Clinical Strategy 2015 to 2018 Version Control Sheet Version Date Author Status Comments 1 For submission 070815 Dr J Medhurst to TDA 2 210915 Dr J Medhurst For submission Includes stakeholder to the Board comments 3 29.09.15 Dr J Medhurst Approved by Board
Central London Community Healthcare NHS Trust 2015 Central London Community Healthcare NHS Trust Contents Section Page 1. Introduction 4 2. Vision and Priorities 5 3. The CLCH Population 7 4. Partnership and Joint Ventures 8 5. Activity and Income 9 6. Current Clinical Services 10 7. The Current Clinical Model 12 8. Quality 15 9. The Case for Transformation 21 10. Clinical Commissioner Changes and Plans 27 11. New Model of Care 32 12. Developments in Clinical Nursing 42 13. Clinical Service Planning 43. Service Development Plans 13.1 Plan 1 44 13.2 Plan 2 48 13.3 Plan 3 51 13.4 Plan 4 56 14. Risks 58 15. Conclusion 59 16. References 60 Appendix 1 Examples of changes made as a result of complaints and patient stories, Page 61 2 CLCH Performance Scorecard 64 CLCH Clinical Strategy Date of Issue:September 2015
Central London Community Healthcare NHS Trust CLCH Clinical Strategic Plan CLCH Clinical Strategy Date of Issue:September 2015
Central London Community Healthcare NHS Trust Current Clinical Model Factors in Strategy Development Clinical Strategy 2015-2018 CLCH Clinical Priorities and Trust Priorities Contracted activity New Clinical model Current Clinical Model: Active support for selfmanagement Primary &Secondary Prevention Improving End of Life Care Effective Meds Management Ambulatory Care Care Co-ordination integrated health & Social care Factors affecting change: Policy Changes Patient Choice/Experience Economic pressures QIPP Technology System changes Harm Free Culture Contract activity changes through procurement The Patient Perspective Commissioning Priorities and Plans Local CCGs At Risk Services Commissioning Intention themes Other changes to the Commissioning Landscape Health Economy Initiatives Existing clinical model plus: New Characteristics: Multi-disciplinary team working New kind of partnership working Supports new specialist/generalist relationships Seeing the patient through a holistic lens Examples seen in four transformation service developments: 1. Managing long term conditions in the community 2. Early discharge and transition services 3. Integrated Children s Care 4. Delivering Improved care through technology Public Health Data CLCH Clinical Strategy Date of Issue:September 2015
1. Introduction. The changing needs of our patients often frail, some with dementia, many with multiple other health problems coupled with the opportunities of new technology may mean we can better support people at home and locally. 1 Simon Stevens, Chief Executive Officer, NHS England, 4 June 2014 This clinical strategy, 2015-2018, has been written for, and about, the patients to whom we deliver care. The clinical strategy sits at the heart of the work of the organisation and links to CLCH s other strategies outlined in the Integrated Business Plan. This strategy outlines the direction of travel for the clinical services in the light of known commissioning intentions, and the Trust acknowledges that a number of other enabling strategies and plans will, in turn, drive the detailed plans for the individual specialties and Divisional clinical services. Community services have as their defining characteristic the delivery of care to patients in and close to their own personal environments. However it is a pathway of care that culminates in that home based consultation and those pathways are changing. This means that CLCH will evolve and change reflecting the emergence of different clinical relationships and working practices. CLCH is the largest standalone community trust in London and offers a population of around 1 million people services that help them remain healthy, recover from an episode of ill health or that intervene to keep them out of hospital. CLCH, in common with all NHS providers faces a profound set of challenges to deliver high quality care to a population that is living longer with limited resource allocation alongside significant recruitment challenges. Our challenge, however, remains unchanged. That is to improve the health and care to our population. To succeed at this challenge CLCH intends to increase the quality of the care we deliver when we find unnecessary variation, maintain the quality of care we know to be good and improve the efficiency of how we do this through integration and streamlining of care. 1 http://www.england.nhs.uk/2014/06/04/simon-stevens-nhs-confed 5
2. Vision and Priorities Our Vision: Great care closer to home Our Mission: Working together to give children a better start and adults greater independence Table 1 The Trust s mission reflects the fact that in delivering great care we believe we are at our best when we work together in partnership with other organisations. We thus embed the mantra of working together in our mission to deliver great care, which is, of course, the Trust s primary concern, and is therefore embedded in the vision itself. Whilst working in partnership is beneficial, CLCH also believes that community services benefit greatly from being delivered by a stand-alone provider dedicated exclusively to community healthcare. This we see as our core and unique strength: no other community health care organisation in London can match our breadth of diversity in terms of service, local patient population knowledge and geography with a focus on a preventative agenda of keeping people healthy and supporting them when they are unwell. Table 1 sets out the Trust Strategic Priorities and demonstrates how they align with the 10 Clinical Principles the trust has adopted. Clinical Principles Alignment to the Trust s Strategic Priorities 1 Optimise clinical outcomes and patient safety Quality 2 Develop and strengthen care pathways Transformation/Integration 3 Embed an organisational approach to improvement Leadership/Governance 4 Have system wide perspective Leadership/Governance 5 6 Develop partnerships that promote integration of care Improve patient experience (no care about me, without me) Transformation/Integration Quality 7 Develop clinical and organisational leaders Leadership/Governance 8 9 Have a unified culture of high standards that promotes compassion, openness and candour Be innovative and bold in the use of technological innovations 10 Deliver improved services Quality Leadership/Governance Transformation/Integration Value for Money Quality Value for Money 6
