Agenda Item 3.3 IMPLEMENTATION OF SETTING THE DIRECTION - WHOLE SYSTEMS CHANGE PROGRESS UPDATE

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1 FOR INFORMATION UHB Board Meeting: 17 January 2012 IMPLEMENTATION OF SETTING THE DIRECTION - WHOLE SYSTEMS CHANGE PROGRESS UPDATE Report of Paper prepared by Executive Summary Director of Public Health Divisional Manager Primary, Community & Intermediate Care This report provides an update on the implementation of Setting the Direction - The Primary and Community Services Strategic Programme (WAG, 2010) Setting the Direction in Cardiff and the Vale of Glamorgan. Setting the Direction - The Primary and Community Services Strategic Programme (WAG, 2010) proposes a system of care that will deliver an easily recognisable model of integrated and evidence based health and social care services in the community. This acts as a bridge between primary care and the acute sector bringing together all partners and will focus on the needs of the individual, moving from a reactive to a proactive model of care. The framework is predicated on whole systems working within the NHS and with local authorities and third sector partners. There is an All-Wales framework approach and each Health Board is progressing this agenda. The vision for primary and community services in Cardiff and the Vale of Glamorgan was previously set out locally through the Programme for Health Services Implementing Setting the Direction Page 1 of 18 Board Meeting

2 Improvement (PHSI). This has formed a strong base on which to deliver the challenges laid out in Setting the Direction. The Division of Primary, Community & Intermediate Care (PCIC) has been structured to enable the delivery of Setting the Direction locally. Within Cardiff and Vale of Glamorgan, the management infrastructure for delivery is in place which includes partnership agreement on localities and neighbourhoods. Neighbourhood teams and networks are also in place with appointed clinical leaders. Each neighbourhood is developing its delivery plan and at the same time ensuring demonstrable progress through defined projects. These are described within the paper. The next 6 months will see consolidation of three key recent changes. It will also see further changes in communications; service delivery and partnership working all of which are laid out within the paper. Action/Decision required Link to other Board Committee (s) and subcommittees Link to Standards for Health Services in Wales Link to Public Health Agenda Link to UHB Strategic Direction and Corporate Objectives / Legislative and To note the progress made to date and to support the continuing implementation of the programme. Presentation to the UHB Board on 22 March Updates as part of Capacity Plan Reports to Strategic Planning and Performance Committee, Board of Directors and the Operational Management Group. Standard 8 Care planning and provision Working to maximise individuals health and wellbeing Welsh Assembly Government (2005) Designed for Life Welsh Assembly Government (2010) Setting the Direction Cardiff & Vale UHB (2010) Making a Difference John Bolton (2010) Achieving greater efficiencies in Implementing Setting the Direction Page 2 of 18 Board Meeting

3 Regulatory Framework Link to relevant evidence base services for older people in Wales Cardiff & Vale UHB (2011) UHB Operational Plan Cardiff and Vale UHB (2010) UHB Five Year Framework for improving health in Cardiff and the Vale of Glamorgan Cardiff Health Alliance (2008) Working towards a healthy city Cardiff & Vale UHB (2011) Unscheduled Care Delivery Plan Cardiff & Vale UHB (2011) Capacity Plan Cardiff & Vale Integrated Health & Social Care Board. Older People s Programme Plan Cardiff Integrated Partnership (2011) What Matters? Strategy Vale of Glamorgan Partnership (2011). Community Strategy Setting the Direction Implementing Setting the Direction Page 3 of 18 Board Meeting

4 INTRODUCTION IMPLEMENTATION OF SETTING THE DIRECTION - WHOLE SYSTEMS CHANGE PROGRESS UPDATE Agenda Item 3.3 Setting the Direction - The Primary and Community Services Strategic Programme (WAG, 2010) proposes a system of care that will deliver an easily recognisable model of integrated and evidence based health and social care services in the community. This will act as a bridge between primary care and the acute sector bringing together all partners and will focus on the whole needs of the individual, moving from a reactive to a proactive model of care. The framework is predicated on whole systems working within the NHS and with local authorities and third sector partners. The framework aims to ensure a degree of consistency across Wales to enable key impacts and outcomes to be identified and monitored. However, accountability for delivery is retained locally with recognition of the need for local flexibility. The vision for primary and community services in Cardiff and the Vale of Glamorgan was set out initially in 2006 through the Programme for Health Services Improvement. That vision aligned well with Setting the Direction, and our delivery structures through the Division of Primary, Community & Intermediate Care (PCIC) enable and lead the delivery of Setting the Direction locally. This report describes what Setting the Direction means for people and services in Cardiff and Vale of Glamorgan. Progress on implementation to date is outlined and the next steps are identified. SETTING THE DIRECTION WHAT DOES IT MEAN FOR CARDIFF & VALE OF GLAMORGAN? The key aim is to maximise health, well-being and independence. This requires a change in focus: From To Illness of patient => Health of person Patient => Individual C&V UHB => Working with partner organisations Services delivered => Population needs Implementing Setting the Direction Page 4 of 18 Board Meeting

