NHS West Cheshire Clinical Commissioning Group Five Year Strategy: 2014/15-2018/19 1
Our Planning Footprint In developing our system vision for 2018/2019 NHS West Cheshire Clinical Commissioning Group is working across a range of planning footprints, reflecting the breadth and depth of our partnerships working and our appetite for working with peers and sharing learning. We recognise that there are benefits from collaborating with NHS colleagues across a wide geographic foot print to share learning and grapple with the challenges of addressing the underlying enablers. Under the banner of the integrated care pioneer programme: Connecting Care across Cheshire, we are working with NHS and local authority neighbours to deliver this. More locally we are working with our public sector partners, Cheshire West and Chester Council, Cheshire Police, Cheshire Fire and Rescue services and the wider public and third sector to look at how the West Cheshire pound can be spent more effectively and efficiently. Recognising that health and social care cannot be delivered, or transformed, in isolation from the surrounding community this looks wider than the delivery of health and care services. This is the Altogether Better Cheshire programme (a community budgeting pilot). Closer to home we are undertaking more detailed work with the providers and commissioners of health and social care within West Cheshire to respond to the challenge of providing more integrated health and care services. We call this the West Cheshire Way. In summary, NHS West Cheshire Clinical Commissioning Group are working on a number of planning footprints with a common theme; that we will only achieve the scale of transformation required by the system through collaborating with our partners: at a local level across the care economy West Cheshire Way within the Local Authority footprint with all public sector agencies as well as private and voluntary sector partners Altogether Better for Cheshire and finally on a county footprint with neighbouring localities on common priorities Connecting Care across Cheshire Our vision for health and care services for the next five years is set out in this context. 2
1. Our vision Fig 1: Ref: http://www.cdhb.govt.nz/what-we-do/pages/default.aspx All of our partnerships and their associated work programmes are focussed on delivering person centred services, where providers of care respond to the needs of individuals rather than individuals having to respond to the demands of the system. We look to international best practice to learn from areas that are further ahead than us in achieving this. The picture above has been created by the Canterbury New Zealand system and reflects our ambition for the future provision of services. Our vision for the health and care system is set out in the West Cheshire Way: The West Cheshire Way has four overall goals, based on a holistic approach where services are designed around the needs of the whole person, rather than around individual diagnoses or procedures: (i) Putting patients at the centre of their care through self-care All services should help people to take more responsibility for their own health and wellbeing. Our staff will offer advice and support to individuals/their carers in person but also in other ways that fit in with people s lives supported by developing technology e.g. by text, phone, email, web sites and social media. (ii) It will support people in the community As much as possible people will be supported to stay well in their own home, in their own community. People will only go 3
into hospital as a last resort. Wherever needed, services will operate seven days a week and 24 hours a day. (iii) It will work across boundaries By joining up primary care, social care, community services and hospital based care it will be easier for people to be looked after in a coordinated way. This will result in the right care, being given in the right place by the right person at the right time. (iv) It will improve the management of long term and complex conditions We will place more emphasis and investment on anticipating problems. We will identify and keep in close contact with people at high risk of hospital admission. When admitted to hospital, there will be a stronger emphasis on minimising the length of stay. Discharge will be planned on admission, with the emphasis on early rehabilitation. Overall, this will mean we need fewer beds in hospital. It is envisaged that teams and services throughout the care economy will use the West Cheshire Way as a lens through which to understand and describe how services will look and feel in the future Local clinicians from across organisations and professions have already started this process, and have developed what we are calling blueprints. These are documents which describe the characteristics of future services and how they will feel for patients. We currently have 4 blueprints: Older people General Practice Urgent Care Long term conditions, The blueprints developed to date are the start of an iterative process to steer our ambition into action. These will be built on over time as we embed this work into our continuous improvement of services. Developing our vision for future service delivery will be led by our clinicians and those delivering front line services. They describe our approach to the six characteristics of a sustainable health and care system. The Altogether Better Cheshire Programme sets out our vision for how these future health and care services need to be embedded in strong, resilient and sustainable communities. Altogether Better for Cheshire is one of four national whole place Community Budget pilot areas testing new, radical and local approaches to delivering public services over a five year period (2011-2015). West Cheshire partners share a bold ambition to radically reshape local public services to make a positive difference and deliver significant improvements for residents, communities and businesses. We will succeed because for the first time all local public services, along with the voluntary and private sectors are working 4