Definition of the Trust Strategic Priorities Quality We believe that good quality healthcare is a fundamental priority for all care delivered in NHS services. We were pleased to be awarded a Good rating by the CQC in the inspection undertaken in Spring 2015, but we can improve. We define quality through three lenses patient experience, safety and clinical effectiveness. Transformation/Integration: By transforming the operations of our clinical and corporate functions we will more effectively provide services which respond better to patients needs and commissioners requirements. Our Trust is making a committed and sustained contribution to the system-wide integration of services which will see the transformation of existing services into new, improved models of care with enhanced integration between health and social care providers. We have an ambitious and large-scale corporate transformation programme with Capita that will see CLCH is changing the way its services are organised. Leadership/Governance We aspire to a leadership culture that enables engagement, positivity, caring, compassion and respect both for staff, and patients. Engagement with patients, the public and staff through a variety of mechanisms is used to gain insights that assist us in improving patient experience and the quality of care. Change is then enabled through supportive line management and meaningful engagement in decision-making are factors linked to improved employee health, productivity and retention rates. Value for money This priority links closely to that of transformation and integration as we improve services and ensure that we are sustainable for the future by solidifying our financial position. The majority of this priority will be linked to the efficiency savings we will be required to make over the coming years. However we will continue to focus on improving the outcomes and safety as we explore how to reduce the cost of achieving those outcomes. Growth Our primary objectives for growth are to deliver stability, quality and value for patients, partners and commissioners. We have a realistic growth plan which does not increase risks for the organisation or our existing commissioners, patients and taxpayers. 7
3. The CLCH Population 3.1 Central London Community Healthcare Trust (CLCH) serves a population which includes approximately one in ten Londoners, predominantly the 1 million people living and working in Barnet, Hammersmith & Fulham, Kensington & Chelsea and Westminster (Figure 1). 3.2 Increasingly, services are being delivered in neighbouring boroughs and in Hertfordshire, Hounslow, Harrow and Brent, where CLCH has been awarded new business in the form of COPD, respiratory, sexual health services, Diabetes, and School Nursing. 3.3 In addition the considerable influx of daily workers and tourists into the central boroughs more than trebles the resident population during the working week. 3.4 CLCH provides care in London, a world city with around 270 nationalities speaking more than 300 languages. Ethnic diversity is matched by religious diversity, with London providing home to sizeable Muslim, Hindu, Sikh and Jewish communities. London also has extremes of wealth and deprivation, with its richest and poorest residents often living in close proximity. Recently we have been successful in being chosen to provide services in new boroughs such as Hertfordshire Figure 1 8
4. Partnerships and joint ventures CLCH has a number of partnerships and joint ventures that enable the Trust to offer comprehensive and innovative patient care, working with: Imperial College Healthcare NHS Trust o o o Community Diabetes Service Running an urgent care centre in Charing Cross and at Hammersmith Hospital Imperial Health Partners Academic Health Partnership on the Collaborative Translational Research and Development project Community Independence Service (CIS) with Imperial College Healthcare NHS Trust, GP networks and mental health trusts CLCH is a member of Imperial College Health Partners, which drives innovation through collaboration with other health providers and universities in North West London Chelsea and Westminster Hospital NHS Foundation Trust and Imperial College Healthcare NHS Trust to identify the incidence of, and clinically effective responses to, the treatment of leg ulcers Chelsea and Westminster Hospital FT in delivering Hertfordshire Sexual Health Services NWL commissioners as key members on the Whole Systems integrated care programme, aiming to integrate health and social care across patient pathways CNWL (with them as a secondary contractor), on delivering prison healthcare in Wormwood Scrubs, and working to improve access to psychological services (IAPT) with us as a secondary contractor), Barnet and Chase Farm Hospitals NHS Trust and the Royal Free London NHS FT on the Triage Rapid Elderly Assessment Team (TREAT) and Post-Acute Enablement (PACE) service projects, which move patients into the community setting more quickly, freeing up costly and sought-after acute beds West Hertfordshire Hospitals NHS Trust on COPD and community respiratory services CLCH works In conjunction with Middlesex University CLCH is involved in direct training of nurses Charing Cross and Hammersmith - Urgent Care Centres 9
5. Activity and Income In 2014/15 the Trust s total income was 198.4m and it employed just over 2,400 whole time equivalent (WTE) staff. Services are now provided from over 600 sites. In 2014/15 CLCH Trust had a total caseload of 243,838 patients with an outturn of 2.40m patient contacts. Of all the patient contacts, 45% are provided in the home. Over three quarters of our income for this activity was received from block contracts with only a small proportion from cost and volume contracts. The four main CCG commissioners, which contribute almost two thirds of CLCH s clinical income, are shown in Figure 2. Figure 2 10
