Service Scope and Service Model. for Multi-Specialty Community. Provider. Document 12

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1 Service Scope and Service Model for Multi-Specialty Community Provider Document 12

2 A. Introduction... 3 B. Process... 3 C. Engagement... 3 D. Service Scope Summary... 4 E. How the Scope of Services Comes Together in this New Care Model... 7 F. Provider Impact Appendix 1 Service Model Appendix 2 MDT Working Framework 2 P a g e

3 Service Scope for Multi-Specialty Community Provider A. Introduction 1. This paper outlines the process and criteria used to develop the proposed service scope for the Multi-Specialty Community Provider (MCP). B. Process 2. The table below shows the process followed to determine the MCP service scope and associated W hole Population Budget (W PB). Date Apr - Sep 15 Apr - Sep 15 Oct-15 Nov-15 Dec 15 - Mar 16 Apr - May 16 May-16 May-16 May-16 Jun-16 Jun-16 Jul-16 Aug-16 Sep-16 Sep-16 Key Activities Create spreadsheet identifying all the service lines commissioned by the CCG Identify services to form part of initial proposed MCP service scope Issue draft scope as part of 2016/17 Commissioning Intentions Meetings held with main providers to discuss the draft scope Spreadsheet updated/validated and refined based on initial provider feedback W eekly meetings with CCG Clinical representation to agree and refine scope Budgets updated to reflect 16/17 agreed values Revised service scope issued to providers Revised service scope presented to Clinical Executive Meeting Service Scope presented to MCP Project Board Meetings held with providers to discuss risks regarding proposed service scope Proposed scope and next steps presented to Board for approval as a basis for consultation Discussion regarding CCG functions Inclusion of NHS Continuing Health Care and Intermediate Care Services Approved by CCG Board C. Engagement 3. The CCG has engaged with stakeholders in a variety of ways to determine the scope of the services for the MCP. 4. Initial meetings were held in the latter part of 2015 with both clinical and financial leads from Dudley Group NHS Foundation Trust (DGNHSFT) and Dudley W alsall Mental Health Partnership NHS Trust (DW MHPT). 5. These meetings focused on the initial proposed scope of services issued as part of the Commissioning Intentions document in October DGNHSFT raised concerns at the time regarding the inclusion of the whole budget for emergency care for Geriatric Medicine and General Medicine. As an outcome of this discussion the CCG agreed that the emergency admissions budget to be included within the MCP should focus on specific areas which the MCP can influence. This has now been amended and reflected in the service scope. 3 P a g e

4 7. DW MHPT agreed that all of their services should form part of the MCP model including inpatient facilities as it was felt these beds were integral to whole mental health pathway. 8. During April and May, weekly meetings were held with various CCG clinical leads to discuss the scope of services being proposed. As a result of these meetings the service scope was refined and redistributed to our main providers. 9. In June 2016 the service scope was discussed with our main providers as part of the Bi- lateral meetings to discuss financial and clinical risk. 10. A Bi-lateral meeting was held with DGNHSFT on 8 June There were no major concerns raised regarding the service scope as most of the issues had been resolved following the previous meeting. 11. At the meeting held with DW MHPT on 14 June 2016, they raised concerns regarding their previous agreement to include inpatient beds within the scope of services to be directly provided by the MCP. The concerns were that the facilities for inpatient services are shared across Both Dudley and Walsall. In fact, a large proportion of the Dudley facilities were occupied by W alsall patients. As a result of this discussion the inpatient beds have been identified as a service for which the MCP might hold a sub-contract. 12. On the 8 June 2016, Black Country Partnerships NHS Foundation Trust ( BCPFT ) raised similar concerns regarding their Learning Disability Services currently being provided at a Black Country wide level. Following these discussions this service has been identified as one for which the MCP might hold a sub contract. 13. Other providers of NHS services were invited to a meeting on 17 June 2016 to discuss the service scope. There were no specific objections to the scope of services being proposed but other risks and concerns were raised, specifically with regard to pathways and operating different models of care for different CCG areas. 14. A meeting was also held with voluntary sector providers on the 21 June Their main concern was how to ensure that Voluntary Sector funding was protected, particularly at a time when Dudley MBC have made substantial cuts to funding. 15. A Pre-consultation workshop was held with members of the patient representative panels on 20 June No concerns were raised with the scope of the services. 16. In August 2016, a meeting was held to discuss CCG functions. As a result of this meeting it was decided to include all NHS Continuing Health Care and Intermediate Care services within the scope of the MCP. D. Service Scope Summary 17. The proposed group of services to be included within the Whole Population Budget are as follows: community based physical health services for adults and children; some existing out-patient services for adults and children including ophthalmology, urology, respiratory medicine, gynaecology, diabetic medicine, dermatology, rheumatology, general geriatric medicine amongst others; primary medical services provided by general practice; local improvement schemes currently provided by general practice; urgent care centre and primary care out of hours service; emergency admissions due to falls and ambulatory care sensitive conditions or from care homes; 4 P a g e

