Eastleigh Southern Parishes Locality Plan 2016/ /19. August 2016

Transcription

1 Eastleigh Southern Parishes Locality Plan 2016/ /19 August

2 Contents 1. Introduction to our Eastleigh Southern Parishes Locality Plan 2. Overview of Eastleigh Southern Parishes Locality 2.1 Our community 2.2 Our healthcare community 2.3 Our spending on healthcare 3. What are our patients needs? 3.1 Demographics 3.2 Who did we talk to? 3.3 What have we heard? 3.4 What do our patients need? 4. Our Priorities 4.1 What are our key priorities? 4.2 How will we deliver our priorities? 4.3 What difference will we make for patients? 4.4 How will our plan fit with broader strategies? 5. Next steps 6. Contact details 2

3 Our VISION is to commission high quality patient-centred healthcare which is equitable and offers patients choice and control over their health - Quality Services, Better Health. 3

4 1. Introduction to our locality plan Welcome to our Eastleigh Southern Parishes Locality Plan, which was created and informed following engagement and consultation with our five locality practices, clinicians and managers from partner and provider organisations, patient representatives and a range of other stakeholders. Our plan is based on needs data and sets out our priorities for action to improve the physical and mental health and wellbeing of our population over the next three years. We have sought to identify and address within our plan areas of variation in quality, health outcomes, availability of services, capacity of service provision, and areas for the development of new models of care. We have identified the challenges we must overcome and defined the actions we need to take in order to ensure the best outcomes for the population we serve. Our plan was created under a collaborative process, for which we offer thanks to all contributors. Going forwards, we will continue to work collaboratively to find solutions to any identified challenges, and to implement actions to deliver our priorities. We have many achievements to celebrate. The Care Navigator service provided by our local GP Federation, Eastleigh Southern Parishes Network Ltd, which supports our patients to access the health and social care support they need, has recently received a positive independent evaluation and, as a result, has been recommissioned for a further three years by our CCG. 4

5 1. Introduction to our locality plan The priorities described in our locality plan are aligned to the work streams being developed with local practices who have all opted for fast follower status as part of the Southern Hampshire Vanguard Multi-specialist Provider (MCP). The MCP are working together to address issues such as: Designing sustainable approaches to enable practices to better manage demand for on-theday access to primary care Developing extended primary care teams built around general practice offering seamless access to community services Setting out practical measures to prevent where possible unplanned admission to hospital for patients diagnosed with a range of Ambulatory Care Sensitive (ACS) conditions, e.g. asthma, diabetes. Our plan places the sustainability of primary care at its core. The current pressures arising in particular from population and demand growth, patients living longer often with multiple long term conditions and difficulties in recruiting and retaining clinical staff are well documented. Our practices in Eastleigh Southern Parishes are not immune from these pressures. We set out in the plan how we will address our priority to both sustain and support change in primary care provision in order to help meet these challenges. 5

6 Overview of Eastleigh Southern Parishes locality Our community Our healthcare community Our spending on healthcare 6

7 2.1 Our community The area defined as Eastleigh Southern Parishes is defined for local government administrative purposes as two areas; Bursledon, Hamble and Hound & Hedge End, West End and Botley. The area is predominately sub-urban, reflecting pressures expected for a location boarding a major city, and is bordered to the West by Southampton City, to the South East by Fareham borough and to the north by Winchester. The population living in our area comprises of: Community Population Household Dwellings Bursledon, Hamble and Hound 18,697 8,115 Hedge End, West End and Botley 36,634 15,231 LOCALITY TOTAL 55,331 23,346 Source: 2011 Census Data 7

