The Greater Manchester Case for Change

Transcription

1 The Greater Manchester Case for Change 1 Healthier Together The Greater Manchester Case for Change

2 Title Author Target Audience Version Healthier Together - The Greater Manchester Case for Change Alex Heritage & Sue Wallis Clinical Strategy Board / NHS Greater Manchester Board Final HTP Reference HTP- 009 Created - date 6 th July 2012 Date of Issue 26 th September 2012 Document Status File name and path Final Q:\SERVICE TRANSFORMATION\Healthier Together\Clinical Workstreams\Case For Change\Greater Manchester Case For Change\ The Greater Manchester Case For Change - FINAL.Docx Document History: Date Version Author Details 06/08/12 V1 Alex Heritage Sue Wallis Initial Draft incorporating Clinical Workstream Cases for Change. Issue for comments 15/08/12 V2 Alex Heritage 16/08/12 V3 Jennifer Platt 17/08/12 Final Alex Heritage Amendments following review from Warren Heppolette & Andrew Burridge. Amendments following review from Jess Williams, Janet Ratcliffe, Nicola Baker, Anne Talbot. Approved by A. Talbot. Submission to Clinical Strategy Board 30/08/12 Final Jennifer Platt Addition of Foreword from GM Authorities 30/08/12 Final Alex Heritage 04/09/12 Final Alex Heritage Approved by: Textual Amendments. Endorsed by Large Scale Change Board Textual Amendments. Endorsed by Clinical Strategy Board. A. Talbot (17-Aug-12) 2 Healthier Together The Greater Manchester Case for Change

3 Contents Foreword by Greater Manchester CCG Chairs... 5 Foreword by Association of Greater Manchester Authorities... 6 Introduction... 7 An Introduction to the Greater Manchester health and care system... 8 Population Health and Care inequalities Transport An understanding of why Greater Manchester s Health and care system needs to change Three Key Messages to our patients and citizens Exploring Variation across Greater Manchester Mortality Quality and Safety Finance and Workforce Summary of Clinical Cases for Change Conclusion Healthier Together The Greater Manchester Case for Change

4 Table of Figures Fig 1.1 Location of Greater Manchester Fig 1.2: Population profile, Fig 1.3 Indices of Multiple Deprivation Fig 1.4 Greater Manchester Local Health Profiles compared to England Average Fig 1.5: Traffic Flows (Motorways, A & B Roads) Fig 1.6: Core Bus Network Fig 1.7: Greater Manchester Metrolink and Rail Network Fig 1.8: Key health inequalities identified in the Local health Profiles Fig 1.9 Greater Manchester Local Health Profiles: Children Fig 1.10: How satisfied or dissatisfied would you say you are with the way in which the NHS runs nowadays.. 19 Fig 1.11: Greater Manchester NHS Secondary Care Providers Fig 1.12: Greater Manchester NHS Secondary Care Providers Map and PCT boundaries Fig 1.13: Greater Manchester CCG PCTs to CCG Fig 1.14: Greater Manchester Local Authority Social Care commissioners Fig 1.15: Number of deaths, all causes, , all persons aged under Fig 1.16: Standardised mortality rates, all causes, , all persons aged under Fig 1.17: Potential years of life lost from all causes of mortality, Number of deaths, all causes, , all persons aged under Fig 1.18: % change in number of deaths, all causes, all persons, aged < Fig 1.19: Summary Hospital-level Mortality Indicator (SHMI), April 2010 March Fig 1.20 AQuA Acute Trust Quality Dashboard Q1 12/ Fig 1.21 NHS Greater Manchester Financial Challenge Fig 1.22: Greater Manchester Provider Establishment Healthier Together The Greater Manchester Case for Change

5 Foreword by Greater Manchester CCG Chairs As clinical leaders of Greater Manchester it is our passion and aim to provide the very best of health and care to our patients and communities. Greater Manchester is changing with vibrant communities growing with many people living longer. However, more people are living longer with multiple long term conditions such as diabetes and COPD which increases the demand on the NHS and social care services. In response to the wider economic climate, our public services in Greater Manchester face unprecedented pressures to ensure that every pound is spent efficiently to provide the best outcomes for every patient. Greater Manchester has a good record of changing to meet these extra demands with many improvements in outcomes for patients. However, parts of our current system were designed for the last century which relies heavily on our hospital services. Building on our previous achievements we believe that our current system can be changed to ensure that people are cared for in the most appropriate place. Care might be delivered in primary and community care settings or even in our patient s own homes, whilst freeing up specialist care in hospitals for those who really need it. Local health communities of Greater Manchester have made good progress in responding to local pressures, however it is recognised that in some cases the local system may achieve greater outcomes for patients by working with wider partners across Greater Manchester. In Summary: Demands on the NHS and Social Care are growing... So the NHS is changing to meet these extra demands and improve the care it provides... But even more change is needed. We are fully committed to leading the Healthier Together programme which will be the catalyst to change the way health and care is provided to ensure high quality services are safe, accessible and sustainable for our future patients and communities. Dr. Wirin Bhatiani Dr. Kirian Patel Dr. Mike Eeckelaers Dr. Chris Duffy Dr. Martin Whiting Dr. Ian Wilkinson Dr. Hamish Steadman Dr. Bill Tamkin Dr. Ranjit Gill Dr. Raj Patel Dr. Nigel Guest Dr. Tim Dalton NHS Bolton CCG NHS Bury CCG NHS Central Manchester CCG NHS Heywood, Middleton & Rochdale CCG NHS North Manchester CCG NHS Oldham CCG NHS Salford CCG NHS South Manchester CCG NHS Stockport CCG NHS Tameside & Glossop CCG NHS Trafford CCG Wigan Borough CCG 5 Healthier Together The Greater Manchester Case for Change