6. Current Clinical Services Central London Community Healthcare, (CLCH), is one of a new generation of health providers who provide care for patients requiring help and support at home or within community settings. Currently CLCH has 69 services including children s community healthcare, supported hospital discharge and integrated care, continuing care, community nursing, rehabilitation and palliative care beds, four Walk in Centers, three Urgent Care Centers and offender healthcare at HMP Wormwood Scrubs. The CLCH health care professionals provide high quality healthcare either in people s homes or at convenient local clinics, helping people to stay well and manage their own health with the right support. Care is provided from more than 69 different services on more than 629 sites, ranging from district nursing, health visiting and home-based rehabilitation to specialist diabetes services and dietetics sessions. Care is provided for people with long-term conditions like respiratory illnesses and heart disease as well as to new mothers with their babies. Services are provided for children and young people and the homeless, as well as those who are coming to the end of their life. Our NHS walk-in centres across London can be attended by anyone without an appointment as an alternative to A & E for less serious injuries and illnesses. The full breakdown of our services is shown in Table 2: Table 2: CLCH service divisions Division Description Services Barnet Community and Specialist Nursing Services Clinic-based services, bedded services, specialist nursing services, cardiovascular disease (CVD) services and locality services across Barnet, Kensington & Chelsea, Westminster, Hammersmith & Fulham and West Hertfordshire. Specialist Nursing and Therapies represents 34% of the Trust s income MSK, podiatry, podiatric surgery, nursing homes, palliative care (community service and bedded unit), continence, tissue viability, urology, respiratory, anticoagulation, stoma, heart nursing, Parkinson s, dietetics, diabetes, specialist weight management, phlebotomy, 24hr nursing, adult speech therapy, community matrons, care navigation, falls, intermediate care, two bedded units (Jade and Marjorie Warren), rapid response, post-acute care enablement service (PACE). 11
Networked Community Nursing & Rehabilitation Children s Health and Development Services Multidisciplinary nursing and rehabilitation services are provided in patients homes, in community clinics or in rehabilitation units across Kensington & Chelsea, Hammersmith & Fulham, Westminster and Barnet. Services cover adults community nursing, adults community rehabilitation services, adults rehabilitation bedded services and therapies bedded services in partnership with Care UK. Networked Community Nursing & Rehabilitation accounts for 23% of the Trust s income. The division comprises all the Trust s children s services and delivers care across Hammersmith & Fulham, Kensington & Chelsea, Westminster and Barnet, as well as Brent from 1st April 2015. Main services include health visiting, school nursing, paediatric therapies and complex children s nursing. The division also provides services for Looked After Children and has close links with the corporate safeguarding team that support all services across the Trust. Children s Health and Development accounts for 21% of the Trust s income. Community nursing, rapid response, night nursing, community matrons, case management, community rehabilitation, community independence service, intermediate care, falls prevention, neurology rehabilitation, wheelchair services, early supported stroke discharge, wheelchair service, bedded rehabilitation at Athlone House and Alexandra House. Health visiting, school nursing, speech and language therapy (SLT) services for children and adults, acute / out-patients SLT services, children and young people occupational therapy services, children s community nursing teams, paediatric dietetics, safeguarding children and adults services. Allied Primary Care Services 17 different primary care service lines are provided across Hammersmith & Fulham, Kensington & Chelsea, Westminster and Barnet. Several are delivered in partnership with both social services and non-nhs organisations. Allied Primary Care Services account for 22% of the Trust s total income. Offender health, sexual health, health improvement, TB, HIV, primary care mental health, GPs with special interests (GPwSI), learning disabilities (Barnet), dental, interpreting, smoking cessation, homeless, walk-in centres and urgent care centres. 12
7. The Current Clinical Model This section sets out a description of the types of care that make up the present clinical caseload of CLCH. As the previous section highlights, provision of care to adults and children in their homes and their communities is the fundamental bedrock of care delivery within a community trust. The type of care, however, varies depending on the identified patient/client group. The model below sets out components of that care. Active support for self management Care co-ordination Primary Prevention/Health Promotion Managing Ambulatory Conditions Core Community services Secondary Prevention Effective medicines management Improving management of end-of-life care 7.1 Active support for self-management Self-management support can be viewed in two ways: 1. A portfolio of techniques and tools to help patients choose healthy behaviours. 2. A fundamental transformation of the patient caregiver relationship into a collaborative partnership. Both are important in the holistic management of patients that receive care from CLCH and will be supported through a cultural shift that always puts the patient/client, at the center of the clinical decision making process. 7.2 Primary prevention Effective primary prevention helps patients to avoid health problems before they occur. Giving children the best start in life provides the greatest benefits, for example CLCH supports and encourages mothers to breastfeed and provides immunization programmes. However primary prevention is valuable at any point in life. Working with other primary care providers especially general practitioners, CLCH is committed to take action to reduce the incidence of disease and health problems within the 13
