MEETING OF THE GOVERNING BODY IN PUBLIC 7 January 2014

MEETING OF THE GOVERNING BODY IN PUBLIC 7 January 2014 Title: Bedfordshire and Milton Keynes Healthcare Review: The way forward Agenda Item: 4 From: Jane Meggitt, Director of Communications and Engagement Purpose of Paper: To update Governing Body members and gain their support on the proposed next steps, in response to the recommendations made in the Bedfordshire and Milton Keynes Healthcare Review Progress Report, published on 29 October 2014. To report on a two month engagement programme with GP members, partners, patients and the public, gathering their views and feedback on the progress report and proposed next steps. Actions required by the Governing Body: Four actions are required by the Governing Body. They are to: 1. Acknowledge the feedback and viewpoints of GP members, partners, patients and the public contained in the engagement activity report and use this information to inform its decision making about the Bedfordshire and Milton Keynes Healthcare Review Progress Report and proposed next steps. 2. Formally accept the recommendations from the study phase of the Bedfordshire and Milton Keynes Healthcare Review, contained in the Progress Report published on 29 October 2014, which was formally received by the Governing Body at its November meeting. 3. Agree the current course of action and proposed next steps being undertaken as part of the Your Health in Bedfordshire programme. 4. To note the importance of a continued close working relationship with Milton Keynes CCG, NHS England, Monitor and the Trust Development Authority during the next phase of the programme to ensure alignment of emerging proposals and consistency of approach. 1

Relevance to Strategic Delivery: [Tick the appropriate box below] Strategic Workstreams To build the relationships across organisations that enable integration of care Supporting mental health and wellbeing throughout life Servicesaccessibleandavailable alongsideandintegratedwith physical healthcareandjointlycommissioned with Local Authorities where possible _ Improving provision of mental healthcare within primary care Preparing for the full introduction Payment Systems To be recognised as a strong clinically led organisation and the local system leader Strategic Priorities Helping adults and older people maintain a healthy life as long as possible Integrating the urgent care system between general practice and hospitals To create an environment that incentivises the pace of change required for transformation Improved population health through increased patient empowerment & support Helping children and young people start a healthy lifetime Workwithourtwo developachildren s Local Authorities to jointly and Young People s Plan.1.1.1.1 of new Integrating healthcare and social care for people with long term conditions (including frailty) Undertakeaclinicallyled of hospitaland communityhealthcare services local review - based Maximising the wellbeing of mothers.1.1 Developinga21 st care; as partofa healthcareservices Century model of paediatric wider review of local.1.1.1 Procure a Mental Health provider Improving care for people with complex needs and for those with dementia.1 Delivering specialist care (such as stroke care) through networks Improving End of Life Care Transforming Primary Care.1.1.1 Improving transition from children s services into services for adults.1 Not applicable to Strategic Delivery IMPACT ASSESSMENTS Equalities/Human Rights A full Equality Impact Assessment will be undertaken on the outputs of the proposed activities contained in this paper. NHS Constitution The views and feedback of patients and the public have been captured in the development of this paper to assist the Governing Body in its decision making process. 2

Financial: Financial analysis will underpin the outputs of the proposed activities contained in this paper. Legal: The legal impact of decisions made in this paper will be fully assessed and published to ensure transparency and openness around decision making. Risk Management: A risk register has been developed to support the programme of work and will be updated on a monthly basis. Sustainability: Part of the analysis of the outputs of any additional analytical work recommended in this paper will need to consider carbon emissions, the potential impact on the environment and a link to travel times. Procurement: Procurement may be an option in the future, but not at this stage of the work programme. Conflict of Interest: All conflicts of interest will be quantified and risks mitigated. For this paper, the development of GP Federations especially in Bedford, Ivel Valley and West Mid Bedfordshire localities may result in a conflict of interest. This will need further investigation, if and when the conflict of interest arises. Executive Summary The Bedfordshire and Milton Keynes Healthcare Review published a progress report on 29 October 2014, setting out the work undertaken during the study phase and making recommendations for developing robust options for local health services. The CCG Governing Body formally received the progress report at its meeting on 5 November 2014 and requested that the views of GP members, partners, patients and the public should be sought to inform its decision making at this meeting. This work has been completed and is contained in a report (Appendix 1) which outlines the key findings of engagement activity undertaken in November and December with GP members, partners, patients and the public. A draft report was shared with, and the approach endorsed by, the Bedfordshire Healthcare Review Joint Health Overview and Scrutiny Committee at its meeting on 17 December 2014. We now propose to take forward a programme of activity, tailored to the differing health systems in the north and south of the county, under the banner of Your Health in Bedfordshire and in line with the recommendations from the Healthcare Review progress report. This will involve an intensive 12-week work programme undertaken jointly with Bedford Hospital and Bedford GPs in the north, and a similar initiative in the south in conjunction with Central Bedfordshire Council and the Luton and Dunstable 3

