DELIVERING THE LEFT SHIFT IN ACUTE ACTIVITY THE COMMUNITY MODEL 1. Introduction The Strategic Outline Case (SOC) and subsequent developing Outline Business Case (OBC) for the reconfiguration of acute hospital services is underpinned by activity assumptions which reduce demand on acute services through what is referred to as a left shift into community provision. This requires a redesign of community provision to be able to safely and effectively manage more patients in the community. The required level of reduction of acute demand to support the acute configuration is as follows:- Non-Elective Admissions Elective admissions Out-Patients 2. Designing the Community Model The programme of work to develop the community model is multi-faceted. A high level overview of the components is shown below. CCG led STP Neighbourhood Workstreams Wider STP programme enablers QIPP(egAdmission Avoidance, Procedures of Limited Clinical Value (PLCV) NHS Right Care National programme committed to reducing unwarranted variation to improve people s health and outcomes. Developing the new community model Build resilient communities and develop social action Place based planning Develop whole population prevention linking community and clinical work and systematic identification of risk and utilisation of social prescribing Neighbourhood level prototypes to test ideas Care closer to home through implementation of neighbourhood care models including teams and hubs and shared care protocols between acute and community End to end condition specific pathways from maintaining wellbeing to end of life Digital Strategy Optimising the use of technology eg Shared care record, Point of Care Testing Workforce Strategy Developing the workforce of the future egurgent Care Practitioners Activity and prevalence modelling at neighbourhood and condition level to determine required resources Exploring different models of service delivery MCPs, Burtzoorg Page 1 of 7 Draft version 1 26.9.16
Further detail on these components of developing the community model are given below: 2.1 QIPP and NHS Right Care CCGs have over the last few years introduced a number of acute demand reduction initiatives through their QIPP programme and more recently Right Care and these will continue in parallel with and complimentary to the new programmes of community development through the STP Neighbourhood Workstreams of which there are 3 (Shropshire, Telford & Wrekin and Powys). NHS Right Care aims to: For patients better access to optimal care; improved outcomes and patient experience; and greater involvement in decisions about their care. For commissioners unites partners across the health economy to focus on priority areas that maximise value, whilst meeting the requirements of the new NHS Improvement Framework. For primary and community care opportunities to redesign patient pathways with a focus on prevention and early intervention. For secondary care active involvement in the redesign of patient pathways across primary and secondary care. Plus, support to meet the requirements of the Carter Review to reduce unwarranted variation. For local authorities a sound, transparent rationale for how limited resources are prioritised, helping meet legal duties under the Health and Social Care Act 2012 to reduce health inequalities.?do we need to add more detail of what these plans contain or is that enough? 2.2 STP Neighbourhood Workstreams In December 2015, the NHS shared planning guidance 16/17 20/21 outlined a new approach to help ensure that health and care services are built around the needs of local populations. To do this, every health and care system in England is required to produce a multi-year Sustainability and Transformation Plan (STP), showing how local services will evolve and become sustainable over the next five years ultimately delivering the Five Year Forward View vision of better health, better patient care and improved NHS efficiency. Sustainability and Transformation Plan (STP) lead for Shropshire and Telford & Wrekin has been agreed as Simon Wright, Chief Executive of Shrewsbury and Telford Health NHS Trust. He is responsible for convening the STP process and overseeing the development of local plans. They have been selected following local discussions about who is best placed to play this role, together with discussions with national bodies. The first draft of our local STP was submitted to NHSE in June and the next draft is due for submission on 21 st October 2016. The local STP governance structure has been agreed and established. This includes 4 core workstreams (1 acute reconfiguration and 3 neighbourhood specific) and a number of enabling workstreams (eg workforce, finance, estates, digital strategy). Page 2 of 7 Draft version 1 26.9.16
The neighbourhood workstreams are the vehicle through which the community model to support the acute reconfiguration is being developed. Each has a chief officer sponsor and and executive officer lead. The Neighbourhood Transformation Groups have 2 main focuses of improving the health and wellbeing of local communities and delivering care closer to home. The work of defining natural neighbourhoods is well underway with some prototype areas already defined and developing their own plans for testing different ways of working based on what they believe are the priorities for their local population. There are a range of functions would could be delivered in neighbourhoods but what and how they are delivered could look different in different areas based on need. 2.2.1 Building Resilient Communities Needs narrative explanation of points from CRG slidestack and how it is being progressed and by whom and by when? Asset based community development Community based approach to shape the local factors that have an impact on health and well-being Generating social value and social action Community Enablement Team Established local governance Locality commissioning Active and effective VCS at risk from reducing grant/contract funding Active community groups - need support to thrive Formal and informal volunteering needs strategic development Page 3 of 7 Draft version 1 26.9.16
Resilient Communities Care & Community Co-ordinators Compassionate Communities Let s Talk Local hubs Early Help Strengthening Families 2.2.2 Whole Population Approach to Prevention Needs narrative explanation of diagram below and how it is being progressed and by whom and by when? 2.2.3 Care Closer to Home The aim of the Care Closer to Home workplan is to design and implement a community based care model and neighbourhood services that: delivers more care in the community and closer to patients homes supports more people to take control of their own health and wellbeing enables the shift from people becoming acutely unwell and requiring care in acute hospitals. The following section provides details of examples of neighbourhood led working initiatives currently in development to test new ideas or expand models of community service delivery: 2.2.1 Neighbourhood Care Team development in Newport and South Telford Add detail 2.2.2 Extended Urgent Care in Bridgnorth Page 4 of 7 Draft version 1 26.9.16