5 all CCG commissioned mental health services; all CCG commissioned learning disability services; intermediate care services and services provided for people assessed as having NHS Continuing Healthcare needs; end of life care; voluntary and community sector services; services commissioned by Dudley MBC s Office of Public Health including health visiting, family nurse partnership, substance misuse and sexual health services; services currently commissioned and/or provided by Dudley Metropolitan Borough Council in relation to adult social care (to be phased in over the contract period); activities currently carried out by the CCG including, in whole or in part, service redesign; financial management; information technology; business intelligence; patient and public engagement; safeguarding; complex case management; NHS Continuing Healthcare and intermediate care assessment; and medicines management. Further detail is set out in Document 21 (Financial Modelling information). Please note financial values will be updated to reflect 2017/18 contract values. Existing Community Services including Mental Health Services 18. This includes adult community services provided by DGNHSFT, all Mental Health Services provided by DW MHPT, Learning Disability services and children s community services provided by BCPFT and community services provided by other NHS and Non NHS Providers. 19. The MCP will receive a W hole Population Budget (W PB) which covers all services deemed to be in scope of delivery. This includes the funding for services provided by non-dudley providers. It is envisaged that the MCP will initially hold a series of sub contracts with these organisations. Existing Primary Medical Services and Primary Care Budgets 20. Primary medical services are included within the scope of the MCP. This assumes that 100% of the practices will sign up integration agreements. 21. Similarly the scope of services assumes 100% of GP Practices will sign up to the local Long Term Conditions Framework. If this is not the case then the budget will be reduced accordingly to create funding for QOF. 22. The Urgent Care Centre and GP Out of Hours service are also included. 23. Prescribing, GP IT and premises also fall within the service scope. Local Improvement Schemes 24. The budgets for these services are included. It is expected that these may form part of a sub contract arrangement with general practice. Outpatient Services linked to Long Term Conditions Management 25. The budget for outpatient attendances associated with Long Term Conditions which are currently undertaken within acute provider settings is included within the service scope e.g. Respiratory and Diabetes. 5 P a g e

6 High Volume/ Low Tech Outpatient Services 26. A number of outpatient budgets have been identified as areas which are in scope and could potentially be better provided within a community setting. These services tend to be high referral areas but require minimal technological input. Examples of these services include Anticoagulation, Dermatology, Physiotherapy, Gynaecology and Ophthalmology. Emergency Admissions which the MCP can influence 27. The budget includes funding for the following emergency admissions:- Falls Admissions from a Care Home Ambulatory Care Sensitive Conditions (ACS) 28. The MCP will not be responsible for providing acute emergency services, however they will be able to influence activity and re-utilise this resource to provide upstream preventative interventions. The MCP will be expected to pay for any admissions associated with the three areas identified. Public Health Services 29. A number of services commissioned by Dudley MBC s Office of Public Health are in scope including: - Health visiting and Family Nurse Partnership Sexual health services Substance misuse NHS Health Checks Adult Social Care 30. Adult social care services will be identified for inclusion and phased in over the contract period. Voluntary Sector Services 31. All voluntary sector services are included. CCG Activities 32. A number of existing CCG activities will be delivered by the MCP. These include:- safeguarding medicines Management complex case management NHS Continuing Healthcare (adults and children) and intermediate care assessment service redesign financial management information technology business intelligence patient and public engagement 6 P a g e

7 E. How the Scope of Services Comes Together in this New Care Model Primary Care Delivery 33. The MCP will be population-based, linked to the registered lists of the GP practices across Dudley. 34. A core function of the MCP will be to support and enable a primary care led model of care supporting GP practices and incorporating GP practices at the heart of delivery. The MCP will have to demonstrate how its operating model will be designed to ensure that the foundation of NHS care will remain list-based primary care. This includes both ensuring that service delivery starts from the practice as well as ensuring that the patient medical records held by the GP form the basis of the medical records for the MCP. 35. W e will expect the MCP to deliver the new model of care in a manner consistent with the three themes of improved access, continuity and coordination. Access 36. W hilst the majority of the population are healthy most of the time, everyone wants decent access to diagnostics and analysis to identify and then solve any problem as quickly as possible. 37. Dudley already has 24/7 primary care access available to the population with the opening of the Urgent Care Centre in April The MCP provides the opportunity to develop extended access in the community that both opens the range of services which could be directly accessible to the public; standardises the means by which that access is obtainable; and improves the timeliness and availability of that access. 39. The MCP will establish an integrated referral and information system (online and phone-based) to standardise access and enable patients to access and book all services provided by the MCP; to access patients medical records and to enable patients to record their expectations and experiences of care. This portal will be integrated with NHS111 and will extend the same functionality to patients for accessing GP practices that are part of the MCP. 40. It will not be possible to provide extended access to all services in all locations, but the MCP will be expected to develop at least one local access centre or hub in each of Dudley s five localities. The ability to establish such access centres will be dependent upon the availability of suitable buildings and may therefore require capital development so a timetable for implementation cannot be determined at this point in time but will be expected to be proposed by the provider as part of the procurement process. 41. The MCP will be expected to develop these centres so that they provide extended access 7 days per week. Not all services will be expected to be available at all times but each centre would be expected to include:- primary care urgent access; ancillary services such as phlebotomy and some minor laboratory testing, chest and long bone x- ray and a pharmacy will also be required during opening hours; a base for community nursing, social care and other therapy services (physiotherapy, podiatry, psychological therapies, etc.) and the facility for open access to these services; the facility for regular consultant out-patients (e.g. dermatology, gynaecology, respiratory care, diabetology, geriatrics, urology, cardiology) some provided by the MCP, some hosted). 7 P a g e