population either through universal measures that reduce lifestyle risks or by targeting high-risk groups. 7.3 Secondary prevention Secondary prevention, systematically detecting the early stages of disease and intervening before full symptoms develop, is based on a range of interventions that are often highly effective in reducing the widening gaps in life expectancy and health outcomes (Marmot Review 2010). CLCH currently provides has services for Chronic Obstructive Pulmonary Disease, (COPD), Heart Disease and Diabetes. 7.4 Improving the management of End of Life Care Research suggests that when people are asked about their preferred place of care, the majority of people will state a preference to be cared for at home or in a Hospice (Gomes B et al, 2013). The CLCH End of Life Care Strategy (2015-18) sets out our plans to improve end of life care and the experience for people and carers using our services at the end of their lives, improve access to end of life care services, improve choice and the coordination of services to reduce inequalities of service provision and increase the proportion of patients who are cared for and die in their preferred place of care. The End of Life Care Strategy includes the provision of end of life care for children and adults with any advanced, progressive or chronic illness regardless of diagnosis. It focuses on generalist and specialist palliative care, including care given in all settings of CLCH (including at home, all community based services, in-patient, specialist inpatient palliative care services, day Hospice, specialist community palliative care services, prison health and nursing and residential care). 7.5 Effective medicines management Medicines management optimises the use of medicines both by patients and the NHS, protecting against the risks associated with the unsafe use and handling of medicines. It supports safe, appropriate and cost-effective prescribing, as well as helping patients to have their medicines at the times they need them, in a safe way and have information about their medicines made available to them. Good medicines management can help to reduce the likelihood of medication incidents and hence patient harm. CLCH improves the management of medicines by delivering: 14
Medication reviews in patients homes, residential and nursing care settings to ensure prescribing standards are met and help with co-ordination of domiciliary support to avoid hospital readmissions due to suboptimal medicines use. Medicines reconciliation on admission and written notification on discharge for patients in our rehabilitation, continuing, intermediate and palliative care wards to support safe transfer of information about patient medication on admission and discharge. Analysis of prescribing data and provide non-medical prescribers with information to benchmark prescribing performance. 7.6 Managing ambulatory care sensitive conditions Ambulatory care sensitive conditions, (ACS), are chronic conditions for which it is possible to prevent acute disease deterioration and reduce the need for admission to hospital. This can be achieved through: active management such as vaccinations and vaccination programmes better self-management disease management or case-management lifestyle interventions primary/community and outpatient service provision social and integrated health and social care provision ACS conditions are categorised as being acute, chronic and other/vaccine preventable. Examples are shown in table 3. ACS emergency admissions are avoidable and emergency admission rates for ACS conditions are viewed as an indicator for the quality of primary and community healthcare provision. Table 3 Acute conditions Chronic conditions Other Vaccine Preventable (OVP) conditions Cellulitis Angina Influenza Dehydration Asthma Pneumonia Dental conditions Chronic obstructive Tuberculosis pulmonary disease Ear, nose and throat Congestive heart failure Gangrene Convulsions and epilepsy Gastroenteritis Diabetes complications Children s services are investigating what illnesses generate emergency admissions for local children and plan to define that suite of conditions enabling focused work on supporting management of these conditions in the community. 15
8. Quality The definition of quality in health care, enshrined in law, includes three key aspects: patient safety, clinical effectiveness and patient experience. A high quality health service exhibits all three. However, achieving all three ultimately happens when a caring culture, professional commitment and strong leadership are combined to serve patients, which is why the Care Quality Commission is inspecting against these elements of quality too. Five Year Forward View, DH 2014 The CLCH Trust Quality Strategy April 2013 March 2016 established three Campaigns for Action. Campaign One A Positive Patient Experience Campaign Two Preventing Harm Campaign Three Smart, Effective Care Each of the three campaigns has a strategic Trust wide group to drive the campaign, provide organisational assurance and to report to the Quality Committee. These are the Patient Experience Group (Campaign One),the Patient Safety and Risk Group (Campaign Two) and the Clinical Effectiveness Group (Campaign Three). 8.1 Campaign One A Positive Patient Experience The Trust is improving patient experiences and has developed both formal groups to engage with our patients and broader communication techniques such as surveys. It is through these wide ranging activities that people contribute to the strategy and the development changes to the Trust s clinical activities. These are described below. 8.1.1 Key meetings with patient representation The Trust Patient Experience Group (PEG) and Quality Stakeholder Reference Group (QSRG) both include patient and public representation, and provide regular forums for staff and patients to share perspectives, consult on new developments and raise quality-related issues across the Trust. The role of the PEG is to monitor and support patient experience in Central London Community Healthcare NHS Trust (CLCH). The QSRG is structured in particular around the annual Quality Accounts process, but also looks more broadly at the quality, patient and public perspectives in relation to wider Trust decision making. 8.1.2 Patient Reported Experience Measures (PREMS) and Friends and Family Test (FFT) The Patient Experience Team works successfully with clinical divisions to increase the volume of surveying across services through telephone, tablet and kiosk surveys along with an increasing use of comment cards. The team has deployed mobile tablet devices in each of the divisions which are being used. Every service is asked to set its own target for completing surveys, ensuring that all services get feedback, and this is then discussed and finalised at the Patient Experience Group meeting. Work is also 16