8 2.1 Our community The number of patients registered with practices in Eastleigh Southern Parishes as at 1 April 2016 is below: Practice Registered List Size Practice Registered List Size Bursledon Surgery 3,766 Blackthorn Surgery 12,439 Hedge End Medical Centre 13,463 St Luke s & Botley 12,724 West End Surgery 7,428 ESP TOTAL 49,820 NB: Any discrepancy between the registered list size and census population is due to the choice of some residents in our area choosing to register with practices not located in our area this is usual for patients living on the fringes of any defined boundary. Patients registered at branch surgeries are included in the main surgery figures. The draft local Plan has yet to be approved by Eastleigh Borough Council. The draft plan proposes options for significant housing development that would increase the population of our community and create additional demand for health and social care services. The council need to provide over 5,000 new dwellings by 2021 which could result (estimated at 2.37 person per dwelling on average based on 2011 census) in c.12,000 new patients potentially seeking registration with a practice in or serving our community. 8

9 2.2 Our healthcare community The Eastleigh Southern Parishes (ESP) locality sits within the South directorate of NHS West Hampshire CCG and is a single natural community covering West End, Hedge End to Bursledon & Hamble. Our health and social care community includes: Five GP partnerships who together care for c.50,000 registered patients from 6 surgery premises Three acute hospitals in Southampton, Winchester & Portsmouth One community hospital - Moorgreen Hospital One GP Federation Eastleigh Southern Parishes Network (ESPN) Limited One fast follower Better. Local. Care. Multi-specialty Community Provider Eastleigh Borough Council Hampshire County Council 9

10 2.3 Our spending on healthcare 2015/16 Eastleigh Southern Parishes Expenditure '000 Values Row Labels NHS Acute Non NHS Acute Mental Health & Communit y Providers Non Acute Primar y Care Prescribing Eastleigh Southern Parishes 26,251 2,868 8,589 7,590 5,890 7,410 Grand Total 26,251 2,868 8,589 7,590 5,890 7,410 The table provides illustrative data on the allocation of CCG spending by provider/sector for our patients during the period April 2015 to March /16 Expenditure 'm Eastleigh Southern Parishes NHS Acute Non NHS Acute Mental Health & Community Providers Non Acute Primary Care Prescribing NHS Acute means hospital based services Non Acute includes Continuing Healthcare/Special Placements, CHC Risk Pool Contribution, Better Care Fund, CAMHS (Mental Health), Other S256 Schemes, Funded Nursing Care, Voluntary Organisations, Private Providers, Patient Transport

11 What are our patients needs? Demographics Who did we talk to? What have we heard? What do our patients need? 11

12 3.1 Demographics Children & young people Current Population 23.4% Expected Change Working age people 58.3% -0.1% Older people % +26.1% Older people % +43.0% The Locality has a young demographic but is also experiencing a process of demographic ageing. This has significant implications for health and social care services, with the need to invest in the health of younger people from an early age to ensure a healthy transition from adolescence into adulthood, and thus promote healthy active ageing. As the population ages, it will put pressure on health and social care services, because older people are more likely to have long term conditions and multiple disabilities. Also people over the age of 65 account for more than 60% of hospital inpatient stays and most health and social care costs. Source: National General Practice Profiles - PHE, 2015 Population forecasts are not available at practice level but it is likely that the ageing population will continue to grow, especially the oldest old.

13 3.1 Demographics As an overall locality, our population has a similar demographic profile to the England profile. However, analysis at a more local level reveals needs across the locality will differ as West End has more older people than the rest of the locality, and St. Luke s & Bursledon more younger people. Evidence suggests our ageing demographic means more are living with significant comorbidities which account for more hospital inpatient stays, so we need to focus on ageing well. Our locality has variable levels of deprivation affecting older people and children - with the Bursledon & Blackthorn patient populations significantly more deprived than our CCGs average. As the burden of disease rises disproportionately with deprivation, this population will have the greatest need. 13

14 3.2 Who did we talk to? Our plan has been developed following informal and formal discussions with a range of our partners, which included smaller meetings with key staff from Eastleigh Borough Council; regular conversations with our local councillors; and at monthly locality commissioning meetings held with representatives our GP practices. A wider Locality Plan Development Event was held on 18 May 2016, and had attendance from a range of our stakeholders with representation from the following organisations: One Community Locality GP Practices Southern Health NHS FT Better. Local. Care. Multi-Specialty Community Provider (MCP) Eastleigh Southern Parishes Network Limited University Hospital Southampton FT Eastleigh Borough Council Adult Services, Hampshire County Council Public Health team, Hampshire County Council Community Independence Teams We thank all individuals and groups for their support and insight. We commit to continuing this dialogue as we progress to the delivery of our plan and our priorities. 14