together to look at how we can make this happen. We plan to significantly reduce costs by eliminating duplication, tackling the root causes of problems and fundamentally redesigning services, tailoring them to address local needs making the best use of the public pound. Altogether Better promotes new delivery models of services that are both innovative and effective. This opportunity captures West Cheshire s ambition to deliver efficient and customer focused services through collaboration with local partners focusing on outcomes for our residents. The Connecting Care across Cheshire programme (Integrated Care Pioneer pilot) is how we will share learning across a wider footprint to deliver the enablers for integrated care at scale and pace. Fig 2: our planning footprints 5
2. Values and Principles We have agreed a set of values that will hold our system together. These values and principles were agreed as part of a joint workshop with ourselves, the Countess of Chester NHS Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust, Cheshire West and Chester Council, GPs and third sector leaders. We will be: Compassionate about patients Empowering of staff and patients Accountable for all decisions Collaborative: always involve partners Mutually respectful to different opinions and perspectives Flexible in our thinking Trusting of others motives and beliefs Transparent and open about our decisions Innovative and creative in our models of care We have agreed eight principles that will underpin our work: Patients are at the heart of the West Cheshire Way The West Cheshire Way is clinically led (and managerially supported) The West Cheshire Way incorporates health, social care and the voluntary sector Everybody recognises the need to work across organisational boundaries We recognise the importance of general practice and its relationship with a defined group of patients We will use a population health based approach that has a prevention focus and is holistic Integrated care will be delivered by groups of health and social care professionals, both generalists and specialists, working alongside each other We will learn from others, including best practice in the UK and internationally; where this does not exist we will seek to establish a local evidence base. 6
3. Current position The NHS is a hugely important service to patients and is highly regarded by the public. We recognise however that it does need to change, both in West Cheshire but also more widely across the country to: Ensure we grasp the opportunity afforded by new technologies. Meet the needs of people who are living longer with complex health and care needs. Provide joined up care that crosses the boundaries of primary, community, hospital and social care. Respond to the global financial pressure in order to achieve high quality services within more limited resources Reduce variation in the quality of care which at times has meant that the NHS has failed to live up to the high expectations we all have. NHS West Cheshire Clinical Commissioning Group is committed to leading the local care economy in transforming the delivery of care to meet these challenges. NHS West Cheshire Clinical Commissioning Group is made up of thirty-seven GP practices that are wholly responsible for designing local health services. We cover a population of around 253,000 people. Clinicians are very much in the driving seat in NHS West Cheshire Clinical Commissioning Group. Each of our thirty-seven member practices elect one of their doctors to sit on our Membership Council, to determine NHS West Cheshire Clinical Commissioning Group s priorities. There are three GP locality groups in west Cheshire. These are Chester City, Ellesmere Port & Neston, and Rural. These groups provide a vital connection to our 7
GP practices, and in turn they provide invaluable input to the Membership Council and to the Governing Body. Our Clinical Senate has members that include senior doctors from local hospitals, nurses, allied health professionals, adult and children s social care and public health. The Senate reports to the Governing Body, and has a major influence on the work carried out by the Clinical Commissioning Group. 3.2 The West Cheshire population In general, West Cheshire has an older age profile compared nationally. The population has a higher proportion of people aged 45+. Nearly 18% of the population are over 65 years compared to 16% nationally. The rural locality has the highest proportion of over 65s (20%) followed by Ellesmere Port (18%). Figure 1: Registered population in NHS West Cheshire Clinical Commissioning Group 2012 14% of NHS West Cheshire residents live within the 20% most deprived Lower Super Output Areas in England (IMD2007). A further 13% live in the second most deprived 20%. It is people living in these communities who experience a disproportionate amount of preventable poor health. Ellesmere Port and Chester localities have the highest proportions of people living in these areas (40% and 29% respectively). The biggest burdens of ill health for the people of West Cheshire are mental health problems, heart disease and stroke and cancers. The key risk factors for ill health are smoking, raised blood pressure, drinking alcohol harmfully and hazardously and unhealthy weight. 8