5 To enable this change, there needs to be a move from an organisational ethos with structures based on the services delivered, to services designed around the needs of the population. The building block for planning and delivery of services in the community is the GP practice; networks of practices will work together at a neighbourhood level. These networks support the delivery of community based services working in partnership to meet local need. The networks reflect natural communities (as far as practicable) with populations of 50 80,000 to enable a critical mass to support services. With UHB partners (local authority, police, fire service and third sector partners) common neighbourhood areas are being established, which will enable truly integrated and collaborative service planning and delivery. Groups of neighbourhoods (Cardiff) and areas (Vale of Glamorgan), aggregate to localities, and further align service provision with the needs of the neighbourhood populations. Setting the Direction describes a system of empowered localities in the form of Locality Networks developed around natural communities as a key platform for local service planning and delivery. These will comprise primary care, community and social care teams, working together across agreed populations to plan and deliver core out-of-hours hospital services. In Cardiff and Vale, there are three Locality Teams with a core management team in each Locality. To support integrated working there is a wider team of people drawn from therapies, public health, secondary care services, social services and the third sector. This integrated approach will reduce duplication and gaps in service, ensuring the needs of the population are met by the most appropriate person/ service/organisation. The delivery of services in the future will be through an organised service provision co-ordinated by a Community Resource Team (CRT) in each Locality. Setting the Direction describes a CRT as one of the key mechanisms for developing advanced skills within the community settings, which is intended to support primary care and hospital clinicians to maintain individuals at home and in the community. In Cardiff and Vale, the CRT will provide a hub of resource (health and social care) that straddles primary and secondary care and complements core community services, to provide enhanced levels of support for individuals who are failing in the community or require support on Implementing Setting the Direction Page 5 of 18 Board Meeting

6 discharge from hospital. It will also work with partner organisations such as the third sector. Figure 1 describes the key co-ordinating role that the CRT will have in each Locality. Primary Care Community Services Voluntary Sector COMMUNITY RESOURCE TEAM Secondary Care Social Services A Communications Hub will support the co-ordination of services across the system. Setting the Direction described this as a model predicated on future systems of communication that are designed to provide a single point of access for the co-ordination, scheduling and tracking of individualised care across the interface between the hospital and community setting. For Cardiff and Vale, the Communication Hub is already working with health, social services and voluntary sector services. The hub is being delivered through the Integrated Health and Social Care Line (IHSCL). It will provide a one-stop-shop for the public, patients, carers, voluntary sector, health and social care professionals. It integrates IT systems and telephony so that there is a single point of contact into services; Implementing Setting the Direction Page 6 of 18 Board Meeting

7 GP out of hours Dental out of hours Locality model (via Community Resource Teams) Referral centre Care co-ordination centre Clinic booking centre Social care services Chronic disease telemedicine monitoring IMPLEMENTATION PROGRESS TO DATE Primary Care The foundation for Setting the Direction is a high quality primary care service; the quality and standard of primary care in Cardiff and Vale is considered good. Three areas were identified for improvement: Open but Full lists historically a significant number of practices in Cardiff operated open but full practice lists. All GP practices across Cardiff are now open and accepting new patient registrations. Student Registrations - The target set in partnership with Cardiff University was to achieve 75% student registrations in 2010/11. This target has been met and exceeded with 83% of students currently registered with a GP. Dental Services access to dental services was sub-optimal and so over the past year the number of urgent access slots available across Cardiff and Vale has been doubled. A 24hour dental helpline has been established, the first of its kind in Wales, to improve access to treatment for patients, making it easier to find a dentist, get advice or access emergency treatment. Communications Hub The Communications Hub has been co-located with the Vale of Glamorgan Council s call centre; this has supported the integration of health and social care from the outset. The establishment of the Communications Hub has been pivotal to supporting the in-house delivery of the out of hours GP services for the Implementing Setting the Direction Page 7 of 18 Board Meeting

