Central Lancashire Local Delivery Plan 2016/ /21

Transcription

1 Central Lancashire Local Delivery Plan 2016/ /21 1

2 Contents 1. Introduction and context 2. Our priorities 3. The health and wellbeing gap 4. The care and quality gap 5. Financial challenges, gap and support requirements 6. Any risks 7. Local governance and the opportunities for collaboration 8. References The Local Delivery Plan has been produced in collaboration with Central Lancashire Health and Wellbeing Partnership and Our Health Our Care partners. 2

3 1. Introduction 1.1 Introduction 1.1 The Central Lancashire Local Delivery Plan (LDP) has been developed in conjunction with partners across Central Lancashire and sets out our framework for delivering improvements across health and social care for our local population. We want to use our collective resources across health and social care to create a radically new health and social care system that is person centred, efficient and effective, combining improvements in experiences, better health outcomes for our local population and better use of wider NHS and social care resources. The Central Lancashire Local Delivery Plan contributes to the Sustainability and Transformation Plan (STP) for Lancashire and South Cumbria. The STP describes the required scale of change across the wider Lancashire footprint and the key priorities. The LDP focuses on local priorities. 1.2 Executive summary 1.2 Within central Lancashire we currently have two Clinical Commissioning Groups (CCGS), one acute hospital delivering services across three sites and one main community and mental health trust and we serve a population of around 390,000 people. By the year 2019, our population is forecast to increase significantly as a result of house building under the Preston, South Ribble, Longridge and Lancashire City Deal as well as further house building in Chorley. In Central Lancashire we operate in a two-tier local authority area, with Lancashire County Council (LCC) having responsibility for the development of the Health and Wellbeing Strategy but we also work with the three district councils of Preston, Chorley and South Ribble. We have a number of vibrant voluntary, community and faith sector (VCFS) networks which work with a number of organisations to plan, develop and provide support to a range of people across Central Lancashire. These range from major regional, national charities to small scale community and faith groups. The health needs of these people vary in different areas. Overall, we have social disadvantage and an increasing population size with a trend towards a more elderly population combined with a higher incidence and prevalence of the health problems associated with this demographic, including high numbers of people with long term conditions, for example, dementia. Despite the growing demand for health and social care services, we only have a limited budget to meet the needs of our communities and within this budget, we need to ensure local people get a range of health and social care services including GP services, hospital care (A&E, planned procedures, specialised services and acute), community services (such as physiotherapy, equipment, advisory and information services, residential care and outpatient s appointments) volunteer and mental health services amongst many others. The Government has been clear that there can be no significant investment in health and social care services either at a national level or locally. This means that the scale of the challenge that the NHS and public services face is vast. We want to bring together and co-ordinate services for people with multiple conditions based on need and our residents also want better and quicker access to seamless health and social care, in settings that are convenient. 3

4 1.3 Aims and objectives Our overarching aim is: Equal and fair access to safe, effective and responsive health and social care for our communities that represent value now and in the future 1.4 This is underpinned by five specific objectives: To improve outcomes and experiences of health and social care by helping our local population take responsibility for prevention and enable them to manage their own care and seek early intervention support. Significant improvement in quality for patients and reduced service variation as defined through the national Right Care initiative. Return the health and social care system to sustainable financial balance by the end of the 2020/21 plan. Promote accessibility and choice, and provide the right care in the right setting to meet the needs of the individual. Reduce over dependency on acute hospital provision particularly for those patient in the over 65 category. Our aim is to move away from a reactive treatment and intervention based system to a preventative, anticipatory, whole person approach to care based on individuals and carers needs. We plan to do this through working together as a partnership to drive and deliver change. We know that high performing organisations require detailed plans, and input from experts to shape those plans, and help us plan for the unexpected. We have spent time discussing these themes and issues and listening to patients and the public, as well as our health and social care partners, and we have learned about their priorities, wants and needs for the future of their health and social care system. This has helped us identify our key priorities. We can only achieve delivery of our LDP if we work collaboratively and develop a high performing culture, which is made up of individual organisations that develop robust plans, hold each other to account, and have a clear programme of change. Locally the Our health, Our Care programme (see section 2.4) will bring together local partners with the aim of transforming care closer to home as well as in hospital. This is a health economy wide programme that seeks to radically redesign how and where health and care is provided in our localities. 4

5 1.5 National drivers for change The NHS Outcomes Framework, together with the Adult Social Care Outcomes Framework, support the Government's desire to improve integration of services where appropriate, and streamline care pathways. The NHS outcomes Framework is structured around five domains, which set out the high level national outcomes that the NHS should be aiming to improve. Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with long-term conditions; Domain 3 Helping people to recover from episodes of ill health or following injury; Domain 4 Ensuring that people have a positive experience of care; and Domain 5 Treating and caring for people in a safe environment; and protecting them from avoidable harm 1.6 These domains are underpinned by the following seven outcomes for patients, which have been taken into account when developing our Local Delivery Plan Outcome 1: Securing additional years of life for the people of England with treatable mental and physical health conditions - this means improving life expectancy for all our population Outcome 2: Improving the health related quality of life of the 15 million plus people with one or more long-term condition, including mental health conditions - this means helping local people with long-term conditions such as diabetes, chronic pulmonary obstructive disease (COPD), cardio vascular disease (CVD) and mental health conditions to manage their health so that they have a better quality of life Outcome 3: Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital this means ensuring that alternative care is available so that fewer people have to go into hospital Outcome 4: Increasing the proportion of older people living independently at home following discharge from hospital this means ensuring that alternative care is available to support older people so that they can leave hospital sooner Outcome 5: Increasing the number of people having a positive experience of hospital care this means fewer general complaints and improved patient satisfaction Outcome 6: Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community this means improving the facilities and support available for people to receive care out of hospital Outcome 7: Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care - this means fewer serious untoward incidents, never events and hospital infections 5