15 3.3 What have we heard? We reviewed all of the available evidence and considered feedback obtained from our dialogue with practices and stakeholders; from this we summarise key challenges for our health and social care community: Overarching Growing pressures on ability to maintain high quality service provision in the context of growing demand, population growth, growth in the expectations of the public and funding pressure on all public services Lack of clear levers to ensure that NHS finances follow the patient as new models of care are established, e.g. from hospitals to new community based services Integration Inconsistent shared access to patient medical records and care plans across health & social care in support of joined-up care Variability of access to patient-centred care plans of consistent high quality commonly supported by all health & social care practitioners Lack of integration of a variety of community services located in different places each operating with separate budgets and specifications Service improvement Evidence of inconsistent frailty care model in existence across the locality, e.g. geriatrician at the front door Lack of suitable/available community-based step-up/step-down care to bring care closer to the patients home at the point of need Inconsistency of timely access to child and adult mental health services 15

16 3.3 What have we heard? Infrastructure Lack of suitable premises/facilities to support more community-based service provision Absence of detailed review of all primary and community service premises to ensure that necessary facilities exist in the community to support our priorities for the delivery of new models of care Concern that existing service capacity will struggle to meet population growth related to anticipated housing development in the locality Filtering demand Variable patient information and education to manage demand for access to services, e.g. signposting to more appropriate health, social or other providers of support to individuals and families Sustainability Difficulty in recruiting and retaining a workforce with the skills necessary across both health & social care sectors Implementing change to support sustainable primary care providers to maintain access to both urgent and routine care Supporting carers Difficulty in encouraging carers to identify themselves as such, particularly unpaid carers looking after loved ones, to enable the offer of support to carers to manage their own health needs Addressing variation Rapid response/same day access is not offered by all health & social care providers Responding to increasing and variable care/nursing home needs and demands on primary and secondary care some of which is related to varying care home staff training and protocols 16

17 3.4 What do our patients need? 1 - Prevention: healthy ageing and self care Promotion of healthy lifestyles for people of all ages (eating healthily, keeping active, not smoking) is essential for healthy ageing - adding Life to Years and reduction in developing multiple chronic conditions, meaning the risk of disability, frailty and loss of independence later in life will fall. Need to encourage older people to eat well and exercise as improved nutrition, hydration and strength/balance can have a significant impact on frailty, falls, independence and hospital admissions. Support for structured brief interventions in primary care which can lead to changes in behaviour, and recognising the importance of community-based services through social prescribing. Supporting primary care to detect long term conditions early, enabling patients to manage own health utilising technologies such as remote monitoring, and also digital solutions such as mobile apps. 17

18 3.4 What do our patients need? 2 - Improvements in ACS Conditions pathways Ambulatory care sensitive (ACS) conditions are chronic conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management, such as vaccination; better self-management, disease management or case management; or lifestyle interventions. Examples include congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension. Amongst the highest admission rates for ACSCs in ESP were the following: COPD, Diabetes Complications, and Dehydration (related to Acute Kidney Injury/Chronic Kidney Disease) so we need to review these ACSC pathways of care and identify/work on areas of improvement. Analysis suggests 4,516 Eastleigh Southern Parishes patients are on medication for one or more ACS conditions, without a formal diagnosis Admissions data suggests the locality has comparatively high levels of admissions versus other CCG localities for diabetes, anaemia, COPD and influenza, pneumonia and vaccine preventable conditions, but low levels for convulsions and epilepsy 8% of admissions of Eastleigh Southern Parishes patients are from care homes, rising to 15% of COPD admissions and 15% of admissions for Pyelonephritis/UTIs. 18