8 Vale of Glamorgan (previously provided by Primecare) from 1 April 2011 and Cardiff (previously provided by Cwm Taf) from 1 October The transfer has been completed and the focus is now on consolidating services and improving performance for the remainder of the financial year. The Hub now also integrates and handles calls for: District Nurse Service 24/7 The District Nurse call handling service was previously provided by Cwm Taf LHB. This service was brought in-house on 30 September 2011, and again the focus is now on consolidating the service and moving on to a modernisation phase. In November 2011 (earlier than planned), a trial of electronic district nurse referrals from surgeries using the Welsh Common Clinical Gateway began. This will be rolled out during Electronic referrals will improve the overall efficiency of the service and will result in financial savings towards the middle of /7 Dental Helpline (November 2011) Prior to November 2011, access to Community / Emergency Dental Services throughout Cardiff and Vale was confusing, with patients being provided with a variety of telephone numbers for various services. The formation of the 24/7 Dental Helpline is a one stop shop for all community and emergency dental activity within Cardiff and Vale that also links in with out of hours provision. Locality Working To reflect natural communities with populations of 50-80,000, the UHB has worked with partners (local authority, police, fire service and third sector partners) to establish common neighbourhoods and areas. Six neighbourhoods have been identified in Cardiff and three areas in the Vale of Glamorgan. The three localities are based upon networks of three neighbourhoods or areas in each locality: Vale of Glamorgan Locality Cardiff North and West Locality Cardiff South and East Locality Implementing Setting the Direction Page 8 of 18 Board Meeting

9 Figure 2 illustrates the Locality model with a focus on the patient s usual place of residence and the role of the GP. Primary, Community & Intermediate Care Division Vale of Glamorgan Locality Cardiff North & West Locality Cardiff South & East Locality Neighbourhoods Western Vale Central Vale Eastern Vale Neighbourhoods Cardiff West Cardiff North Cardiff South West GP Practice Neighbourhoods City & South Cardiff South East Cardiff East Patient s Home With the establishment of these three Localities, historical boundaries are being removed to enable strong integration. For example: joint management of health and adult social services in the Vale of Glamorgan alignment of Older People and Intermediate Care (OPAIC) community services with the three Localities via the senior nurse structure. Each Locality with its networks and community resource team is managed by a senior team. The management team includes: - Locality manager - Locality lead nurse. - Neighbourhood community directors (GP leads) - Locality leads for pharmacy, primary care, public health, child health and therapies - Senior social services representative (Cardiff). Implementing Setting the Direction Page 9 of 18 Board Meeting

10 In the Vale of Glamorgan the Locality Manager is a joint appointment with the Vale of Glamorgan Local Authority. Clinical leadership and engagement has been essential in embedding this model. GPs have been appointed as Community Directors to one of two roles. Neighbourhood lead clinical leadership at neighbourhood level, developing the network. Integration team clinical lead this team focuses on improving patient pathways focusing on the integration between primary and secondary care. The locality/neighbourhood management teams have been fully in place for four months. They are developing their partnerships, their strategic direction and at the same time taking forward specific projects to ensure some early tangible progress (making a difference to communities). Figure 3. Achievement by Neighbourhood Neighbourhood Action Outcome Western Vale Following a 12 week engagement period a number of community based services transferred from ABMU to Cardiff and Vale UHB. This included the Western Vale health visiting team and district nursing team as well as community podiatry and community physiotherapy. Central Vale Recently concluded a formal period of stakeholder engagement regarding the patient experience at Barry Hospital, working closely with the CHC and Third Sector colleagues. The stakeholder engagement survey received 98 responses over an eight week period and will help inform and shape priorities for the future of Barry Hospital. The transfer ensured a number of clinical governance issues around continuity of care were addressed, with better access to services for patients. Stakeholders informing the development of Barry Hospital as a community resource. Implementing Setting the Direction Page 10 of 18 Board Meeting