6 1.7 National drivers for change The Five Year Forward View (FYFV) sets out a clear direction for the NHS, showing why change is needed and what the models of care could look like. The FYFV sets out the need to address the current gaps in health and well being, care and quality and funding and efficiency. Multi Speciality Community Providers (MCPs) Within Central Lancashire we are looking to move towards a locality based model where care is shifted into communities. In the FYFV this is described as a Multi Speciality Community Provider. Under this GP- led model, GPs (possibly merged or federated practices) could employ consultants (including nurses and hospital specialists) and could integrate with mental health, social care and community services with the aim of delivering fully integrated out-of- hospital care. In order to develop an effective locality model there needs to be a radical redesign of how health and care is provided and in what settings. Under this model we will be able to deliver services to people who do not require hospital services and can be treated for their conditions in a community setting. Whilst the economy has recognised the challenges and developed a locality based model, further work is required to define the organisational form these may take. We want to be ambitious and look at services and settings of health and social care from a person centred perspective, not organisational, the Our health, Our Care programme of work is key to these transformational challenges. These challenges will include care planning for people with long term conditions including diabetes, chronic vascular disease and chronic lung conditions. Within Central Lancashire we will develop this new model of care across three localities (as described on pages 14). The hub model of delivering extended GP access at one site for a large population of patients is already being developed by several of the Prime Minister s seven day GP access pilots in other areas of the UK. However, this should be seen as a stepping stone to a radically transformed primary care offer, in which a far wider range of services will be integrated on site around primary care hubs. This could include specialist in reach, diagnostic and out patient services, mental health and social care for example. 6

7 In order to develop an effective locality model, there needs to be consideration of what care can be provided in what settings. This will be complemented through in-reach services from other providers, such as the hospital trust. The out of hospital model will need to dovetail into a new model for acute care (including outreach) provided by the hospital trust. The Our Health Our Care programme, therefore, is key to ensuring that these models are developed alongside each other, and that interdependencies are considered. Underpinning any model of transformation has to include prevention. The LDP aligns with the Lancashire Health and Wellbeing Strategy, which sets out a commitment to work differently in order to meet the needs of our population as they change and grow. The FYFV sets out an ambition to take national action on prevention supported by local actions that local areas could take to go further and faster in relation to tackling those health risks and inequalities that are prevalent in their areas. In section three we outline some of the Central Lancashire challenges in relation to prevention and management of long terms conditions. In order to build reliance we need to empower patients, both in terms of the information they have access to, and by promoting choice. The commitment in Central Lancashire is to work with patients and patient groups to understand current delivery and honour their entitlement to choose. This is especially important for our patients accessing mental health services so that they can make informed choices along the way. In April 2016 NHS England published the General Practice Forward View (GPFV). This document sets out how NHS England will support development and innovation in primary care. We know locally we have challenges in recruiting into general practice (detailed in section 3.7) the GPFV sets out a number of investment plans and opportunities to help close local gaps. The GPFV sets out specific practical steps regarding workforce, workload, infrastructure and care redesign, which underpins the models of care in the FYFV. 7

8 1.8 Local drivers for change The Our health, Our Care programme aims to transform care delivered in and out of hospitals. This will involve ensuring the estates and facilities at local hospital sites are modern, fit for purpose, fit for the future and rebalance the health economy to enable community and primary care to be delivered at scale. This challenges traditional thinking and critically has an ethos of no unnecessary waiting, no unnecessary cost and no compromise on quality as key standards. Right care shows us that locally there is over dependence of intervention in hospital and significant variations in outcomes and cost. The new service model will come from a change of commissioning philosophy and practice moving from one that is reactive treatment based services to one that is more individual, and population focused with personalised healthcare services as the norm. We only have a limited budget to meet the majority of health and social needs for all local people. With this budget, we need to ensure local people have access to a comprehensive range of health and social care services, based on need. The Government has been clear that there can be no significant investment in healthcare services either at a national level or locally, and we have seen investment in social care reduce by 20% over recent years. This means that the scale of the challenge that the NHS shares with local people is vast, not least because locally our population is forecasted to grow significantly over the life of this plan. Also the shape of households across Central Lancashire is changing, with an increasing proportion of adults and older people living alone. This places greater risk of social isolation, and we want to ensure not only that people live longer, but also healthier. This means we need to support active ageing and prevent loneliness and ill health. The key pressures on the economy arise from population growth as a result of the 'city deal', workforce gaps, historic under investment in primary care, demand in social care and a provider deficit. As part of the wider Lancashire and South Cumbria Change Programme work we know the challenges faced across Lancashire as a whole, with an estimated combined deficit of 900 million, our ambition in Central Lancashire is to deliver the change required at scale to contribute to this challenge by 2020/21. We sit alongside a wide range of stakeholders from other locations within Lancashire on the Lancashire Health and Wellbeing Board (including providers of health and social care and other clinical commissioning groups) and contributed to the development of a vision for Lancashire that every citizen in Lancashire will enjoy a long and healthy life. This vision for wider Lancashire is described in more detail in the Lancashire Health and Wellbeing Strategy underpinned by three high level goals as follows: Better health: Improving healthy life expectancy, and narrowing the health gap Better care: Delivering measureable improvements in people s experience of health and social care services Better value: Reducing the cost of health and social care 8

9 1.9 Local drivers for change Hospital services case for change Our hospital services: Are delivered in buildings that are not fit for purpose, and are not efficient Don t meet the needs of care closer to home Have limited access to discharge pathways which means that patients have longer hospital stays than they need to Duplicated clinical services across two sites which leads to Inefficient estate metrics (compared to Carter) Poor clinical adjacencies Lack of capacity available for the growth in specialised services contracted to LTH We need to make changes so we: Can respond to the challenges we are facing Can continue to provide the highest standards of care and effective services Are viable for the future Are working in harmony with the wider economy We need to meet the challenges of: An aging population An increase in patients with long term and multiple conditions Unhealthy lifestyles An increasing demand on hospital services, to be delivered with finite resources Our aims are to: Continue to deliver safe and effective care Continue to provide good patient experiences Provide care that is more flexible and less tied to buildings Provide services that are sustainable into the future and can move with the times We anticipate that once the models of care have been agreed and sized, and after any required consultation, that Lancashire Teaching Hospital will then start a process of modernising its hospital estate to ensure that it is efficient and fit for the future. 9

10 1.10 Clinical Service Strategy The trust has developed a Clinical Service Strategy which sets their models of care for the future, and the principles they will work to, to ensure that this is delivered in collaboration with the rest of the health economy. 10

11 1.11 Locally our vision for primary care is an integrated system that harnesses the power of working together to provide proactive and equitable care, which meets the needs of patients both now and in the future. For Central Lancashire this means tailoring services to population need and size 11