8 42. Each centre could also incorporate the full range of GP practice-based services run by existing local practices. Continuity 43. About one fifth of our population are living with at least one long-term condition (LTC). The Five Year Forward View identified that Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected episodes of care. The dialogue with our local population so far has identified that this cohort of the population, as well as good access, also want effective continuity of care with a professional they can trust. 44. We have already developed a new outcomes framework for GPs whereby all a patient s LTC requirements are addressed as a whole package and the individual sets their own goals for achievement to be measured thus encouraging a shared responsibility in the achievement of outcomes for the individual. This is underpinned by a single IT system and workflow-processes that now ensures a consistent approach is adopted for every patient in every practice across our CCG. Intelligent standardisation and use of technology enables us to make a consistent offer of service to our whole population whilst also enabling that offer to be delivered more efficiently. 45. However, it is only the GP that is currently funded on a capitation basis, incentivised to achieve this set of outcome-measures. Many specialists currently located with the hospital also provide LTC management to patients, and may even differentially retain an interest with particular patients because of either perceived (or real) variations in the quality of primary care. However, currently there is no requirement for them to take a shared responsibility for resolving these variations so we expect the MCP to change this by creating a system whereby the specialists are part of the same shared capitation-based funding, working to the same shared outcome measures. 46. So the MCP will provide the full range of long-term conditions management services to support patients in the management of their condition(s). This includes social prescribing practice. Patients with a range of social, emotional or practical needs will be referred to a range of local initiatives often provided by the voluntary and community sector, to address the holistic non clinical needs of patients. 47. Specialist services including specialist consultants and community services, will operate to the same outcome objectives as general practice for each long-term condition; and will provide support, education and training, advice and guidance to general practice. A multi-disciplinary approach to developing shared care will ensure that specialists and generalists are working together in the shared interests of their patient; and patients will be clear how the different clinicians are working together with them, providing clear continuity of care, to contribute to the management of their condition. 48. The method of delivery of this integrated approach is already being piloted in Dudley with, for example, the introduction of multi-disciplinary working between specialist mental health services and general practice. 49. The initial areas where we will expect the MCP to align services to achieve continuity of care, working to a set of shared outcome objectives, will be with the long-term conditions that are most significant to the Dudley population. This includes diabetology, respiratory medicine, and mental health services. Coordination 50. Within the population of people with long-term conditions we have an ever rising cohort of individuals living with frailty and complex-comorbidities (as evidenced in their current utilisation of hospital-based care) who, in addition to access and continuity, also need effective co-ordination of health and social care. Effective care planning, taking into account the whole needs of the person, is essential to ensure all individuals supporting a person s care work effectively together. 8 P a g e

9 51. Dudley s existing model of care already includes multi-disciplinary community teams (MDTs) supporting each practice to coordinate the care needs of our most vulnerable patients: 52. Our multi-disciplinary teams around each GP practice enable the co-ordination of care for our most complex patients. In order to maximise the potential for staff to work effectively together all the relevant staff now work with the same population of patients so that they can communicate with each other effectively and also take a shared responsibility in the outcomes for those people. We will expect the MCP to continue to build on this approach so that all relevant communitybased services are structured to work with the same population in this way. 53. We have also already introduced one new component to the MDT the voluntary sector link worker these individuals came with no professional boundaries and so enable the teams to look at the whole needs of the person, not just their health requirements. Individuals who were previously socially isolated are now connected back into their local communities; small non-health related problems are resolved which then gives confidence to individuals and reduces their utilisation of healthcare; patients report how their quality of life has improved; and many now contribute more by being part of social groups, adding social value back into their community. We will expect the MCP to build on this way of working with the voluntary sector to recognise the value of supporting community, carer and social networks to help maintain the resilience and quality of life for individuals. 54. The next stage of this development is to replicate this way of working - where we bring relevant services to work effectively together to apply across the whole system of care for people with frailty and complex conditions. So the MCP will provide the full range of community based (and where appropriate hospital-based) services that support complex care coordination, both at a local practice level and across the whole Dudley system. 55. This brings together services that are designed to help prevent people s need for an urgent care admission to hospital (such as falls prevention and community rapid response services), together with hospital-based care that has the potential to be delivered in the community, together with the rehabilitation and support services that are designed to enable people to return home as quickly as possible. This also includes services that support people to be looked after in their own permanent care setting whether that be their own home or a care home; and services that will support people at the end stages of their life. 9 P a g e