Hospital. Better Care Funds developed with Bedford and Central Bedfordshire Councils will form part of this work The work in Bedfordshire is consistent with and supports delivery of our five-year vision for the local health system. The detail can be found in our two and five year strategic plans published in 2014, in our commissioning intentions for 2015/16 and in our joint Better Care Fund plans developed with local authority partners. This work will also complement the implementation plans being developed following the announcement of a new mental health service provider. The work outlined in this paper is also consistent with the NHS Five Year Forward Plan published by NHS England in October 2014 which sets out a vision of a better NHS, the steps the health service should take to get us there and the actions we need from others. It shows how the health service needs to change to deliver the services needed by patients in the future and argues for a more engaged relationship with patients, carers and citizens so that we can promote wellbeing. The timescale for the proposed work falls into three phases: Phase 1. November to December 2014: Preparation work, including winter planning and delivery of initiatives outlined in our Plan for Patients 2014/2015 Phase 2. January to April 2015: Finalise and implement the next steps of the review in North Bedfordshire with Bedford Hospital and confirm approach with MKCCG and review partners Phase 3 Post May (after general election): Finalise and undertake formal consultation (if required) and implement plans for improved services in primary, community and hospital care (vertical integration) and networked provision of some hyper-acute specialist services A parallel work programme is also being undertaken by Milton Keynes CCG (MKCCG) and Milton Keynes Hospital with the aim of finding a clinical and financially sustainable solution for Milton Keynes Hospital. A close working relationship, underpinned by joint governance arrangements, will continue between Bedfordshire and Milton Keynes CCGs, NHS England, Monitor and the Trust Development Authority to ensure alignment of emerging proposals which complement and strengthen both health systems. Part of this may result in a joint consultation with MKCCG during 2015. There are a number of risks associated with the proposed work outlined in the paper associated with challenges of developing a clinically and financially sustainable health service in Bedfordshire. Four key risks have been identified with mitigating actions. A fuller and more detailed risk register will be developed as the work progresses. Background The Bedfordshire and Milton Keynes Healthcare Review was formally launched in early 2014 with the aim of generating options for delivering sustainable, high quality health services for the people of Bedford Borough, Central Bedfordshire and Milton Keynes, that the CCGs could take to formal public consultation as appropriate. 4