19 3.4 What do our patients need? 2 - Improvements in ACS Conditions pathways The table below shows indicative emergency admissions for each ACS condition that could be avoided if WHCCG were to achieve in line with the best performing CCGs on emergency admissions (10 per 1000) ACS Condition Annual Reduction in NEL Admissions 2.3i Angina 4 2.3i Asthma 8 2.3i COPD i Congestive Heart Failure i Convulsions and Epilepsy i Diabetes 4 2.3i Hypertension 1 2.3i Iron Deficiency Anaemia 2 3a Angina 0 3a Cellulitis 13 3a Convulsions and epilepsy 7 3a Dehydration and gastroenteritis 18 3a Dental conditions 1 3a ENT infections 18 3a Flu, pneumonia & vaccine preventable 19 3a Perforated/bleeding ulcer 5 3a Pyelonephritis and kidney/utis 25 Annual Reduction in NEL admissions 160 Indicative savings FYE

20 3.4 What do our patients need? 3 - Integrated, responsive frailty care services Our ageing population continues to grow, so therefore we need to plan for health & social care services that enable people to live independently and access care at the right place at the right time. The success of previous services (e.g. Rapid Response) and pilots of additional community services (e.g. Care Navigators and Enhanced Recovery & Support at Home) need to be incorporated into the vision of an Extended Primary Care Team - a single, cohesive and responsive community service that works closely with community-facing geriatricians to manage complex and frail patients. 20

21 3.4 What do our patients need? 4 - Accessible, sustainable, good quality primary care services There has been increasing strain on primary care, both nationally and locally, which has led to a range of issues including: difficulties in recruiting and retaining GPs and allied healthcare professionals increased patient demand and expectations increases in the volume of patients with complex/multiple health needs increased work associated with new care homes being built in the area Our growing and ageing population with complex multiple health conditions means that personal and population orientated primary care will be central to the maintenance and development of the locality healthcare system. To ensure the future provision of accessible, sustainable, good quality primary care services for patients, we will seek to implement new models of care, supported by a review of local service provision in the community including Moorgreen Hospital, seek to release the benefits of primary care working at scale, and make use of new technologies in order to manage demand, improve access to services and support patients in the management of their own health. 21

22 3.4 What do our patients need? 4 - Accessible, sustainable, good quality primary care services In developing new models of care to meet the needs of patients we will seek to: Redesign access to primary care creating GP led clinical teams with a mix of skills and disciplines, utilising new technologies to manage patients who need same day appointments and freeing up GP time to properly support those patients with more complex needs. Develop Extended Primary Care Teams joining up the care provided by professionals who support the same patient, pooling the resources of primary care, community and mental health services, pharmacists, social care and the voluntary, community and social enterprise sector. Bring specialist support nearer to patients in their communities reducing the time taken to access specialist input and reducing the number of separate steps in care pathways. Promote prevention and self-management supporting people to manage their own health, linking patients with social support systems in their community and identifying when a non-clinical intervention will provide the best experience and outcomes for patients. 22

23 3.4 What do our patients need? 4 - Accessible, sustainable, good quality primary care services In seeking to release benefits attainable from primary care working at scale, we will explore options to enable accessible, sustainable, good quality primary care: Economies of scale practices creating common policies and procedures once, sharing work between each other and combining purchasing power to achieve best value from available resources Quality improvement sharing professional development, clinical governance and service improvements and in-house expertise to benefit all practices Workforce development - providing new opportunities to train and support staff, improving resilience and enabling new ways of working Enhancing care and new services using collaboration at scale to make possible improved access, introduce new members of the workforce, and provide innovative care in ways which may not be possible at the scale of a single practice Resilience helping practices to improve resilience through sharing back office functions, developing portfolio roles to aid recruitment of GP and support staff and creating shared pools of specialist staff. 23

24 3.5 Moving to Wider Primary Care at Scale

25 Our Priorities What are our key priorities? How will we deliver our priorities? What difference will we make for patients? How will our plan fit into broader strategies? 25