10 56. We will expect the MCP to establish a new continuum of care that places the locus of responsibility in the community, not the hospital; that links Dudley-wide services directly into the existing MDTs to enable them to provide enhanced proactive and responsive support to their patients; and that integrates services across the system so that there are no longer any artificial transfers of care or delays in care there will be one MCP team, based in the community, that takes responsibility for the care of the frail elderly at every stage in the continuum of their care. 57. The care model is explored further in Appendix 2 and MDT working in Appendix 3. The Frailty Pathway 58. The model of integrated care is central to our vision of care for our elderly and frail population. Our vision is for older people and their carers to access high quality care where the MDT is responsible for the whole pathway thus removing transfers of care. 59. In 2015/16 Dudley CCG had 17,560 emergency admissions for people aged 65 and over. This was an increase of over 1000 on the previous year reflects an increasing trend of hospital utilization. 60. Further analysis identified that 12.6 % of all the over 65 admissions were patients who are residents in residential and nursing homes. There has also been a year on year increase in conveyances to hospital, particularly out of hours. 61% of non-elective admissions from care homes are out of hours. 61. The model also includes the development of new initiatives and enhanced resources in the community with the key objective of reducing transfers to hospital, reducing admissions for unnecessary, non-life threatening conditions that could be managed in the community and enabling more people to die in their preferred place of care. 62. There will be a phased approach to introducing these schemes building on the development of geriatricians working with practices and care homes to support complex frail elderly patients Phase One (Early 2017) Commence tele-medicine support to care homes and extra care housing schemes. This will provide a reactive 24/7 service, using installed technology in care homes to connect via secure video link with a clinical hub when a resident needs clinical input. This will be supported by a 7 day highly skilled care home team comprising of community nurse practitioners supported by an on call GP. This team will be reactive including retrieval of patients in ED/EAU and will also work proactively with patients and care home staff. The Community Mental Health Team will commence a crisis assessment and home treatment service to manage and care for patients with an exacerbation of their illness particularly those with a dementia condition. PhaseTwo (2018) Subject to evaluation, the tele-medicine model has the capacity to be extended to the 8,000 vulnerable patients receiving tele-care through Dudley MBC. An acute frailty assessment and treatment unit will be established within the hospital. This will enable patients to be assessed and treated within a clinical setting and may include initiating intravenous antibiotics. The equipment in this unit will be particularly suited to the needs of 10 P a g e

11 the frail elderly to avoid decompensation. For example, the assessment of patients in recliner chairs. The new unit will be aligned to existing rehabilitation and reablement services and a new 7 day responsive community frailty team extension of the above care home team consisting of a community geriatrician/ GPSI in geriatrics, nurse practitioners, AHPs, pharmacist and social care. This team will take referrals from GPs and MDTs as well as handover from the acute frailty unit. Following acute management and intervention, the patients will be retrieved back to the MDT for their ongoing care management. Phase Three (2020) The deployment of a clinical Single Point of Access (SPA) telephone triage combined with tele-medicine, will provide the first point of contact for the elderly population and extend also to other cohorts with significant needs for example people with long term conditions. 63. The MDTs will be established to maximum capacity and include paramedics to provide a responsive service via the SPA (see diagram below). 64. Underpinning this work will be the development of the palliative care and end of life services. This includes the extension of the palliative care team to become a 7 day service, the introduction of EPaCCS (electronic palliative care coordination systems) and a bespoke palliative and end of life care training course for care home staff. 11 P a g e

12 Recipients Service developments Phase 1: Early 2017 Residents in:- Residential and Nursing care homes Extra Care Housing Schemes Telemedicine (funded non- recurrently) 7 day care home teams Community mental health crisis and home treatment team 7 day palliative care teams Additional elements added in Phase 2: 2018 Additional 8,000 people receiving tele- care supported with tele-medicine (following successful evaluation) Acute frailty assessment and treatment unit 7 day community frailty team Additional elements added in Phase 3: 2020 onwards Whole population (over 65 s and those with significant need) Clinical SPA Extended MDTs 12 P a g e

