we will endeavur t increase effectiveness within the current system and release capacity thrugh enabling an integrated wrkfrce t perate mre efficiently. We will mnitr the impact n the existing services and als mnitr the ptential fr the creatin f new demand that is ften missed frm the evaluatin f prjects. Lnger term the MCP wishes t develp and utilise new cmmunity hspital facilities and further encurage treatment f patients within their wn hmes. Dependant n future demand grwth this may enable the acute trust t reduce their bed base, leading t large-scale cst reductins. The plans fr the MCP are cnsistent with the East Kent University Hspitals FT (EKUHFT) clinical strategy. System wide bed mdelling has already begun, t enable further develpment f this wrk. The MCP is directly represented n the East Kent Strategy Bard, established in early September t tackle the whle system challenges facing the health and scial care ecnmy, thrugh its psitin within this grup the MCP is cmmitted t supprt system sustainability acrss the East Kent lcality. 14

15 8. Encmpass MCP s Aim, visin and values 8.1 Aim Encmpass MCP is develping services that will perate frm Cmmunity Hub Operating Centres (CHOCs) in Whitstable, Canterbury, Faversham and Sandwich. The MCP is develp innvative care pathways integrating cmmunity, primary and secndary care in a seamless prcess that allws patients t pass thrugh the healthcare system withut repetitin and duplicatin due t true prvider integratin. It als seeks t integrate health and scial care services at a cmmunity level in a way that supprt hlistic assessment, supprt and care fr peple. It seeks t deliver services that: Prvide wrapped arund care t meet the full needs f peple accessing services, delivered lcally; Imprved quality f care fr service users and carers and imprved health utcmes fllwing treatment; Practively supprt peple t maintain their health and wellbeing and independence fr as lng as pssible, receiving the right care in the right place and at the right time. This will be underpinned by prvisin f gd quality patient and carer infrmatin; Supprt peple t enable them t access high quality infrmatin; Reduce duplicatin f assessments, recrds and services; Prvide linked data sets enabling tracking f the care f individuals with cmplex needs; Enable easy and effective referral pathways fr health practitiners t enable access t multidisciplinary skilled staff that supprt the care planning and delivery f care fr the patient; Supprt the develpment f self-care strategies; Utilise Telehealth and Telecare effectively and efficiently; Prvide a Single Pint f Access fr Scial Prescribing; and Are financially sustainable and affrdable t the whle system ecnmy. 15

16 8.2 Visin MCP visin is t develp a new mdel f care that delivers: High quality, utcme fcused, persn centred, crdinated care that is easy t access and that prmtes wellness and enables peple t live independently fr as lng as pssible. MCP Visin and alignment t the Canterbury and Castal CCG Strategy: Imprve the health and wellbeing f lcal peple by wrking in partnership with lcal cmmunities t create a sustainable health care system, integrating hspitals, GPs, scial care and cmmunity services including the vluntary sectr. CCG wide Cmmunity Netwrks prgramme Cmmunity Netwrks have been established acrss the CCG and ffer the ptential t ffer accessible and respnsive services that extend well beynd what is currently available in general practices. Cmmunity Netwrks aim t: Make sure health and scial care services are meeting the needs f ur ppulatin. Functin as advisry grups fcusing n the needs f their cmmunities. Infrm and drive cmmissining pririties thrugh engagement in the CCG s Cmmissining fr Value prgramme. The diagram belw illustrates this: 16

17 Next steps: Encmpass MCP regards the Cmmunity Netwrks as an integral cmpnent f effective stakehlder engagement t underpin the c-design f the MCP new mdel f care. MCP Visin and alignment t Natinal Vices Narrative The Natinal Vices Narrative statement f c-rdinated care encapsulates what service users say that they want frm integrated care acrss the Vanguard area: Overarching summary service user perspective Care Planning Infrmatin I can plan my care with peple wh wrk tgether t understand me and my carer(s), allw me cntrl, and bring tgether services My Gals/utcmes Transitins Cmmunicatin Decisin Making Alignment t the Six Principles : A new mdel f partnership with peple and cmmunities: Encmpass MCP is fully cmmitted t develping its mdel f care in alignment with the Peple and Cmmunities Bard s six principles fr changing the way that health and care relate t peple and cmmunities. The six principles set ut the basis f gd persn centred, cmmunity fcused health and care. This is illustrated thrughut the Value Prpsitin. 17

18 Scial prescribing will be CHOCs will deliver crdinated persn Wrking with all sectrs t supprt mdel C-design via engagement with Netwrks Carers will be supprted in line with Visin and values via CHOCs Health prmtin and preventin embedded at practice level 8.3 Values The MCP vanguard values underpin the prpsed new mdel f integrated care: Patient and Primary Care at its heart - pr-active care and preventin thrugh early identificatin, crdinated care planning and delivery in primary and cmmunity care setting; Care shuld be persn-centred, easy t access, and well-crdinated, enabling clear transitin thrugh services based arund clearly identified and agreed care decisin pints ; Peple are supprted t stay well and maintain their health and independence fr as lng as pssible, living in the place f their chice, supprted by apprpriate integrated multi-agency cmmunity service prvisin; Self-care and self-management is prmted and supprted; Carers are effectively supprted; Care shuld take place in the mst apprpriate setting, based n what is clinically apprpriate, safe and effective shifting unnecessary activity ut f the acute setting and int the cmmunity; Services are underpinned by integrated IT acrss the whle system (including cmmunity IT slutins fr all cmmunity staff) ; and Cst affective care maximising health pprtunities fr the lcal ppulatin. 18

19 9. Encmpass MCP s transfrmatin prgramme Encmpass MCP is seeking t deliver a transfrmatinal change prgramme acrss the health and scial care landscape. The Lgic Mdel and assciated Value Generatin Hypthesis Tree illustrate the change prgramme in the fllwing bands: Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce. The scale f the change prgramme is brad, encmpassing preventin, early interventin, primary and cmmunity health services, scial care, hme care, residential and nursing care and in reach t acute health care. It als seeks t deliver an ambitius wrkfrce develpment prgramme, that will facilitate Encmpass MCP t deliver a fully integrated mdel f care supprted by a flexible and respnsive wrkfrce that is able t deliver the right care and services, delivered by the mst apprpriate prfessinal, in an apprpriate setting, and within the ptimal timeframe. 9.1 Develping Primary Care In 2015/16 Encmpass MCP sught t cmmence building capacity in primary care by extending GP services t perate frm 8am t 8pm six days a week. The service cmmenced n 7 Nvember but it has prved peratinally challenging t identify the GP wrkfrce t cver clinics acrss all three hub lcalities and take up f appintments has als been patchy. In line with the New Care Mdel s Vanguard Prgramme eths f testing, evaluating and where apprpriate adjusting prjects based n early evidence, we prpse re-visiting the perating mdel fr develping primary care in 2016/17. In 2016/17 we will pause delivery f the extended service, given the peratinal challenges that it has presented. We will instead fcus n scping demand, review the wrkfrce capacity t deliver extended services, explre ptins t perate a skills mix wrkfrce mdel t deliver primary care services (inclusive f GPs, Nurse Practitiners and ther prfessinals) and map the interface with ut f hurs services, which are currently subject t re-prcurement. This will als enable the MCP t explre hw the extended primary care team will interface peratinally at a hub level with the Cmmunity Hub Operating Centres. It will enable the MCP t fully explre hw we ensure that ur primary care services are making best use f resurces, delivering best practice t supprt patients mst effectively, Fr example, this may include mdelling utilisatin f lnger appintment slts fr patients with lng term cnditins. It shuld als be nted that by taking this apprach, the MCP will be well-placed t respnd t the develping natinal cntract wrk. 19

20 The Paramedic Practitiner Hme Visiting service became fully peratinal acrss the MCP in December. The scheme cntinues t prve successful in terms f quality, patient experience and impact n the wider health system. Early evaluatin indicates a 10 per cent reductin in cnveyances t hspital fr the areas supprted by the PP teams. Furthermre, GPs are reprting that the additinal time available t them within practice is enabling them t fcus clinic time n thse patients wh require lnger appintment slts, such as cmplex LTC and end f life patients. Cmmunity paramedic staff are als reprting high levels f satisfactin with the wrkfrce mdel. When surveyed 81 per cent f paramedics said they feel that integrating with GPs has increased their primary care cmpetence. 75 per cent f cmmunity paramedics feel that they have been able t prvide a better service t the cmmunity and patients. In 2016/17 the MCP seeks t cntinue the PP service and explre hw this is embedded within the primary care team and the CHOCs. Encmpass MCP is als develping GP with a Special Interest services in the specialities f ENT, neurlgy, cardilgy, phthalmlgy and clrectal. The MCP s GPSI prgramme is aligned t the CCG s pririties in respect GPSI prvisin, as well as the acute Trust s strategy t reduce utpatient activity in the acute setting acrss a range f specialities. This system wide, crdinated apprach t managing utpatient demand in a range f specialties will ensure that all parties are wrking twards the same purpse t deliver high quality, patient fcused specialist care that is cst effective and supprts planning at a Trust and CCG wide level. Furthermre, the MCP sees a value in develping the primary care wrkfrce thrugh its GPSI Prgramme. Extending the range and scpe f the primary care skills base will deliver benefits nt just in terms f service delivery but als in terms f enriching the GP wrkfrce acrss the MCP lcality supprting its nging stability and sustainability. Encmpass will als be utilising utpatient clinics fcused n End f Life care, delivered in hub based utpatient clinics, in the first instance this will be in Estuary View. The clinics will enable services traditinally delivered in secndary care t be accessed in the cmmunity, clser t hme. An advanced nurse practitiner, cmmunity nurse and cnsultant will wrk tgether, ffering care in clinics and in patient s hmes. The prpsed integrated mdel (Nursing and Beynd Health) The MCP integrated mdel f care will deliver hlistic health and scial care services thrugh Cmmunity Hub Operating Centres (CHOCs) lcated in Whitstable, Canterbury, Faversham and Sandwich. Each CHOC will supprt clusters f GP practices. Althugh there will be rm fr lcal variatin in each CHOC, t enable services t be tailred t meet specific ppulatin needs, each CHOC will include as a cre: Integrated nursing and scial care services Health preventin and health prmtin services Access t vluntary and cmmunity services via scial prescribing We are wrking t cnfirm the CHOC sites, with a view t cllcating them with existing cmmunity health facilities. Fr example, the Whitstable CHOC is likely t perate frm Whitstable Medical Practice. Sites fr the ther CHOCs are being finalised. Sectins 9.2 and 9.3 belw describe in detail the tw elements f the prgramme that frm the integrated mdel. 20

21 Schematic f the Mdel f Care Cmmunity Hub Operating Centres (CHOCs) The develpment f a fully integrated health and care service with the MCP will require an extensive change management and rganisatinal design prgramme t supprt its delivery. Whilst we will seek t build n existing integrated services where apprpriate, the ambitin acrss bth the health and scial care system is t develp a transfrmatinal mdel f care, supprted by a skilled, stable and integrated nursing and care wrkfrce that is fit fr the future and ffers bth career prgressin, prfessinal develpment and high levels f jb satisfactin. Each hub will incrprate: General Practice Integrated nursing and scial care (including dmiciliary care) Functinal therapy services Access t vluntary and cmmunity service via scial prescribing Health prmtin and preventin services Integrated mental health services 21

22 9.2 Develping Nursing Integratin Integrating practice and cmmunity nursing will maximise use f existing nursing capacity. In Nvember the MCP cmmissined impower Cnsulting Ltd t undertake an audit f nursing services acrss the MCP lcality. The MCP has shared the audit reprt with the NCM Team, as well as with partners lcally. It prvides an excellent baseline frm which t develp the integrated service in 2016/17. In 2015/16 the MCP has fcused n integrating nursing services t supprt tw specific pathways catheter services and wund care. The new integrated pathways will functin frm hub lcalities, currently based in surgeries in Faversham, Whitstable and Canterbury and will release capacity within cmmunity teams t enable staff t supprt thse patients mre likely t end up in acute care. It will address unnecessary admissin, delayed discharge and reduce length f stay. They will functin as a single integrated clinical team built arund the patient pathway. In 2016/17 the MCP will cmmence the change management prgramme t bring tgether the cmmunity nursing and scial care services acrss the lcality t start building the new Cmmunity Hub Operating Centres (CHOCs). The change prgramme will see all nursing services re-aligning t the CHOCs frm April 2016, with a phased integratin f scial care resurces, cmmencing with Whitstable CHOC in April. The CHOCs will perate apprpriate and cmprehensive assessment f patients hlistic health and care needs, drawing n a fully integrated team wrkfrce, as set ut in the fllwing sectin Beynd Health. In additin t cmmunity nursing, the MCP will be reviewing hw specialist nursing and cnsultant led services link int the pathway f care fr thse patients accessing care acrss a range f prviders (acute, cmmunity and primary care). This will als link t the scping f GPSI services in primary care, t ensure that we are maximising the utilisatin f the full range f specialist clinicians that might supprt patients with specific cnditins. Develping the cmmunity mental health wrkfrce will als be a critical element f the integrated nursing team at a hub level. We will build capacity within the current Canterbury CCG service t ensure that each CHOC has a cmmunity mental health wrker t supprt adult mental health service users as part f its team aligned t GP practices, recruitment will cmmence in April with wrkers in pst frm June The MCP is building n the pilt service intrduced by CCGs acrss East Kent in 2014/2015 which has delivered prmising results. A key perfrmance indicatr was t supprt the repatriatin f secndary care patients, where apprpriate, t primary care t deliver better care fr patients with a stable lng term mental health cnditins in Clusters 7, 11 and 12. Within the Canterbury CCG lcality 201 patients seen f which 103 patients transferred t cmmunity care, 30 are nw under GP care and 46 have mved int access services (including 15 nw in emplyment and 8 attending university. By extending the capacity f this wrkfrce and aligning t the CHOCs the MCP will seek t extend the fcus f these wrkers t manage step up t secndary care, as well as supprting step dwn care. The MCP will als wrk with the CCG in 2016/17 t scpe and develp a cmmunity based dementia diagnsis and supprt service. 9.3 Beynd Health The MCP will develp and perate an integrated health and scial care mdel which incrprates a brad range f persn-centred and utcme fcussed interventins, encmpassing preventin, early interventin, primary and cmmunity health services, scial care, hme care, residential and nursing care and in reach t acute health care. 22