12 1.12 Measuring success By 2020/21 we plan to have moved away from a reactive hospital based-system of unplanned care, to preventative, anticipatory, whole person approach to care. We will design and commission services, which will be integrated across the appropriate health and social care spectrum, and redesigned with the patient and their carers at the centre. For emergency and acute care we will have a high quality well resourced system that is able to operate at national standards to offer the best response to patient needs. As a consequence, patients and carers will be able to navigate through systems with ease, and we as system leaders will be able to promote equality and choice. We will have clear measurable indicators of success which include: Reduced mortality Reduced length of stay and readmission rates Improved service quality Reduced health interventions Improved life expectancy Reduced variation in outcomes Sustainable delivery Increased early intervention and focused evidence based prevention Key enablers 1.13 Key enablers The key enablers across the local health economy that are driving our plans are shown in the diagram above. Success is being measured through improved health outcomes and patient experiences of health and social care, and ultimately in reduced mortality, increased life expectancy and quality of life for both existing and future generations. We are committed to engaging with patients in service redesign. All Our health, Our Care partners are committed to the aspiration to reduce clinical variation and improve outcomes, which will result in the Central Lancashire economy benchmarking in at least the top quartile performance against those organisations across the country with similar challenges and complexities. The Our Health, Our Care programme will set out our in hospital and out of hospital transformation aims and objectives by radically redesigning the provision of health and care across the health economy. The partners have prepared a five year financial outlook to support the strategic and two year operating plans. The starting position is the financial plan must facilitate improving outcomes and maintain quality. The financial plan is explicit in dealing with the financial gap and any related risk and mitigation strategies.. 12

13 Section 1 summary Gaps and challenges Emerging Thinking Meeting the needs of our local populations: Health inequalities Increasing population through the City Deal and general aging population Agreed aims and objectives Shared understanding of the problems Our Health, Our Care programme Meeting the targets and outcomes as set nationally: NHS National Outcomes Framework NHS Constitution targets Ensuring that we are able to work collaboratively as a whole health economy New models of care Appropriate health and social care integration Primary care innovation and investment Population based commissioning 13

14 2. Our priorities 2.1 In order to transform health and social care between now and 2020/21 our LDP sets out how we will do things differently and work together as a health economy in order to deliver our plans. We have already delivered against our ambition to transform services with a number of developments including: Implementation of a range of primary care services, including a Community Deep Vein Thrombosis (DVT) service in Chorley, a local anti-coagulant service, a vascular screening service, a diabetes local service and pulse screening All our GP practices have implemented a Primary Care Improvement Plan Introduced direct to test pathways across a range of services and improved access to diagnostics for all GPs, resulting in a 3% reduction in GP referrals Commissioned a review of placements for complex and out of area cases, bringing patients closer to home Improved the quality of prescribing and achieved savings of just under 1m Better Care Fund agreed Establishment of a Patient involvement network, patient advisory group and young person s health advocates Establishment of the Our health, Our Care Programme Management Office to drive delivery of our key transformation programmes Review of our supporting governance structures Intensive Home Support (IHS) services have been established in Central Lancashire. This is delivered in partnership with Healthcare at Home to provide multidisciplinary clinical and therapy services for patients in their own home or usual place of residence. This service is for the frail, elderly population and serves to prevent hospital admission. 14

15 2.1 continued In mental health services, our aspiration is that people of all ages with mental health problems should receive at least the equivalent level of access to timely, evidence based, clinically effective, recovery focused, safe and personalised care as people with a physical health condition. The physical needs of people with mental health conditions need to be assessed routinely alongside their psychological needs and vice versa. Community mental health services are being re-designed to work more closely with local GPs to provide personal and responsive care that will reduce the need for hospital admission. LCFT now provides Eating Disorder Services across the whole of Lancashire after successfully winning the contract to provide the service in Chorley & South Ribble and Greater Preston. Mental health services for older people have been improved and are now available seven days a week from 8am until 8pm. Physical health services for the frail elderly population have also been developed in partnership with neighbouring acute hospitals, local authorities and wider healthcare providers. We have recently introduced care homes support initiatives culture of care which have been put in place to drive up the quality of care in care homes. The aim of culture of care is to ensure: staff can provide good care to patients patients have a good experience of their care episode staff feel valued and satisfied that they are able to raise their concerns when necessary. To improve patient care To reduce non-elective activity in admissions of older people / people with long term conditions to hospital. To improve staff morale. 15

16 2.2 Our vision is that in the future our local population will have far more personalised health and social care choices, better support to navigate the system, access to 24/7 care at the appropriate level and location, (care delivered closer to home) pro active management for those with long term conditions and greater support and guidance to enable them to manage self care. Through the Our Health, Our Care programme, we want to work with patients and partners to determine what services will be provided in what setting. Using the agreed locality modelling of three local footprints and LCC 10 service planning areas, which have been informed by our estate strategy, our priorities for the next two years shall include: Analysis of current service provision within each tier of the model (as described on pages 16 to18) Co-produce with stakeholders, including patients, new models of services for each tier of the model, which shall be driven by joint clinical leadership Reassign current provision that support the new model of services, into the locality footprints 2.3 Integrated localities map There are three integrated localities. These are: Chorley South Ribble Preston There are ten service planning areas. These are: Chorley: Central, East and West South Ribble: East, West and Leyland Preston: Central, North, East and West > 16

17 The localities have been structured in line with the current strategic plan incorporating feedback from a stakeholder workshop. There are 117 residential and nursing homes across the two CCG areas, equating to 3,791 beds. Chorley and South Ribble has 63 homes and 2,138 beds, whereas Greater Preston has 54 homes and 1,653 beds. The current model of care home residents being registered with practices across the localities is not efficient and creates additional burdens on primary care services. With an increasing ageing population this demand could increase. Under the locality model we can look to provide a multi disciplinary in-reach team from one provider that supports care homes. Section 2.4 describe the localities in more detail detail on 17