Our lifestyle behaviours are changing and this will impact on need for services. Incidence of smoking-related ill-health such as lung cancer is falling in men but not necessarily in women. Prevalence of obesity related ill-health such as diabetes is increasing. Half the recent increases in the prevalence of diabetes are due to trends in obesity and half due to the ageing population. The modelled prevalence of binge drinking is high across the area compared with the national average and the rate of alcohol-related hospital admissions is high compared nationally and is rising. Alcohol related hospital admissions have increased by 80% between 2002/03 and 2009/10. The incidence of skin cancer, caused by harmful exposure to UV light, is high compared nationally and has risen more sharply than the national increase In light of this we know that redesigning healthcare services alone is not enough. We need to be working with public health and others in the local authority to ensure that our communities are resilient and that people are supported to make healthy choices to stay well. This is reflected in the Cheshire West and Chester draft Health and Wellbeing Strategy Over the next 10 years, the population is expected to increase particularly amongst those aged over 65 years. The number of young people is predicted to decline however the birth rate has increased recently and the number of younger children is set to increase particularly in Ellesmere Port and Chester. The increase in the number of births has been particularly apparent in our more deprived localities where outcomes are poorest and a so greater intensity of support will be needed in these areas. The ageing population will mean that more people are living long enough to develop conditions of ageing, become frail and develop functional, sensory and cognitive impairment. These people however only represent a small minority of older people but will rely on informal or formal care and multiple services. The number of people with more than one long-term condition will increase as the population ages. It is estimated that 12% of people aged over 65 have 3 or more long-term conditions. 3.3 Impact of these changes on services Our population has been ageing over a number of years and services have been seeing the impact but not all the increased demand for services is attributable to demographic change. For example, between 2004/05 and 2010/11 our population increased by 2% and in some age groups increased more dramatically the number of over 85s increased by 26%. Yet overall emergency hospital admissions increased by 23%. Demographic change can only explain a 6% rise in emergency admissions over this period. The increase in service use may be due to a combination of changing public expectations, changes in how services respond or technological advances. These shifts translate into a financial growth pressure of 19.1million in West Cheshire over the coming five years. There has been an increase in people staying very short lengths of stay in hospital across all age groups but in the very old there has also been an increase in those staying longer so now a greater proportion of emergency bed-days are accounted for by older people. 9
3.4 Financial outlook NHS West Cheshire clinical Commissioning Group will begin financial year 2014/15 in recurrent financial balance (ongoing expenditure is within recurrent funding). The financial plan for the coming 2 years has been generated using national planning guidance and local planning assumptions. The local assumptions have been agreed with local health partners as part of the development of the West Cheshire Way strategy. We will plan to generate a surplus of at least 1% of funding in both financial years. In addition, a significant amount of money will be protected for non-recurrent, or oneoff, use in year. This funding will be used to support the local health and social care economy transformation agenda. We will plan to receive the minimum level of allocation growth in both financial years based on NHS England pace of change policy. This will mean that our resources will grow by at least current national GDP growth estimates. This is better than had previously been expected. We have agreed a reasonable level of contingency to mitigate against in-year pressures, including the mandated 0.5% contingency. A reserve to fund the anticipated cost of population changes has also been agreed with an additional 4.5 million set aside in each of the next 2 years. In addition, in line with national expectations, we have set aside 5 per head of registered population for improving the care for older people. Based on current planning