The review brought together five partners: Bedfordshire CCG (BCCG), Milton Keynes CCG (MKCCG), NHS England, and the two national regulators Monitor and the Trust Development Authority. With funding from Monitor, McKinsey & Company was contracted to support the review with research and analysis. The key drivers for the review were outlined in a Case for Change document published in April 2014. These included both financial and clinical quality pressures on local health services from the growing and ageing population in Bedfordshire and Milton Keynes. Clinical commissioners in Bedfordshire and Milton Keynes face a combined deficit of 210m by 2023/24 unless changes are made to the way in which local services are delivered. The review published a progress report on 29 October 2014. The report outlined the evidence gathering and analysis that had taken place, and how this has helped develop options for further detailed consideration this is referred to as study phase in this paper. The report encourages local NHS organisations to bring more healthcare closer to people s homes and to better integrate services so that local hospitals, community services, social services and GPs can deliver improvements in general practice and provide a broader range of local services and more preventative care for the elderly and vulnerable. The report also proposes a future for Bedford and Milton Keynes hospitals that will enable both to maintain core services that are valued by local people, including urgent care and inpatient beds. It suggests that one of the two hospitals could also support some less commonly needed but more complex services. These conclusions reflected the extensive partner, patient and public engagement work undertaken between January and July and conversations with local people and clinicians about their experience of the NHS today and their ambitions for developing high quality services over the next decade. Recommendations from the Healthcare Review progress report The Healthcare Review progress report published on 29 October recommended that commissioners use the information contained in the report to develop robust plans for redesigning local health services, that they can then take back to their local populations and, as appropriate, to public consultation. The report identified the following actions that we would need to take in order to achieve this. Develop plans to offer more care closer to home via multi-disciplinary teams, involving primary care, community health services and social care. Carry out further detailed work on the preferred options for the future provision of hospital services. This will include involving neighbouring commissioners to understand the impact any changes will have further afield. Develop a detailed plan outlining the practical steps that need to be taken to prepare for public consultation. These include: ensuring that patients, public, clinicians, local councils and other stakeholders continue to have ample opportunity to feedback on this report and further work. 5

Engagement activity carried out to support Governing Body decision making Our Governing Body formally received the progress report at its meeting on 5 November 2014 and requested that the views of GP members, partners, patients and the public should be sought to inform its decision making at this meeting. This work has been completed as is contained in a report (Appendix 1) which outlines the key findings of engagement activity undertaken in November and December with GP members, partners, patients and the public. Feedback was gathered through a variety of mechanisms including: Our Stakeholder Forum for patients and the public (26 November) Meetings and presentations to the Bedfordshire Healthcare Review Joint Health Overview and Scrutiny Committee, Bedford Borough and Central Bedfordshire Health and Wellbeing Boards, Bedford Borough and Central Bedfordshire Healthwatch A voluntary sector event (15 December) Public online survey Presentations at each CCG Locality Board, which represents GP members A summary of the report for staff at Bedford Hospital and presentations at its staff meeting and patient council Formal responses from Bedford Hospital, Luton and Dunstable Hospital, Bedford Borough and Central Bedfordshire Healthwatch, UNISON and the Bedfordshire Healthcare Review Joint Health Overview and Scrutiny Committee A draft of the engagement report was shared with, and the approach endorsed by, the Bedfordshire Healthcare Review Joint Health Overview and Scrutiny Committee at its meeting on 17 December. A rich body of informative and useful feedback was gathered through the engagement process, falling broadly into five categories general comment, hospital services, care closer to home, integration and the CCG approach to partner, patient and public engagement. Full details can be seen in the report which is attached in Appendix 1. Our response to the progress report: next steps We have been working with Bedford Hospital, the Luton and Dunstable Hospital, local authority partners, Milton Keynes CCG, SEPT, NHS England, Monitor and the Trust Development Agency to agree next steps. Proposals have been developed to take forward a programme of activity, tailored to the differing health systems in the north and south of the county, under the banner of Your Health in Bedfordshire and in line with the progress report s recommendations. The work will focus on three key objectives: 6

1. To develop a clear strategy and contractual framework for care closer to home, underpinned by quality standards and robust clinical pathways. 2. To develop a business case for hospital services which support integrated care, which provides a plan for a clinically and financially viable system for Bedfordshire. 3. To develop a strategy and plan for partner, patient and public engagement. This means that: In the short term we will develop and agree a care closer to home strategy based on national best practice standards and steps to improve how hospital and community services can be delivered more efficiently. This strategy will start to be delivered during 2015/16. In the medium term, the CCG will develop and agree business case(s) and the associated contractual changes for the care closer to home and acute services productivity improvement programmes in 2015/16 so that implementation can begin in 2016/17. In the longer term, where formal consultation on major service change is required, the programme will begin planning for implementation phases during 2016/17, which will deliver a vertically integrated system of care, aligning the care closer to home strategy with the effective networking of Bedford Hospital with regional and national providers of specialised services, such as Addenbrookes. Effective engagement and communication will underpin the Your Health in Bedfordshire programme, generating the necessary public and clinical support and providing a strong foundation and strategy, if required, for formal public consultation. To deliver this work, we have set up an intensive 12 week work programme working jointly with Bedford Hospital and Bedford GPs in the north (the North Bedfordshire Acute and Community Programme) and we are undertaking a similar initiative in the south working with Central Bedfordshire Council and the Luton and Dunstable Hospital. Better Care Funds developed with Bedford and Central Bedfordshire Councils will form part of this work. Key outputs of this work will include: Specifying a streamlined and consolidated urgent care service which offers the public a multi-disciplinary team available through simpler routes of access Agreeing a wider primary care development strategy, provided at scale, including: Development of GP networks / federations participating in a vertically integrated system of hospital and community services Closer working with specialists; third sector and NHS providers to deliver care in a more integrated and co-ordinated manner Promotion of excellence in the management of long-term conditions Working with local councils to use the Better Care Fund plans to test plans for joined-up integrated care 7