6 Foreword by Association of Greater Manchester Authorities In Greater Manchester local government is leading collective efforts to deliver an ambitious public service reform agenda and secure economic growth. We want Greater Manchester to be known as a city region where all people benefit from increasing prosperity and opportunity. We know health and social care expenditure accounts for 6bn (nearly one third) of public sector expenditure in GM. This scale of spending is unsustainable given the financial challenges to the NHS and local authorities in the light of demographic change and reducing budgets. Too great a proportion of these resources are currently focused in response to acute need and avoidable crises. Hospital and local social care services have in the past faced criticism due to a perceived failing to integrate. Acute hospital care is generally not provided in a vacuum but incorporates a wide range of issues across organisations including community services, avoidance of inappropriate admissions, and discharge into home or other care settings. More broadly, our requirements for a safe and sustainable hospital system need to understand the pressures upon an interdependent care system, and our collective intentions for prevention, independence and wellbeing. Local government has a crucial role to play supporting the NHS to understand the relationship with housing and transport. Local elected politicians need to be engaged throughout the programme, given the importance of these proposals to their local communities. We recognise that the scale of the challenge facing social and health care requires system leadership that works across organisational boundaries. Healthier Together provides a major opportunity for us to change our services to meet the needs of GM residents, under the direction of a GM Health Commission (soon to be reconvened as a GM Health & Wellbeing Board). AGMA is keen to participate within Healthier Together and looks forward to working closely with NHS GM, GM Clinical Commissioning Groups, and the acute sector in GM. Steven Pleasant Chief Executive Tameside Council Lead Chief Executive for Health On behalf of AGMA 6 Healthier Together The Greater Manchester Case for Change

7 Introduction The Greater Manchester Case for Change seeks to provide an overview of the Greater Manchester health and care economy whilst identifying strategic areas for change. This document supported by eight separate clinical work streams for change provides the foundation and first step of the Healthier Together programme. The document is structured to provide an overview of Greater Manchester including: An Introduction to the Greater Manchester health and care system; An understanding of why Greater Manchester s Health and care system needs to change; The exploration of the variation across Greater Manchester; A summary of the Clinical Cases for Change. The Greater Manchester Case for Change has been developed in conjunction with other key programmes and aligns with other important strategy documents including the Greater Manchester City Region Community Budget Pilot, Greater Manchester Joint Strategic Needs Assessment and Greater Manchester s Local Transport Plan. The Healthier Together programme has developed strong partnerships with a number of organisations that have been utilised to support the cases for change. 7 Healthier Together The Greater Manchester Case for Change

8 An Introduction to the Greater Manchester health and care system It is estimated that across England the NHS treats 1 million people every 36 hours. Many of these people have their lives saved or improved because of the care they receive from dedicated NHS staff. The NHS is there when we need it most, providing round the clock, compassionate care and comfort. It plays a vital role in ensuring that as many of us as possible can enjoy good health for as long as possible a matter of fundamental importance to us, our family and friends. Greater Manchester is a vibrant and dynamic conurbation with great potential for economic growth and prosperity. However, the population of Greater Manchester has traditionally suffered some of the poorest health in England. Good progress has been made in addressing the health challenges posed by the burden of disease associated with social deprivation, poor mental health, cancers, cardiovascular disease and poor lifestyle choices leading to problems of obesity, alcohol related morbidity and smoking related disease, however further focus to reduce health inequalities is essential. The current organisation of health services in Greater Manchester was designed to meet the needs of the last century. Today, the greatest requirement is the ongoing care of people with multiple long term conditions and, to meet these needs, the NHS needs to take a more strategic approach to shifting the balance of care from hospital to community, primary, social and self care. It is also recognised that access to specialist care needs to be improved across Greater Manchester. The presence of leading international institutes within Greater Manchester should ensure that all national quality standards are met ensuring current inequalities of access and related outcomes for patients are improved. A further challenge is that the current organisation of hospital services in Greater Manchester is not financially sustainable. Over recent years, despite achieving planned cost savings, a number of Trusts in Greater Manchester are facing challenging financial difficulties. This situation must be addressed to ensure high quality services are consistently provided. The Greater Manchester Health and Social Care system faces a significant challenge in making changes whilst still maintaining a service 24 hours a day, 7 days a week and seeking to deliver against the five NHS Outcome domains: 1. Preventing people from dying prematurely; 2. Enhancing quality of life for people with long-term conditions; 3. Helping people to recover from episodes of ill health or following injury; 4. Ensuring that people have a positive experience of care; 5. Treating and caring for people in a safe environment and protecting them from avoidable harm. (Department of Health (2011) The Operating Framework for the NHS in England ) The Greater Manchester case for change supported by 8 clinical work streams and aims to provide the foundation for achieving the programmes vision and outcomes. 8 Healthier Together The Greater Manchester Case for Change