being undertaken within Offender Health to establish the best method of gaining feedback from service users and how we can incentivise them to take the time to provide feedback. CLCH receives the highest number of responses to the FFT question of any community trust in London, with the next closest only having half our number. 8.1.3 PLACE (Patient-Led Assessments) Patient assessors are fundamental to the success of PLACE (Patient Led Assessment of the Care Environment) and must form at least 50% of the PLACE team. The PLACE assessment considers premises with inpatient services from a non-clinical perspective and assesses five areas: Cleanliness; Condition, appearance and maintenance; Food and hydration; Privacy, dignity and wellbeing; and Dementia Friendly Environment. 8.1.4 Sign up to Safety and other Trust wide initiatives CLCH is one of two Community Trusts which has taken part in a report to identify how Trusts are bringing patient experience data together. The report includes a case study of our recent patient engagement events as part of our Sign up to Safety campaign. The report can be found at: http://www.membra.co.uk/case-studies/making-sense-andmaking-use-patient-experience-data 8.1.5 Patient Stories The Trust has collected and analysed a range of patient stories (250 in 2014/15) and over the last quarter has undertaken themed analysis of these using the CQC Domains for each Division. Stories are presented at each Trust Board meeting and at the Quality Stakeholder Reference Group meetings. Changes as a result of patient stories have taken place in many services such as Intermediate Care Team, School Nursing Service, Athlone House Rehabilitation Unit, Falls Services, Wheelchair Services, Podiatry, and the Neuro-Rehabilitation Team. Examples of how changes have been made as a result of complaints and patient stories, are illustrated in Appendix 1. 8.1.6 You Said, we Did acting on the patient voice CLCH has a range of You Said we Did improvements which demonstrate the changes we are implementing as a result of patients feedback. The feedback from patients will continue to be monitored both locally and across the trust to evaluate the impact of changes. 17
8.1.7 Example of actions taken as a result of the 15 Steps Challenges 2 Actions are taken forward by the service and are reported to the Quality Stakeholder Reference Group. Actions have included: Update and review podiatry brochure. Encourage distribution within main reception and with first time referrals. Recruitment of volunteers to support reception, to assist with activities and patient story collection and support for family and friends day. Stressing the importance of the welcome and the queuing system to make sure people are seen appropriately. Key overarching themes/issues from the Patient Experience data relate to waiting times, access to services, and communications. Each service receives the patient feedback monthly and many local initiatives are developed from the feedback received. In addition there are some trust wide programmes to improve patient experience. These include the implementation of our End of Life Care Strategy with related workstreams, Achieving Excellence Together programme for District Nurses, and the Compassion in Care programme which incorporates a myriad of improvement projects to improve the experience of patients. As part of the Compassion in Care programme the trust has introduced staff development called Knowing you Matter to emphasise the need for compassionate care and developing resilience. 8.1.8 Listening Events The Trust carried out Listening events during May 2015 across our four principle boroughs, with the focus on understanding patient experience for the development of Trust Always Events. Each was led by a non-executive director who introduced sessions and participated in and listened to the discussions. An online survey and telephone interviews were also conducted to gather views. Key themes were identified and are illustrated in Figure 3 below. The Trust will develop an Always Event plan which will provide a framework for what should happen for every person, every time they encounter healthcare from CLCH. 2 http://www.institute.nhs.uk/productives/15stepschallenge/15stepschallenge.html 18
Figure 3 Continuity of care I like to see one person throughout my care I want people looking after me to be experienced, professional and competent Healthcare professionals should be well-prepared Good communication skills are very important to me Compassion. I want you to listen to me and it is very important to me that you treat me as an individual not a condition Small things matter such as being on time and appearance Being seen quickly and also having the option of late appointments. Friendly manner - a welcoming smile goes a long way, especially when I am feeling anxious. 8.1.9 Involving Patients in Research Increasing work is being done to engage with patients to deliver the best care to the communities we serve through the use of research. There are a number of ways in which we seek to involve and engage patients in this and other aspects of research including: Involving members in research projects Liaise with researchers and advertise studies in GP surgeries and health centres to increase and facilitate recruitment to studies Utilise CLCH s external webpage currently research features there and members of the public are directed to the Head of Research & Development Encourage researchers to involve patients at the outset in their research projects including in the design Draw on the national research campaign by the NIHR: Research saved my life Raise awareness at annual CLCH research conference 8.1.10 Development of a membership and Council of Governors As CLCH progresses towards Foundation status, the Trust is developing a membership and Council of Governors. The membership will be made up from the people we care for, our partners, staff, and local communities; they will be able to elect governors who 19