13 F. Provider Impact 65. The table below shows the proposed total value of MCP services by current provider. This will be adjusted to reflect 2017/18 contract values. Further detail is set out in Document 21. Current Providers Partially Integrated Model: Total 000's The Dudley Group NHS Foundation Trust 80,758 NHS Business Services Authority (Prescribing and Oxygen spend) 54,823 Dudley and Walsall Mental Health Partnership NHS Trust 28,544 Black Country Partnerships 15,820 Dudley Metropolitan Borough Council 10,210 Malling Health Ltd 3,000 Shaw healthcare (Group) Limited 2,599 The British United Provident Association Limited (BUPA) 2,518 CGL 2,464 The Royal Wolverhampton NHS Trust 1,989 Sandwell and West Birmingham Hospitals NHS Trust 1,735 West Midlands Ambulance Service NHS Foundation Trust (Non-Emergency 1,646 Patient Transport) University Hospitals Birmingham NHS Foundation Trust 1,603 Shropshire NHS Trust 1,200 Birmingham Women's and Children's NHS Foundation Trust 1,055 Other 23,693 Total Partially Integrated Budget 233,657 Additional Budgets for Fully Integrated Model: GMS Contract (includes MPIG and PMS transition) 25,353 Primary Care Premises 4,701 Other 9,974 Total Additional Budgets for Fully Integrated Model 40,028 Total Whole Population Budget 273,684 Financial Reporting 66. It is likely that there will be a significant mobilisation phase for a contract of this value and complexity. During this interim period the actual costs for the services within the W hole Population Budget will differ from the budgeted figures within the current service scope. 67. The CCG w i l l m on i t o r e x pend i t u r e f o r each service line over the coming months and this will be reported to the Finance, Performance and Business Intelligence Committee as an appendix to the monthly Finance and Performance Report. 68. This will allow both the new provider and the CCG to understand the volatility of the services within the MCP scope. 13 P a g e

14 APPENDIX 1 MCP Service Model A. The Centrality of general practice 1. Our model rests upon the unique position of primary care starting with the person registered with the practice. The MCP will be population-based, linked to the registered lists of the GP practices across Dudley. A core function of the MCP will be to enable a primary care led model of care supporting GP practices and incorporating GP practices at the heart of delivery. The MCP will have to demonstrate how its operating model will be designed to ensure that the foundation of NHS care will remain list-based primary care. This includes both ensuring that service delivery starts from the practice as well as ensuring that the patient medical records held by the GP form the basis of the medical records for the MCP. The role of the GP is therefore fundamental. B. Integrated Services 2. An ageing population with multiple chronic conditions requires care to be provided in an integrated manner as opposed to supplying the predominantly episodic and curative interventions that typifies care at present. The MCP s service delivery model addresses these imbalances and General Practice takes overall responsibility for the care provided by other services. 3. The services are summarised below and explored in more detail on the basis of the factors that the population of Dudley have described as important to them access, continuity and coordination underpinned by more generic population health improvements, system and staff benefits and the empowerment of Dudley communities. 11 P a g e

15 i. Whole Population Services which are Primary care led and predominantly focused on prevention and population health management. These services work on the basis of segmented population stratification, predictive modelling, actuarial analysis, self- care and patient activation; ii. Rapid Access Services largely delivered on a locality basis and designed to respond to urgent care needs whilst identifying proactively potential onset or exacerbation of illness and ensuring an integrated approach to patient management within a community setting; iii. On-going Care Services delivered at a GP level predominantly through multidisciplinary teams (MDTs). These are delivered at scale on a locality through Local Access Hubs (see document 17) effectively forming a mutual network of care with a wider network of community based and voluntary sector services and access to value added treatments from secondary care; iv. High Care Need Services that operate as a step up mechanism for the more vulnerable, complex care patients or patients with increasing acuity that require more enhanced condition management to prevent an admission to hospital and stepping down to On-going Care Services. 12 P a g e

16 The diagram below outlines some of the changes expected across the system of care. 1. Whole Population Services 2. Rapid Access Services 3. Ongoing Care Services 4. Highest Care Need Services Outcomes Access Continuity Coordination NHS Health Checks, Integrated Children and Adult Wellness Services Access Hubs including specialist nursing and consultant led services operating at scale along with requisite diagnostic aids. Contraception services and integrated sexual health services. Near Patient testing, Avatar and centralised interoperable systems for enabling access to appointment booking (Integrated Referral and Information System). Prescription Ordering Direct (POD). Urgent Care Centre, Paediatric Assessment Unit Redesign. Specialist triage Services. Improved patient experience, more efficient and effective utilisation, healthier lifestyles, a healthier community. Community Health Champions Telehealth and direct access to services connecting to other public services including voluntary sector services. Named primary point of contact, ACS Conditions Management Framework. Interoperable IT system with greater functionality and shared access to records. Stabilisation and management of acuity, reducing risk of exacerbation, reducing variation and health inequalities gap. Self-Management Programmes, Patient Activation and Carer Support Services Lead GP Coordinating locality approach, Telecare, Integrated 0-19 services primary mental health services (counselling, IAPT etc) MDT Working for Children and Adults, Community Rehabilitation Services Community Discharge Impact Team. Community Impact Service for Frail Elderly Patients managing admission, Integrated Falls and Fracture Liaison Service, Integrated Palliative and End of Life Services, Frail Elderly Assessment Unit facilitation discharge, MDT working for Mental Health Patients. MDDT working for children with complex situation/conditions Reduced social isolation, improved EOL Care, Improved condition management and patient activation. Population Health Empowering people & Communities System and Staff 13 P a g e