9 Healthier Together Vision: For Greater Manchester to have the best health and care in the country Outcomes: Improve the health and wellbeing of people in Greater Manchester - safe services based on best practice, clinical standards and better specialist care in our hospitals Improve equality of access to high quality care - improved, timely access to appropriate staff, facilities and equipment across the whole of Greater Manchester Improve people s experience of healthcare service - integrated care provided in the most appropriate setting to provide better outcomes and experience for patients Make better use of healthcare resources - care provided by sustainable organisations that allow best possible use of the total resource available to the health and social care system in Greater Manchester. 9 Healthier Together The Greater Manchester Case for Change

10 The Healthier Together programme is one element of a wider public sector reform agenda that seeks to improve outcomes for all Greater Manchester residents. With the publication of the Greater Manchester Strategy in 2009, Greater Manchester set itself an ambitious vision for 2020 to secure long-term growth and enable the city region to fulfil its economic potential, whilst ensuring that our residents are able to share in and contribute to that prosperity. The last two years have seen governance arrangements in Greater Manchester become more robust and mature, enabling us to secure a range of bespoke agreements with Government in our recently agreed City Deal, helping to empower us to make our own decisions about what is needed to support growth. Our unique governance arrangements are supported by an increasingly streamlined set of delivery structures and a new cross partner focus on public service reform. Our current models of public services are not fit for the coming challenge of delivering growth, particularly given the scale of planned reductions in public spending. We need a transformational reduction in demand and dependency, with people and places becoming more resilient and selfreliant. Greater Manchester therefore needs a radical programme of public service reform over the next three to five years which will both reduce high levels of dependency and demand for a range of public services and support our growth plans, by helping connect people to opportunities, reduce worklessness, improve skills and workforce productivity. The 2010 Spending review set out plans for Community Budgets which would enable partners to redesign public services in their areas, agreeing outcomes and allocating resources across different organisations. The Greater Manchester proposal for a Community Budget covers a wide range of themes. It addresses the current service response to troubled families, offenders and children. There is a health and social care strand running through all of them, reflecting the case for a greater integration of response including integrated commissioning across the public sector. 10 Healthier Together The Greater Manchester Case for Change

11 Population Greater Manchester is a metropolitan county in North West England, with a population of 2.6 million. It encompasses one of the largest metropolitan areas in the United Kingdom and comprises ten metropolitan boroughs: Bolton, Bury, Oldham, Rochdale, Stockport, Tameside, Trafford, Wigan, and the cities of Manchester and Salford. Greater Manchester spans 493 square miles (1,277 km 2 ). It is landlocked and borders Cheshire (to the south-west and south), Derbyshire (to the south-east), West Yorkshire (to the north-east), Lancashire (to the north) and Merseyside (to the west). There is a mix of high density urban areas, suburbs, semi-rural and rural locations in Greater Manchester, but overwhelmingly the land use is urban. Fig 1.1 Location of Greater Manchester Source: Greater Manchester Local Transport Plan p.7 It has a focused central business district, formed by Manchester city centre and the adjoining parts of Salford and Trafford, but Greater Manchester is also a polycentric county with ten metropolitan districts, each of which has at least one major town centre and outlying suburbs. The Greater Manchester Urban Area is the third most populous conurbation in the UK, and spans across most of the county s territory which presents a significant challenge to public services. Number of people per hectare: 19.5 (E&W avg: 3.4) Households without car / van: 32.8% (E&W avg: 26.8%) Lone parent households (with dependent children): 8.0% (E&W avg: 6.5%) Ethnicity: White 91.1%; Pakistani 3%; Indian 1.5% Limiting long-term illness: 20.4% (E&W avg: 18.2%) General health not good : 11.1% (E&W avg: 9.2%) (Source: Greater Manchester Joint Strategic Needs Assessment) 11 Healthier Together The Greater Manchester Case for Change

12 Greater Manchester has a younger population structure than the national average with lower proportions aged over 45 than across the North West and England (Figure 1.2). Fig 1.2: Population profile, 2010 Source: ONS/ NHSIC This population profile emphasises Greater Manchester as a growing and vibrant conurbation that continues to see a rising demand on health and care services. Furthermore, this younger population structure will have an impact upon the annual birth rate with many new communities forming around economic hubs (Manchester City Centre, Media City UK) with expectations of a modern health and care system providing the right care at the right place and right time. 12 Healthier Together The Greater Manchester Case for Change