18 2.4 Developing our localities and hospital-based care By joining our workstreams under one transformation programme, Our Health, Our Care, we are able to consider jointly what services need to be provided in hospital and what services can be provided in an-out of-hospital setting. This fits with the hospital trust s strategic direction, following the development of their Clinical Service Strategy in This indicated an intent to see more services provided in a transitional setting by reshaping and redesigning the way our workforce is organised so that it can support more care being delivered in an out of hospital setting e.g. outpatients and diagnostic services. In terms of the locality models, and the descriptions that follow, the Our Health, Our Care programme will seek to describe what services will be provided in which setting. An acute model of care will sit above and support all three locality models. The health economy is agreed that this Acute model of care will look different to its current and that it may well reduce in size from its current form. We are committed to shifting resources towards interventions that prevent ill health and reduce demand for hospital and residential care services. An acute model of care will serve all locality models (see page18-20) with District General Hospitals services (page 21-22). The health economy is agreed that this Acute model of care looks different to its current state, and that it may well reduce in size from its current form because it is only having to treat people who are genuinely in acute need. Any reconfiguration of services that is required following the development of the new models of care, will be subject to public consultation, and indeed will be developed utilising extensive public and patient engagement. It is also worth noting, that the hospital trust is not only the provider of both local district general hospital services to Greater Preston, Chorley and South Ribble, but also holds a significant number of specialised services contracts. These services cover a wider population of 1.6 million people across Lancashire such as the regional trauma centre at Royal Preston Hospital. The programme of redesign through Our Health Our Care is working with both specialised services and local commissioners to recognise and work through these interdependencies. It is the Trusts strategic aim to grow and develop these services to ensure the people of Lancashire can receive their care locally. The five main provider trusts have come together to form a Provider Partnership Board who will seek to make recommendations to the Joint Committee of Commissioners regarding the challenges facing acute services. The following four slides indicate the outline models of care that we are seeking to develop in central Lancashire. This provides an illustration of the MCP model referred to in section 1.8, and provides an illustration of how we will seek to integrate these locality models with a redesigned hospital model. This clinical redesign work will be undertaken through Our Health, Our Care programmes. 18

19 Chorley Locality 19

20 Preston Locality 20

21 South Ribble Locality 21

22 Future Hospital Model 22

23 Future Hospital Model 23

24 2.4 Our Health Our Care Programme The Our Health Our Care programme is the key programme of change that will help us to deliver against the challenges as set out in this LDP, and achieve the aims and objectives within five years. It brings together partners from across the health economy, through a robust governance structure, and strong programme arrangements. The programme will first of all develop an agreed health economy-wide case for change, which will set out the challenges facing us in more detail. It will then move to solution design, where it will develop a model of care that will make the health economy clinically and financially sustainable. Through a Clinical Design Board, (with representatives across the health economy), this process will include agreeing quality standards, criteria, a long list of options and through to developing a short list. A finance and investment group (SRO, DoF s) will act as a gateway to assess and confirm any models developed are viable. This process will include robust public and patient engagement The clinical design work will be undertaken in three working groups: Hospital care Locality care Prevention, early help and self care This process will conclude with a pre-consultation business case, which will open up a formal public consultation period in which options for the reconfiguration of services can be discussed. A draft timeline is set in the diagram overleaf and it is expected that this process will begin July to Sept This will then fit into a wider programme of work, which will take us towards delivery within five years, as per the second diagram. 24

25 2.5 Timeline of Products for delivery 2015/20 Dec June 16 June Aug 16 Sept Mar 17 Mar 17 June 17 June 17 Mar 20 Mobilisation Case for Change Solutions Design Consultation Implementation Products 1. Programme plan 2. Governance structure 3. Programme structure 4. Resource plan 5. Baseline Data Model 6. MOU Vision principles, behaviours 7. Communications & engagement strategy 8. External assurance process 1. Baseline data model 2. Context 3. Changing needs 4. Outcomes and financial challenges 5. Do nothing scenario 6. The hopeful future what good looks like 7. Next steps (call to action) 8. Political & stakeholder buy in 9. C&E plan 1. Case for change 2. Quality standards 3. Benefits framework 4. Long list of options 5. Evaluation criteria 6. Clinical interdependencies 7. Medium list of care components 8. Hurdle criteria 9. Sensitivity analysis 10. Recommended option x Engagment events 1. Preconsultation business case 2. Extensive stakeholder engagement plan 3. Consultation plan 1. Detailed implementation plan 2. Detailed finance, quality, workforce and estates plans 3. Finalise contractual mechanisms 4. Capital business case 5. Implement service change 25

26 2.6 Path to consultation 26

27 2.7 Clinical service strategy framework 27

28 Section 2 summary Priorities Emerging Thinking Our Health Our Care Transformation Programme (Development of new models of care, which will lead to a new in hospital and out of hospital strategy) Constant conversation with our population Alignment with Strategic Transformation Plan, and working with the Lancashire and South Cumbria Change Programme and workstreams Clinical and financial sustainability Agreement of local governance structures Tiered service planning Stakeholder mapping Joint clinical leadership Agreement of locality footprints Primary Care Quality Contract MOU / Case for change Our Health Our Care 28

29 3. The health and wellbeing gap 3.1: Context In the health economy, the CCGs are responsible for commissioning healthcare for two different areas for more than 386,000 people, almost all of whom are registered with a GP practice within our area. Our area has large variations in deprivation, from relatively deprived to relatively affluent. The central urban areas of Greater Preston and Chorley have areas where deprivation is high and health needs significant, as opposed to rural areas in the North of Preston and South Ribble, which are relatively affluent and have a low population density. We operate in a two-tier local authority area, with Lancashire County Council having responsibility for the development of the health and wellbeing strategy, but we also work locally with the three district councils of Preston, Chorley and South Ribble who are responsible for the wider determinants of health. The Lancashire health and wellbeing strategy has been developed by the Lancashire Health and Wellbeing Board. The strategy sets out the desired goals which are underpinned by the LDP: Working together to Achieve changes in the way that partners work: resulting in more effective collaboration and greater impact on health and wellbeing in Lancashire Learn the lessons arising from this collaboration to strengthen future working together Getting results that Deliver improvements in health and wellbeing, for the people of Lancashire Deliver early wins and plan specific areas for action that will help bring key health and wellbeing outcomes, whilst modelling desired shifts in the ways that partners work 29

30 3.2: Demography and changing need NHS Greater Preston CCG comprises of 33 GP practices serving more than 212,000 people. NHS Chorley and South Ribble CCG comprises of 32 GP practices serving more than 174,000 people. By the year 2019, our population is forecast to increase significantly as a result of house building under the Preston, South Ribble and Lancashire City Deal and further house building in Chorley. Over the period of the plan the prediction is for at least 6,067 new homes to be constructed with average occupancy of 2.3 people per home. This will put significant additional demand on health services in our area. 3.3 Our biggest challenges are in Greater Preston, where levels of deprivation are more than twice the national average and life expectancy for both men and women is significantly lower. However there are also big variations within Greater Preston with the highest levels of deprivation concentrated in fairly distinct geographical areas. This has a significant impact on how we target and commission services. There are wide variations in levels of income and wealth across Central Lancashire with poverty and social exclusion existing side-by-side with affluence. There are large areas of deprivation and the population is ethnically diverse. We know that many of the causes of poor health in our population are preventable with improved living conditions, social relationships and support, healthier behaviours and better quality health and social care services. How is demand changing? We also expect our local population (in line with national trends) to live longer and this increase in life expectancy is forecast to continue, impacting on population size particularly in the over 65 population. Over the period of the five year plan it is expected to increase 1.9% year-on-year, in comparison with a 0.5% growth year-on-year in the under 18 and a 0.1% growth in adults of a working age. There is a 10.7 year (males) and 6.7 year (females) mortality gap between those living in the most and least deprived areas of Central Lancashire. The data on the following pages shows our population projections and life expectancy compared to England averages. 30