23 Our aim is t: Deliver persn-centred care and supprt embedding the principles f care self-care and selfmanagement and the philsphy f n decisin abut me withut me invlving the persn in their care planning frm the start; Imprve peple s experience and prmte their health and wellbeing; End the current crisis driven mdel f care; Create a value driven and utcme fcused culture that nurtures creativity and innvatin in meeting peple s needs; Supprt peple t access gd quality advice and infrmatin that enable then t self-care/manage; Create the right cnditins which enable peple t find slutins that, where apprpriate, supprt their wellbeing utside f traditinal medical r service driven mdels f care and supprt; Encurage cmmunity develpment and increase vlunteering, befriending and gd neighbur schemes; Supprt carers in their vital rle thrugh the prvisin f advice and individually tailred supprt; Prvide flexible and practive mdels f care and supprt that can increase and decrease accrding t need; Facilitates prfessinals t d the right thing and prvide persn centred hlistic supprt that prmtes wellbeing; Prvide respnsive mdels f lng term care that can flex up r dwn accrding t peple needs; and Bring services tgether t ensure better cmmunicatin and better use f resurces and create a better user experience. Our mdel is described thrugh three grups f interventins; Prmting Wellbeing, Prmting Independence and Supprting and Maintaining Independence. Thugh it must be nted this is just a means f describing differing types f interventins and that all supprt will be fully integrated, sils will be avided and peple will be able t access the right care at the right time in rder t be as independent and well as pssible at all times. Prmting Wellbeing These services aim t prevent, delay r avid peple entering int frmal scial care r health systems, by enabling peple t manage their wn health and wellbeing. Wellbeing services are universal, based in lcal cmmunities and utilise lcal resurces. They address the issues that lead t peple entering int frmal care systems, such as scial islatin, falls and carer breakdwn. Access t gd quality infrmatin and advice will be the crnerstne f ur wellbeing ffer, enabling peple t identify and access the supprt that they want in rder t maintain living fulfilled lives. Our eths will be a life nt a service ; this is based n cnsistent feedback that current mdels f supprt fit peple int a narrw band f available services; whereas future supprt needs t be mre persnalised t enable peple t achieve the utcmes that matter t them. 23

24 GPs and ther health/scial care prfessinals find it difficult t keep abreast f all that is available in the cmmunity t supprt peple s wellbeing. We will develp mdels f supprt that enable peple t access the resurces in their lcal cmmunity that keep them infrmed, cnnected, active and well. We will be explring hw scial prescribing mdels supprted by ne t ne supprt can use techniques like guided cnversatin t help peple think abut their needs and get the supprt they require. We will investigate hw we can supprt peple t plan fr later life and be mre in cntrl f their care and supprt needs. Peple d nt knw what is available either thrugh cmmissined supprt in the vluntary sectr r prvided via ther grups such as churches. We want t develp Cmmunity Hub Operating Centres (CHOCs) which will be lcal infrmatin and advice hubs that are in prminent and visible lcatins, where peple can pp in fr advice and supprt. Scial islatin and lneliness is a huge issue; central t ur mdel will be develping schemes which help peple cnnect fr mutual supprt, activity and fun. Keeping peple cnnected keeps them well! We will wrk with and thrugh the cmmunity and vluntary sectr t maximise use f ur cmbined resurces, using tls such as asset mapping t ensure traditinal and nn-traditinal types f supprt frm part f ur wellbeing ffer. Our fcus will be n building cmmunity capacity and resilience in cmmunities and levering in nn-traditinal prviders t imprve the range f supprt ffered. The MCP will utilise the Health Fundatin s Practical Guide t Self-Management Supprt t ensure that selfmanagement is embedded within the new mdel f care. In particular it will ensure that the fllwing fur principles f persn-centred care are delivered thrughut its services: Affrding peple dignity, cmpassin and respect. Offering crdinated care, supprt r treatment. Offering persnalised care, supprt r treatment. Supprting peple t recgnise and develp their wn strengths and abilities t enable them t live an independent and fulfilling life. Intelligence Led Mdel f Health Preventin Kent Cunty Cuncil Public Health Team will wrk with the MCP t test a new Health Trainer mdel, t assess hw a cunty wide service culd be changed t becme mre effective at reducing future demand in an intelligence led mdel f health preventin. The Cuncil has already cnsulted publicly t transfrm the apprach t health imprvement services. This enables learning f lessns fr replicability and implementatin acrss Kent. The transfrmed mdel will bring clser integratin with General Practice and the hub mdel, including thrugh better patient targeting by analysing GP lists and identifying thse patients at high risk f chrnic disease. The impact f the interventin will be mnitred thrugh the number f visits t GPs, changes in risk taking behaviur and in the lng term develpment f disease and usage f acute service. We will wrk clsely with leading experts t develp a systematic prcess t identify high risk patients. The benefit f being integrated within General Practice will mean that the health trainers will be able t wrk with practice clleagues clsely t fully understand the individual s needs. This initiative will be clearly linked with the scial prescribing prgramme f wrk underway t ensure a hlistic alternative t particularly thse peple wh are frequent fliers t General Practice fr issues better served thrugh scial and cmmunity resurce, than a medically prescribed respnse. 24

25 A behaviural insights study will aim t understand hw peple will best respnd t challenges arund imprving their health thrugh engagement with integrated services in new settings, and what kind f cmmunity supprt will be mst effective. This will fcus n studying hw best t engage the target grup and what kind f service wuld best respnd t their needs, with supprt t step dwn frm a service and utilise the cmmunity resurce rather than a service. Fr patients, the learning frm the behaviural insights wrk will be applied t infrm the design f the right messages, whilst it will be essential t ensure that the GPs are aware f the pprtunities f the preventative prgramme and understand hw best t access it fr the benefit f their patients, therefre guidance will be develped fr bth patients and GPs. This will build n a prgramme f insight wrk already underway t get t the heart f the appraches that deliver real behaviural change. There is a prgramme f behaviur insights wrk underway cmmissined by KCC and this investment will blster this specifically fcused in the Vanguard area t build the understanding int the new health trainer mdel and int the Health Scial Prescribing prgramme. Scial Prescribing A key element f Encmpass MCP s mdel relates t the establishment and rll ut f a scial prescribing prgramme acrss the MCP lcality. Scial prescribing seeks t use the Peple Pwered Health mdel f building generatinal resilience fr imprved health and well-being thrugh: Building strng scial netwrks Exercising mre Eating mre healthily Feeling mre supprted and in cntrl f lives. It is underpinned by a clear referral management prcess, and clear evaluatin mdel. The MCP is wrking with Red Zebra, a lcal vluntary sectr umbrella rganisatin t develp and embed the scial prescribing mdel within the MCP s cmmunity hub-based services. In 2016 scial prescribing will becme ne f the cre services t which practitiners are able t refer, and als that peple will be able t access directly. By embedding scial prescribing within the cmmunity integrated team, it will becme a standard ffer t peple, fr the first time systematically prmting health and wellbeing and self-management as a matter f curse. Prmting Independence These services als aim t prevent r delay peple entering int frmal care systems by prviding shrt-term supprt that prvides the best lng-term utcme fr an individual. Fr sme peple, these cnsist f shrt term interventins that enable peple t recver frm episdes f ill health r injury and t return t their previus level f health. Fr ther peple, especially thse with a lng term cnditin r a disability, these may be fixed term services that prvide training and skills develpment that maximises independence and enables peple t live as independently f frmal care systems as pssible. The CHOCs will ffer therapy services and prvide access t assessment and advice regarding equipment and assistive technlgies. We will lk t integrate Occupatinal Therapy services prvided by KCC and the Kent Cmmunity Health Trust whilst maximising the pprtunities f the newly jintly cmmissined cmmunity equipment prvider, NRS. This will imprve access, ptimise services, and remve the risk f duplicatin and 25

26 variatin in assessment and prvisin, making it easier fr peple t get the equipment that helps them remain independent and well. The MCP will bring tgether KCC s enablement service and Kent Cmmunity Trust intermediate care services t ensure peple have rapid access t shrt term therapeutic interventins that prevent hspital admissin, supprt recvery frm illness and enable peple t get back n their feet. The service wuld be designed t supprt peple with cmplex needs including thse with mving and handling issues i.e. duble handed care and imprtantly peple living with dementia. The service wuld respnd rapidly t supprt peple t stay ut f hspital and thrugh the CHOCs will be aligned t the paramedic service. The service will prevent acute admissins and supprt timely and effective discharges and will wrk n the understanding and belief that yur wn bed is best, and that in mst cases peple are mre cmfrtable in their wn hmes and therefre recver and regain their independence mre quickly if gd quality therapeutic supprt can be prvided in their wn hmes. Supprting and Maintaining Independence Sme peple will need nging supprt t remain living in their wn hmes and cmmunities. These services aim t maintain individual wellbeing and self-sufficiency, keep peple safe and enable peple t live and be treated with dignity, enabling peple t live in their wn hmes, stay cnnected t their cmmunities and avid unnecessary admissins t hspitals r care hmes. We plan t investigate and develp a nurse led hmecare service which brings tgether KCC cmmissined hmecare services and the Kent Cmmunity Health Trust nurses t prvide an utcme fcussed flexible and respnsive specialist services t supprt peple living at hme. This mdel ffers a real pprtunity t develp a wrkfrce mdel that is fit fr the future, and which explres the pprtunities t train and develp carers and health care assistants and nurses t deliver hlistic care fcused n patient need. Fr example, this may include training dmiciliary care wrkers and carers t carry ut medical prcedures such as insulin injectins fr insulin dependent peple in receipt f hme care, and wh wuld therwise require daily nursing visits. We will prvide wrap arund hlistic supprt fr peple with mre intense/cmplex needs. Key t this mdel will be a trusted cmmunity wrker wh is given the resurces t build a team r circle f supprt arund that individual. This will supprt specific high risk individuals including thse with dementia r very unstable lng term cnditins. Integrated enablement/intermediate services and integrated nurse led hmecare services will als prvide peripatetic supprt t care hmes in the area; the teams will in reach t lcal care hmes t prvide specialist supprt fr residents and t help staff develp skills and cnfidence. Develping an integrated wrkfrce strategy is an essential element f ur plan. We must ensure that there is a genuine career pathway acrss an integrated health and scial care system and that we encurage yung peple int careers by supprting them t gain qualificatins and skills. Links with lcal higher educatin cllages and schls will be imprved. 9.4 Develping estate infrastructure Encmpass MCP is wrking with the CCG, KCC, primary care, the Acute Trust and the Cmmunity Trust t develp the estate infrastructure t ensure bedded capacity is apprpriate acrss the MCP lcality. Furthermre, the bed mdelling that will underpin this is based n lcal need and demand and is embedded in the East Kent Strategy t ensure that the whle system is able t meet demand in the future. The MCP will 26

27 seek t develp health and wellbeing services t meet lcal demand, increase educatin and training resurce as well as cnsulting space. This will result in: Peple having access t high quality services delivered in apprpriate settings; C-lcatin f services t supprt integrated wrking in the cmmunity; GP direct cmmunity bed management in MCP lcality; Reductin in admissins and LOS t acute as patients managed in bedded cmmunity prvisin under care f GP. Whitstable The mdel includes cmmunity hspital prvisin that facilitates direct GP admissins; nursing hme prvisin and extra care prvisin, inclusive f a day centre. This will be delivered in a range f new settings c-lcated n the Estuary View site, and in line with the Kent Cunty Cuncil s nursing hme and extra care strategies. It shuld be nted that this will cme n stream in the secnd phase f the MCP s prgramme, with a target f the new facilities being peratinal frm April Canterbury Nrthgate In Canterbury, Nrthgate Medical Practice successfully bid fr GP Infrastructure Funding t supprt the develpment f the Nrthgate Health and Wellbeing Centre which will be linked t Nrthgate Medical Practice, enabling the Practice t expand the services it prvides in primary care. The Health and Wellbeing Centre will add cnsulting rms, health educatin space and therapy rms as well as cnsultant led clinics and pssible additinal diagnstic facilities. The Nrthgate patient participatin grup was invlved in the c-design f the funding bid and have added their full supprt t it. The Wellbeing Centre will supprt a reductin in rutine utpatient appintments and attendances in secndary care, imprvements in patient utcme and reductin in hspital admissins as well as imprving rapid diagnses fr treatable cnditins such as diabetes and cancers. Canterbury Medical Practice Canterbury Medical Practice has develped a GP Premises Develpment Business Case in respect f re-mdelling f practice infrastructure acrss the Canterbury West lcality. An imprtant cmpnent f this is addressing transfrmatinal change in Primary and Out f Hspital Care. It is part f an nging prcess f delivering the strategic challenges mst recently utlined in the Five Year Frward View, breaking dwn the barriers in hw care is prvided between family dctrs and hspitals and health and scial care. As such it is very much aligned t the delivering bth the MCP s integrated health and care mdel and the Canterbury and Castal CCG Strategy. It wuld see tw red rated time-limited premises replaced with a new purpse built Primary Care facility, c-lcated n the Kent and Canterbury Hspital site. This is the first stage f a the develpment f a Health and Scial Care Village mdel n the acute site at the Kent and Canterbury Hspital. Canterbury Medical Practice and Cssingtn Huse Surgery, wrking cllabratively with ther stakehlders that include EKHUFT, KCHFT, NHS England, their patient grups and ther lcal practices, have pursued a mdel f care that aims t break dwn the barriers f care prvisin. Mst recently theses plans have becme aligned t Canterbury CCG strategy and the Vanguard 27