13 Health and Care inequalities Significant inequalities in health are present within Greater Manchester. Recent analysis taken from the Local Health Profiles suggests that not only do gaps in health outcomes exist between the most and least deprived populations within the Greater Manchester area, the population is generally deprived (Figure 1.3). Fig 1.3 Indices of Multiple Deprivation Source: Greater Manchester Local Transport Plan p.15 Greater Manchester comparators: 7 of the 10 Greater Manchester PCTs have significantly higher levels of internal inequalities in life expectancy than the England average, no Greater Manchester PCT has lower than average levels of internal inequalities. The male life expectancy gap in Greater Manchester is 14.4 years, the difference between the most deprived area in Manchester PCT (68.9 years) and least deprived area in Trafford PCT (83.3 years). The female life expectancy gap in Greater Manchester is 11.1 years, the difference between the most deprived area is Oldham PCT (74.6 years) and least deprived area is Bolton PCT (85.7 years). This level of variance across Greater Manchester presents a significant driver within the Greater Manchester Case for Change. The identified programme outcomes are clear that all Greater Manchester residents should have greater parity of access to high quality, safe and sustainable services to impact upon health outcomes and life expectancy. Further analysis of each Greater Manchester local authority compared to England averages in key areas shows an overall poor position for Greater Manchester (Figure 1.4). 13 Healthier Together The Greater Manchester Case for Change

14 Comparison to England average Local Authority General health Deprivation Children living in poverty Life expectancy Life expectancy gap. most and least deprived areas Year 6 children classed as obese Rochdale Generally worse Higher than average. 12,815 Lower for men and women 11.6 years lower for men. 9.9 years lower for women 20.7% Trafford Better Lower than average 6,860 Higher for women 10.6 years lower for men. 5.7 years lower for women 16.4% Wigan Mixed Higher than average 12,110 Lower for men and women 11.1 years lower for men. 8.0 years lower for women 19.3% Tameside Generally worse Higher than average 10,625 Lower for men and women 10.4 years lower for men. 8.8 years lower for women 19.7% Stockport Mixed Lower than average 8,605 Similar for men and women 11.3 years lower for men. 8.9 years lower for women 16.5% Salford Generally worse Higher than average 13,125 Lower for men and women 12.1 years lower for men. 8.2 years lower for women 23.1% Oldham Generally worse Higher than average 14,400 Lower for men and women 11.1 years lower for men 10.3 years lower for women 17.3% Manchester Generally worse Higher than average. 36,155 Lower for men and women 10.8 years lower for men. 7.1 years lower for women 23.7% Bury Mixed Lower than average 7,045 Lower for men and women 10.8 years lower for men. 8.0 years lower for women 20.2% Bolton Generally worse Higher than average 13,775 Lower for men and women 13.5 years lower for men years lower for women 21.2% Fig 1.4 Greater Manchester Local Health Profiles compared to England Average Source: 2012 Local Health Profiles, AHPO Social Care The relatively poor average health of the population of GM is not only a financial challenge to health and social care institutions; it acts as a drag to the achievement of sustainable economic growth objectives, and a barrier to the achievement of individual aspiration and ambition. Greater Manchester needs more people to benefit from growth, fewer people dependent on or unnecessarily using public services, and local services integrated around people and families and linked to quality and safe specialised services. Health and Social Care expenditure accounts for 6bn, or nearly one third, of public sector expenditure in Greater Manchester. This scale of spending is unsustainable given the financial challenges to the NHS and to local authorities in the light of demographic change and reducing budgets. Care across institutional boundaries is often fragmented and not responsive to patient/client choice and control. Actions are therefore required across a whole spectrum: 14 Healthier Together The Greater Manchester Case for Change

15 Prioritisation of interventions that improve health and well being and promote independence; Increasing the capacity of the community and voluntary sector, supporting carers, and explicitly encouraging self-care; Prioritisation of services that seek to target and prevent unplanned use of the social care system; Furthermore, the unsustainable model of care and support services is based on the unaffordable cost of admissions to residential care. The emergence of reablement and the presumption that people can get better and be independent from service again has had clear strategic influence on the practice of most Local Authorities. Similarly the presumption for direct payments and carer support is about avoiding assessing for a service toward a focus on need, self-directed solutions and independence. Local Authorities have a key wider role than social care in building stronger communities and in supported housing as a wider and more sustainable component of healthy lifestyles. Mental Health and Wellbeing Existing high levels of deprivation, the experience of the recession, higher rates of unemployment and the changing demography indicate the potential for an increased demand upon mental health services. Dorling (BMJ,2009) identified that para-suicide rates in young men who are unemployed are 25 times higher than in employed young men, and a joint paper published by the Royal College of Psychiatrists,NHS Confederation and London School of Economics (2009) noted a wide range of effects on mental health services due to the financial recession. The extent to which unemployment will increase as a consequence of the current economic challenges is unclear, but it will almost certainly increase. This will bring a correlating increase in associated social and psychiatric disorders including depression and other common mental health disorders, risky drinking behaviours, problematic substance misuse and problems associated with anti-social personality disorders. Health and Wellbeing services are currently commissioned through PCTs, however this will change as responsibility will go to Public Health leadership under Local Authority responsibility. Their approach may change and the possibility of the greater utilisation of the 3rd sector must be considered as many of the well being services provided do not involve clinically qualified staff. The Any Qualified Provider guidance re-enforces a direction of travel toward greater market and provider development. A recently launched Greater Manchester Health and Wellbeing Consortium to act on behalf of third sector organisations in order to seek, secure and manage public sector contracts underlines the importance of this issue for current and statutory providers in the area. The new mental health strategy (2012) for England details the government s expectation of parity of esteem between mental and physical health services. Changes therefore in the scope, access arrangements or of providing physical health services must consider and reflect on any impact on mental health services and ensure these are mitigated, or improved. 15 Healthier Together The Greater Manchester Case for Change