assumptions, financial efficiencies of approximately 20 million per year will be required in each of the next 5 years in order to sustain the local health economy. It is envisaged that about half of these efficiencies will be delivered by nationally imposed efficiency requirement with the remainder being delivered from a combination of pathway and service innovation, strategic service change and the prevention agenda. Early indications are that our priority programmes could deliver up to 29 million of efficiencies over the next 5 years. The significant focus of these programmes will be to mitigate the likely impact of an ageing population. Plans will continue to be finalised during financial year 2014/15 with, potentially, a more significant impact from 2015/16. The following table maps out the potential financial impact from the initial modelling: Programme m 2014/15 m 2015/16 m 14/15-18/19 Starting well 0.160 0.160 0.800 Being well 0 1.554 6.214 Ageing well 1.520 3.420 15.202 Primary care 0.285 1.353 5.699 Mental health 0.260 0.260 1.300 10
Total 2.225 6.747 29.214 During 2014/15 we will be required to utilise 2.5% of recurrent funding on nonrecurrent, or one-off, schemes. In addition, we will also receive any surplus generated at the end of each financial year. NHS West Cheshire Clinical Commissioning Group will, therefore, begin 2014/15 with a non-recurrent reserve of in excess of 12 million. The level of non-recurrent requirement reduces to 1% during 2015/16. Along with commissioning for quality and innovation (CQUIN) funding, this nonrecurrent funding will provide support to the significant amount of transformation required and the potential need to double run some services as they transition out of the acute setting. During 2015/16, the full implementation of the Better Care Fund will mean the pooling of a minimum of 24.3 million across the Cheshire West and Chester footprint ( 3.8 billion nationally). This will ensure that services are jointly commissioned to facilitate, where appropriate, significant numbers of patients being treated closer to their homes. The total allocation for 2015/16 has been reduced by 15.812 million to reflect our share of the fund. Governance arrangements are currently being agreed. A separate Better Care Fund plan has been submitted to NHE England. Financial planning assumptions, along with the 2014/15 financial budget, were signed off by the governing body in March 2014. A separate and detailed 5 year financial plan has been submitted to NHS England In order to support the scale and ambition of the Commissioning Plan going forward, we will support the transition to integrated care delivery using the financial levers available to us as commissioners. In consultation with clinicians and senior management within the main providers, we have identified the indicators we believe will demonstrate improvement against our seven strategic health outcomes and in doing so will support the transition to seven day working to provide a more responsive and patient-centred service, particularly for urgent and emergency care. The ambition is to incentivise collaboration across care settings in achieving the plans detailed above as measured by progress against the strategic outcomes underpinning our five year strategy. Significant non-recurrent funding will be made available to the Countess of Chester NHS Foundation Trust, Cheshire & Wirral Partnership NHS Foundation Trust (for Mental Health and community services) and to primary care in 2014-16 to incentivise and facilitate a change in working practices to deliver the desired outcome improvements. 11
4. Improving quality and outcomes In consultation with clinicians and senior management within our main providers, we have identified seven strategic health outcomes and the indicators we believe will demonstrate improvement against these outcomes. In doing so we will support the transition to seven day working to provide a more responsive and patientcentred service, particularly for urgent and emergency care. Underneath each outcome we have aligned a suite of indictors which will allow us to measure progress against our outcomes. Outcome More care closer to home Indicators Reduce time spent in hospital for those with a long term condition % home births Change to be achieved by 2015/16 Baseline: 4 day Length of stay - to reduce to peer average Baseline: 1% - to increase to at least peer average of 3% Change to be achieved by 2018/19 To be confirmed Reducing unplanned admissions Improving the patient experience Integrated care through case management, Reduce unplanned hospitalisation for asthma, diabetes and epilepsy and lower respiratory tract infections in under 19 s, reduce emergency readmissions within 30 days of discharge from hospital reduce readmission of neonates within 28 days, reduce emergency admissions for acute conditions that should not normally require hospital admission, reduce inappropriate use of A&E for people with mental health Real time patient experience Improve children s and young people s experience of care Increase the proportion of >65 year olds still at home 91 days after discharge from Baseline: 317 to achieve at least peer average Baseline: 15% - to achieve peer average Baseline: to be collected - to achieve peer average Baseline: 2056.6 to achieve 3% reduction quarter 1 12