Refining hospital options to improve co-ordination of care within an integrated system, including: Development of a vertically integrated hospital and community system enabling local services to better support vulnerable people to be cared for outside hospital and deliver swifter assessment, diagnosis, treatment and discharge from hospital Defining core hospital services and networking of hyper-acute services to develop sustainable and modern district general hospital services that can meet the clinical standards of the future Ensuring national best practice measures are introduced locally to improve efficiency Formal consultation (if required), including: A Pre-Consultation Business Case (PCBC) providing a shortlist of viable options for major service change Formal consultation plan and documentation Proposals consistent with our five year vision for the Bedfordshire health system The work proposed in this paper for Bedfordshire is consistent with and supports delivery of our five year vision for the local health system. The detail can be found in our two and five year strategic plans published in 2013 and refreshed in 2014, in our commissioning intentions for 2015/16 and in our joint Better Care Fund plans developed with local authority partners in 2014. This work will also complement the implementation plans being developed following the announcement of a new mental health service provider. A good example of a key area of collaborative working to deliver the CCG vision are plans contained within this proposal to develop a simplified urgent care system. A number of initiatives are being explored by local GPs as they move to GP federations, Bedford Hospital, SEPT, Bedford Borough Council and the CCG. For patients living in Bedford and its surrounding villages, this could include the option to move the Walk in Centre based at Putnoe to the Bedford Hospital site in 2015. All proposals will involve patient and public engagement and public consultation. Working collaboratively with Milton Keynes CCG and national regulators A parallel work programme is also being undertaken by Milton Keynes CCG (MKCCG) and Milton Keynes Hospital with the aim of finding a clinical and financially sustainable solution for the Trust and surrounding health economy. As in Bedfordshire, this work will build on the outputs of the review and will follow a similar timescale. It is important that we continue to have a close working relationship with Milton Keynes CCG, NHS England, Monitor and the Trust Development Authority during the next phase of the programme. New governance arrangements are currently being finalised and these will ensure alignment of emerging proposals which 8

complement and strengthen both health systems. Part of this may result in a joint consultation with MKCCG during 2015. Aligning with national strategy: NHS Five Year Forward Plan and work being undertaken by local NHS partners The work outlined in this paper is also consistent with national strategy as described in the recently published NHS England document: Five Year Forward Plan. This strategy sets out a vision of a better NHS, the steps the health service should take to get us there and the actions we need from others. It shows how the health service needs to change to deliver the services needed by patients in the future and argues for a more engaged relationship with patients, carers and citizens so that we can promote wellbeing. During the engagement programme to support this paper, synergies between the review progress report and the NHS Five Year Forward View were drawn. These are outlined below. Bedfordshire & Milton Keynes Healthcare Review Progress Report Things cannot stay the way they are Better access to more services, closer to home Greater integration across all health and social care services Improved efficiency and quality to meet needs of growing population We need a modern district general hospital at Bedford with inpatient beds delivering core services including inpatient A&E, maternity and paediatrics Hospital care has become more complex hospitals need to work in networks to provide the sharing of scarce expertise, NHS England Five Year Forward View A radical upgrade in prevention and public health. One new option will permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care. The NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. So to sustain a comprehensive highquality NHS, action will be needed on all three fronts demand, efficiency and funding. Less impact on any one of them will require compensating action on the other two. Smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. 9