16 Transport An effective transport network is an essential catalyst to realise the potential of Greater Manchester as it connects people to places in a sustainable manner places where they can work, study, shop, relax, and access health and public services. The social and environmental geography of Greater Manchester poses complex challenges for transportation systems challenges for transportation systems. Among the most notable challenges are: Traffic congestion and parking difficulties; Longer commuting; Difficulties for non-motorized transport; Environmental impacts and energy consumption; Accidents and safety. Greater Manchester as a city region has been delegated increased autonomy from central government to create innovate ways of meeting the generic challenges posed by urbanised demands on transport. Changes to health and care services will need to respond to the Greater Manchester Local Transport Plan ( ) and ensure that any significant changes to health and care services are fully assessed in terms of transport and access. As a predominately urban conurbation, Greater Manchester has good road, bus and rail network (Figures 1.5, 1.6 & 1.7). Access to health and care services for patients and visitors remains a significant priority for the Healthier Together programme. Fig 1.5: Traffic Flows (Motorways, A & B Roads) Source: Greater Manchester Local Transport Plan p Healthier Together The Greater Manchester Case for Change

17 Fig 1.6: Core Bus Network Source: Greater Manchester Local Transport Plan p.69 Fig 1.7: Greater Manchester Metrolink and Rail Network Source: Greater Manchester Local Transport Plan p Healthier Together The Greater Manchester Case for Change

18 An understanding of why Greater Manchester s Health and care system needs to change It is clear from the snap-shot introduction that the health of our population is not as good as it should be. Greater Manchester has poorer outcomes than the England average in many areas and significant variation across our 10 Local Authorities. Deeper analysis taken from the Local Health Profiles (Figure 1.8) suggests that ten largest gaps in health outcomes between the most and least deprived populations within the Greater Manchester area are: 1. Liver disease Those in the most deprived areas are 8 times more likely to die prematurely than those in the least deprived areas 2. Mental health and wellbeing Those in the most deprived areas are 6 times more likely to experience extreme anxiety and depression as those in the least deprived areas 3. Diabetes Those in the most deprived areas are 4 times more likely to die prematurely than those in the least deprived areas 4. Quality of life Those in the most deprived areas are 3 times more likely to be experiencing extreme pain and discomfort than those in the least deprived areas 5. Infant mortality 6. Coronary heart disease Babies in the most deprived areas are 3 times more likely to die than those in the least deprived areas Those in the most deprived areas are 3 times more likely to die prematurely than those in the least deprived areas 7. Lung cancer Those in the most deprived areas are 3 times more likely to die prematurely than those in the least deprived areas 8. Stroke Those in the most deprived areas are 3 times more likely to die prematurely than those in the least deprived areas 9. Child health and wellbeing Those in the most deprived areas are 2.5 times more likely to die than those in the least deprived areas 10. Accidents Those in the most deprived areas are twice as likely to die as those in the least deprived areas Fig 1.8: Key health inequalities identified in the Local health Profiles Source: Local Health Profiles, April 2012, AHPO These unjustifiable differences in health inequalities remain persistent across Greater Manchester. There are many other indicators that can be used to highlight inequalities, however analysis related to children; who will be using and experiencing our public services for the next generation, highlights a powerful difference between a child currently born in Manchester and a child born in Stockport (Figure 1.9) 18 Healthier Together The Greater Manchester Case for Change

19 Fig 1.9 Greater Manchester Local Health Profiles: Children Source: Local Health Profiles, AHPO As Greater Manchester s communities change and develop, individual s expectations of public services are changing too. Many households have access to the internet and combined with greater social mobility is resulting in a communication and connectivity revolution that is not isolated just to younger people. Many people expect to access information about a service immediately and be able to access it with convenience (i.e. after work or at the weekend) Furthermore, this information empowerment allows our health and care providers to be reviewed and assessed against each other, and to other industries highlighting inefficiencies or poor experiences. The recently published British Social Attitude Survey highlights overall satisfaction with the way the NHS across Britain runs fell by 12 percentage points from 70 per cent in 2010 to 58 per cent in This is the biggest fall in one year since the survey began in 1983 (Figure 1.10). Fig 1.10: How satisfied or dissatisfied would you say you are with the way in which the NHS runs nowadays. Source: British Social Attitude Survey (2011) 19 Healthier Together The Greater Manchester Case for Change