17 4. This implies significant additional activity in primary and community settings. The MCP starts with the person registered with the GP. The GP as the focal point then brings in and coordinates services in the community including those provided by the voluntary sector. The changes expected are explored in more detail as follows: a) Access 5. Our patient and public feedback confirms that the majority of our population want good access to services. This starts with primary care with over one and a half million contacts this is the cornerstone of our healthcare system. 6. Good access to healthcare takes several forms: easily booked and timely appointments are important; but increasingly people want options on the type of appointment (phone advice, Skype, , 1:1 with the appropriate person) as well as on the time of appointment (day, evenings and weekends). 14 P a g e

18 7. We expect the MCP to improve access at every level as follows: i. Whole Population Services: 8. The MCP will improve access to whole population services which are Primary care led, prevention focused and underpinned by population health management processes. 9. A lot of the services currently commissioned by Public Health in Dudley are configured to work in this manner. Further redesign is required to improve proactive and systematic identification of factors that are amenable to rapid interventions and ensuring sufficient service spread across Dudley primary care services. 10. The MCP will ensure a mechanism is in place to identify individuals from health checks that would require access to an Adult Wellness Service. The Adult Wellness Service will have a single point of access including a universal offer of healthy lifestyle self-help resources including 24/7 access to information and support including smoking cessation, weight management, physical activity, improved diet and general wellness. 11. The Adult Wellness Service will ensure seamless transition from the Young People s Wellness Service. The Young People s Wellness Service will ensure targeted support and interventions to meet the varying needs of children and young people in Dudley. These support interventions should include a range of self-help strategies and specialist services including:- open access integrated sexual health services, treatments, advice and prevention; substance misuse services; smoking cessation services across a range of service locations; pathways into CAMHS tier 2 services. ii. Rapid Access Services 12. Whilst the majority of the population are healthy most of the time, everyone wants decent access to diagnostics and analysis to identify and then solve any problem as quickly as possible. 13. The development of Local Access Hubs will be fundamental to ensuring expert knowledge is easily accessible without the need for accessing acute care services. iii. On-going Care Services 14. These are services delivered at a GP Practice level through multi-disciplinary teams (MDTs). These are delivered at scale on a locality level through Local Access Hubs forming a Mutual Network of Care. 15. Improved Access to on-going care services will require centralised and interoperable information systems with access to appointment booking for both staff and patients. 16. The MCP will develop and deliver an integrated Referral and Information System (See document 17) on the basis of the following key features:- 15 P a g e

19 creating a single telephony and online digital point of access for patients, and health and social care professionals; seamless and immediate navigation to appropriate professionals within the MCP for patients to clinicians, and clinicians to clinicians, which also minimises requirements for transfers; Governance and systems which reduce the number of repeat assessments that service users experience; governance and systems which reduce the number of repeat assessments that service users experience; and links through to patient reported outcomes and collecting patient experience and feedback on services. 17. The development of an Integrated Referral and Information System will require at the very least an effective interoperable solution with NHS Another key feature for improving access is the development of a Prescription Order Direct Service (POD) (see document 25). The POD is a call centre which handles requests for repeat prescriptions in place of a GP Practice repeat prescription ordering system; standard questions are asked at the point of requesting a repeat prescription and prescriptions are only passed to the GP Practice for issue if deemed necessary by the trained call handler. The MCP will be expected to develop this approach and ensure sufficient spread across Dudley. 19. Improved Access to on-going services will require an appropriate level of near patient testing. Near-patient testing offers a number of potential advantages in primary care, including earlier diagnosis, communication of diagnosis, and disease management, with potential for improved health and care outcomes. Other potential advantages include reducing health inequalities by being accessible to certain hard to reach socioeconomic or ethnic groups. Use of simple urine testing strips and blood glucose measurements are routine in primary care, although more sophisticated near-patient tests have been limited to anticoagulant monitoring, diabetes management, and testing for C- reactive protein and Helicobacter pylori. 20. The MCP will be required to understand and plan for the provision of enhanced near patient testing for on-going care services. iv. Highest Care Needs 21. Highest care needs services operate predominantly on the basis of a step up from other services. For all intents and purposes, these are services that are effectively working as gate keeper services to acute care. 22. For the majority of Dudley residents this will be about improved access to urgent care where required. The MCP will need to make improvements to the current Urgent Care Centre infrastructure (both children and adults) in line with the improvements that are currently planned which include the expansion of current assessment areas, along with the required diagnostic availability to support increasing demand and in addition to that, further process efficiencies are expected that will ensure a seamless transition of care from urgent back to lower acuity services as required. This will be underpinned by a 16 P a g e