28 Faversham prgramme. This develpment will supprt likely changes in the future prvisin f acute services by EKHUFT in the lcality in the future. The MCP will explre the ptins fr imprved cmmunity integrated inpatient facilities in Faversham. Sandwich and Ash The MCP will explre the ptins fr prviding cmmunity facilities in Sandwich and Ash. 28

29 9.5 Wrkfrce redesign including educatin and training As referenced in 9.1, 9.2 and 9.3 abve, key t the success f the MCP s integrated mdel f care will be its ambitius prgramme f wrkfrce redesign. Educatin, Training and Wrkfrce planning is key element f Encmpass MCP s mdelling. The prpsals made within this Vanguard Value prpsitin are underpinned by a Primary Care East Kent wide strategy fr Educatin, Training, and Research that supprts the current and future needs f a multi-prfessinal and interdisciplinary cllabrative wrkfrce. Such strategic aims are vital and integral t the wider wrkfrce planning agenda that takes int accunt bth lcal and natinal pririties. In rder t deliver the clinical service aims described within this Value Prpsitin, the MCP has aligned with ther prviders within East Kent fr the purpse f develping an integrated multi-prfessinal educatin strategy thrugh the East Kent Cmmunity Educatr Prvider Netwrk ( EK CEPN). The Cmmunity Educatin Prvider Netwrk is tasked with increasing capacity fr future wrkfrce training in the cmmunity and the develpment f the current and future wrkfrce arund the needs f a gegraphically defined ppulatin. Crrect and best use f any service mdel is dependent upn the apprpriate educatin and training f its users. Within the implementatin f the Five Year Frward View this requires a cherent and rapid change t the way individuals and teams within Health and Scial Care currently train, learn and maintain their scpe f practice. Mrever, a change in the traditinal hierarchies and prfessinal cultures acrss health and scial care is essential in rder t enable integratin and real-time cllabratin with shared NHS values. Within East Kent this challenge is being addressed thrugh the evlutin f the EK CEPN (Training Hub ) f which Vanguard is part. Thus the verarching educatinal and training aims within Vanguard are c-terminus with the East Kent CEPN. Thrugh wrkfrce redesign acrss nursing, scial care and dmiciliary care we will develp a flexible lcal wrkfrce that has the ptimum skills mix and prfile t supprt MCP ppulatin chrt. This will result in: Wrkfrce that is delivering excellent clinical and scial care Peple will get right care, frm the right prfessinal, in the right setting and at the right time. Wrkfrce that is delivering excellent clinical and scial care Maximising use f specialist clinical staff, thrugh t vluntary sectr supprt wrkers. Safe, transparent prfessinal pathways f care Maximising pprtunities t train and retain staff at a lcal level, ffering career prgressin within and acrss prfessinal staffing grups. Thrugh GPwSI training and educatin the MCP will build a skilled and cmpetent GP wrkfrce that will result in: Effective referral demand management. High quality triage Stable and cmmitted lcal wrkfrce. 29

30 SUMMARY OF KEY DELIVERABLES BY PROGRAMME AREA AND QUARTER DELIVERABLE Q1 Q2 Q3 Q4 DEVELOPING PRIMARY CARE Extended General Practice Scping demand and capacity in Primary Care Scping cntinued and develping service mdel Prcurement if required (if nn list based service mdel) Prcurement cncluded and prep fr new mdel f primary care frm April 17 GPSIs Implement extended GPSI services fr ENT and neurlgy. Scping fr ther services Develping ther GPSI service inc scping demand and wrkfrce End f Life Clinics Develp clinics New cmmunity clinics cmmence at EVMC and hme visiting acrss lcality INTEGRATED NURSING Integrated nursing fr wund care and catheter pathways New clinics and pathways fully peratinal Mnitring impact, scping extensin Integrated nursing teams First Team in place in Whitstable April 16 Further integratin wrk up Teams in place in Canterbury and Faversham and Sandwich Cmmence OD and wrkfrce redesign prgramme Onging CM and OD prgramme Respnd t nursing audit recmmendatins Actin changes 30

31 BEYOND HEALTH Prmting wellbeing Scial prescribing live in Whitstable Scial prescribing rll ut t full lcality Embedding in CHOCs and referral pathways Evaluating and develping as required Prmting independence Build functinal therapy assessment services t supprt enablement Develp KCC/KCHT jined up functinal therapy services Implement single assessment enablement service Ensure self- care and self -management principles are embedded in CHOC teams Integrating health and scial care Scial care and health team in Whitstable t cmmence integrated wrking. Test integrated mdel in Whitstable CHOC t infrm OD and planning Target fr peratinal integrated teams acrss lcality Mar 17. Test Buurtzrg mdel in integrated team (undertake training prgramme, develp wrkfrce Test Buurtzrg mdel in integrated team (undertake training prgramme, develp wrkfrce Health Trainers in CHOCs OD prgramme t embed new practice aligned HT prgramme OD prgramme t embed new practice aligned HT prgramme Embed and test and evaluate impact f new mdel DEVELOPING ESTATES INFRASTRUCTURE Secure prject resurce t develp bid Wrk up f bids Wrk up cmplete and prcurement cmmence 31

32 DEVELOPING IT INFRASTRUCTURE GP clinical systems Migrate GP practices n t EMIS WEB Link EMIS WEB t ther GP clinical systems Infrmatin sharing (with GP clinical system) Develp MIG infrmatin sharing frm EKHUFT, KCHFT, KMPT, KCC Deply MIG infrmatin sharing frm EKHUFT, KCHFT, KCC Deply MIG infrmatin sharing frm KMPT Supprting clinical infrastructure Cnfigure CHOC - Whitstable and Faversham Cnfigure CHOC - Canterbury and Rural Deply Wund Care system Supprting infrastructure Encmpass main ffice cnfiguratin TRANSFORMING WORKFORCE Extensive OD prgramme t be scped. Onging develpment with academic partners 10. Innvatin and IT Enablers - using technlgy t make infrmed decisins n accessing health care The MCP is lking t utilise technlgy t supprt bth clinicians and service users t interface effectively with the system, with a key driver being the sharing f patient and clinical infrmatin between multiple teams and rganisatins. T enable this we will deply IT systems and infrastructure in the fllwing ways: 32

33 GP clinical systems member GP practices will either use EMIS WEB r will use applicatins that allw fr read / write access between differing GP clinical systems Infrmatin sharing using the MIG (Medical Interperability Gateway) t enable clinical infrmatin cllected by partner rganisatins t be viewed within the GP clinical system Supprting clinical infrastructure develping the IT infrastructure t allw multi-specialty teams t perate frm the CHOCs; we will als deply applicatins utside f the GP clinical system that will enable a jined-up apprach t care delivery (e.g. Wund Care) Supprting infrastructure deplying supprting infrastructure t enable the delivery f ur crprate management and gvernance (e.g. MS SharePint) We are wrking with an external prvider t develp SHREWD, a real time escalatin tl that will be used within the CHOCs t supprt patient flw arund the urgent care system. The MCP will als be investing in the develpment f Wait Less, a public facing APP that enables service users t identify in real time what services are accessible t them and what wait times they might experience, and travel times t lcatin. This will be designed at a lcal level, built n feedback frm peple wh will be using the APP. It ffers imprved: Clinical Benefits imprved time t assessment, imprved diagnsis, better utcmes (fewer admissins) Patient Experience- quicker access t care, imprved expectatin, mre cnvenience Quality - APP t imprve time t assessment, access and diagnsis. Reduced pressure n busy A&E departments The prf f cncept and develpment csts will be in the regin f 80k and will require sign ff by all prviders and sign ff thrugh the East Kent Surge and Resilience Bard. 11. Research, Evaluatin and Replicability Research and evaluatin The Centre fr Health Service Studies (CHSS) at the University f Kent has been wrking with Encmpass t establish research capacity and a research supprt ffice within the Vanguard. This wrk has been in cllabratin with the Kent Surrey Sussex Clinical Research Netwrk t pl resurces and ensure that high quality natinal studies can be delivered in the Vanguard. The aim is t facilitate and generate research activity within the Vanguard and member practices with the gal f making research part f the nrmal activities f the Vanguard and its cnstituent practices. Research will cntribute t the Vanguard s develpment and activities by: generating new knwledge 33

34 imprving the quality f patient care prviding educatin pprtunities fr staff in practices and the Vanguard imprving staff recruitment CHSS will undertake tw initial evaluatin prjects within the Vanguard. The first invlves evaluating the impact integrated nursing apprach within the Vanguard. This research will be led by Prfessr Jenny Billings (CHSS) Directr f the Centres Integrated Care Research Unit. The aim will be t assess the impact n patient care and wrkfrce. The secnd prject will examine the rle f paramedic practitiners and evaluate their impact n the prvisin f primary care. The abve prgramme f research and evaluatin will cmplement the internal evaluatin being undertaken by the MCP analysts. Furthermre, the MCP will seek t engage Public Health clleagues frm KCC in the research and evaluatin prgramme t ensure that all elements f the MCP mdel are evaluated in a cmprehensive and crdinated manner. The table belw seeks t illustrate the MCP s evaluatin strategy: Evaluatin Strategy encmpass aim Develp a new mdel f care that that delivers high quality, utcme fcused, persn centred, crdinated care that is easy t access and that prmtes wellness and enables peple t live independently fr as lng as pssible Evaluatin aim Evaluatin t understand whether the elements f the new mdel f care have wrked, als hw and why enabling us t learn lessns fr spreading successful interventins and develping new nes Evaluatin phases During planning and set up During implementatin and mdel develpment After implementatin / nging Evaluatin tls Lgic mdel Value generatin hypthesis trees Evidence and best practice Rapid cycle evaluatin NCM natinal metrics dashbard Encmpass natinal and lcal metrics dashbard Cntract and activity perfrmance reprts Chrt case matching using linked care dataset University f Kent Centre fr Health and Services Studies research and evaluatin Mnitring f impacts using chrt case matching and cunterfactuals Evaluatin activities Mnitring f prgress against lcal and natinal utcme, utput and enabler / prcess metrics Interviews, qualitative and quantitative research t establish the hw and why Replicability The MCP has sught t build strng and effective wrking relatinships acrss East Kent, as well as at a Natinal level, t ensure that the mdel being develped sits within the wider whle system transfrmatin prgramme, and is aligned t the Sustainability and Transfrmatin Plan. By wrking clsely with partners in 34

35 neighburing CCGs, and with the natinal team, the MCP is cnfident that it will be well placed t supprt replicatin in ther areas where that is deemed desirable and apprpriate. Outcme measures The MCP will be wrking up a suite f utcme indicatrs against which t evaluate the prgramme s impact. Initial utcme measures will include the fllwing: 2016/17 A reductin in unscheduled hspital attendances, 999 calls, A&E, ZLOS in particular and reduced Admissins frm Care Hmes (what is the crss ver t the CCG Care Hmes prject); Reductin in GP visits t care hmes (Geriatrician input t care hmes and/r skilling up nursing prvisin in care hmes); Reduced GP referrals t utpatient departments and reductin in fllw up appintments; Reduced numbers attending hspital fr mental health prblems. Imprved physical health status fr patients with LTCs and mental health issues; Increased utilisatin f cmmunity nursing imprved use f existing resurce. Reductin in admissins fr thse with LTC; Create efficiency within existing resurce cmmissining fr value t be measured by individual pathway; Via public health preventin prgramme, develp practive wellbeing prgramme that delivers increasing self-care and self-management particularly in LTC; Imprved patient experience and health utcmes. Imprved invlvement f patients in their wn care planning; Imprved efficiency within scial care. Frm 2017/18 A reductin in hspital admissins (including ZLOS fr cnditins that can be managed in a cmmunity setting); A reductin in length f stay, particularly fr lder peple wh can receive cmmunity rehabilitatin; A reductin in delayed transfers f care; A reductin in the number f peple being admitted t lng term care fllwing hspital admissin; A reductin in time spent n clinical and care dcumentatin, als greater safety, thrugh the develpment f a single, shared electrnic patient recrd; A reductin in carer breakdwn and scial islatin; Better pprtunities fr educatin, learning, research, staff recruitment and retentin. 35