20 This high level analysis can be corroborated by local patient and representative groups who report access to many services as fragmented and/or confusing. The combined impact of greater access to information with growing dissatisfaction and uncertainty of how to access health and care services highlights the current complexity of the system and lack of true integration. Many patients will receive care from a number of organisations under the umbrella of the NHS, however will often experience parts of the pathway that are not connected or duplicated. As our Greater Manchester communities have changed and developed, so has our health and care system in part response. The evolution of treatments and technology coupled with enhanced training for doctors and nurses means that many traditional services can be provided in a very different way. Patients are encouraged to take control of their ongoing management of certain conditions, often receiving care in a primary or community setting. Advancements in care often means that procedures that traditionally have meant a stay in hospital can be done more efficiently with patients being supported in the comfort of their own home. Health and care providers have started the integration journey that is allowing some of hospital sites to focus more on specialist care; seeking to consolidate excellence driven by academic research and innovative technology. Recently Greater Manchester has seen excellent results from the reconfiguration of Stroke, Heart Attack (PPCI), Neonatal Intensive Care and Major Trauma. This allows a more concentrated focus of doctors, nurses and support teams that are highly skilled and undertake complex procedures on a regular basis enhancing outcomes for patients. Greater Manchester should be established as the leading centre in the North of England for Health research strengthened by the role of the Academic Health Science Network and the alliance with the universities. This will provide opportunities for Greater Manchester research participation for our patients to ensure the first breakthrough is here and the first beneficiaries are Greater Manchester patients. 20 Healthier Together The Greater Manchester Case for Change

21 Three Key Messages to our patients and citizens Demands on the NHS and social care are growing... We can look forward to living longer which is great cause for celebration. But we need to plan ahead and make sure the NHS and local services are ready for the extra demands that older people will place on care services. Our lifestyle choices can put extra demands on the NHS, for example, poor diet, smoking and lack of exercise are contributing to long term health problems such as diabetes and obesity that need ongoing care and support. Fantastic advances in medical technology and treatment mean we can do much more to treat people, illnesses that would have been life threatening in the past are now treatable but there may be long term consequences that need ongoing care. The mix of patients moves from being a reasonably stable ratio of new cases to surviving patients to one where there are increasing numbers of survivors needing appointments and ongoing care. Expectations of the NHS are also growing; the public expect more and higher quality services. Greater access to online material, social media forums is changing the way individual s access information and expect a response 24 hours a day, 7 days a week. This rise in demand expectation is against a context of reducing resources in the public sector. The NHS and local authority services cannot continue to do what they are currently doing and therefore must look to more ambitious solutions to ensure all individuals have access to high quality, accessible, safe and sustainable services for the future. So the NHS is changing to meet these extra demands and improve the care it provides... It is recognised that the care for people with long term health conditions and older people is best provided outside of hospital where possible. People can be empowered to self care, with more care services being offered within the community or in people s own homes. The NHS and Local Authorities are providing innovative services to keep people out of hospital where possible, or get people home sooner if they do need to be admitted. We recognise that hospital is not always the answer and that for many older people hospital admission can result in loss of independence or, worse still, the risk of picking up an infection. Innovative use of new technology is allowing treatment at home and access to GPs is being improved to avoid unnecessary use of urgent and emergency care services. Within our hospitals, lives are being saved by hospitals working together to provide the best possible care. Recent changes to provide key elements of stroke care in fewer, but more specialist centres are saving around 200 Greater Manchester residents lives every year. In addition, improved treatment and rehabilitation support means that every year around an extra 300 more people are returning to their own homes after a stroke rather than needing nursing home care. Doctors and nurses have also developed the necessary expertise and have the technology to undertake more and more operations that allow patients to go home on the day of their operation. Recovery times are quicker than for more invasive procedures of the past so it is better for individuals and the NHS. A number of hospitals are working in partnership recognising that sharing resources 21 Healthier Together The Greater Manchester Case for Change

22 including creating multi-disciplinary teams and joint medical rotas is a good first step in maximising limited resources. But even more change is needed. We believe that further change is needed to respond to the sustained rise in demand, whilst striving to improve every individual s health. There is a need to do more to prevent ill health with greater focus on empowering people to take greater responsibility for their own health. This includes leading healthy lifestyles whilst also taking responsibility as a member of their community and taking responsibility for using services appropriately. There is a significant need to improve the support that is provided for people with long term conditions, especially individuals that have multiple conditions or co-morbidities. Too many people end up in hospital because appropriate services are not available in their community. Nationally, there are more than two million unplanned admissions for people aged over 65, which is equivalent to 68% of all emergency bed days. At any one time over 65 s use over 51,000 acute bed days in the NHS. Staff and patients agree that in many cases hospital is not the best place for these people to receive care but there are still insufficient alternative services, usually because funding is tied up supporting expensive hospital care. The way hospital services in Greater Manchester have evolved and are currently organised, with a hospital in each borough providing a similar broad range of services, was designed to meet the needs of the last century. It is clear that this is not suited to the way in which a broad range of individuals require care. Many of the excellent developments we have seen have arisen from local interest rather than from strategic planning. This has led to variations in the range and quality of services available in different areas, resulting in inequality of access to services in different areas. As more people receive appropriate treatment at home or in the community, those patients that do need to be admitted into hospital, especially in an emergency, are likely to have more complex needs. They are most in need of very specialist care and being assessed by a senior doctor will improve their chances of recovery. Senior doctors are not available in all specialities on site 24 hours a day, 7 days a week due to the large spread of services across Greater Manchester. This means that Greater Manchester has an inequity of provision out of hours and at weekends often leading to poorer outcomes for patients. 22 Healthier Together The Greater Manchester Case for Change