20 retrieval mechanism operating from within the GP led MDT although it is expected that the majority of the population will not require an MDT follow up and as such will default to GP care and whole population services. 23. In line with the gate keeper function, highest need services will ensure effective access to triage and guidance with an appropriate level of skill and resource to ultimately manage an admission to hospital only where absolutely required. 24. The MCP will need to ensure an interoperable IT system is in place that will allow for exchange of information across the Dudley Care System, ensuring all necessary patient information supports holistic care provision at any care delivery point. b) Continuity 25. About one fifth of our population are living with at least one long-term condition (LTC). The Five Year Forward View identified that Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected episodes of care. The dialogue with our local population so far has identified that this cohort of the population, as well as good access, also want effective continuity of care with a professional they can trust. The MCP will be required to organise all of its care services to deliver against this as follows: i. Whole Population Services: 26. We have already developed a new outcomes framework for GPs whereby all a patient s LTC requirements are addressed holistically and the individual sets their own goals for achievement to be measured thus encouraging a shared responsibility in the achievement of outcomes for the individual. This is underpinned by a single IT system and workflow-processes that now ensures a consistent approach is adopted for every patient in every practice across our CCG. Intelligent standardisation and use of technology enables us to make a consistent offer of service to our whole population whilst also enabling that offer to be delivered more efficiently. 27. However, it is only the GP that is currently funded on a capitation basis, incentivised to achieve this set of outcome-measures. Many specialists currently located within secondary care also provide LTC management to patients, and may even differentially retain an interest with particular patients because of either perceived (or real) variations in the quality of primary care. However, currently there is no requirement for them to take a shared responsibility for resolving these variations so we will contract with the MCP to change this by creating a system whereby the specialists are part of the same shared capitation outcomes. 28. In Dudley we already have an established network of community health champions which include residents (including those from minority ethnic communities), front line staff in Dudley Council, pharmacies and opticians and workplace champions who have access to support through an e-bulletin, network meetings and a website, as well as access to training such as Making Every Contact Count (MECC). Public health and the CCG also jointly fund a Youth Health Champions programme delivered by the voluntary sector. The 17 P a g e

21 CCG wishes to look at how Patient Participation Group members can work differently and become community health champions. There are opportunities to develop this alongside MECC training which is going to be rolled out from February In addition, Healthwatch Dudley work with volunteers and train Community Information Champions who use the Community Information Directory to help signpost individuals to activities, help and support. 30. The MCP will ensure these activities are working as a unified health champion offer. ii. Rapid Access Services 31. The MCP will provide the full range of rapid access long-term conditions management services to support patients in the management of their condition(s). 32. Based in the Local Access Hubs, specialist services including traditionally hospital based specialist nurses/consultants and specialist community services will operate to the same outcome objectives as general practice for each long- term condition; and will provide support, education and training, advice and guidance to general practice. 33. A multi-disciplinary approach to developing shared care will ensure that specialists and generalists are working together in the shared interests of their patient; developing care plans with patients and providing clear continuity of care. 34. The method of delivery of this integrated approach is already being piloted in Dudley with, for example, the introduction of multi-disciplinary working between specialist mental health services and general practice. 35. The initial areas where we will expect the MCP to align services to achieve continuity of care, working to a set of shared outcome objectives, will be with the long-term conditions that are most significant to the Dudley population. This includes diabetology, respiratory medicine, and mental health services. 36. The continuum of care should also include services affecting the wider determinants of health such as wider community and voluntary sector services thereby ensuring the care offer is both holistic and personalised to the needs of the individual. iii. On-going Care Services 37. The MCP will ensure there is a named primary contact for every patient who accesses services across Dudley. This approach will ensure continuity between service transitions thereby enabling seamless care provision. 38. The MCP will ensure there is a systematic approach to managing Ambulatory Care Sensitive Conditions (ACSC) right across the care spectrum. This could involve developing an ACSC framework underpinned by an appropriate intelligence gathering and data processing mechanism that will support both clinical decision making and analysis of impact in this key area. 18 P a g e