represent their views. Through the Council of Governors, members will be able to influence the way we develop and improve the healthcare we deliver, making us more accountable and more responsive to local healthcare needs. 8.2 Campaign Two Preventing Harm The safety of our patients and staff is an absolute priority and good progress has been made towards building a culture of openness and learning from experience. An example of this is the work being undertaken on pressure ulcers. CLCH is committed to providing the highest quality services possible for the patients/users/clients we serve. Good quality healthcare depends on getting the basis right; safe, effective harm free care provided wherever possible at home or as near to home as possible in a clean and pleasant environment. CLCH actively encourages the reporting of all incidents and this has been a key element of Campaign Two of the Trust Quality Strategy: Preventing Harm. Staff are reminded of their responsibilities to report incidents during a new staff induction e-module and through regular contact between the Patient Safety Managers and the divisional staff. The current Quality Strategy (April 2013 March 2016) will be refreshed within the year with further measures of success identified. In 2015 we launched the Trusts safety improvement plan as part of the national Sign up to Safety campaign, developed with support from the Kings Fund. The Trust will host four Sign up to Safety workshops each year and is actively engaging with frontline clinicians to support them in identifying and resolving a safety issue relevant to their area. In addition to this the Trust held listening events with patients and members where they were asked what more is possible around safety if patients and clinicians worked more closely together. Themes were identified from this and were shared with clinical staff who are leading on the development of service improvement plans. 8.3 Campaign Three Smart, Effective Care Safe and effective care delivery requires a focus on maintaining good practice through the adoption and adherence of accepted standards, and identifying areas for improvement through inquiry and review. CLCH has separated the different clinical strands into separate working groups that are clinically led. These include the following: 8.3.1 Adoption and adherence to accepted standards NICE Core Working Group Medicines Management Group Falls Steering Group Catheter Associated Urinary Tract Infection (CA-UTI) Steering Group Venous Thromboembolism (VTE) Working Group Pressure Ulcer Working Group Record Keeping Steering Group Policy Ratification Group 20
End of Life Care Steering Group 8.3.2 Improving Outcomes through Inquiry and Review Clinical Outcomes Much work has been undertaken developing outcomes, and this is illustrated further in the document. Research Audit Service evaluation 8.4 An example of how the trust has performed in the area of providing for the three campaigns for action (a positive patient experience, preventing harm and smart effective care) is provided in the Performance Indicators in Appendix 2 8.5 The Clinical Quality Governance Structure is illustrated in figure 4. Figure 4. 21
9. The Case for Transformation The NHS is facing one of the most challenging financial and organisational environment seen in decades. A sustainable system of healthcare needs to be delivered locally which resonates with the national assessment. 9.1 External Case for Transformation Commissioners and providers are expected to be able to cope with the challenges of an aging population and increased prevalence of chronic diseases, as well as shift the current focus from acute care towards prevention and the facilitation of self-care and integrated care. This care needs to be well co-ordinated, and resources need to be directed to the patients with greatest need so that (King s Fund 2015). 9.1.1 Background A number of documents have been published recently which support the case for transformation. The Kings Fund has published discussion pieces regarding the future configuration of community Trusts. These show an emerging consensus about the impact that community services can have and what is needed to improve their effectiveness. The main steps identified to transform care include providing services which: Reduce the complexity of services Build multidisciplinary teams for people with complex needs, including social care, mental health and other services Support these teams with specialist medical input and redesigned approaches to consultant services particularly for older people and those with chronic conditions Offer an alternative to hospital stay And Organising services in order to: Wrap services around primary care Build an infrastructure to support the model based on these components including much better ways to measure and pay for services Develop the capability to harness the power of the wider community 9.1.2 The conclusion supported the need for service changes that incorporated QIPP challenges and resulted in improved quality of care and service, the use of innovation leading to a productive efficient service and that focused on prevention as well as treatment. 9.1.3 The Five year Forward View, published by the DH in 2014, highlighted that the traditional divide between primary care, community services, and hospitals has 22