36 36 VALUE PROPOSITION

37 12. Activity, Finance and Evaluatin Detailed Prfile 12.1 Develping Primary Care Extended Wrking Investment As set ut in 9.1 abve, Encmpass MCP will fcus n scping and develping the extended primary care mdel in 2016/17. This will require a resurce investment f circa 50k t fund a prject manager t fcus n develpment f primary care. This investment will be nn-recurrent transfrmatinal develpment funding, it will nt supprt direct service delivery. Paramedic Practitiners Investment, Resurce Sustainability and Evaluatin Building n the successful cmmunity paramedic practitiner pilt undertaken in Whitstable prir t the frmatin f the MCP, paramedic practitiners have nw been implemented acrss the MCP. The number f visits that can be undertaken per week equates t 150 per week and in the shrt term it has been agreed that this will require an investment f 45 per visit. On average paramedics are spending 45 minutes within the patients hme. The paramedic practitiners are undertaking GP hme visit requests n behalf f GPs and the pilt evidenced a clear reductin in the ttal number f 999 cnveyances t hspital. The utcme f the Whitstable pilt shws that there has been a reductin f apprximately 15% in cnveyance level. Early indicatins shw that since the pilt has been rlled ut acrss the whle MCP, cnveyance levels have begun t reduce (by up t 10% in the first mnth f peratin). Paramedic teams are nw aligned t hub areas within the MCP and rtate between dedicated paramedic practitiner and emergency vehicles. The reductins in cnveyances are being generated thrugh building relatinships with bth patients and GPs within hub areas. Alngside releasing financial efficiency savings this scheme is enabling GPs t undertake further wrk such as visiting palliative care patients with the capacity that is being released. Patients are reprting increased satisfactin and demnstrating hw alternative use f and develpment f existing wrkfrce can have significant impacts n the lcal ecnmy. The MCP is wrking with the University t undertake a detailed evaluatin f this prject in terms f the wider impact within primary care. Paramedic practitiner investment and savings table 2015/ / / / / /2021 Investment 100, , , , , ,000 SECamb Saving A&E Saving , , , ,938 UC Saving , , , ,876 Ttal Investment Required / Saving Achieved 100, , , , , ,814 37

38 A&E and Unscheduled care activity and finance ver 5 years table VALUE PROPOSITION EKHUFT A&E Activity 2014/ / / / / / /2021 Activity 12,570 12,834 13,103 13,379 13,646 13,919 14,184 Expected Reductin in A&E Attendances - 1,310-2,007-2,047-2,784-2,837 Resultant Activity 12,570 12,834 11,793 11,372 11,599 11,135 11,347 Finance 1,164,748 1,189,208 1,214,181 1,239,679 1,264,472 1,289,762 1,314,267 Expected Reductin in A&E Cst , , , ,938 Resultant Finance 1,164,748 1,189,208 1,214,181 1,079,135 1,100,718 1,067,055 1,087,329 T Unscheduled Care Activity (Shrt Sta 2014/ / / / / / /2021 Activity 11,329 11,567 11,810 12,058 12,311 12,570 12,834 Expected Reductin in UC Attendances Resultant Activity 11,329 11,567 11,548 11,656 11,902 12,013 12,266 Finance 6,914,081 7,059,277 7,207,522 7,358,879 7,513,416 7,671,198 7,832,293 Expected Reductin in UC Cst , , , ,876 Resultant Finance 6,914,081 7,059,277 7,207,522 7,037,792 7,185,906 7,225,785 7,378,417 GPwSI Services Investment, Resurce Sustainability and Evaluatin The MCP prgramme includes a range f GPSI services that clinicians are keen t expand. Sme services are already well established, whilst thers will require wrk up. It is anticipated that the MCP will wrk alngside the CCG t explre hw best t develp services, based n ppulatin needs and in line with the MCP principles. Initial analysis f service pathways indicates that the current GPSI services related t ENT, phthalmlgy, cardilgy, clrectal and neurlgy require develpment. Within ENT and Neurlgy there is significant variatin in referrals t secndary care, the MCP intends t capitalise n examples f gd practice acrss the lcality and will invest 49k in existing GPSI cntracts t shift activity frm the Acute. It is likely that these changes will be implemented in Q2 f 16/17. Full investment will be requested as anticipated savings will nt be negtiated int the cntract during the 16/17 financial year. Due t the need t undertake baseline wrk and ensure that new clinics d nt generate unnecessary demand the prpsals fr ther areas will be wrked up during 16/17. Furthermre, the MCP will be lking t develp GPSI services that ffer sustainability linked t accreditatin and re-accreditatin. The MCP is requesting 24k f funding t invest in prject management time as well investing 90k t supprt the training and educatin f a further six GPSIs acrss the lcality within the specialities utlined abve. We anticipate having further detailed analysis f GPSI services set ut in future bids. The cst f treating patients in the cmmunity is less fr these services and therefre will be sustainable frm 17/18 nward. Anticipated financial efficiencies are small and can be easily erded by generating additinal demand fr these services. Hwever, the MCP will wrk t mitigate against this and are wrking with the acute trust t ensure that new services can help t relieve the pressures within secndary care. End f Life Clinics Investment, Resurce Sustainability and Evaluatin Develpment f the cmmunity based clinics referred t in sectin 9.1 abve will require an investment f 92k. It is likely that in additin t imprving patient experience and quality, the delivery f these clinics will likely result in a reductin in EL admissins. The MCP will be lking at hw this can be evaluated, bth in terms f financial impact but mre imprtantly quality fr patients and families. 38

39 12.2 Develping Nursing Integratin and the Integratin f Services Beynd Health Integratin Investment and Savings Table 2016/ / / / /2021 Investment Required 1,272, , , , ,580 Expected Admissins Savings 0-1,374,808-1,374,808-1,374,808-1,374,808 Expected Excess Bed Day Savings 0-318, , , ,753 Ttal Investment Required / Saving Achieved 1,272,700-1,027,981-1,027,981-1,027,981-1,027,981 Develping Nursing Integratin and the Integratin f Services Beynd Health Investment The MCP's intentin t create integrated teams acrss hub sites, clearly requires significant shifts t where resurces are currently aligned and will be phased acrss 16/17 with the hpe f fully aligned team by September Table 1 belw sets ut the current investment frm the health and scial care ecnmy that is aligned t the develpment f the MCP integrated mdel f care acrss a number f rganisatins. This demnstrates that whilst we are seeking additinal investment t facilitate service transfrmatin, partners acrss the health ecnmy are als aligning existing resurce t the MCP prgramme. Partner Organisatin Kent Cmmunity Fundatin Trust 6,765,092 Kent Cunty Cuncil 6,920,998 Ttal 13,686,080 The MCP is seeking additinal investment t facilitate integratin and is requesting funding f x which cnsists f the fllwing: 250k fr wrkfrce develpment 153k t test the Buurtzrg mdel 124k fr peratinal managers t versee hub develpment and delivery 300k fr premises 145k fr I.T. integratin f recrds and hardware fr cntrl rms 39

40 18k fr lcal Shrewd specificatin 98k fr the cntinuatin f year 1 nursing prjects 113k fr additinal mental health nursing 122k fr the extensin f scial prescribing services 48k t supprt the develpment f the health trainer prgramme Investment in mre detail Practice and Cmmunity Nursing Integratin Investment The MCP has used funding received thrugh the 15/16 transfrmatin funding t undertake an audit f practice and cmmunity nursing cnsisting f a number f elements. These were: A desktp review f activity and staffing numbers; A survey designed t understand relatinships between GPs, practice nurses, cmmunity nurses and HCAs; A diary card exercise t gain detailed understanding f nursing activities, time spent with patients, travel time etc; Interviews with nursing staff t clarify and add depth t diary card findings; A gd practice review. The audit has prduced extensive analysis that will be the fundatin fr making imprvements t the nursing service and measuring thse imprvements ging. The main findings suggest a number f issues including pr relatinships between GPs and nurses, pr referrals t cmmunity teams, I.T. barriers and nn-husebund patients being treated in their hme. Wrk undertaken t date t develp catheter clinics in primary care and imprve healing rates thrugh better wund care will cntinue in 16/17 and further investment will be required. Skill mix is currently being reviewed within primary care and the alignment f cmmunity teams t hubs has been wrked thrugh and has infrmed the investment frm existing resurce calculatins abve. It is envisaged that the MCP will prcure expert cnsultancy services t undertake the rganisatinal develpment required and feel that this wrk is imperative t the successful integratin f teams due t the strength f feeling with regard t cmmunicatins between prfessinals. In the shrt term the MCP will seek t emply tw peratinal managers fr each hub t aid their develpment. As the MCP will be gathering evidence and adapting wrking practices as it develps it is felt that this rle is required in the shrt term. The c-lcatin f teams within hubs and fr sme staffing grups at a practice level will require changes t the use f existing estate as well as I.T. investment t prvide practical infrastructure. The need fr integratin f recrds t minimise duplicatin and administratin, a key finding frm the audit, will require shrt-term investment whilst a suitable slutin is fund fr the lnger term. Mental Health Nursing Integratin Investment An investment f 113k will be required t add three cmmunity mental health wrkers int the integrated teams frm July Expected csts have been taken frm the primary care mental health wrker pilts that 40

41 have been undertaken in Ashfrd and Canterbury CCGs. An additinal 11k has been built int the VP t cver prject management supprt fr this wrk. Scial Care Integratin Investment The MCP has wrked with Scial Care t understand the number f scial wrkers and assciated care staff (inclusive f thse utsurced) that is available t integrate int hubs. This wrk remains in its early stages and prvides an estimate f the number f staff, skill mix and ptential alignment t hubs but is still subject t change. Scial care infrmatin and finance is nt as detailed and nt held in the same gegraphical regins as health data but is being develped t better align t the MCP and lcal Clinical Cmmissining grup requirements. In the lnger term it is hped that these budgets culd be pled as per natinal directin and this represents a significant step tward the true integratin f health and scial care. Single Patient Access fr Scial Prescribing Investment The Scial Prescribing scheme is nw being develped acrss the MCP area fllwing a successful pilt during 14/15 in the Whitstable area. The Vanguard is cmmitted t enhancing the rle f the vluntary rganisatins within the new mdel f care and is requesting a small amunt f transfrmatin funding t enable this t cntinue and expand resurces t enable a greater number f assessments t be undertaken. This will equate t 122k and wuld be expected t be fully absrbed int the cmmissining budget frm 2017/18. N additinal investment will be required fr the integratin f Age UK int hubs. Health Trainer Investment 48k will be required t fund change management expertise n the GP list apprach t health trainer delivery. It will als supprt additinal health trainer capacity whilst the new apprach embeds, management capacity t implement the new health trainer mdel and assciated sftware csts, and will supprt additinal behaviur insights wrk specific t the vanguard. Develping Nursing Integratin and the Integratin f Services Beynd Health Resurce Sustainability and Evaluatin In cntrast t a traditinal apprach t re-designing services where a pathway r a particular element f a pathway is reviewed, the MCP will integrate services withut a prescriptive expectatin f hw activity will shift. This apprach is being taken fr tw reasns. Firstly the audit identified that 264 patients accunt fr 43.6% f the verall patient cntacts. These are cmplex patients with multiple cnditins and as such they need t be reviewed as individual cases. Secndly, a lack f gd quality data des nt enable a detailed financial mdel t be develped. The verall expectatin is that by integrating nursing services activity undertaken in a cmmunity setting will be carried ut in the right place and by the right prfessinal. Fr example ensuring nn-husebund patients are treated by practice nurses will result in an increase in capacity within the cmmunity nursing wrklad. In turn, cmmunity nurses will be able t fcus n areas such as blcked catheters and catheter replacements therefre reducing unnecessary admissins. It is likely that there will many areas identified which will release capacity between teams and reduce duplicatin allwing a targeted effrt t reduce unnecessary admissins, reduced the number f delayed discharges, ensure patients are placed ut f hspital in the right place and reduce length f stay. The MCP is ging t target a reductin f circa 2,500 zer and ne day length f stay admissins where the patient received n prcedure during their stay. This equates t 27% (similar t findings f the natinally 41