26 4.1 What are our key priorities? 1. Integrated & Responsive Frailty Care Services Providing a high quality, holistic, integrated and responsive community service which works closely consultant geriatricians to manage stable & unstable frail patients. 2. Prevention: Healthy Ageing and Mental Wellbeing Working with our partners on the identified health promotion areas in each age group: self-harm, obesity and exercise for children & young people ; obesity, exercise and smoking for adults in their middle years; and good nutrition and exercise for older people. 3. Improvements in Ambulatory Care Sensitive Condition Pathways Further improving the identification and management of patients with COPD, Diabetes, Dehydration & Influenza across whole pathways to reduce rates of unplanned admission to hospital. 4. Sustainability of Accessible Good Quality Primary Care Services Explore new models of care including Working at Scale and new technologies to create capacity in general practice; manage patient demand; and ensure the future sustainability of primary care. 26

27 4.2 How will we deliver our priorities? Priority 1 - Integrated & responsive frailty care services Workstream Actions Outcome 1. Community Signposting Increased signposting by primary care to existing community services to provide mental and physical health & wellbeing support for frail patients and their carers, from dementia support, to information on respite care, and local gardening services. Utilisation of social prescribing to improve the quality of life of stable frail patients (e.g. reduce social isolation) and prevent their deterioration, recognising the importance of carers in supporting frail patients in their own homes. 2. Extended Primary Care Teams Work with partners to strengthen and improve community care services including across the primary/secondary care interface Reduction in the number of non-elective admissions among the top 5% unstable frail, complex group of patients Continue to engage via the locality MCP with programmes to facilitate the development of extended primary care teams 3. Delayering Specialist Care Increased access to specialists in community setting 4. Technology Locality roll out of IT system-interoperability tools (e.g. MIG, Vision 360) and support the development of the Hampshire Health Record 5. Falls Prevention Support schemes that promote better balance, strength and nutrition in older people 6. End of Life Care Locality review of EOLC services and support including patients/carers seeking advice; night sitting; and the hospice-at-home model. Delivery of community-based carousel clinics providing easier access to specialist support and reducing the number of separate steps in care pathways Improved sharing of patient care plans, escalation plans and patient records among all care providers Reduction in number of non-elective admissions due to falls Increase in number of patients with well coordinated care in their final stage of life, dying in their preferred choice, with access to specialist advice & support 27

28 4.2 How will we deliver our priorities? Priority 2 - Prevention: healthy ageing and mental wellbeing Workstream Actions Outcome 1. Healthy ageing Work with partners, including Public Health services and schools to increase awareness of benefits of maintaining a healthy weight and regular exercise Increased promotion by practices of the benefits of healthy weight and regular exercise and referral to appropriate local services (e.g. Health Works, Slimming World/Weight Watchers) 2. Mental health Locality review of local child & adult mental health provision, including IAPT, the new CAMHS, and the new Hampshire Youth Access service providing counselling, therapeutic groups and online resources for children aged Reduction in levels of obesity among young people and adults Reduction in conditions related to unhealthy lifestyles, e.g. Type 2 diabetes Identify service gaps and areas for improved partnership working towards reducing deliberate self-harm among young people and adults. Closer working with Hampshire County Council to increase mental health education in schools and developing closer links with Health Visitors and School Nurses by working with Public Health and Southern Health. 3. Carers support Practices to set up a 'Carers Corner' with resources and information on self-identification for carers Carers reporting improved support to help them to continue in their vital role Practices to continue to read code information on their patients' carers and offer practical solutions to meet carers health needs, e.g. joint visits or sequential appointments Practice to offer seasonal flu vaccination to all identified carers 28