23 Exploring Variation across Greater Manchester Health and Social Care Organisations Secondary and Tertiary healthcare services in the Greater Manchester economy are provided by 9 NHS organisations (Fig 1.11 & 1.12): Org Code Org Name RBV THE CHRISTIE RM2 UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST RM3 SALFORD ROYAL NHS FOUNDATION TRUST RM4 TRAFFORD HEALTHCARE NHS TRUST RMC ROYAL BOLTON HOSPITAL NHS FOUNDATION TRUST RMP TAMESIDE HOSPITAL NHS FOUNDATION TRUST RRF WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST RW3 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST RW6 PENNINE ACUTE HOSPITALS NHS TRUST RWJ STOCKPORT NHS FOUNDATION TRUST Fig 1.11: Greater Manchester NHS Secondary Care Providers Source: AQuA Fig 1.12: Greater Manchester NHS Secondary and Tertiary Care Providers Map and PCT boundaries In addition, a range of elective services are also commissioned from a number of private provider organisations. Org Code Org Name NT4 BMI NVC RAMSAY HEALTHCARE NT3 SPIRE HEALTHCARE NPG SPAMEDICA 23 Healthier Together The Greater Manchester Case for Change

24 The commissioning of healthcare is being reorganised from 10 PCT s into 12 Clinical Commissioning Groups(Figure 1.13) which are currently planned to be: PCT CCG Code PCT Name Code CCG name 5F5 SALFORD PCT --> 01G NHS Salford CCG 5F7 STOCKPORT PRIMARY CARE TRUST --> 01W NHS Stockport CCG 5HG ASHTON LEIGH AND WIGAN PCT --> 02H NHS Wigan Borough CCG 5HQ BOLTON PCT --> 00T NHS Bolton CCG 5J5 OLDHAM PRIMARY CARE TRUST --> 00Y NHS Oldham CCG 5JX BURY PRIMARY CARE TRUST --> 00V NHS Bury CCG 5LH TAMESIDE AND GLOSSOP PCT --> 01Y NHS Tameside and Glossop CCG 5NQ HEYWOOD, MIDDLETON & ROCHDALE PCT --> 01D NHS Heywood, Middleton & Rochdale CCG 5NR TRAFFORD PCT --> 02A NHS Trafford CCG 00W NHS Central Manchester CCG 5NT MANCHESTER PCT --> 01M NHS North Manchester CCG 01N NHS South Manchester CCG Fig 1.13: Greater Manchester CCG PCTs to CCG Source: AQuA Finally, Social Care needs are commissioned by a number of Local Authorities including: Org Code Org Name BL BOLTON BP OLDHAM BR SALFORD BN MANCHESTER BQ ROCHDALE BS STOCKPORT BW WIGAN BU TRAFFORD BT TAMESIDE BM BURY Fig 1.14: Greater Manchester Local Authority Social Care commissioners Source: AQuA There is a sophisticated and well developed system of monitoring and evaluating of all elements of the Greater Manchester health and care system that is reported locally, regionally and nationally. A number of key data sets can be utilised to provide a snap shot analysis of Greater Manchester providers that further empathises the strategic need to change. 24 Healthier Together The Greater Manchester Case for Change

25 Mortality Across the Greater Manchester health economy, as in the rest of the country, rates of death from circulatory diseases, including stroke and coronary heart disease, and cancers, particularly lung have fallen over recent years. However, despite these reductions, rates across GM health economy remain at or above the regional and national averages. Furthermore, that gap is, in some cases widening rather than closing as the GM health economy fails to keep pace with the reductions in disease experienced across the rest of England Analysis shows that across the GM health economy: Actual and standardised mortality rates (SMR) have reduced over the last 17 years (Figure 1.15, Figure 1.16). An SMR is a way of comparing the number of the observed deaths in a population with the number of expected. It is expressed as a ratio of observed to expected deaths, multiplied by 100. The England numbers all equal 100 and so are not shown. The Greater Manchester area has a standardised mortality rate for all causes of mortality that is at or above the England average with the exception of Trafford PCT which is slightly under. In addition, the areas covered by Salford, Bolton, Oldham, HMR, T&G and Manchester PCTs are also above the North West regional figures (Figure 1.16). Age standardised data suggests that around potential years of life were lost as a result of higher than expected all-cause mortality between 2006 and 2009 This equates to about 5300 years of life lost each year (Figure 1.17). The rate of reduction in deaths across the GM health economy is lower than in the North West as whole and in England (Figure 1.18). Fig 1.15: Number of deaths, all causes, , all persons aged under 75 Source: NHS Information Centre for Health and Social Care Fig 1.16: Standardised mortality rates, all causes, , all persons aged under 75 Source: NHS Information Centre for Health and Social Care 25 Healthier Together The Greater Manchester Case for Change