31 Percentage of people living in 20% most deprived areas in England (Index of Multiple Deprivation, 2015) South Ribble district Preston district Chorley district Greater Preston CCG patients Chorley & South Ribble CCG patients England 0% 5% 10% 15% 20% 25% 30% 35% 40% 31

32 Chorley Preston South Ribble England Soure: PHE, PHOF Female Life Expectancy at Birth Male Life Expectancy at Birth Chorley Preston South Ribble England Soure: PHE, PHOF 3.4 Health profile Life expectancy for both men and women is lower in our area than the England average, and there remain too many avoidable deaths from four main disease categories: cancer, respiratory, heart disease and stroke. There is a considerable body of evidence to suggest that areas of high deprivation experience poor health outcomes. The mortality statistics for the CCGs area show some significant differences. Early deaths from heart disease and stroke are significantly higher in Greater Preston than in either Chorley or South Ribble, as are early deaths from cancer and smoking related deaths, all of which are above the England average for Greater Preston. Analysis shows the health economy is overly dependent upon acute hospital care and if it was performing at the level of our comparator groups, we could reduce acute costs by circa 20m. It is also overly dependent upon providing urgent care in hospital settings and if it was performing at the level of our comparator groups, we could reduce acute costs by circa 5m. The impact of this means that there are pressures on the acute sector to meet the increased service demands. Sustainability is about more than just increasing years of life it about increasing QUALITY of life in those additional years and this relies on models of care that provide access to early intervention services and then ongoing self care and management of long term conditions. 32

33 3.5 Increasing need As the population ages, the demand on health services within the area will increase disproportionately. For example those people over 65 make up 17% of the present population within the region, whilst the latest 12 month full period for unplanned admissions to hospital shows that patients over 65 account for 38% of those admissions. This illustrates the relative demand that an aging population will bring. The prevalence of conditions such as chronic obstructive pulmonary disease, chronic heart failure and diabetes are relatively higher in this age group. A good example is the forecast of dementia prevalence within the region. As the population over 65 increases and life expectancy increases, the prevalence of dementia will increase. The forecast shows that over the period of the plan, the population is expected to increase by 3.2% whereas dementia is forecast to increase by 18% (see chart below). The data is also showing that the population is expected to increase in the age range 65+ and a reduction in the age range 20-44, compared to the national average. 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% -2.0% -4.0% Projected population growth by 2021, by age < all ages Chorley & South Ribble Greater Preston England Source: ONS, 2012-based Subnational Population Projections for CCGs 33

34 3.6 The key demographic and health challenges for our area Population growth and age As a university town, Greater Preston has a big student population and accordingly the population is relatively young compared to the national profile especially in the age group for both males and females. Conversely, the population in Chorley and South Ribble is relatively older compared to the national profile. The population overall is expected to get relatively older and increase significantly in number over the next 10 years. This will give our CCGs some significant challenges in providing services as people aged over 75 use healthcare proportionally more than the rest of the population. Deprivation Greater Preston has very diverse deprivation levels with 29.7% of the population in the most deprived quintile and 22.8% in the least deprived quintile, and about 6,250 children living in poverty. Chorley and South Ribble are relatively affluent when compared to the national average. The profile of deprivation shows that Chorley is becoming slightly more deprived and South Ribble slightly less deprived. There are currently about 2,900 children living in poverty in Chorley and about 2,650 children living in poverty in South Ribble. Mortality The health of people in Greater Preston is varied compared with the England average. Life expectancy for both men and women is lower than the England average. It is 10.7 years lower for men and 6.7 years lower for women in the most deprived areas of Preston than in the least deprived areas. The health of people in Chorley is varied compared with the England average. Life expectancy for women is lower in Chorley than the England average. It is 8.7 years lower for men and 7.2 years lower for women in the most deprived areas of Chorley than in the least deprived areas. The health of people in South Ribble is varied compared with the England average. Life expectancy for men is higher in South Ribble than the England average. It is 8.9 years lower for men and 6.5 years lower for women in the most deprived areas of South Ribble than in the least deprived areas. Alcohol, smoking and drug use Over 18s alcohol related hospital admissions have increased significantly over the last 10 years in Greater Preston and South Ribble and there are more alcohol specific hospital stays for under 18s in South Ribble. There is also more drug misuse in Greater Preston than the national average. Smoking prevalence is lower than both national and North West England levels in both Chorley and South Ribble. However this is increasing in South Ribble and falling in Chorley. Smoking in pregnancy is higher in all three areas. 34

35 3.6 The key demographic and health challenges for our area in mental health and learning disabilities Child and Adolescent Mental Health Services We have increasing numbers of children and young people between the ages of 10 and 24 being admitted to hospital for self harming. We know that we have staffing challenges and increasing complex case loads. Currently we have longer than average waiting times fro referral to assessment for non urgent cases. Adult mental health Improving access to psychological services is a key priority in the Lancashire and South Cumbria STP. In Chorley and South Ribble nearly 1 in 5 adults in employment have been or are in contact with secondary mental health services, this is lower in Greater Preston however combined this still means in Central Lancashire the need is greater than average and access to these services needs improvement. Parity of Esteem Valuing mental health alongside physical well being We need to close the gap with physical health services whether that s a gap in access, in quality, in research, or even in the aspirations we have for people. The FYFV for Mental health sets out two key themes for improving Mental Health Services and measuring progress towards parity of esteem. People facing a crisis should have access to mental health care 7 days a week and 24 hours a day, right care, right time, right place., in the same way that they access urgent physical care. Establishing an integrated approach to mental and physical care Learning Disabilities Learning Disabilities is a key priority at Lancashire and South Cumbria STP footprint and there are already a number of priorities identified and an established programme of work. The Right Track Transforming care in Lancashire (2015) sets out an inpatient commissioning plan with the aim of creating a sustainable forensic service for people with Learning Disabilities ensuring the availability and access to highly specialised services for our most vulnerable people. There are huge challenges nationally with limited provision and availability of non-institutional accommodation in the community. 35