42 recgnised MCap tl) f all shrt stay admissins and shuld result in a grss reductin f 1.4m. In additin the MCP anticipates a reductin in length f stay and s a cnservative estimate f 318k has been included reflecting a 50% reductin in excess bed days and 4% against verall bed days. We have cmmenced discussins with the acute prvider abut the anticipated financial efficiency savings, frming a starting pint fr the lcal Sustainability and Transfrmatin Plan. Clearly this will develp beynd the submissin f this value prpsitin but is a wrking estimate. Using the baseline activity and areas fr imprvement identified thrugh the nursing audit, bth prcess and utcme targets will be measured and are in the prcess f being defined fr the shrt term. Fr mental health, scial care services and health trainers the expected activity changes will be mre clearly defined and existing rganisatins targets and measures will need t remain in place where the change desn t impact the majrity f the service. One f the key datasets that the MCP will use t the evaluate this prgramme is the lcally develped linked care dataset. This currently encmpasses acute, cmmunity, GP, scial care and mental health data as well as a number f smaller prviders s a patient s jurney can be fllwed and the interventins leading t and pst admissins can be identified. The MCP is cmmitted t reviewing this data and using it t prduce chrts that will be cmpared against in future years. Ideally the 264 patients that accunt fr 43.6% f the wrklad will be put int a chrt t see hw they their cntacts change nce integratin is fully implemented. Hwever, gvernance issues will have t be reslved in rder fr this t happen. In additin the MCP will wrk with the University f Kent t explre alternative ways f evaluating the prgrammes. An area f particular interest is rbustly prving the impact f the vluntary sectr within integrated teams. The MCP is currently develping and investing in an academic prgramme f wrk with a view t evaluatins beginning as sn as is pssible Develping Estate Infrastructure Investment fr infrastructure The MCP will be bidding fr further transfrmatin funding in 17/18 t develp estate and further capacity in the cmmunity. This will cnsist f a number f areas: Develping a cmmunity hspital at the Estuary View site. Funding will be required t duble run services whilst the existing cmmunity inpatient beds are clsed. This is estimated t be circa 4m; Develping cmmunity beds at the Kent and Canterbury site. Funding will be required t transfrm existing estate and manage transitin csts. As part f this wrk, an existing practice in the Canterbury area is intending t develp new estate n this site and is bidding thrugh the primary care infrastructure fund. This has clear alignment t the MCP visin f develping a hub at this site; Develping cmmunity integrated inpatient facilities in the Faversham and Sandwich and Ash lcalities. This is yet t be explred but it is likely that funding will be required; Develping a Health and Wellbeing Centre at Nrthgate Medical Practice, with capital funding requirements expected t be in the regin f 1m. This will be bid fr thrugh the primary care infrastructure fund and has clear alignment t the MCP visin f develping preventative services within the hub area. In the shrt-term the MCP is requesting 150k funding t prcure prject resurce t prepare the full investment case fr develping estate. It is expected that these cases will be wrked up in full by September 42

43 2016. The prcurement prcesses that will fllw will likely mean that duble running will nt ccur until Q2 f 17/18. This wrk is being underpinned by the system wide wrk n bed mdelling lead by the East Kent Strategy Bard. This sphisticated mdelling will help t build the case fr investment and meet the needs f the lcal acute prvider t reduce the acute bed base. It is expected that significant savings will be derived frm shrter lengths f stay, mre cst effective estate and a pull apprach frm the acute setting. In the lnger term, the cmmissining f a new cmmunity hspital and nursing hme will be sustainable and deliver savings thrugh the de-cmmissining f acute hspital wards, and the clsure f existing estate. Crprate Csts There is an additinal funding request f 1.67m t supprt the further develpment f the MCP fr 2016/17. In future years and as an rganisatinal frm is develped this will change significantly. As this is currently uncertain, significant crprate funding requirements have been included fr 17/18 and beynd but wrk will be undertaken t reduce these ging frward. Staffing csts include funds t supprt GP backfill during the develpment f the clinical mdel and GP at scale prpsals. These GPs will be representative f ttal target ppulatin. A payment mechanism has been develped in which a flat rate is paid t practices fr their engagement that is carefully mnitred. In additin, external resurce has been purchased t supprt MCP develpment. This is reflective f the fact that GP led MCPs d nt have the same ability as larger rganisatins t absrb additinal prject wrk int nrmal business. The develpment team fr the MCP has acquired sme premises t wrk frm bth fr management and clinical staff as the mdel f care is develped. Additinally, there are csts included fr cmmunicatins and engagement, csts fr ptential data platfrms t supprt the develpment f capitated payment and csts fr cnsultancy as there is an intentin t undertake MCP rganisatinal develpment wrk. Als included in the crprate csts is an allcatin t supprt the research and evaluatin prgramme that the MCP has cmmissined frm Centre fr Health Services Studies at the University f Kent. As is prudent, there is a cntingency allwance fr crprate spend given that the MCP has grwn in ppulatin size rapidly. 43

44 13. Prgramme Management and Gvernance The MCP established a Partnership Steering Grup that includes senir representatin acrss the health and scial care cmmissiner and prvider landscape. It has been peratinal since February The Grup perates under a clearly defined terms f reference, and is establishing its sub grup structure, that will fcus n peratinal design and delivery f the full MCP wrk prgramme. The MCP has nw decided t frm a General Practice Leadership Bard that will ensure that all 16 practices wh are members f the MCP have a strategic and decisin making rle. This will becme increasingly imprtant as the MCP develp its rganisatinal and cntractual frm in 2016/ Cmmunicatins and Engagement Strategy fr the MCP Effective cmmunicatins and engagement is essential fr the develpment f Encmpass s plans t develp ur new mdel f care. Our patients, their carers and ur stakehlders, the peple wh rely n lcal health services, are uniquely placed t help us develp the services we will prvide, and advise us n what wrks best fr them and the areas that culd be imprved n. As the way health services are prvided and used changes, we want t make sure ur patients, carers and stakehlders feel fully infrmed and invlved in the decisins we make. We als want t make sure that we d this in a way that meets NHS standards and statutry duties. An effective cmmunicatins and engagement strategy will help us t raise awareness f the services available t patients, prvide infrmatin n cmmn cnditins t supprt self-management and diagnsis f care as well as encuraging healthy lifestyles. We want t invlve patients and members f the public in discussins and decisins abut hw their healthcare will be prvided in the future and t be given infrmatin t enable help them t d this. This includes infrming patients and the public abut the healthcare services available t them lcally and natinally and ffering easily accessible, reliable and relevant infrmatin t enable them t participate fully in their wn healthcare decisins and chices. T d this, we will deliver high quality cmmunicatins and engagement. We will take a planned and sustained apprach t cmmunicatins and engagement t fulfil ur visin fr ur residents t have access t the best healthcare available, the pprtunity t imprve their physical, mental and scial wellbeing and t be invlved in decisins abut their wn health and healthcare. We will engage and cmmunicate s that: Peple knw wh we are and what we d. 44

45 Peple knw what services we prvide and hw t access them. Peple can make infrmed chices abut their health and lifestyle. We can equip peple with the skills and knwledge t be able t self-care and self-manage their cnditins. Health services are used effectively. Peple can publicly hld us t accunt. Our strategic bjectives and the delivery f ur plans are supprted thrugh engaging peple, partners and stakehlders. Our care mdel develps thrugh better invlvement and engagement f the peple wh use services. Service prvisin is jined up. Quality f care imprves. The reputatin f, and cnfidence in, the lcal NHS is upheld. Other parts f the NHS can learn frm ur develpment. 45

46 Annex A Value Generatin Assessments Value generatin hypthesis tree Drivers Evidence Metrics T develp a new mdel f care that that delivers high quality, utcme fcused, persn centred, crdinated care that is easy t access and that prmtes wellness and enables peple t live independently fr as lng as pssible Develping Primary Care : - Scpe GP extended prvisin - Develp GPSIs - Increase PP utilisatin - EfL cmm. Clinics Integratin f practice, cmmunity and mental health wrkers with services beynd health including scial care and the vluntary sectr Develping Estate Infrastructure Transfrming the Wrkfrce Clinical utcmes will be imprved via integrated care hubs and specialist treatment in the cmmunity Shift activity frm secndary t primary and cmmunity setting resulting in: Reductin in secndary care activity Quicker diagnsis and treatment fr rutine care Integrated teams delivering reductin in verall caselad time per patient and ptimum patient utcmes. Reductin in cnditins linked t scial islatin (e.g. MH) Reduced sec. care activity. Decrease in delayed discharge Create lcal hubs and deliver patient care clser t hme C-lcatin f services Reductin in the use f secndary beds fr patients wh can be treated in the cmmunity Ensure patients receive the best level f care by the right prfessinal. Develp a flexible and respnsive wrkfrce wh want t deliver patient centred care Patient experience will be imprved thrugh a fcus n self-care & increased access t earlier cmmunity-based care Scpe extended access t GP services, drawing n Year 1 learning. Allw patients t be seen in the right envirnment fr their cnditin clser t hme. Reduce waiting times Reduce hand ffs between rganisatins. Mre cnsistent care delivered by fewer prfessinals Scial prescribing will imprve patients health and wellbeing thrugh imprved access t self care and self management Ensure patients are treated in the right care setting at the right time. Ensure a mtivated wrkfrce t deliver high quality care and supprt Safety/quality f the service will be safeguarded thrugh an IT system that integrates recrds acrss the cmmunity Allw patient recrds t be shared with ther health prfessinals imprving bth the quality and safety f care whilst a single patient recrd is develped. Cnsistent quality f care delivered by prfessinals in different wrkfrce areas. Crdinated planning and reductin in handffs result in better quality care. Deliver high quality, custm designed, energy efficient and fit fr purpse estate Build a wrkfrce that will have the capability t deliver high quality care in a sustainable way Resurce requirement f 3.9M is reasnable and the required wrkfrce can be put in place Allw the scping and develpment f an extended primary care service, integrated health and scial care cmmunity services delivered thrugh peratinal hubs, supprted by integrated IT c-lcated n 4 sites at a cst f 3.9m in 16/17. Resurce input frm the existing health and scial care ecnmy f 13.7m in 16/17. Require investment f 150k in 16/17 t further develp the case fr change in respect f bed utilisatin bth health and scial care. Likely requirement significant funding t duble run services. In 17/18 Create a wrkfrce willing and able t deliver sustainable efficiencies fr the abve level f investment Resurce sustainability will be driven thrugh increased efficiency and imprved staff retentin Reduced attendance, admissins and utpatient activity equating t 2.3m delivered in 17/18. Shifting mind-sets t embrace 7 day services and clser interactin between prfessinals. Use f linked care dataset t chrt match patients cmparing patient jurney nw t patient jurney in 17/18. Will allw c-lcatin f services and efficiency gain thrugh seamless transfer f patients thrugh the system Create a sustainable wrkfrce Develpment f a whle ppulatin budget and gain/lss share arrangements t incentivise sustainable changes in behaviur acrss the whle system. 46

47 Clinical utcmes Clinical utcmes VALUE PROPOSITION Value generatin assessment (1/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Clinical utcmes will be imprved via integrated care hubs and specialist treatment in the cmmunity setting. Scpe extended access t primary care thrugh extended wrking 8-8 seven days a week. Right care, right time, right place, right clinician will result in: - reductin in unscheduled A&E attendances, nward admissins, and ambulance cnveyances Audits have demnstrated patients in wrng place Acute Trust busy A&E, agency csts Clinical utcmes are prer fr patients attending hspital at weekend Mnitring f the scheme chrt analysis Access t GP will imprve lnger term health and reduce admissins Reductin in unscheduled A&E attendances Onward admissins Reductin in OOH cnsultatins. A reductin f X A&E attendances. A reductin f X nward admissin. A reductin in X OOH face t face cntacts. GPwSI and utpatient develpment. Reductin in secndary appintments, reduced fllw-up rates. One stp shp. End f Life clinics and hme visiting via cmmunity based service t reduce hspital admissins at EL and imprve patient experience Evidence frm existing services f reduced fllw-ups Referral rate analysis shws lw frm existing services Waiting times see elective mdel Mnitring new schemes fllw-up rates, referral rates, waiting times. Evidence frm WISH prject Referral rates Fllw-up rates Reduce new utpatient referrals and fllw up attendances levels t lcal best practice. Paramedic Practitiners. Reductin in cnveyances and A&E attendances f up t 10%. Faster respnse t hme visit requests. GP capacity t deal with cmplex patients in surgery. EOL care. Access t patient recrds Successful Whitstable pilt. Mnitring f service rll ut Reductin in cnveyances and A&E attendances. Reductin f A&E attendances 10% Reductin f cnveyances f 10%. Value generatin assessment (2/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Clinical utcmes will be imprved via integrated care hubs and specialist treatment in the cmmunity Integrating practice and cmmunity nursing will maximise use f existing nursing capacity. It will release capacity within teams t address unnecessary admissin, delayed discharge and reduce length f stay. Result in a single integrated clinical team built arund the patient. It will be underpinned by apprpriate and cmprehensive assessment f patients hlistic health and care needs, drawing n full integrated team wrkfrce (see Beynd Health VGA belw als): Audit: 46% f cmmunity nursing wrklad relates t 5% f patients Tackling pr quality patient referral data. Husebund and nn-husebund cnfusin criteria. Ineffective wrking relatinships Pr IT infrastructure circa 75% f caselad has n access t patient ntes frm ther settings Linked care dataset chrt case matching Helping cmmunity trust t develp currency t better mnitr activity in husebund setting Apprpriate management f husebund and nn-husebund patients Prcess measures such as imprved quality f referral 2017/18 reductin in unnecessary admissin, delayed discharge, LOS 95% success in ensuring that husebund and nn husebund patients are seen in the crrect setting. Prcess targets - Deliver full integratin f nursing by September 2016/17 - Deliver 50% imprvement t access recrds - 95% success in triage f referrals that reduces administratin time and increases time fr direct care. Integrating mental health nursing. Imprved cmmunity mental health prvisin care being delivered in the mst apprpriate setting. Reductin in secndary activity thrugh managing patients transfer back t primary care thrugh apprpriate pathway management and shared care. Evidence t shw that 50% f patients seen by primary care MH wrkfrce repatriated t cmmunity wrkfrce Respnd t the natinal drive fr investment in MH services Imprve knwledge f existing services and understand further ptential value added element f bring mental health wrker int integrated teams. Increased repatriatin frm secndary care MH service Deliver full integratin f nursing by September 2016/17 Maximise integratin in 17/18 47