increasingly become a barrier to the personalised and coordinated health services patients need. The report identified that over the next five years and beyond, the NHS will increasingly need to dissolve these traditional boundaries. Long term conditions are now a central undertaking of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected episodes of care. As a result there is now quite wide consensus on the direction the NHS will be taking. Changes needed: Increasingly we need to manage systems networks of care not just organisations. Out-of-hospital care needs to become a much larger part of what the NHS does. Services need to be integrated around the patient. For example a patient with cancer needs their mental health and social care coordinated around them. Patients with mental illness need their physical health addressed at the same time. The Five Year Forward View articulates the need and expectation that providers will be able to continue to find between 2-3% efficiency savings up until 2020. This will not be done unless we genuinely transform our clinical and support operations. 9.1.4 The Dalton Review, carried out by Sir David Dalton, Chief Executive of Salford Royal Hospital NHS Foundation Trust, was commissioned by the Secretary of State for Health to undertake a review of how different organisational forms could accelerate service transformation - to meet the challenge of improving both the quality and sustainability of clinical services. The outcome of the review, published in December 2014, describes a spectrum of potential relationships ranging from the relatively informal, such as strategic clinical networks, through to more formal contractual relationships between organisations; and finally consolidated organisational forms such as multi-site hospital chains. The review proposes that the greater the degree of consolidation the greater the efficiency gains to be made. 9.1.5 The NHS Confederation published a discussion paper in July 2015 focusing on the role of community health services in reshaping care. The early thinking in this paper focuses how community services and primary care could work even more closely. It suggests; i. Community-based models co-ordinated around people s needs ii. Community services focus on whole-person in order to help lead and develop care models iii. Partnership between community health and primary care, where community health services could provide practical support to enable primary care to work at a much larger scale more quickly iv. Through community services enable better ways for specialists and generalists to work together, support self management, and develop the crucial partnerships for prevention and wellbeing. v. Care models need to use innovations found across health services 23
vi. vii. Population needs and input from staff and patients to drive the new care models A strategic approach to maximizing the value of community health services. 9.2 Internal Case for Transformation - Key drivers for change for CLCH 9.2.1 The key drivers influencing the clinical strategy stem from patients changing needs, commissioners strategies and developments in technology, economic pressures and government policy. 9.2.2 With the population growth taking place across London directly correlated with healthcare needs, healthcare activity is expected to increase and to change (Figures 5 and 6) Figure 5, Population projections by geography, 2014-2019, in thousands. Source: Office of National Statistics 9.2.3 Each borough and county that CLCH serves has an individual profile but all are expecting growth in the over 65 population (figure 5). 24
9.2.4 Although London currently has lower levels of people with long term conditions than the England average, demographic trends mean that in the future we will have a much older population with more complex health needs. Combined with a growing population, there is increasing health needs in London. Figure 6: Population % with LTC, by common LTC types. Source: Quality and Outcomes Framework, Disease Register, 2012 9.2.5 Increasing numbers of patients with multiple long term conditions adds to the complexity of their healthcare needs and the impact of multi-morbidity is profound. People with several long term conditions have markedly poorer quality of life, poorer clinical outcomes and longer hospital stays. 9.2.6 Providers of community healthcare, such as CLCH, have the expertise to manage multiple conditions and can seamlessly integrate with partners, such as primary care, which means that most patients with long term conditions can be effectively managed outside of acute hospitals, reducing the cost to the NHS whilst improving patient experience. Using information from public health data such as the JSNAs and Atlas of Variation, will enable CLCH to work in partnership with the wider primary care community to deliver tailored efficient clinical services. 9.2.7 Other notable factors include: The total number of children under 18 is rising, the main growth taking place in the over 5s, which shows there is a rising demand for school nursing. An increasingly diverse population with contrasting deprivation profiles. Community health care services need to be tailored to the needs of an ethnically diverse population, for example by providing non-english language support, supporting access to healthcare and self-management. 9.2.8 The projected increase in children and younger people is illustrated by age group in Figure 7. 25
Figure 7 - Population ( 000s) under 19 by geography 2014-2019 A summary of the key factors affecting change are listed in Table 4. Table 4 Policy Changes Patient Choice and Experience Economic Pressures Two themes in national policy that are currently influencing our healthcare environment are the drive for greater health and social care integration and the desire to shift care out of hospital settings, closer to home. New models of commissioning focus on the patients journey through the healthcare system. Streamlining this journey makes it easier for patients to follow and encourage joint working relationships between providers. The Five Year Forward View has clearly stated the importance of supporting health prevention, promotion and well-being in the populations. Two new service models will make a difference to patients - the primary and acute care system (PACS) model, and the multispecialty community provider (MCP) model. The Trust will be working with closely with commissioners and other healthcare organisations to explore the potential impact these could have on patient care and us as a standalone community trust Increasing patient expectations for choice and personalised budgets. Patient choice is a particularly important driver where there is competition between providers. All NHS services are under funding pressure, driving a 26