11 Eastern Vale Cardiff North Cardiff West Cardiff South West Cardiff East The Penarth integrated care team (PICT) working with nursing homes. A chronic obstructive pulmonary disease (COPD) project is being implemented. The project sees a Consultant Respiratory Physician attending a GP surgery in the area each month, to hold joint consultations with a GP and a practice nurse seeing known complex COPD patients. A different practice is visited each month. Successful bid via the Neighbourhood management team for a healthy eating/exercise scheme (January - March 2012). This project is a collaboration between Leisure Services, Dietetics and the Community Director (GP). Establishment of St Davids Hospital User Group looking at the patient experience and profile of the Community Hospital. Working with Cardiff Council, undertook citizen engagement with those individuals living in the Trowbridge area of the city. Although this was based around the regeneration of the area the team were able to discuss the new Rumney Primary Care Centre plans and invite individuals to become involved in a Health Impact Assessment. Agenda Item 3.3 Significant reduction in emergency admissions. The aim of project is to assess whether the approach improves patient care, minimising exacerbations and reduced referrals to acute services. Integrated working with partner organisations to improve the health and well-being of the neighbourhood. Agreement to establish St David s Hospital as the base for the new CRT. Integrated working with partner organisations to enable citizens to influence the planning of services. Implementing Setting the Direction Page 11 of 18 Board Meeting

12 Cardiff City and South Cardiff South East Working with Cardiff Council regarding the requirements of the new health suite in the new Homeless Single Assessment Centre. The Community Director has been working with a Consultant radiologist to develop a pathway for MRI scans with the aim of improving referral quality. This has being implemented across Cardiff and Vale via Community Directors. Agenda Item 3.3 Integrated working has identified gaps in service and potential areas for focus. Has resulted in a significant decrease in MRI referrals. Community Nursing Services Community and primary care nurses are pivotal to meeting the range of population health needs from promoting health and preventing ill health to dealing with increasingly more complex needs through to end of life care. To support community nurses to use the full range of their skills in improving health and well being, the role of community nursing needed to be re-defined. This process began with District nursing services through the development and approval of a service specification. The service is organised at a neighbourhood level with strengthened links to General Practice to ensure that the service targets the needs of those particular neighbourhoods. This supports the implementation of the Welsh Government recommendations within the Community Nursing Strategy for Wales. Community Resource Teams (CRT) A three phase approach to the development of CRTs across the three localities has been taken; this is an important component of the capacity plan for the UHB. The CRTs represent the first investment into new models of care within the community setting beginning to extend the community infrastructure. Phase 1 (December 2011): Realignment and expansion of current reablement services (UHB and Local Authority) based. The remodelling of these services will provide a CRT nucleus, whose primary purpose will be the pull of patients from hospital services into the community. Implementing Setting the Direction Page 12 of 18 Board Meeting

13 Phase 2 (April 2012): Further expansion and alignment to allow a focus on prevention and proactive support to high risk patients in the community/care home setting, reducing reliance upon hospital attendance and admission. Phase 3 (2012/13): Further service integration where it is identified that it will add value and demonstrate improved outcomes for patients and service efficiency. The existing CRT infrastructure for each Locality varies, with the Vale being the most advanced and Cardiff North and West needing to set up a complete new service. The Vale service has been in place from 1 November with the health and social care team co-located and delivering the CRT pull service. For Cardiff South and East, the former CELT service has been used as the basis for the new CRT extending its coverage to the whole locality population. Cardiff North and West is completing recruitment to posts. Operating a CRT requires co-location of its core health and social care staff. The team will be located at St David s requiring support from the PFI partner. Interface with Hospital Services Integrated service delivery can only be achieved by a much stronger primary/secondary care interface; this is a key role for the GP Community Directors (CDs). The CDs forum provides a vehicle for formal discussion and development of the interface. The CDs are using pathway design, problem solving and delivery as the practical method to build integration. Four CD fora have been held, with strong involvement from secondary care to discuss, develop and deliver a total of 12 pathways across 7 specialties. As an example, for unscheduled care, a revised falls pathway (elder fallers) and end of life pathway have been implemented. Collaborative work with primary, community, secondary care and WAST has resulted in the elder fallers pathway. The purpose of the pathway is to reduce inappropriate conveyance or admission to hospital by timely notification of fallers to the GP practice. Measurable impact will be available from the end of March. Implementing Setting the Direction Page 13 of 18 Board Meeting