In July 2016 a small local working group was established to develop a proposal for expanding the rural urgent care service offer to the Bridgnorth and surrounding GP practice population. The working has now met 3 times and has confirmed its focus for prototype as frailty and same day urgent access to local assessment, diagnostics and treatment or referral for treatment. It is proposed that the prototype would run for a minimum of 6 months. The proposal is to deliver this through:- a community hub model from Bridgnorth Hospital building on the existing DAART service at the hospital and utilizing and expanding the skill set of the existing nursing staff in the Minor Injuries Unit. The service will be underpinned by integrated pathways with acute and the local community teams to support admission avoidance. The service will be nurse-led and team delivered, supported by access to GP where necessary. Point of Care Testing will be available for rapid access to test results to support clinical decision making. An assessment of the workforce knowledge, skills and aptitude requirements has been completed and this is being overlaid with the current workforce skill set to identify where there are gaps. Local clinicians have a planned visit on 3 rd October to the Urgent Care Centre in Crewe to better understand how their nurse led ambulatory emergency care pathways operate and bring the learning back to inform the Bridgnorth model. The next key steps are:- Finalise the clinical model Activity modelling to determine demand and required opening hours Identify workforce gaps both in terms of skills and capacity Share the prototype plan with wider local community partners and local population to gain support and ownership to utilize this service over default to acute for appropriate cases. If the above identifies the need for additional resources requiring additional investment, develop and submit a business case to CCG/STP for non-recurrent funding. The aim is to introduce this prototype early in the first quarter of 2017. 2.2.3 Extended Urgent Care in Ludlow through closer working between primary care and MIU Neighbourhood lead to add detail of current prototype status 2.2.4 Community Hub development in Market Drayton Neighbourhood lead to add detail of current prototype status 2.2.5 Virtual clinics between GPs and Community teams in Whitchurch Neighbourhood lead to add detail of current prototype status 2.3 Activity and Prevalence Modelling at Neighbourhood and Patient Condition level Ruth Lemiech to add the detail. Page 5 of 7 Draft version 1 26.9.16
2.4 End to End Clinical Pathways Six condition specific pathway multi-stakeholder task and finish groups have been meeting during August and September to develop end to end pathways from prevention through treatment to end of life (where appropriate) which define the community offer in support of the Acute Outline Business Case. The 6 agreed pathways are Respiratory (including Paediatric Asthma), Chronic Kidney Disease (CKD), Diabetes, Heart Failure, Preventing Falls and Fractures and Frailty. As can be seen from the diagram below the pathways will describe the interventions to be delivered at each stage of illness progression and where the responsibility for delivering those interventions will reside. The pathways will also reflect the following guiding principles agreed by the Futurefit Clinical Design Work stream:- End to end from prevention to treatment Do only what is needed, no more, no less; and do no harm Professionals routinely providing only the service which requires their level of clinical ability or expertise Put patients in control of their conditions, with a focus on preventing deterioration and complications, avoiding crisis and preventing referral to more acute services Home is best Maximise the opportunities for innovation through use of technology Support partnership care arrangements and smooth transitions for patients between clinicians, settings and organisations All clinical activity that does not absolutely need to be carried out in a hospital will take place in the community Funding will follow the patient to ensure that resource is in the optimal delivery setting All existing or previous related pathway work, whether through ongoing CCG service redesign programmes, Right Care or QIPP, is being taken into account in this programme of work, with the emphasis on consolidating it into high level pathways and adding to where there are gaps. Page 6 of 7 Draft version 1 26.9.16
All 6 of the pathways are now at varying stages of drafting. Once agreed as final draft by the Task and Finish Group, wider stakeholder engagement to sense check the proposed pathways will be undertaken. It has been agreed that the pathway development for Respiratory will be progressed through the existing LHE Right Care work programme as this already contains the requirement to develop pathways for respiratory conditions. The timeline for the pathway work is to have final drafts completed in October followed by wider stakeholder engagement. Where implementation of pathway or component parts of the pathway can proceed at pace, this will be facilitated. 2.5 Wider STP Programmes The Enablers It is recognised that there are some key underpinning enablers to a successful community delivered model. These are being progressed via existing strategy/operational groups or newly established workstreams under the STP governance structure. Not least of these workstreams is the Digital Strategy. One of the foundation stones to effective and seamless patient journeys and care delivery whether acute or community is access to a shared care record and this is a priority within the locally agreed Digital Strategy. Also of importance is the development of and access to technology for patients to support self care. 2.6 Exploring Alternative Models of Service Delivery It would be good if someone could add a brief on what stage of thinking and agreement there is for trying new models of care eg MCP, Burtzoorg and any others we might be thinking about or if not the detail then the approach each CCG intends to take to exploring these as alternatives to the status quo. 3. Investment Plan for Building a Robust Community Offer Someone?not sure who? Needs to write a section on how we plan to invest in building the community model or at least how we plan to get to a plan key points to answer for me are:- What level of investment is available What commitment is there from partners to release resources to follow the patient (staff rotating acute to community or permanent transfer Is there investment for double running whilst we release enough resource/or money from acute for it to pay for itself or even save money What is the phasing of the development of the community model and its concomitant investment plan Page 7 of 7 Draft version 1 26.9.16