48 Clinical utcmes Clinical utcmes VALUE PROPOSITION Value generatin assessment (3/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Clinical utcmes will be imprved via integrated care hubs and specialist treatment in the cmmunity Building n t the Integrated nursing team t include integrated scial care and where apprpriate dmiciliary care. Als, where apprpriate, clear cmmunicatin and aligned practice with registered care agencies t ensure that peple receive ptimal care and supprt frm the right persn at the right time, underpinned by apprpriate and cmprehensive assessment. This will result in: - reductin in unscheduled A&E attendances, nward admissins, and ambulance cnveyances. - Reductin in delayed discharge frm hspital. Evidence frm Natinal integratin mdels. Evidence frm lcal Integrated Discharge Team prjects acrss Kent. Evidence frm KCC Enablement Service prgramme. Cntinue t evaluate lcal schemes and build learning int lcal wrkfrce and pathway redesign f the integrated H&SC team as apprpriate. Unscheduled activity, cnveyance, attendance and 0-1 LOS % assessments undertaken and care plans put in place Discharge frm hspital in line with EDD planning. TBC TBC TBC Utilising Vluntary sectr resurce apprpriately and ptimally t deliver hlistic care and supprt t peple and/r carers. This will result in: - Reductin in scial islatin amngst peple and/r carers. - Increased independence and resilience. - Reductin in demand n crisis services as peple are identified early and directed int apprpriate service in timely manner. Lcal evidence frm Age UK Pilt Prgramme, Crss Rads carer supprt service and Red Zebra Live Well in Whitstable Pilt Evidence frm natinal Scial Prescribing schemes in Rtherham and Essex. Nursing audit fund a very lw awareness amngst health prfessinals f vluntary services. Cntinue t build evidence base and evaluate early rll ut f schemes. Wrk with University f Kent t ensure that rle f vluntary sectr and cmmunity in building resilience and independence is mdelled int research and evaluatin. Cnsider ther cmmunity resilience prgrammes that may be relevant eg DERiC (Develping and Empwering Resurces in Cmmunities prgramme. Referral int SP. Uptake f service, self reprted efficacy f interventin. Age UK pilt metrics. 50% increase in knwledge f vluntary sectr services in the lcal area. Value generatin assessment (4/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Clinical utcmes will be imprved via integrated care hubs and specialist treatment in the cmmunity. Rll ut f KCC led redesign f OT services in respect f duble handed care (DHC).This will result in: - Optimum best clinical practice; - Disseminated training and cnsistent best practice acrss multiple agencies acute, SC, dm. Care and cmmunity OT - Reductin in number f clients requiring DHC. Evaluate impact f DHC prject led by KCC. Draw n best practice Natinal Guidelines. Lcal evaluatin f scheme t infrm decisin making n extensin f apprach t ther OT practices. Reductin in DHC caselad. 10% reductin in caselad. Health trainers t be aligned with the integrated team and health prmtin pprtunities t be identified thrugh hlistic assessment. Health trainer wrkfrce t be aligned t GPs. This will result in: KCC PH Team s current service re-design and cnsultatin prvides evidence base fr GP fcused/aligned health prmtin service. MCP will prvide pilt site fr testing new mdel f wrking and infrm future service redesign and rll ut. Increase referrals t health trainer service. Imprve visibility fr GP. Increase referrals by x. - Hlistic assessment f patient. - Practive identificatin f health prmtin needs t reduce risk f CHD. 48

49 Clinical utcmes Clinical utcmes VALUE PROPOSITION Value generatin assessment (5/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Clinical utcmes will be imprved via integrated care hubs and specialist treatment in the cmmunity Develping estate infrastructure t ensure bedded capacity is apprpriate acrss the MCP lcality, and based n lcal need and demand. Develp health and wellbeing services t meet lcal demand, increase educatin and training resurce as well as cnsulting space. This will result in: - Peple having access t high quality services delivered in apprpriate settings. - C-lcatin f services t supprt integrated wrking in the cmmunity. - GP direct cmmunity bed management in MCP lcality. - Reductin in admissins and LOS t acute as patients managed in bedded cmmunity prvisin under care f GP. Draw n natinal evidence that exists fr cmmunity design. East Kent wide bed mdelling wrk being undertaken currently t establish ttal bed capacity requirements and aid the develpment f a prgramme f change. MCP t deliver inpatient care fr nn-acute patients clser t hme. Full business case fr investment in develping facilities t be cmpleted by September Increased step up capacity in 17/18 Faster discharge frm acute setting in 17/18 Reductin in LOS in 17/18. Value generatin assessment (6/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Clinical utcmes will be imprved via integrated care hubs and specialist treatment in the cmmunity Thrugh GPwSI training and educatin the MCP will build a skilled and cmpetent wrkfrce that will result in: - Effective referral demand management. - High quality triage Deanery evidence base fr training Activity and demand evidence base frm current health ecnmy. Develp evaluatin prgramme with Deanery. Map and evaluate current and new GPSI services. As per GPwSI metrics abve As per GPwSI metrics abve - Stable and cmmitted lcal wrkfrce. Thrugh wrkfrce redesign acrss nursing, scial care and dmiciliary care we will develp a flexible lcal wrkfrce that has the ptimum skills mix and prfile t supprt MCP ppulatin chrt. This will result in: - Wrkfrce that is delivering excellent clinical and scial care - Peple will get right care, frm the right prfessinal, in the right setting and at the right time. - Wrkfrce that is delivering excellent clinical and scial care - Maximising use f specialist clinical staff, thrugh t vluntary sectr supprt wrkers. - Safe, transparent prfessinal pathways f care - Maximising pprtunities t train and retain staff at a lcal level, ffering career prgressin within and acrss prfessinal staffing grups. Internatinal and natinal examples. Nursing audit and audits undertaken via KCC Natinal guidance frm prfessinal and regulatry bdies. KEA Enablement prgramme Drawing n evidence and expertise frm the NCM ALB partners. Optimal skills mix. As per Integratin wrk stream set ut abve As per Integratin wrk stream set ut abve 49

50 Patient experience Patient experience VALUE PROPOSITION Value generatin assessment (7/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Patient experience will be imprved thrugh a fcus n selfcare & increased access t earlier cmmunitybased care Extended access t primary care increased accessibility fr rutine - cnvenience Urgent reduced hand ffs, better envirnment, waiting times, reduced travel Patient satisfactin surveys GP survey Patient satisfactin surveys GP survey TBC TBC TBC TBC End f Life cmmunity clinics will imprve patient experience by prviding supprt in lcal setting and als at hme GPwSI shrter waiting times, better cmmunicatin (e.g. SMS) leading t reduced DNAs, care clser t hme, smther pathway, less hand ff, ne stp shp Evidence frm existing services TBC TBC Paramedic Practitiners. Seen mre quickly, seen in wn hme Single prfessinal cntact instead f multiple cntacts 100% patient satisfactin Patient satisfactin surveys prvider and practice Qualitative evidence t be cllected demnstrating wider impact f scheme n hw GPs use freed up capacity t supprt cmplex patients/el patients Sustainable patient satisfactin TBC in baselining 100% Value generatin assessment (8/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Patient experience will be imprved thrugh a fcus n selfcare & increased access t earlier cmmunitybased care Integrating practice and cmmunity nursing.: - Better cntinuity f care - Seamless transitin - Imprved patient experience - Easier access t cmmunity nursing team Audit suggest patient time spent n direct care culd be increased Direct patient engagement n service redesign t supprt new pathways Ptential develpment f patient diary card similar t wrk already cmpleted with nursing staff T be develped inline with patient diary card prpsal TBC TBC TBC Integrating mental health nursing will supprt patients transferring frm secndary t primary care services. Increased wellbeing in cmmunity setting, including return t wrk and University. Patient survey evidence indicates psitive patient experience, including increased satisfactin with speed f respnse, cntinuity f care, reductin in stigma. Frm pstimplementatin review f pilt Cntinued evaluatin f impact f scheme. Evaluatin f impact f increased wrkfrce t prevent escalatin (step up) f patients frm cmmunity t secndary care. Cntinued use f existing surveys Number f assessments int the acute setting ver time perid t be cnfirmed TBC Reductin in assessments TBC 50

51 Patient experience Patient experience VALUE PROPOSITION Value generatin assessment (9/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Patient experience will be imprved thrugh a fcus n selfcare & increased access t earlier cmmunitybased care Integrating health and scial care wrkfrce in integrated hub teams will result in multi-prfessinal hlistic assessment f individual need and a fcus n enabling, prmting and supprting independence Lcal evidence frm Kent Enablement Service (KEA). Evidence frm Vanguard chrt e.g. Dudley. Patient insight frm planned patient diary card/survey Patient self assessment f need/independen ce. Baseline f patient n assessment and pst enablement. TBC % patients reprt increased satisfactin (Baseline required) TBC % reductin in lng term care use (Baseline required) Vluntary sectr embedding the scial prescribing mdel will result in peple: -Being able t building strng scial netwrks, having imprved health and wellbeing, feeling in cntrl f lives. Scial prescribing prgrammes in Rtherham, Essex and Lndn ffer emerging evidence base Develp evaluatin framewrk thrugh wider prgramme t draw ut impact f SP n patient s wider jurney. Tbc TBC Therapies embedding therapists in integrated hub based teams will result in imprved access t multi-prfessinal hlistic assessment f need, fcus n enablement and prmting independence. OT review f duble handed care in KCC. Evidence frm vanguard chrt. Tbc Patient survey and self assessment pre and pst interventin Tbc Health prmtin vanguard t test new health trainer mdel f prvisin fcused n GP list based assessment f risk. Will result in: - Targeted interventins drawing n risk assessment at GP practice level. - Patients able t access supprt quickly and easily, Evidence frm Prf Chris Bentley - Centre fr Health and Scial Care Research Lcal behaviural insights study t understand hw peple will best respnd t challenges arund imprving their health and wellbeing. tbc Tbc Value generatin assessment (10/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Patient experience will be imprved thrugh a fcus n selfcare & increased access t earlier cmmunitybased care Peple will be seen and treated in the mst apprpriate lcal facility resulting in less travel, mre access t family and carer supprt. Peple will receive jined up care, delivered by a seamless jined up multiprfessinal team resulting in less duplicatin, delay and handffs. Where an admissin t a cmmunity bed is required, GP bed,management will ensure admissin and discharge is ptimally managed. Visits t ther cmmunity integrated services undertaken and further visits planned. T be wrked up in line with the 17/18 business case TBC TBC 51

52 Safety/quality Patient experience VALUE PROPOSITION Value generatin assessment (11/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Patient experience will be imprved thrugh a fcus n selfcare & increased access t earlier cmmunitybased care GPwSI training and educatin will result in patients having access t high quality primary care based services that will reduce referral t secndary care Evidence frm existing GPwSI pathways fr ENT and ther specialties Tbc Patient Survey TBC Nursing wrkfrce develpment will result in patients experiencing jined up care, frm the right prfessinal, with less hand ffs. Draw n existing mdels f gd practice eg vanguard chrt and ther lcal mdels Farnham. tbc Patient diary card TBC Carer wrkfrce develpment will result in peple being supprted t live independently, with a flexible and apprpriately skllled carer wrkfrce able t prmte enablement and wellbeing. Tbc Tbc Patient diary card Tbc Value generatin assessment (12/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Safety/quality f the service will be safeguarded thrugh an IT system that integrates recrds acrss the cmmunity Scping extended access t primary care will i) incrprate the ability fr GPs t access clinical recrds f patients utside f the practice list resulting high quality and safe cnsultatins. ii) Identify the pprtunity fr lnger appintments fr cmplex and EL patients resulting in high quality assessments and planning. Medical Interperability Gateway (MIG) has been well received in East Kent. It currently enables A&E clinicians t access GP recrds. GP Survey t identify scpe f pprtunity with regard t mdelling lnger appintments int appintment management system. Referrals t ther hub based services TBC TBC GPwSI. Gd wrkfrce, better quality service. Better skilled wrkfrce able t manage referrals mre effectively resulting in: i) Reduced waiting times Evidence frm existing ENT services Full evaluatin n the impact f suite f diagnstics supprting clinics TBC TBC ii) Care clser t hme Paramedic Practitiners will build effective wrking relatinships with GPs, and will have access t patient recrds t supprt treatment at hme. Paramedics building knwledge and skillset in Primary care resulting in high quality patient care and sustainable primary care wrkfrce Successful Whitstable pilt Paramedic staff survey shws evidence that PPs feel skills are being develped and utilised. Onging evaluatin thrugh the CHSS research and evaluatin prject. Cntinuatin f staff survey TBC TBC 52

53 Safety/quality Safety/quality VALUE PROPOSITION Value generatin assessment (13/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Safety/quality f the service will be safeguarded thrugh an IT system that integrates recrds acrss the cmmunity Integrating practice and cmmunity nursing. Patient seen by right clinician in crrect setting n an ptimal care pathway resulting in: - High quality cntacts and reductin in multiple cntacts, supprted by single patient recrd. SHREWD will enable Hub Managers t access real time data n system pressures t supprt effective patient management. Audit shwed 43.6% activity fcused n small number f patients imprving the quality f cntacts will result in better utilisatin f the nursing service verall. SHREWD already perating acrss mst f Kent t unable quicker system escalatin and respnse t bed pressures Onging evaluatin f cmplex patients via the CHSS wrk prgramme. TBC TBC TBC TBC Integrating mental health nursing. Sharing f infrmatin embedding MH within practice/cmmunity team Nne MH IT Interperability t be develped TBC TBC Value generatin assessment (14/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Safety/quality f the service will be safeguarded thrugh an IT system that integrates recrds acrss the cmmunity Integrated scial care and therapy assessment f patients will result in apprpriate hlistic care and supprt thrugh apprpriate sharing f infrmatin t enable rbust assessment (unlikely t deliver full integrated recrds fr patients due t range f cmmercial care prviders) SHREWD see abve Direct nline referral fr GPs int vluntary sectr service via scial prescribing scheme and patient will receive direct cntact thrugh scheme.. TBC SHREWD see abve Red Zebra drawing n mdels delivering in Sheffield and Essex. TBC TBC TBC TBC Number f referrals, and number f fllw ups TBC TBC TBC 53