14 Within the Emergency Unit (EU), joint work has been undertaken by the PCIC Division and the Medicine Division to explore options for redirecting patients. In October 2011, the GP screening service pilot was launched. A GP is based within the EU to screen patients and redirect patients when appropriate. In the first six weeks (running five days a week) 288 patients were redirected 190 sent back to own GP surgery 48 booked into GP out of hours 44 sent home with advice 6 other (e.g. dentist) Where redirection to a GP or the GP out of hours service was identified the Communications Hub was used to arrange appointments. Vulnerable Groups Excellent partnership working has enabled the development of the Homeless People and Vulnerable Groups Health Action Plans (HaVGHAPs). Results Based Accountability approach has been undertaken to develop the organisational HaVGHAPs that are a requirement of Welsh Government. Multi agency workshops have been held to develop key indicators surrounding the health needs of the homeless population, Gypsies and Travellers and Asylum Seekers. These will be developed into a multi-agency action plan. NEXT STEPS Consolidation Securing health improvement along with ensuring quality, safety and sustainability of services must be achieved. For the new developments, the next 6 months will focus on consolidation of: GP OOH CRTs Phase 1 Call-handling capability of the Communications Hub Further progress Communications Hub Implementing Setting the Direction Page 14 of 18 Board Meeting

15 - The Communications Hub will provide a transport co-ordination service take a leading role in the UHB adverse weather policy implementation; - The hub is linking closely with the voluntary sector as the UHB works closely with the Health and Social Care facilitators. The hub will provide access to Care and Repair and Befriending services by the end of January 2012; - The management of the clinical referral centre will transfer to the IHSCL improving the CRC functionality and offer significant linkage with the pathways being developed by CRC in the community. A business case will be produced in February 2012; - Discussions are underway on transferring the management of the outpatient booking function to the IHSCL. It is expected that delivery of such a service in the IHSCL will realise significant financial and operational benefits. Business case to be produced in March 2012; - It is proposed that by the end of June 2012, the IHSCL call handling will be integrated with Vale Local Authority. This will mean that any call coming into the IHSCL will be answered by the next available agent, regardless of whether it is a Local Authority or NHS Call Enhanced services The current support arrangements for nursing homes, including GP Enhanced Services provision, is under review. The outcome will be consulted upon in March CRT Phase 2 expansion of the three Locality teams (additional resource funded as part of the capacity plan) and alignment with other Locality services. This will allow a focus on prevention and proactive support to high risk patients in the community/care home setting thus reducing, reliance upon hospital attendance and admission. Currently planned for April 2012, albeit this must be informed by lessons learned from Phase 1. Implementing Setting the Direction Page 15 of 18 Board Meeting

16 It is proposed that by April 2012, Cardiff Local Authority Adult Intake & Assessment Team will be based in the Hub with the Vale team. Over the course of the year, it is intended to move to an integrated assessment team which will improve access and functionality of the service. Setting the Direction Board At present Setting the Direction is seen as the business of the Primary Care and Community division with its partners. However it requires involvement and indeed redesign of the whole system in order to realise its potential. It needs involvement of not only its partners but all of the UHB divisions. To enable such whole systems engagement a Board is to be established. This will oversee and drive implementation with a particular focus on pace. CONCLUSION The vision for primary and community services in Cardiff and the Vale is consistent with Setting the Direction. There has been good progress made to date that provides a solid foundation for the next phases of development. The challenge is to drive the pace of change, ensure whole systems engagement and demonstrate measurable outcomes. RECOMMENDATION The Board is asked to: To NOTE the progress made to date To SUPPORT the ongoing implementation as described within the next steps section. Implementing Setting the Direction Page 16 of 18 Board Meeting

17 IMPACT ASSESSMENT Health Improvement Workforce Education and Training Financial Legal Equality Environmental The focus of this is to maximise the health, wellbeing and independence of individuals. Supports workforce modernisation and the development of partnership working. Able to identify gaps across the whole (health and wellbeing) system. Financial impact identified as part of the Capacity Plan. Of note is different organisations legal framework. Of note is different framework of employment policies between organisations. Not applicable. RISK ASSESSMENT Clinical/Service Financial Reputational The full impact of the service developments will be realised during and after the winter period. Implementation is dependent upon the release3/ shift of resources to community. CRT s Phase 2 is included in the capacity plan. Pace of implementation within Cardiff and Vale, particularly for the CRT s is key. Implementing Setting the Direction Page 17 of 18 Board Meeting

18 Acronyms and abbreviations CD Community Director CHC Community Health Council COPD - Chronic Obstructive Pulmonary Disease CRC Clinical Referral Centre CRT Community Resource Team EU Emergency Unit GP General Practitioner HaVGHAPs - Homeless People and Vulnerable Groups Health Action Plans IHSCL Integrated Health & Social Care Line OMG Operational Management Group OOH Out of Hours UHB University Health Board WCCG Welsh Clinical Communications Gateway Implementing Setting the Direction Page 18 of 18 Board Meeting