36 Disease prevalence Mental health Over the last 10 years, all-cause mortality rates have fallen in Greater Preston, Chorley and South Ribble. The early death rate from heart disease and stroke has fallen in Greater Preston and South Ribble and early deaths from cancer have also fallen in South Ribble. However, there are more smoking related deaths and early deaths from cancer in both Greater Preston and Chorley against an improvement in the trend nationally. There have been falls in the rates of cervical and breast screening in Chorley and South Ribble. Hip fractures have increased significantly in Greater Preston in the previous two years to 602 per 100,000 population 65+ against an England average of 452 per 100,000 and there are relatively low diagnosis rates in primary care for hypertension, and chronic obstructive pulmonary disease in all three areas. Infant deaths in Greater Preston are significantly higher than the national figure and deteriorating, and there are more new cases of tuberculosis. There are more over 18s with a diagnosis of diabetes in all three areas. There are high levels of malignant melanoma in Chorley and South Ribble compared to the national average and the situation has deteriorated from the previous year. There are more hospital stays for self-harm, and self-harm is significantly higher than the England average in Greater Preston, Chorley and South Ribble, and continues to deteriorate. Mortality from suicide is increasing faster than the England average in all three areas. There are also relatively low diagnosis rates in primary care for dementia in all three areas. Obesity There are fewer healthy eating adults in Chorley (27.8%) and South Ribble (26.5%) than the England average (28.7%), but there are proportionately fewer obese people in Chorley and South Ribble than the England average. The level of obesity of children in Year 11 in Greater Preston is reducing against an increasing national trend. Teenage pregnancy and sexually transmitted diseases There is an increase in acute sexually transmitted diseases in Greater Preston and higher than average rates of teenage pregnancies 36

37 3.7 Workforce challenges Across Central lancashire we are facing two fundamental workforce challenges: In the short term vacancy rates are high across both the health and social care sectors, creating an overdependence and over reliance on locum and agency staff, which puts pressure on budgets and ultimately can compromise on quality of care Longer term we need to invest in the design and development and implementation of new models of health and care roles that will be required as service models focus on more personalised, community based care, These new models need to challenge traditional thinking with scope for portfolio careers There is a perceived divide between primary and secondary care which often manifests itself into a lack of partnership working. This can cause barriers and makes it difficult for individuals to move across health care settings, often to the detriment of the patient Research undertaken across Central Lancashire in 2015 identified a number of key gaps and priorities. The main priority is to develop a single locality based workforce plan aligned with the CCG commissioning plans that covers primary, secondary, community, mental health and social care. This will require a cohesive and proactive approach to health economy workforce numbers - less fire-fighting and more advanced planning by the health economy, delivered by the CCGs and its providers working closely with HENW, CLWEG and Local Education and Training Boards and aligned to the Lancashire and South Cumbria Change Programme programme. The research confirmed the data we had that we have an aging general practice workforce with almost 30% of GPs reaching retirement age in the next ten years. It also showed that less than half the primary care nursing workforce is delivering long term conditions care, and that 63% of those that are, are aged over 50 and due for retirement in the next 5 to 10 years time. We also have higher than the national average numbers of administrative and clerical staff in primary care and the highest vacancy rates in secondary care are amongst professional, scientific and technical, medical and dental staff. Developing a joined up approach to workforce planning would help to address the shortcomings in workforce data intelligence whilst creating opportunities to develop a care-based rather than a professionally led model that encourages clinicians to work more flexibly across the wider system Existing workforce strategies tend be based on higher education advancement, often ignoring advancement for staff on bands 1 to 4 who are the staff most likely to have face-to-face involvement with patients on a daily basis 37

38 3.8 Workforce Challenges Social care: Consistent with the workforce gaps we have in clinical roles we also know that within Central Lancashire we face a number of social care workforce challenges. The Lancashire and South Cumbria Change Programme Alignment of Plans Report (Ernst and Young) highlighted the following: Pay for social care workers in Lancashire is below the national average at 6.91 per hour as opposed to nationally, there are also huge gaps between entry level social care roles and this in the NHS The introduction of the national living (minimum) wage will help to address the pay inequalities however in turn this will place additional cost pressures on the system The above can lead to a workforce who feel disengaged, undervalued and ultimately lead to higher turnover, vacancy rates and high numbers of temporary workers, all of which impact on quality of care. The report stated that temporary staffing usage across Lancashire is twice the national average Typically there is a low initial skill base across the social care workforce. In order to upskill the social care workforce we need to invest in induction programmes that are robust, and give support to complete formal qualifications and ongoing training and development 38

39 Promoting unique attributes of geography, unique career options, work-life balance, 'growing our own Factors that help enhance recruitment Factors that help enhance retention Respect, appreciation of skills, career progression, feeling informed and engaged in the local health and social care strategy Factors that help local workforce strategy Proactive data capture and planning, unified workforce think-tank, information flow, communication, human resource management, cross barrier working Factors that help porfolio working across boundaries Cross organisational skill mix, removal of barriers, enhanced understanding of patient journey and skills targeted to the patient need The research identified some regional barriers specific to Lancashire, which can affect recruitment and retention of the workforce: It was acknowledged that the geographical spread of Lancashire presented some challenges to travelling between hospitals and also when delivering community-based care. In addition there can be barriers around public transport, which adds another challenge, in particular for trainees who require access to a vehicle to travel. Whilst using public transport is an option, travel can regularly be at unsociable hours to fit with early/late shift patterns, which timetables do not always fit in with. Currently the approach to workforce planning is reactive, fragmented and siloed with few collaborative links both within and across organisations. Together as senior leaders we need to commit to working together to drive improvement in cross organisational strategic workforce planning and use high quality intelligence and exiting system capabilities to ensure local health and social care services are future proofed. 39

40 Section 3 Summary Health and wellbeing gaps Emerging Thinking Deprivation variations Growing population Management of long term conditions Mortality gap Over dependency of acute care Lifestyle for example alcohol, smoking and drug abuse Above average suicide rate Workforce Prevention Early intervention Self care, Self management Crisis management Integrated health and social care services Collaborative working Accessibility and choice Improve outcomes and experience of health and social care 40