54 Safety/quality Safety/quality VALUE PROPOSITION Value generatin assessment (15/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Safety/quality f the service will be safeguarded thrugh an IT system that integrates recrds acrss the cmmunity High quality, fit fr purpse facilities, inclusive f interperable IT t facilitate effective care and treatment f patients by multi-prfessinal teams. Tbc Tbc TBC TBC Value generatin assessment (16/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Safety/quality f the service will be safeguarded thrugh an IT system that integrates recrds acrss the cmmunity GPwSI training and educatin supprted by apprpriate cnsultants within a clear prfessinal framewrk including access t all relevant diagnstic facilities. Lcal ENT clinics Wrk thrugh the East Kent wide CEPN prgramme TBC TBC Nursing and carer wrkfrce t be develped t supprt hlistic care and treatment f patients in the cmmunity. This will result in less risk f gaps in care prvisin. It will be underpinned by clear prtcls n prfessinal accuntability and safety. tbc tbc tbc Tbc TBC 54

55 Resurce requirement Resurce requirement VALUE PROPOSITION Value generatin assessment (17/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce requirement f 3.9m is reasnable and the required wrkfrce can be put in place Extended primary care access requires an investment f 50k t design and scpe hw primary care can achieve 7 day wrking. Pilt scheme undertaken as part f MCP year 1 prjects. Csts f running Saturday 8-8am services prpsed and used. Varius mdels in place lcally t incentivise GP wrking at the weekend. Understanding f the desired utcmes fr a 7 day primary care service and therefre the investment ptins. Unit cst f delivering the service Number f rutine and unscheduled appintments delivered ver and abve existing cre cntract requirements PSSRU cst f GP/practice nurse appintments by 17/18. Appintments delivered thrugh existing cntracts t remain at histric level. GPwSI. Requires an investment f 157k t perate GPwSI clinics and fr investment in equipment. This includes training and educatin csts. Wish Prject in Whitstable demnstrated the need fr investment in these services t incentivise reduced referrals and utpatients. Understanding if the cst f these services in the cmmunity can be reduced further t drive real financial benefit thrugh price in cmparisn t the acute sectr. Unit cst per case f delivering the service. Demand bth lcally and acrss the EK health ecnmy. Reduce cst per case cmpared t existing CCG prices and cntracts. Number f clinics delivered acrss all specialities is expected t be TBC which will equate t 450 patients seen. Paramedic Practitiners. Requires an investment f 351k fr payment t PPs fr carrying ut GP hme visits Existing pilt has demnstrated the need fr investment in sftware t share patient recrds and measured the cst f average time spent with patients. Review f price t ensure maximum efficiency. Review demand n an n-ging basis t assess if further investment is required. Ttal number f hme visits requested Ttal prprtin f hme visits suitable fr paramedic practitiners. Maintain existing level f verall hme visit requests per practice. 20% f patients eligible fr visiting by a paramedic practitiner. Value generatin assessment (18/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce requirement f 3.9m is reasnable and the required wrkfrce can be put in place Integrating practice and cmmunity nursing requires an investment f 487k t: Align teams t hubs and t wrk 8am 8pm 7 days a week. This equates t an investment f 6.8m frm the lcal cmmunity trust. Undertake extensive rganisatinal develpment wrk between all prfessinals. Invest in the n-ging develpment f a patient diary card. Invest in I.T t allw system interperability. Develp physical space fr teams t perate frm Emply peratinal managers t versee the develpment f hubs and manage change. Lcal cmmunity trust have prvided ttal staffing numbers, skill mix and assciated cst as well as expected alignment t each hub. Lcal cmmunity trust have agreed t a prgramme f rganisatinal develpment wrk. Audit wrk t drive a baseline highlighted significant issues with wrking relatinships between GPs, practice and cmmunity nursing staff. The audit wrk als highlighted significant inefficiencies in I.T. systems. Whether perating at this level will result in a requirement fr greater staffing levels. Whether Skills gaps will emerge nce teams are fully integrated Visits t Dudley CCG and Farnham t understand sme f the financial detail f their mdelling and t lk fr further efficiency. Imprved staff relatinships and satisfactin with elements f the new integrated service. Thrugh develpment f cmmunity currency and capitated payment begin t measure activity level baselines. Increase GP satisfactin with cmmunity nursing service by 50%. Imprve attitudes and perceived effectiveness f MDTs by 50% fr GPs and cmmunity nurses. Increase capacity within the integrated teams t allw increase in verall cntacts and ensure patients are seen by the right prfessinal. Integrating mental health nursing requires an investment f 113k t: Develp physical space fr teams t perate frm (finance included in sub-assertin 1) Emply peratinal managers t versee the develpment f hubs and manage change. (finance included in sub-assertin 1) Investment cncept f aligning staff based n exiting pilts with primary care mental health wrkers. Understand I.T interperability issues with MH systems. Whether perating at this level will result in a requirement fr greater staffing levels. Unit csts in cmmunity versus csts f patients in the acute sectr. Increase in patients n cmmunity caselad Expected cntacts per day is TBC 55

56 Resurce requirement Resurce requirement VALUE PROPOSITION Value generatin assessment (19/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce requirement f 3.9m is reasnable and the required wrkfrce can be put in place Integratin f scial care int integrated teams requires an investment f 202k t: Align teams t hubs and t wrk 8am 8pm 7 days a week. This equates t an investment f 6.9m frm scial care. Develp physical space fr teams t perate frm. (finance included in subassertin 1) Emply peratinal managers t versee the develpment f hubs and manage change. (finance included in subassertin 1) The scial care directrate within the Cuncil have prvided ttal staffing numbers, skill mix and assciated cst as well as expected alignment t each hub. Natinal evidence and drive twards pling budgets between health and scial care. Whether perating at this level will result in a requirement fr greater staffing levels. Whether Skills gaps will emerge nce teams are fully integrated Understand I.T interperability issues with MH systems. What relatinship issues exist? Identificatin f areas f duplicatin. Caselad baseline versus future expected baselines. TBC wrk t be undertaken t actually develp and hld caselad infrmatin in health Integratin f the vluntary sectr requires and investment f 122k t: Extend the scial care prescribing prject at a cst f 122k. Wrk with age UK t get them linked mre clsely t integrated teams Whitstable pilt fr scial care prescribing shwed a small investment resulted in significant impact fr patients Whether perating at this level will result in a requirement fr greater staffing levels. Available vluntary capacity N f patients referred t scial prescribing N f patients assessed It is expected that scial prescribing will be able t respnd t TBC number f appintments per day including TBC assessments. Value generatin assessment (20/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce requirement f 3.9m is reasnable and the required wrkfrce can be put in place Integratin f therapy teams int integrated teams requires an investment (included in Integrated Nursing sum) Align teams t hubs and t wrk 8am 8pm 7 days a week Develp physical space fr teams t perate frm. (finance included in subassertin 1) Emply peratinal managers t versee the develpment f hubs and manage change. (finance included in subassertin 1) Wrk undertaken by scial care clleagues n the crss-ver and duplicatin in therapies identifies the need t align t teams and create efficiency Understanding if existing staffing levels are sufficient. Are there are ther elements f OT that wuld benefit frm the same apprach. Caselad baseline versus future expected baselines. TBC wrk t be undertaken t actually develp and hld caselad infrmatin in health An investment f 48k in health prmtin and preventin services t: Develp health trainers Supprt first aid training in schls prgramme (n investment in service required) Very limited pilt undertaken at Nrthgate practice. Operating as a larger pilt site t infrm the Kent wide cnsultatin. N f health trainers aligned t practices N f referrals t health trainer service. It expected that there will be TBC X trainers acrss the MCP in 16/17 It is expected that there will be TBC X referrals t the service acrss the MCP 56

57 Resurce requirement Resurce requirement VALUE PROPOSITION Value generatin assessment (21/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce requirement f 3.9m is reasnable and the required wrkfrce can be put in place Investment t develp estate infrastructure t: Fund the emplyment f dedicated prject resurce t the develp business cases fr new facilities r changes t the peratins f existing facilities at a cst f 150k in 16/17 Duble run a new cmmunity hspital site at Estuary View whilst existing capacity at the Whitstable and Tankertn hspital is clsed at a cst f TBC in 17/18. An investment f TBC in 17/18 t supprt a trial perid f changing acute capacity at the Kent and Canterbury site int cmmunity capacity. Investment will required in 17/18 t supprt the Faversham hub mdel but this is yet t be determined. An investment f TBC in a new Health and Wellbeing centre in Nrthgate Maintenance csts t the health ecnmy f perating run dwn estate at the Whitstable and Tankertn site are inefficient. The inapprpriate usage f acute beds fr cmmunity wrk is causing significant financial issues fr the lcal acute prvider, identified natinally thrugh the Mcap tl. East Kent wide bed mdelling wrk being undertaken currently t establish ttal bed capacity requirements and aid the develpment f a prgramme f change. Review f existing estate t understand utilisatin. Full wrk up fr the case fr investment t be cmpleted. MCP cntributin t system wide bed requirements. MCP cntributin t reducing csts in the lcal acute site. Full business case fr investment in develping facilities t be cmpleted by September Value generatin assessment (22/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce requirement f 3.9m is reasnable and the required wrkfrce can be put in place An investment f 250k (already included abve) t supprt transfrming the wrkfrce fr: GPwSI training and educatin Develping the nursing wrkfrce (included in resurce requirement abve) Develping the carer wrkfrce Natinally recruitment fr a number f frnt line staff grups is pr. Audit wrk carried ut by the MCP n nursing suggest significant rganisatinal develpment wrk shuld be undertaken. This is likely t be similar acrss a number f prfessins. Understand financial implicatins frm any change f rganisatinal frm which will mean staff mve frm existing rganisatins. Increased up take in GPwSI training. Imprved staff survey results. Increase in uptake by TBC%. Imprvement in staff survey by TBC 57

58 Resurce sustainability Resurce sustainability VALUE PROPOSITION Value generatin assessment (23/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce sustainability will be driven thrugh increased efficiency and imprved staff retentin Primary care wrkfrce mind-set changes t wrking in a different way and mre n a shift basis. Investment will need t be recurring fr a number f year dependent n the mdel put in place and utcmes expected. Pilt scheme was unable t prve r disprve whether there was a direct impact n A&E activity due t failing services in ther parts f the system. Qualitative evidence cllected thrugh patient surveys shwed that abut 10% f patients wuld have gne t A&E, and 30% wuld have therwise called 111. Hw 7 day primary care culd actively relieve pressure and therefre create financial efficiency and enable the cst f running 7 day wrking can be absrbed within existing health ecnmies. Reductin in activity and assciated savings in secndary care and OOH. T be defined nce the prpsals fr 7 day wrking are develped. Extended GPwSI and diagnstic services will reduce utpatient referrals. Evidence frm existing services f reduced fllw-ups Evidence frm referral rate analysis shws lwer referrals where existing services are in place. Investigatin as t whether the service culd benefit the Kentwide health ecnmy thrugh delivery f service t ther lcalities Reductin utpatient activity and assciated finance Reductin f 450 new utpatient and an assciated saving f 6k in 17/18 fr ENT and Neurlgy services. The Paramedic Practitiner pilt will lead t net savings f 130k thrugh cnveyances t secndary care. Develpment f wrkfrce t build relatinships with patients and ther HCAs will result in a sustainable team. Whitstable pilt demnstrated a 15% reductin in attendances as a result f integrating paramedic practitiners with practices. Sustainability when prject n wider scale Lts f qualitative evidence n hw GPs are using the capacity the prject releases. Needs t be turned int quantitative evidence. Reductin in cnveyances and A&E attendance. A reductin in verall A&E attendances f 15% resulting in a saving f 482k. in 17/18. Value generatin assessment (24/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce sustainability will be driven thrugh increased efficiency and imprved staff retentin Integrating practice and cmmunity nursing will allw capacity t be released acrss all nursing teams with a view prviding mre efficient cmmunity services which in reach int the acute and reduce unnecessary financial pressures caused by avidable admissin, reduced length f stay and delayed discharge. A flexible wrkfrce will be created with many mre pprtunities fr a diverse prtfli f wrk and career prgressin. The RCN have prvided evidence t shw that the cmmunity nursing can reduce the csts f lng term care and relieve acute pressure. Investigatin as t hw new cntracting mdels and capitated payment can supprt driving efficiency. Develpment f cmmunity currency t better understand existing inefficiencies. Reductin in lw level avidable admissin. Reductin in delayed discharge. Reductin in length f stay. Review f the cst f delivering care in the cmmunity versus the acute as integrated teams develp. Deliver material savings in acute spend target = 2,500 admissins and 1,400 bed days Deliver material savings the cst f prviding this care t patients thrugh the change in setting target net savings = 1m. Integrated mental health shuld release capacity within the acute setting. The mainstreaming f mental health int lcal hubs arund GP practices. Existing pilts successfully managed t repatriate circa 50% f secndary care patients int a cmmunity setting. Investigatin as t hw new cntracting mdels and capitated payment can supprt driving efficiency. Understand natinal directin with regard t mental health funding and currency. Further reductin in the acute caselad Understand cst f delivering these services in the cmmunity rather than the acute setting. Deliver a reductin f TBC in the acute caselad. 58