specialist services and treat more patients We need to simplify and consolidate urgent care Integrated urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services. Proposed timescales The timescales for the proposed work outlined in this paper are set out as follows. Phase 1. November to December 2014. Preparation work, including winter planning and delivery of initiatives outlined in our Plan for Patients 2014/2015. These have included GP-led work to improve services for patients with long term conditions such as diabetes and coronary heart disease, the development of hospital at home services and the introduction of a new Bedoc-led services for patients with minor injuries at Bedford Hospital A&E. Phase 2. January to April 2015. Finalise and implement the next steps of the review in north Bedfordshire with Bedford Hospital and confirm approach with MKCCG and review partners. This will include detailed work in four key areas: Specifying a streamlined and consolidated urgent care service which offers the public a multi-disciplinary team available through simpler routes of access Refining hospital options to define what constitutes a modern district hospital and improving co-ordination of care within an integrated system Agreeing a wider primary care development strategy, provided at scale A Pre-Consultation Business Case (PCBC) providing a shortlist of viable options for major service change and a formal consultation plan if required Phase 3 Post May (After general election). Finalise and undertake plans for formal consultation (if required), implement plans for improved services in primary, community and hospital care (vertical integration) and networked provisions of some hyper-acute specialist services Potential risks and how we will mitigate against them The urgency around the delivery of the proposed work outlined in this paper cannot be under estimated given the rising financial challenges across the Bedfordshire and Milton Keynes health systems. The Governing Body should be aware however that this is not a low risk piece of work and the chances of 100 per cent success, based on other programmes across the country is less than we would like. 10

In Bedfordshire however there is acknowledgment and commitment across health and social care system to tackle the issues raised in the review case for change and to make the changes which will safeguard local services for the future. The four key risks include: Finding a clinically and financially sustainable solution which is politically acceptable to key partners, patients and the public, understanding that in a challenged financial health economy, trade-offs are likely to have to be made A lack of engagement and buy-in from hospital and community clinicians and GPs to the proposed options for a modern district general hospital, a vertically integrated health system and a networked system of delivering some specialist services Neighbouring health systems develop alternative models of service delivery which are incompatible with the vision for service change in Bedfordshire Patients and the public are unable to commit to significant behaviour changes to support the new ways of working, for example using alternative services to Accident and Emergency and some services provided further away from their own homes. Steps are being taken to mitigate the above risks in the following ways: Key partners such as Bedford Hospital, Luton and Dunstable Hospital, GPs and the local authorities are part of the proposed work programme and will be involved every step of the way A detailed communications and engagement plan is being developed based on the best practice approach developed for the review to ensure stakeholders, patients and the public are involved in the programme and that it is undertaken in an open, transparent way with no surprises Hospital doctors, clinical staff and GPs will lead the work and their expertise and experiences, coupled with those of patients, carers and the public, will shape the outcomes and options proposed Governance arrangements are being put in place to ensure that options developed as part of the Bedfordshire work are aligned with and support proposed service changes in neighbouring counties A communications and engagement strategy is being developed to raise awareness of the review s case for change and how patients and the public can support proposed options for services changes A fuller and more detailed risk register is being developed to support the programme of work and will be reviewed on a monthly basis as part of robust governance arrangements. Recommendations The Governing Body is asked to: 1. Acknowledge the feedback and viewpoints of GP members, partners, patients and the public contained in the engagement activity report and to use this information to inform its decision making about the Bedfordshire and Milton Keynes Healthcare Review progress report and proposed next steps 11

2. Formally accept the recommendations from the study phase of the Bedfordshire and Milton Keynes Healthcare Review, contained in the progress report published on 29 October 2014 which were received by the Governing Body at its November meeting. 3. Agree the current course of action and proposed next steps being undertaken as part of the Your Health in Bedfordshire programme. 4. To note the importance of a continued close working relationship with Milton Keynes CCG, NHS England, Monitor and the Trust Development Authority during the next phase of the programme to ensure alignment of emerging proposals and consistency of approach. 12