41 4. The Care and Quality Gap 4.1 Commissioning for value Right Care is a programme designed to increase the value from the resources allocated to healthcare and directly address variations in spend, activity and outcomes in three ways: Improved clinical involvement in commissioning Stronger patient involvement through shared decision making Supporting commissioners with knowledge, information and coaching to consider the legitimacy of variation, and therefore whether the level of variation needs addressing Using Right Care data packs we are able to identify those opportunities where we have the greatest variations both in terms of spend and outcomes. Adoption of a Right Care approach will help us to optimise the five key ingredients of improvement in healthcare systems so that achievement of better population healthcare is, in turn, optimised too. These ingredients are: Clinical leadership of the improvement agenda; use of indicative data to identify where to look; clinical engagement in designing optimal pathways and systems (What to Change); Use of evidential data to build the case for what to change, and; optimal utilisation of improvement processing to ensure that the healthcare pathways and systems that have been designed locally, and proven they are viable and achievable, are delivered. The table below shows those opportunities across Chorley, South Ribble and Greater Preston. On the next page we have outlined some of these opportunities in more detail alongside the quality gaps and our priorities. 41

42 Opportunity Examples Examples of quality gaps Our plans Maternity & early years Respiratory COPD Cancer Pathway Flu vaccines taken up by pregnant women Smoking at time of delivery Higher infant mortality rate Lower breastfeeding rates Excess deaths with patients with COPD End of life care Emergency admissions pressures Breast cancer detected at an early stage Breast cancer screening in women aged Bowel cancer screening 1 st definitive treatment within 2 months of urgent GP referral Maternity review Urgent care centre procurement COPD ambulatory care pathways Cancer action plan Intensive support team at LTH Cancer work stream at Lancashire and South Cumbria Change Programme level Musculoskeletal/trauma Mental health Circulation Stroke/CHD Gastro-intestinal Hip replacements emergency readmissions 28 days Poor PROMS results Emergency hospital admissions for self harm Higher suicide rates than average People with mental illness and /or disability in settled accommodation Completion of IAPT treatment Higher risks TIA cases treated in 24 hours Stroke patients spending 90% of their time on a stroke unit Patients returning home after treatment Emergency admissions for alcohol related liver disease Mortality from gastrointestinal disease in the under 75s MSK Pathways review and improvements Physio Procurement IAPT Action plan Mental health work stream at Lancashire and South Cumbria Change Programme level CHD pathways Lancashire wide stroke services review Public health alcohol awareness Cancer pathways action plans Neurological Emergency Care Admissions Mortality from epilepsy under 75 years Patients with epilepsy on drug treatment and convulsion free from 18 plus Alignment of constitution targets Patient experience Self care, education and prevention Review specialised services Access to appropriate services Procurement urgent care cent Care home primary care scheme GPs outcomes contract 42

43 4.2 Meeting the needs of our complex population Our public health colleagues, through the Joint Strategic Needs Assessment (JSNA), have provided us with crucial insights to our local population, providing local needs profiles for our CCG, their localities and GP practices. Many of the health challenges facing our local communities are related to our demographics and include: Ageing population across both CCGs. One third of Greater Preston CCG population lives in deprivation quintile 1 (the most deprived in the country) whereas only one eighth of the Chorley & South Ribble live in similar areas. 7,000 children in Greater Preston live in poverty. There is a 12 year (males) and 9 year (females) mortality gap between those living in the most and least deprived areas of the CCG footprints. Those identified living in deprivation quintile 1 have higher levels of chronic disease and disability. Recorded prevalence of asthma and depression are above the national average across both CCGs. In Greater Preston, 19% of year six children are obese. Those living in the most deprived areas are six times more likely to experience severe anxiety and depression compared to those in the least deprived areas Tobacco consumption remains an issue: Greater Preston has a significantly higher prevalence of smoking in adults aged 18+, 2013, and both CCGs had a significantly higher number and rate of hospital admissions for diseases that are wholly or partially attributed to smoking in persons aged 35 and over in 2010/11. Tuberculosis continues to cause health problems and inequalities despite being a treatable condition. The number of cases of dementia is expected to rise as a result of both population growth, in particular amongst the elderly. Latest data show opportunities for improvement in screening rates (especially for breast cervical and bowel cancer / pre-cancer) and immunisation rates in both CCGs and in immunisation rates (such as the preschool booster) in Greater Preston. Both CCGs have higher than average numbers of people with one or more long term condition. We are working to get both CCGs in the upper quartile of performance by the end of the five year plan. The plan for performance over the two years reflects this trajectory. At present Greater Preston is in the lowest quintile and Chorley and South Ribble in the second lowest quintile. 43

44 4.3 Improving health outcomes for our patients Overall the health of our populations are worse than the England average Chorley and South Ribble is in the upper quintile nationally for potential years life lost. Both CCGs have started to see an improvement (a downward trend) in the past two years and we plan for that trend to continue. There are specific disease areas where there are opportunities to improve outcomes Circulation problems (CVD) Musculoskeletal System problems Cancer & tumours Endocrine, nutritional and metabolic problems Neurological system problems Gastrointestinal Respiratory system problems Genitourinary Mental health problems Hospital care could be improved All hospitals in Lancashire had higher in hospital mortality than the national average (but LTH not significantly so). There are opportunities to reduce communicable diseases including Cl Difficile (currently increasing) and MRSI (currently static). In terms of the proportion of people reporting poor patient experience of inpatient care, at present both CCGs are performing in the lowest quintile nationally. The forecast for the plan is that we expect to move to the second quartile performance over the five year plan. The trajectory for the next two years reflects this ambition. Achieving value for money Our plans also address the opportunities to improving spend and achieving value for money, in particular in the highest areas of spending in our health economies, which are: Circulation Cancer services Respiratory Musculoskeletal Both CCGs spend more than 20% over the peer group average in all of the following areas of elective spend: Renal (+20% both CCGs) Lung cancer (50% - CSR; 30% GP) Stroke (+41% - CSR; +22% GP) Heart disease (+150% - CSR; +160% GP) Trauma and injury (+140% - CSR; +36% GP) > 44