26 Fig 1.17: Potential years of life lost from all causes of mortality, Number of deaths, all causes, , all persons aged under 75 Source: NHS Information Centre for Health and Social Care Long term change (1993 to 2009) Last 10 years Fig 1.18: % change in number of deaths, all causes, all persons, aged <75 Source: AQuA Analysis Last 5 years ( ) ( ) Year on Year % change in deaths from all causes (all persons, aged <75) GM health economy -2.03% -1.96% -1.11% North West -2.27% -2.21% -1.30% England -2.16% -2.14% -1.22% Reducing in-hospital mortality Summary Hospital-level Mortality Indicator (SHMI) is the ratio between the actual number of patients who died following a hospital treatment and the number that would be expected to die. The expected number of deaths takes into account a number of factors including the average England death figures for a given procedure and the characteristics of the patient concerned. It covers all deaths reported of patients who were admitted to acute, non-specialist Trusts and either die while in hospital or within 30 days of discharge. The NHS Information Centre for Health & Social care advise that the SHMI requires careful interpretation, and should not be taken in isolation as a headline figure of ant Trust s performance. In their view it is best treated as a smoke alarm' and when used in conjunction with a range of measures can provide an indication of whether individual Trusts are conforming to the national baseline of hospital-related mortality. Further analysis of Hospital Standardised Mortality Ratios (HSMR) can be presented to enhance the overall picture for each provider unit. 26 Healthier Together The Greater Manchester Case for Change

27 Analysis of Greater Manchester SHMI(Figure 1.19) shows that 6 of the 9 providers in GM have a high SHMI despite their similar levels of both actual deaths and the reductions in actual death rates they have achieved over the last 5 years. Fig 1.19: Summary Hospital-level Mortality Indicator (SHMI), April 2010 March 2011 Source: NHS Information Centre for Health and Social Care Crude death rates for patients admitted on Saturdays and Sundays and for deaths on Saturdays and Sundays are higher than on weekdays. Crude death rates (e.g. the number of deaths per day divided by the number of discharges or admissions per day x 100) are sometimes used to assess the relative safety and effectiveness of weekend services. It is true that these measures show higher crude death rates at the weekend. However, it must be noted that the number and pattern of weekend discharges and admissions is markedly different to that during the week and therefore the denominator (number of discharges or admissions) will have a major impact on the difference in rates. 27 Healthier Together The Greater Manchester Case for Change

28 Quality and Safety Regular monitoring of Acute Trust quality and safety metrics highlights variability across Greater Manchester (Figure 1.20). Although a snapshot of performance it is recognised that variance between providers should be minimised to ensure that all patients receive the expected level of care across GM. 28 Healthier Together The Greater Manchester Case for Change

29 Fig 1.20 AQuA Acute Trust Quality Dashboard Q1 12/13 Source: AQuA Observatory 29 Healthier Together The Greater Manchester Case for Change

30 Finance and Workforce Greater Manchester has a well established Quality Innovation Productivity and Prevention (QIPP) programme that is seeking to ensure all resources are effectively utilised and required savings can be reinvested to manage the increasing demand. The financial challenge within Greater Manchester (Figure 1.21) presents one of the largest strategic drivers requiring significant change within Greater Manchester. Fig 1.21 NHS Greater Manchester Financial Challenge Source: Service Transformation PMO A large proportion of the health and care economy relates to the employment of staff which provides the high levels of care to patients and their families. Figure 1.22 provides a breakdown of Medical, Dental, Qualified Nurses, Midwives and Health visiting staff in Greater Manchester secondary care providers. Fig 1.22: Greater Manchester Provider Establishment Source: AQuA 30 Healthier Together The Greater Manchester Case for Change

31 It is imperative that Greater Manchester fully utilises the high skilled and trained workforce to maximise their potential. There are positive examples of organisations starting to federate and share workforces to respond to internal and external pressures. Furthermore, the priority by providers, the North West Deanery and nursing schools to ensure high quality training to doctors, nurses and midwives must be included within any reconfiguration of services. The Greater Manchester health and care estate is a mixture of modern purpose built facilities and inherited traditional hospital buildings that were built for the last century. Estate maintenance and repair costs provide ongoing cost pressures, especially when seeking to provide innovative technological solutions. It is imperative that all estate is utilised in an efficient way that maximises the initial capital investment and subsequent running costs. Greater Manchester has started to develop more innovative options for treatment out of core house (8am- 6pm), however there is a significant amount of estate that could be utilised outside normal working days. The strategic challenge for the health and care system is to change the traditional Status Quo view of funding the health and care system and move to a New Success model that will ensure integrated financial sustainability whilst allowing focus on joint outcomes. Social Care Primary & Community Hospital 30p 20p 50p Status quo 35p 25p 40p Old success 85p New success 15p Joint Outcomes In practice, this new approach to financial vitality should focus on new investment models for public sector organisations in Greater Manchester. Other health economies across the world have developed innovative models where joint outcomes for patient groups are shared across a series of providers with a single accountable provider (Corrigan & Laitner, 2012). This enhances the ability of providers to achieve efficiencies whilst recognising the political impact associated with changes to public sector expenditure. 31 Healthier Together The Greater Manchester Case for Change