care planning and risk stratification Greater Continuity of care and risk sharing Safer services Increasing patient empowerment and self-care reablement/rehabilitation, reduce the number of medically optimised >65 year olds in an Improve outcomes from planned treatments Improve functional ability for those with a long term condition (including mental health), improve recovery from fragility fractures reduce the number of mental health patients presenting in crisis out of hours, reducing the number of long term placements into residential/nursing homes increase normalisation of birth through reduced intervention rates reduce neonatal mortality and stillbirth reduce premature mortality from the major causes of death through motivational Patient involvement in care planning Health related quality of life for patients with LTC quarter 1 quarter 1 quarter 1 quarter 1 quarter 1 Achieve peer average Baseline 6.4 to achieve peer average Increase by 1% first year then 0.5% second year 13
5. Interventions Our 2 year operational plan outlines the programmes of work we have established to deliver these outcomes. We do not intend to duplicate these here, as we know that our in order to achieve our strategic vision we need to fundamentally change the way the health and social care system is supported. Hence our strategic plan will focus on those system-wide enablers which will need to be in place for our programmes to deliver. Intervention Description outcome Investment Implementation Barriers Confidence levels A process that designs in significant public, patient and carer engagement, at all levels Services coproduced with, and a system understood by, patients and the public medium Integrated clinical communication, including sharing medical records, to enable the identification of risk Building on our Insight and Intelligence report we will use the West Cheshire Way narrative and blueprints to talk to the public about how and why services could change. Developing an Integrated health and social care record More efficient and effective clinical communication, Tbc Tbc Capacity to carry out robust engagement that sits alongside all of our change programmes Developing skills to use innovative methods of engagement March 2014 Need to ensure that the technical solution is supported by the necessary cultural changes high A 5 year financial model (health/social care) which models the shift in activity from beds to Health and social care wide shared planning assumptions An economically sustainable health system which can enable whole system change n/a First draft agreed for 2014/15 planning Risk that continued austerity may discourage openness medium 14
community An approach to wellbeing and self-care at scale A system plan that incorporates better use of our facilities (recognising that this might include other resources). A workforce engagement and culture change programme A governance model that is clinically led and recognised by all organisations including A shared process of measurement and evaluation Working with local authorities to support a behaviour changes enabling communities to be more resilient There is an opportunity for the public sector in west Cheshire to pool physical resources (such as facilities) in order to deliver services in a more efficient and joined up way The service changes outlined in our programmes will require staff to work differently, we need to ensure that they are leading this change Given the complexity of our planning footprints we need to ensure that there is no duplication of effort across programmes and that there are clear lines of reporting and accountability Reduced pressure on NHS services as people are more able to stay well A clear understanding of which resources exist and their capacity on a locality rather than service footprint Service redesign led by front line clinicians, in the interests of patients. An efficient and accountable redesign programme tbc Ongoing No clear evidence base on what drives large scale population change tbc March 2015 Capacity to scope what exists across all organisations tbc Ongoing Capacity and capability to enact wide ranging cultural change Tbc ongoing The complexity of the planning environment low medium medium medium 15
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6. Governance overview To support collaborative working we are keen to minimise the introduction of additional layers of unnecessary bureaucracy. As a result a streamlined governance structure has been developed that aims to support the ability to share and align locality progress and maximise learning across all of our planning footprints. Overall coordination will rest with the Cheshire West and Chester health and Wellbeing Board.. Fig 3: Governance structure 17
7. Impact Within five years, the communities of Cheshire will experience world class models of care and support that are seamless, high quality, cost effective and locally sensitive. Better outcomes will result from working together with better experiences of local services that make sense to local people rather than reflecting a complex and confusing system of care. More individuals and families will be able to are able to live independently and with dignity in communities rather than depending on costly and fragmented crisis services. People will experience enhanced life chances rather than widening health inequalities. 18