22 39. A key element of MDT working is the role of the care coordinator. The coordinator function will be the focal point for all care transitions between Whole Population, Rapid Access, Ongoing Care and Highest Need Services. Where patients are admitted to hospital the care coordinator will support the MDTs to organise appropriate services for the retrieval of those patients once their hospital episode is nearing completion. Therefore, this will require robust communication mechanisms with partners across the care system. iv. Highest Care Need Services 40. The MCP will ensure continuity of care by ensuring there is an appropriate standardisation of referral information both within the MCP and externally, particularly in regard to the acute care system. Currently, significant progress has been made in this regard through the development and implementation of automated and standardised referral templates on the GP Practice EMIS system so that the same agreed dataset is sent for every referral. This then avoids any omissions or errors in data and secondary care to improve the efficiency of its response in acting upon the referral information. This capability needs to be developed further to enable the MCP to improve local advice and guidance and then on-going demand management capabilities which will then enable the MCP to contribute to any agreed gain sharing arrangement for the management of elective care. 41. Provision of integrated patient care records is key to maximising improvements in quality of care and reducing clinical risk and variation. This is an important enabler in terms of releasing time for front line staff to deliver care. 42. The MCP will use mobile devices for access to patient records so staff are able to maximise time ordinarily lost in transit to office bases. c) Coordination i. Whole Population Services: 43. We will expect the MCP to establish a new continuum of care right across the system that places the ethos of care delivery on personalised care planning. 44. This will require a fundamental shift from the current essentially diagnosis led care planning system which has resulted in an ostensibly medical model of care and system driven outcomes, to a much more patient directed model of care effectively placing the individual patient in charge of their care and activated towards health improvement underpinned by a holistic service infrastructure that is geared towards delivering against the requirements of the individual. 19 P a g e

23 45. In summary, the MCP will be required to effectively shift the system towards: effective Self-Management Programmes; patient activation; personalised care planning; effective community health and care engagement programmes. 46. In line with the holistic care approach across the care spectrum, the MCP will ensure carer support services are organised and effective. A joint Dudley Carers Strategy with Dudley MBC and the CCG is now at the final stages of development. The strategy includes a focus on supporting and involving carers (particularly where there is an increasing number of older people who are carers of older people, or who are themselves carers of adult children with learning or physical disabilities) one of the 6 principles for engaging people and communities set out in the MCP Framework and the Five Year Forward View. 47. There are a number of actions the MCP could implement to address these challenges:- the need for a risk profiling tool to support demand management (carers often don t recognise they are in crisis) and help prevent hospital or institutional care; to identify more carers via the MCP network of services including both the formal and informal networks of care; to ensure MDTs identify carers and constituent and appropriate services either refer on or deliver the support that is required; raise the profile of carers via education and training programme with key teams who have contact with people who are carers. ii. Rapid Access Services: 48. The development of Local Access Hubs will be fundamental to ensuring expert knowledge is easily accessible without the need for accessing acute care services, this will be a key feature of Rapid Access Services. A range of rapid access services will ensure a faster response for individuals with higher acuity that can be safely managed within the community environment with the appropriate level of support. 49. In addition to improved access to specialist nurse/consultant led services, the MCP will ensure an appropriate use of tele-medicine approaches that will also aid conversation and ultimately clinical decision making between professionals delivering care. 50. Rapid access services will act as a point of escalation from on-going care services and will also aid decision making at that lower level, therefore an appropriate concentration of skills, resources and infrastructure is required. Services at this level are expected to work much more on a locality basis than at an individual practice level on a day to day basis. 20 P a g e

24 iii. On-going Care Services: 51. Dudley s existing model of care already includes multi-disciplinary community teams(mdts) supporting each practice to coordinate the care needs of our most vulnerable patients as described previously. 52. Our multi-disciplinary teams around each GP practice enable the co- ordination of care for our most complex patients. In order to maximise the potential for staff to work effectively together all the relevant staff now work with the same population of patients so that they can communicate with each other effectively and also take a shared responsibility for shared outcomes for a shared population. We will expect the MCP to continue to build on this approach so that all relevant community-based services are structured to work with the same population in this way. 53. We have also already introduced one new component to the MDT the voluntary sector link worker these individuals came with no professional boundaries and so enable the teams to look at the whole needs of the person, not just their health requirements. Individuals who were previously socially isolated are now connected back into their local communities; small non- health related problems are resolved which then gives confidence to individuals and reduces their utilisation of healthcare; patients report how their quality of life has improved; and many now contribute more by being part of social groups and thus adding social value back into their community. We will expect the MCP to build on this way of working with the voluntary sector to recognise the value of supporting community, carer and social networks to help maintain the resilience and quality of life for individuals. iv. Highest Care Need Services: 54. The next stage of MDT development is to replicate this way of working - where we bring relevant services to work effectively together to apply across the whole system of care for people with frailty and complex conditions. So the MCP will provide the full range of community based (and where appropriate hospital-based) services that support complex care coordination, both at a local practice level and across the whole Dudley system. 55. Within the population of people with long-term conditions we have an ever rising cohort of individuals living with frailty and complex-comorbidities (as evidenced in their current utilisation of hospital-based care) who, in addition to access and continuity also need effective co-ordination of health and social care. 56. This means bringing together services that are designed to help prevent people s need for an admission to hospital (such as falls prevention, end of life and telehealth services); with hospital- based care that has the potential to be delivered in the community; and the rehabilitation and support services that are designed to enable people to return home as quickly as possible. This also includes services that support people to be looked after in their own permanent care setting whether that is their own home or a care home. 21 P a g e

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