59 Resurce sustainability Resurce sustainability VALUE PROPOSITION Value generatin assessment (25/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce sustainability will be driven thrugh increased efficiency and imprved staff retentin Integrating scial care int integrated teams will result in an increase in capacity and a mre flexible and respnsive wrkfrce. Natinal evidence f successful integratin f teams. The financial impact n bth health and scial care f integratin Have clear baseline activity levels fr bth health and scial care. T see increased utilisatin f all services. Target TBC The use f a scial prescribing tl will prvide significant supprt t patients and release financial efficiencies frm reduced cntacts acrss health services Wrk undertaken in the Suth West demnstrated the impact vluntary sectr services can have. Evaluate whether any financial efficiencies can be derived using the University t aid this evaluatin N f patients wh wuld therwise have accessed ther services withut the supprt. Reductin in unnecessary use f health / scial care services. Target TBC Therapies Health prmtin Value generatin assessment (26/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce sustainability will be driven thrugh increased efficiency and imprved staff retentin The prvisin f cmmunity inpatient facilities c-lcated in hubs alngside an extended primary and cmmunity care services will create efficiencies thrugh breaking dwn barriers between rganisatins. This prvisin f mre cmmunity beds shuld reduce financial pressure in the acute sectr which exists due t multi-site csts. Greater levels f skill will be develped in the cmmunity allwing a mre flexible wrkfrce fr the future. Other similar MCP mdels that are further develped have demnstrated better wrking. Hw t ensure that cntracting and payment systems incentivise the lcal system t wrk tgether and ensure patients are given the right level f care and in the right setting. Reductin in delayed discharges Reductin in avidable admissins Reductin in length f stay T be wrked up in line with business case fr 17/18. 59

60 Resurce sustainability VALUE PROPOSITION Value generatin assessment (27/27) Drivers Evidence Metrics Develping Primary Care Develping Nursing Integratin Beynd Health Develping Estate Infrastructure Transfrming the Wrkfrce Primary assertin Sub-assertin Evidence available Further evidence t be gathered Metrics Target Resurce sustainability will be driven thrugh increased efficiency and imprved staff retentin The investment in educatin acrss the MCP will be a key enabler in the delivering a sustainable wrkfrce wh will be at the frefrnt f new mdels f care. In additin fr sme aspects f training such as GPwSIs there will be a direct impact in respect f the GPwSI prgramme as prpsed by the MCP. Develpment f relatinships between nursing and ther prfessinals will result in value being generated in the wrkfrce which will benefit the health ecnmy fr years t cme. As per GPwSI prpsal abve. Nursing audit results identified pr relatinships between individuals in the lcal ecnmy. Identify pssibility with regard t change f rles and wrkfrce redesign acrss nursing, scial care and dmiciliary care t create a sustainable and attractive wrkfrce fr the future which enables prviders t recruit and retain staff. As per Integratin and GPwSI prgrammes abve As per Integratin and GPwSI prgrammes abve 60

61 Annex B Encmpass MCP Partnership Steering Grup Terms f Reference 1. Purpse f the Steering Grup 1.1 The Steering Grup will versee the Encmpass MCP s wrk prgramme, as endrsed by NHS England Natinal Five Year Frward View New Mdels f Care Prgramme Team. The funder practices jintly submitted a bid t NHS England, and was has been selected as ne f 29 sites t prttype new appraches fr care design and delivery that have been develped t meet the needs f lcal ppulatins. 1.2 The Natinal Prgramme will wrk thrugh crdinated natinal and reginal supprt t help the Steering Grup accelerate the implementatin f these lcally-wned cmmunity-fcused mdels. This supprt will facilitate clinical innvatin and mre crdinated persn-centred care, as well as learning and benefiting frm greater and mre respnsive citizen and cmmunity engagement. These frerunners will be evaluated thrughly, with a view t being replicated elsewhere acrss the cuntry, and prvide real-life examples and learning fr hw current barriers t transfrmatinal change may be vercme. 1.3 The Steering Grup will cmprise representatin frm the multi-agency bdies that will versee, enable and facilitate the develpment and implementatin f the MCP s wrk prgramme. Accuntability fr the sites is yet t be determined by the Natinal New Mdels f Care Team. Whilst the CCG remains the statutry authrity respnsible fr cmmissining health services fr its lcal ppulatin, it will wrk with the MCP t explre hw the MCP can be supprted t take n delegated cmmissining respnsibility fr its MCP patient chrt. 2. Scpe f the MCP Wrk Prgramme 2.1 The MCP prgramme strategy is t transfrm the quality and cst effectiveness f health and scial care fr the lcal ppulatin serviced by its 16 member practices, which represent a patient ppulatin f 169,806. The implementatin f the strategy will build n the achievements and experiences t date f the Whitstable Integrated Health and Scial Care pilt. T date the pilt has fcused n develping: An integrated cmmunity lng term cnditins management service; 61

62 A cmmunity urgent care service; A cmmunity elective care service. The MCP prgramme will fcus n develping: An integrated health and scial care mdel f care that fcuses n delivering high quality, utcme fcused, persn centred, crdinated care that is easy t access and that enables peple t stay well and live independently fr as lng as pssible in their hme setting. The mdel will include cmmunity hspital prvisin that facilitates direct GP admissins; nursing hme prvisin and extra care prvisin, inclusive f day centre prvisin. 2.2 The aim f the MCP mdel f care is t secure: High quality, utcme fcused, persn centred, crdinated care that is easy t access and that prmtes physical and mental health and wellbeing, and which enables peple t stay well and live independently fr as lng as pssible. 2.3 The bjectives frm this mdel f care are t: Develp high quality, utcme fcused and cmmunity based persn centred physical and mental health care and wellbeing services. Services will be crdinated, and where practicable, c-lcated within hubs lcated in Whitstable, Faversham and Canterbury. This will imprve diagnsis and treatments utside hspital and create a mre patient centred mdel f care. Wrk twards setting up extended Primary Care and Cmmunity Services, starting with a Saturday service t cver what is seen as the weekend time f mst demand. The effectiveness f this new service can then be evaluated, and the service mdified as apprpriate. This will maximise access t primary care this will be inclusive f GP, nursing, mental health and paramedic practitiner services. Enable better step up and step dwn, with less delayed transfers f care. This will als enable faster and mre successful discharge t a patient s hme. Enhance the use f IT t facilitate bth streamlined cmmunicatin between patients, clinicians and carers; and t maximise the use f tele care and telemedicine t maintain supprt self-care and self-management t prmte independence. Create a mre cst effective service. By treating patients in the lcal cmmunity setting we will reduce the cst f sme utpatient prcedures and utpatient appintments thrugh expanding the use f GPs with special interest t triage referrals. We will reduce the number f OPD fllw up appintments, making these ne stp where pssible. Increased educatinal and cmmunicatin pprtunities will imprve GP case management, ratinalise investigatins and make referrals t secndary care easier. Fcus n preventin t ensure that as a whle health and scial care system we are wrking seamlessly t supprt peple t stay well and t live independently, with 62

63 apprpriate supprt where it is necessary. By fcusing n preventin we will seek t manage bth admissins t hspital and admissins t nursing hmes. Explre a new cntracting mechanism based n capitated budget. This will allw us t have the cntrl ver hw t deply resurces available in a way t achieve best utcmes fr ur ppulatin. Meet the aims f the Kent Accmmdatin Strategy. The bid supprts the strategy f KCC, the CCG and Kent s district cuncils t supprt peple, including thse with dementia, t maintain independence as lng as pssible. Wrk with vluntary grups and charities t ensure that the Vanguard is making best use f pprtunities that exist t utilise these services lcally. 3. Rle f the MCP Partnership Steering Grup 3.1 The Steering Grup will versee, enable and facilitate the develpment and implementatin f the MCP wrk prgramme. In particular, it will versee individual utcme fcused wrk streams fcused n: Clinical pathways and wrkfrce redesign; Financial and activity analysis; Cntractual mdelling and gvernance; Human Resurces and Organisatinal Develpment; Develping Infrastructure (Infrmatin Management and Technlgy and Estates); Cmmunicatins and engagement; Develping General Practice at Scale. 3.2 Key deliverables fr the Steering Grup will include: Agreeing the scpe f the MCP mdel s cverage in respect f the ppulatin and range f services included within it. Agreeing the cmmissining mdel t supprt its implementatin. Agreeing the key utcmes that the MCP mdel will deliver, and the metrics by which it will be measured. Develping the estates plan that will supprt the mdel. Ensuring that strategies acrss the partner rganisatins are in place t enable delivery f the wrk plan. Develping wider partnerships with the vluntary sectr and cmmunity thrugh the Cmmunity Netwrks. Ensuring that cmmunity equipment services prvisin and transprt prvisin, which facilitate and enable effective cmmunity service delivery, are in line with the MCP wrk prgramme. 63

64 Ensuring that the IT infrastructure required t supprt the MCP is in place, inclusive f telemedicine and telehealth. 4. Timescale 4.1 The timescale fr the wrk prgramme is yet t be cnfirmed but an utline timeline f key milestnes is attached t this Terms f Reference. 5. Membership f the Steering Grup 5.1 The Steering Grup membership has been prpsed t ensure that all partners are apprpriately represented in terms f managerial, clinical, financial and estates expertise. 5.2 The current membership list is: Dr Jhn Ribchester Chair Ann Judges Prgramme Lead Dr Richard Brice, Whitstable Medical Practice Dr Peter Biggs Nrthgate Medical Practice (Vice Chair) Dr Sakel, Saddletn Rad Practice Dr Jacky Buchanan, Whitstable Medical Practice Dr Anne Weatherly, The Butchery, Sandwich Dr Sarah Phillips, Newtn Place Medical Practice Dr Guarav Gupta, Faversham Medical Practice Dr Kim Gardener, Canterbury Medical Practice Dr Dan Hrtn-Szar, Nrthgate Medical Practice Dr Alisn Bwhay, University Medical Centre Dr Mark Jnes, Clinical Chair Canterbury & Castal CCG (CCCCG) Lrraine Gdsell MCP Executive Lead and Transfrmatin Prgramme Directr Canterbury &Castal CCG (CCCCG) Mark Lbban Directr f Strategic Cmmissining Kent Cunty Cuncil (KCC) Mags Harrisn Transfrmatin and Pineer Prgramme Manager, KCC Christy Hlden Head f Strategic Cmmissining - Accmmdatin Slutins Lesley Strng, Directr f Operatins, Kent Cmmunity Health Fundatin Trust (KCHFT) Liz Shutler Directr f Strategic Develpment, East Kent University Health Fundatin Trust (EKUHFT) Ivan McCnnell - Executive Directr f Cmmercial Develpment and Transfrmatin, Kent and Medway Partnership Trust (KMPT) Ray Davey, Interim Chief Finance Officer, CCCCG Carlyn Nelsn, Practice Manager, Whitstable Medical Practice 64

65 Kaye Blanfrd, Clinical Services Manager, Whitstable Medical Practice Dr Sam Bennett, Public Health Cnsultant, KCC Karen Sharp Head f Cmmissining, KCC Amy Dibben, MCP Finance Cnsultant Paul Suttn, CEO Suth East Cast Ambulance Service (SECamb) NHS Fundatin Trust David Muir, Cmmunicatins Lead, Suth East Cmmissining Supprt Unit (SECSU) (Assciate Member t attend as apprpriate) Dr Rbert Stewart, KCC (Assciate Member t attend as apprpriate) Christy Hlden Head f Strategic Cmmissining - Accmmdatin Slutins 5.3 In additin t the cre Steering Grup membership, the Grup may seek t c-pt additinal partner representatives t attend Steering Grup meetings as required. 6. Gvernance 6.1 Accuntability fr the new mdel f care will rest with the Partnership Steering Grup. All rganisatins represented n the Steering Grup shuld therefre ensure that the relevant nminated representative is f sufficient senirity t have delegated decisin making pwers t ensure that the MCP is able t prgress swiftly with develping the new mdel f care. 6.2 The Steering Grup will determine its sub-grup structure. It is prpsed that wrk is prgressed in seven wrk streams as fllws: Clinical pathways and wrkfrce redesign; Financial and activity analysis; Cntractual mdelling and gvernance; Human Resurces and Organisatinal Develpment; Develping Infrastructure (Infrmatin Management and Technlgy and Estates); Cmmunicatins and engagement; Develping General Practice at Scale. 6.3 The charts belw illustrate the MCP wrk prgramme s Steering Grup and seven wrk stream grups in terms f gvernance: 65

66 7. Meetings 7.1 The Steering Grup will meet n a bi-mnthly basis. Dates will be established after t first meeting. 7.2 The Grup will be qurate prvided that the fllwing are in attendance: Chair r Deputy Chair 1 x CCCCG representative 1 x MCP member practice representative frm each Hub lcality 1 x KCC representative 1 x representative (r nminated deputy) f lead partner rganisatins 66