29 4.2 How will we deliver our priorities? Priority 3 - Improvements in ACSC pathways Workstream Actions Outcomes 1. Influenza Practices share draft Flu Plans each year and agree/implement effective strategies to achieve vaccination target levels set out annually by Public Health England Practice and community care nursing teams agree, in advance of the flu season, and implement a joint strategy to maximise the offer of and delivery of Flu vaccine to all housebound patients 2. COPD Primary care supported to improve case finding by: Running GRASP-COPD tool. Reviewing patients using inhalers without a diagnosis. Primary care supported to optimise COPD management in primary care by: Ensuring newly diagnosed patients have education on inhaler technique and reviewing this at their annual review. Encouraging patients to stop smoking, attend pulmonary rehab and improve their nutrition, as appropriate. Encouraging patients to self-manage using new technologies e.g. my COPD and support groups as appropriate. Agreeing a self-management plan with each patient including provision of rescue medication, if appropriate. Accessing CIRS team for advice/referral for patients who become difficult to manage in primary care. Referring patients with acute exacerbations to secondary care, as necessary. Locality Commissioning Team to work with secondary care to explore the management of COPD patients with acute exacerbations in an ambulatory care setting to avoid unnecessary hospital admission. Year on year increases in both individual practice and aggregate locality level flu vaccination rates for all target at risk patient groups Reduction in number of non-elective admissions to hospital due to seasonal influenza Improved quality of life of patients with diagnosed COPD Reduction in number of non-elective admissions to hospital due to COPD Scope and develop a business case for a communitybased hub for ambulatory emergency care pathways 29

30 4.2 How will we deliver our priorities? Priority 3 - Improvements in ACSC pathways Workstream Actions Outcome 3. Dehydration/ Acute Kidney Injury (AKI) Practices supported in identification of patients at high risk of AKI including: Presence of chronic kidney disease, diabetes, heart failure Age over 65 years Hypovolaemia and nephrotoxic combinations of medications Develop process to ensure clinical care systems flag high risk patients Develop and support protocols to aid clinical decision making when accessing and managing acutely unwell patients at risk of AKI, dehydration and admission Reduction in non-elective admissions to hospital due to dehydration/acute kidney injury (AKI)/chronic kidney disease (CKD) Undertake strategic business case for the provision of ambulatory emergency clinics in a community setting 4. Diabetes Practices to support prevention and early identification by: Discussing weight loss opportunistically with patients BMI >30/central obesity. Engaging in schemes by partners (e.g. Public Health) to identify pre-diabetics and prevent progression. Undertaking HbA1C/fasting glucose on those presenting with recurrent infections e.g.: candidiasis and boils. Routine testing of groups at high risk of developing diabetes including patients over 40s with high hypertension, gout; PCOS; as well as those with a strong family history, blacks and South Asians. Ensuring recall systems are in place to annually test patients who have had gestational diabetes or abnormal GTTs. Primary care supported to optimise diabetes management in primary care by: Ensuring tight blood pressure control <140/80. Ensuring individual HbA1C targets are met. Management of appropriate patients in the community Reduction in the prevalence of diabetes and its complications Reduction in non-elective admissions due to diabetes 30

31 4.2 How will we deliver our priorities? Priority 4 - Sustainability of accessible good quality primary care services Workstream Actions Outcome 1. Prevention & self management 2. Extended Primary Care Teams 3. New Models of Care Offer options to patients to help them self-manage their condition through technology enabled care services e.g. telehealth Explore and implement tools to encourage selfmanagement of minor ailments, via econsult (webbased access to consultation with a GP), or similar initiatives Continued commitment to establishing extended primary care teams to strengthen the provision of community care services for patients living in their own homes and in care homes Explore options for the delivery of more accessible primary health care, such as local Primary Care Hubs that employ allied health professionals, work at scale across practices and have the capacity to offer extended hours opening where required Empowering patients to take control of their own health Reduction in demand for on-the-day access for minor, selflimiting conditions Effective locality delivery of electronic consulting platform Providing GPs with support to manage complex patients. Reduction in unplanned hospital admissions of elderly frail, complex patients Ensuring the future sustainability of Primary Care by making it an attractive career choice with benefits such as portfolio working Effective utilisation of the skills of allied health professionals in the delivery of primary care. Improved capacity for provision of access to urgent on-the-day services 4. Estates/facilities Develop strategic business cases for the development of a primary care Hub(s) within or supporting the locality, e.g. Moorgreen Hospital and Eastleigh Health Centre Undertake a strategic review of the health and social care estate within the locality to ensure it remains aligned to our priorities and future need Provision of suitable premises to support the delivery of sustainable primary care services at scale and new models of care, e.g. Extended Primary Care teams, de-layering of specialist support 31