45 4.3 continued Securing and improving quality cannot be achieved by the CCGs in isolation. We recognise that our patients journeys cut across primary, secondary and specialist health and social care and that those services are commissioned and delivered by multiple organisations and professions both within and outside the NHS. We are committed to supporting the recommendations highlighted by the Francis Report, the Keogh Review, the Cavendish Review and the Berwick Report. The CCG is participating in the AHSN Patient Safety Collaborative, the Making Safety Visible Programme and a number of AQuA programmes, including the mortality collaborative and advance team training programme for safety in healthcare. An integral part of participation in these programmes is the development of measurement of harm and the building of capacity and capability to secure improvement. We are also working with Health Education North West to capture intelligence from healthcare students. Systematically and continuously improving the quality of services across settings of care represents a significant challenge for the CCGs and partner agencies. As financial resources are constrained, we need to improve quality and outcomes through innovation in service design, efficiency, and a continued focus on prevention of ill health alongside treatment and care. We know that we need to improve year on year to have a positive effect on health outcomes and patient experience. We are eager to make realistic and measurable progress against nationally and locally agreed standards. We want health care in our area to be the best in class, whilst commissioning for greater effectiveness and efficiency, and have created the capacity within our CCGs to lead and sustain this. The quality strategy that describes our responsibilities, approach, governance and systems to enable and promote quality across the local health economy will be refreshed this year. 45

46 Prevention The health economy not only sees prevention as a way of tackling the persistent inequalities in life expectancy, but also an important element in improving health outcomes. In response to the health and economic challenges described in the Call to Action, the CCGs will work with Health and Wellbeing Boards, local government, providers and other partners, to develop further plans that look forward to the next five years and those mapped out within this plan. This work will be undertaken using the five step framework for prevention. Our approach locally will focus on a model of performance, assurance and improvement, aiming to achieve more effective, safer services which deliver a better patient experience. In order to achieve this we will: Commission services that are safe, evidence based, personal and effective Promote the continuous improvement in the safety and quality of commissioned services Ensure the right quality mechanisms are in place so that standards of patient safety and quality are understood, met and effectively delivered Further develop and embed the ethos of seven day access Provide assurance that patients safety and quality outcomes and benefits are being realised, and to recommend action if the safety and quality of commissioned services is compromised at any stage Monitor outcomes for local populations and ensure systems are in place to address areas for improvement Create a research and innovation culture that supports continuous improvement in the safety and quality of commissioned services Ensure a robust mechanism is in place to approve and monitor the implementation of clinical commissioning policies 46

47 Section 4 summary Care and quality gaps Patient experience Patient choice Right care opportunities: Maternity and early years Cancer pathways Mental health Respiratory Neurological Emergency care Circulation Stroke/CHD Emerging Thinking Lancashire wide work streams, including workforce Maternity review Cancer action plan Lancashire wide stroke services review Friends and Family Test Evidence based commissioning Quality strategy Clinical policies review Prescribing 47

48 5. Financial challenges 5.1 Background This section examines the financial challenges and provides an assessment of the efficiency and productivity challenges that will face the health economy over the planning horizon. NHS England has not published national financial guidelines for the development of local plans although CCGs have been issued with indicative five year whole health economy allocations. 5.2 Central Lancashire financial challenge The financial challenge has been defined at a pan Lancashire level through the work done by Lancashire and South Cumbria Change Programme; the collective financial challenge facing the economy has been estimated at 804.8m over the next five years. The drivers of this deficit are cost inflation, growth in population, demand growth arising from demographic changes and reduced funding for local authorities. Local authorities will face the largest challenge. On current trends adult social care costs across Lancashire will exceed existing funding by 53% over the next five years. Each health economy will experience these pressures differently based upon their own health needs and population demographics. The challenge for Central Lancashire will be circa 221m; which is more than its population share for Lancashire. In Central Lancashire the City Deal will bring in new housing and population growth that will not be matched by equivalent funding growth. This will place existing services under additional pressure. The financial pressure will be offset by allocation growth and productivity and efficiency opportunities, although these on their own, will not be sufficient to ensure the local health economy is in a financially sustainable position by the end of the five year planning period. The residual gap of circa 150m will need transitional funding from NHS England. m Estimated financial Gap 221 Allocation growth -58 RightCare Pathway -20 Change Provider points of delivery -18 Prevention & Self Care -6 Trust Deficits and Loans 31 Residual Gap

49 5.3 Transformational change The residual financial gap of circa 150m will need to delivered through the transformational change programme, Our Health, Our Care and the redesign of the balance of healthcare provision across Central Lancashire. The phasing of the transformation will mean that there will be a need for double running as appropriate services are shifted from one sector, predominately acute hospitals, into community and primary caresettings. 5.4 Future commissioner allocations NHS England has announced the place based allocations for the health economy. Over the planned period the allocation will increase for 541.7m to 599.8m, an increase of 58.1m. The majority of the increase will be to cover inflation estimated at circa 2% leaving a balance of real terms growth of circa 8m over the period. NHS England have applied the following principles in respect of place based allocations: Equity from 2016/17 all CCGs are no more than 5% below target for total place based allocation Alignment with need changes to the allocations methodology intended to improve the alignment of funding and need Alignment with strategic direction higher funding for GP services. The place based allocations have been built up from the three separate components: CCG core services Delegated primary care services Specialist services CCG Core Services Primary Care Total A target allocation has been set for each component for each CCG and this has been compared to the 2015/16 funds received, the difference (referred to as distance from target) informs how much resource each CCG receives in 2016/17 and beyond. 000s 000s 000s ,724 44, , ,786 53, ,842 Growth 50,062 8,080 58,142 The Central Lancashire CCGs have a place-based growth increase of 3.7% in 2016/17 leading to a closing distance from target of 0.3%. The implications for the local health economy are that the revenue allocation will not increase over the planning period other than to match inflationary pressures. 49

50 5.5 Financial Health of the Economy The economy enters the planning period with underlying financial and resource constraints which will impact on the delivery of the plan going forward. These are: Financial legacy The CCGs have used non-recurrent resources to maintain services and have a brought forward deficit of c 4m in 2016/17 The local trusts, in particular Lancashire Teaching Hospitals, have significant deficit positions. Both have agreed control totals, deficits net of sustainability and transformation funds with NHS Improvement for 2016/17; LTH c 10m, LCFT c 4m.The estimated uncovered position, including loans, is c 31m 5.6 How we use our Resources The majority of the expenditure in 2015/16 was on acute hospital activity. The current service model is overly dependent on acute hospital activity, particularly for the over 65s. The intention is to refocus the balance of health care over the plan period. Resource legacy The economy has historically under invested in primary and community workforce and infrastructure and has one of the lowest levels of expenditure, expressed as /head of population, in the region The economy has significant workforce pressures in all sectors The care home sector is highly fragmented and there have been a number of issues with provider stability which are not yet resolved Population growth arising from the City Deal is already being experienced in areas of Chorley and Preston which is unsupported by local health infrastructure 50