32 4.3 What differences will we make for patients? Priority Area Differences made for patients Preventing illness and supporting patients to self care Self care Supporting people to address lifestyle factors that increase our locality population s risk of ill health by: Utilising healthy lifestyle advice through the use of technology and using digital solutions and apps to support people to manage their long term conditions. Undertaking case finding to enable patients to access the right support and treatment earlier. Further utilising the role of the care navigators to link people to the wealth of community-based local support Taking a whole person approach in every interaction between patients and care professionals Making Every Contact Count. Empowering patients to draw on their skills, abilities and circles of support Information technology - We will support our patients to monitor and manage their own health and long term conditions via the use of remote monitoring devices, possibly available via phone apps, and by access to on-line healthcare advice including signposting to the most appropriate source of help. We will enable the sharing, with appropriate patient consent, of relevant information within medical records between each clinical service involved in the assessment and treatment of our patients; making available the right information at the right time. Already, all of our patients can opt to make GP appointments and reorder prescriptions on-line with their practice website. In future, our adult patients will also be presented with options for a secure consultation on-line with their GP. Consultations with a GP or other healthcare professional will increasingly be available via video link or Skype; particularly in the period outside of normal practice opening hours. Patients will have the option to request a consultation with their GP via a web-based interface e.g. e-consult. Patients feel supported to take charge of their own care through education, regular reviews and the use of new technologies. If a patient s condition deteriorates, they will know what to do and who to contact for advice and support. 32

33 4.3 What differences will we make for patients? Priority Area Differences made for patients Supporting patients living with long term conditions Improving direct access to treatment - Increasingly, with support from extended Primary Care Teams, our patients will follow appropriate care pathways that allow for direct access to assessment/diagnostic tests/treatment. We will work with specialist colleagues to increase the availability of certain GP direct access diagnostic tests reducing the need for patients to be referred to a hospital first for diagnostic testing. This would provide opportunities to locate some types of diagnostic tests in the community, e.g. x-ray, ultrasound, ECG, thereby reducing the need for many of our patients to travel to hospital for tests. Ambulatory care sensitive conditions we will seek to support Primary Care to further improve the identification and management of patients with these conditions, so patients have clear escalation plans and are aware what to do if their condition deteriorates. We will also work to reduce the number of unplanned hospital admissions related to these ACS conditions, bringing WHCCG in line with the best performing CCGs nationally for ACSC emergency admissions (10 per 1000). Providing access to diagnostic tests in a community setting Treating and rehabilitating patients faster Reducing demand for GP appointments Reducing the number of steps in care pathways Patients and professionals will know how and where to access the right care and support, first time, in a setting as close to the patient s home as possible Patients will have access to a range of appropriate high quality services accessible in their local community, treated by the most appropriate clinician for their care. 33

34 4.3 What differences will we make for patients? Priority Area Differences made for patients Delivering high quality care for our frail patients Supporting independence Supporting older/frail patients to remain as independent as possible in their own homes with appropriate patient-centred health and social support, and the knowledge of the availability of rapid community response, short-stay hospital back up and suitable alternative care settings when the need arises Carers Support Recognising that much of the care is delivered by unpaid carers, we will offer information and support to carers, and work to ensure that carers are supported to look after their own health. Dementia - Offering advice and support to improve lifestyle choices in preventing dementia. Support GP practices to become dementia friendly and support campaigns to convince people concerned about their memory to come forward to their GP. End of life care Implementation of locality service specification for End of Life Care. Reduce the number of falls in older people 2% year on year reduction in number of injuries due to falls in those aged 65+ Improved identification of paid and unpaid carers Greater support for carers own health Access to dementia advice and support at the right time Timely access to dementia assessment Access to EOLC advice and support for patients and carers Patients supported to die in their place of choice 34

35 4.3 What differences will we make for patients? Priority Area Differences made for patients Ensuring primary care is sustainable for the future Strategic site hubs Community services will remain accessible closest to where patients live, but to share available workforce, cost efficiency, clinical supervision and the complexity of service offered, some services will be provided at the level of clinical hubs. Hubs can be physical or virtual - with specialist staff offering clinics across the locality on a rotational basis. We will consider local options for hubs in Eastleigh town and Moorgreen Hospital, which are able to offer a wider range of services and diagnostic tests. High quality primary care services local primary care services are highly rated by our patients, and we will continue to secure the sustainability of these in the future, achieving good ratings in the GP Patient Survey. Have access to more services out of hospital Be assured that those services have the capacity to keep pace with growth in both demand and our patient population Know we have a potential base from which to support the delivery of access to GP services during 8am to 8pm over seven days of the week High patient satisfaction with the quality of primary care services they receive 35

36 One Team programme GP Transformation Stakeholders and patients 4.4 How will our plan fit into broader strategies? Strategy Hampshire and Isle of Wight Sustainable Transformation Plan West Hampshire CCG Operating Plan Delivery L Better Local Care Long term conditions New models of care Primary care Locality Plan Safeguarding Urgent & emergency Care Safe, patient-centred quality care Local Authority Voluntary Sector Prevention & self-care Out of Hospital NHS constitution standards Equity & parity of esteem Mental health & learning disabilities Children & Maternity Incentives Quality progression Scheme CQUINs (local and national) Prioritising Locality Workshop Commissioning cycle and intentions Identifying needs Operating Plan Benchmarking: Public Health Health profile Local Intelligence Better Local Care events Feedback from service users Analytics CSU Business Intelligence HHFT review National Guidance NHSE s Five Year Forward View NHSE s General Practice Forward View Vision & values Local drivers for change Commissioning strategies Aims, objectives and KPIs NHS RightCare Commissioning for Value Atlas of Variation National Benchmarking Network

37 5. Next steps Work is underway to draft and agree the detailed work plan which will outline the delivery of our priorities as defined in this Locality Plan. We will ensure on-going dialogue with both our practices and stakeholders to support the implementation of our work plan to deliver our priorities, and the sharing of success and lessons learned during the term of the plan. Close working with our practices and stakeholders in the delivery of our locality plan to ensure achievement of our priorities through joint working Informal discussions to share the plan are underway, with more formal presentations planned at the Eastleigh Health & Wellbeing Board on 15 September Engagement with patient representative groups is planned via both Hampshire Healthwatch and each practices own Patient Participation Group (PPG). We will convene further events in May 2017 and May 2018 with our wider stakeholders to inform progress against delivery, and where necessary, use the opportunity to re-evaluate our direction of travel. Report on progress will be made and actions taken via monthly locality meetings with representatives of our locality practices. We will determine the most effective forms of seeking feedback from patients and service users, informed by our equality impact, as part of a balanced assessment of demonstrable improvements made in the quality of care experienced. Our plan is set for a three year term but the influence of change is inevitable and we recognise the need to reassess progress, to tackle obstacles creatively and refresh our plan periodically. We will consult appropriately on proposed changes with our practices and stakeholders. 37

38 6. Contact details Locality Clinical Director: Dr Karl Graham, GP, Eastleigh Southern Parishes Locality Clinical Director, NHS West Hampshire CCG Director lead: Natasha Kerrigan, Director of Commissioning (South), NHS West Hampshire CCG Commissioning Managers: Martyn Rogers, Senior Commissioning Manager Out of Hospital Transformation (South), NHS West Hampshire CCG Hannah Beauchamp, Commissioning Manager Community Development (South), NHS West Hampshire CCG Locality Practices & Locality GP Representatives: Blackthorn Health Centre Dr Neeraj Sonpal Bursledon Surgery Dr Vivian Ding Hedge End Medical Centre Dr Karl Graham St. Luke s & Botley Surgeries Dr Alan Mayers West End Surgery Dr Olivia Rodrigues Website: Telephone: info@westhampshireccg.nhs.uk 38

39 Appendices To follow: Appendix I Work Plan (in draft to be added provides timelines and action owner and RAG rating) Appendix II Eastleigh Southern Parishes: Overview of Population and Health Needs Hampshire County Council April 2016 Appendix III Equality Impact Assessment (in draft to be added) 39