need for greater efficiency whilst maintaining or improving quality of services. Technology Diagnostic equipment is reducing in size and cost enabling many diagnostic procedures to be undertaken in a community setting, providing opportunities to improve quality and experience whilst making efficiencies for providers and reducing costs. A Culture of Harm Free Care Commissioning Intentions System Changes Workforce The QIPP Challenge The Francis report, (February 2013), The Berwick report, (August 2013) and Keogh report, (July 2013) restate the duty of healthcare providers to make paramount the quality of patient care, especially patient safety. The most important of these, reflected both in national and local intentions, are co-ordination of care in managing conditions out of acute hospitals to reduce unnecessary attendances. Secondly, to enhance preventative measures in children and adults to reduce the prevalence and impact of disease and its consequent costs for society. In October 2013 the Secretary of State accepted the proposed changes to NHS services in North West London which will reduce the current hospital provision to five major acute hospitals as the implementation of the strategy named Shaping a healthier future begins. This requires enhancing primary and community healthcare to achieve more care in and closer to home. Co-commissioning by Barnet CCG and London Borough of Barnet is leading to integrated locality based teams. New challenges are introduced through delivering the clinical and organisational priorities of high quality safe care, which is clinically led. The following principles establish a cultural framework: Clinical leadership capacity Professional development and partnership opportunities Competent and empowered workforce Clinical engagement with the commissioning process Clinical service redesign ensuring that care pathways reflect the service user needs at the centre A well- motivated, cared for workforce to deliver exceptional services The QIPP challenging, focusing on delivering better quality care using innovation at the same time as driving up performance and preventative measures, is a feature of the longer term strategy. 27
10. Clinical Commissioner Changes and Plans Analysis of current commissioner priorities highlights the continued focus on relocating care from acute to community settings, and the integration of care around patient needs. 10.1 Public health commissioning priorities include health promotion and prevention. We are working in partnership with a number of Boroughs to prioritise health promotion and prevention strategies that focus on obesity, oral health, sexual health and healthy lifestyle choices for families We have jointly appointed an integrated partnership project lead with the three inner London boroughs. The project will design and implement integrated pathways between health and social care providers making it easier for families to support their children to have the 'best start in life' 10.2 Local Clinical Commissioning Groups CLCH is increasing its focus on strengthening relationships with all our commissioners as we believe strong relationships enable effective strategic and operational care. The CCGs provide 68% of CLCH s income P 10.3 Commissioner Intention themes In order to succeed in the market, providers need to respond to commissioner priorities. Table 5 summarises the CLCH view of CCG strategic priorities, their relative importance, and which market segments will be impacted. The most important of these, reflected both in national and local intentions, are co ordination of care and managing conditions out of acute setting to reduce unnecessary attendances, admissions and re-admissions Table 5 CCG commissioning intentions Commissioner intentions priorities Encourage first point of contact outside the acute to reduce unnecessary attendance and admission Implications for providers Need network of access points that reach different patients in the community, e.g. schools, social clubs, care homes, etc. Ensure that locations are convenient. Patients and carers need to be educated about their care options and appropriate access points, as do those who patients and their carers rely on, e.g. GPs, Ambulance Service, 111. Introduce care pathways that prescribe / encourage appropriate care outside the hospital. Key segments impacted Urgent care, LTC, end of life 28
Coordinate care to strengthen patient handling and quality of care Integrate health and social care to prioritise prevention and reduce duplication Put greater focus on outcomes to consistently drive up quality of care Introduce case management and care coordinators, supported by cross organisation/agency multi disciplinary teams. Requires significantly increased trust between organisations to enable more joint / joined-up working. Requires clear roles and responsibilities, and agreed escalation protocols. Requires increased data, data quality, access and sharing, and a single view of the patient. Requires 24/7 live coverage. Requires improved coordination of care to ensure planned hand-overs are smooth. Includes need to align on prevention, education and treatment. Much closer working with social care required at a minimum to achieve better outcomes. Potential organisational and budgetary mergers required to make this integration real. Requires agreed set of outcome metrics, allowing comparability. An opportunity to self-define outcome measures and promote performance. Development of new contractual frameworks e.g. lead provider. Anticipate growing demand for performance transparency from commissioners, from patients directly. Anticipate in time greater use of PbR and on a compulsory basis. Requires better systems and data to track and report performance; stronger service line performance management. An increased focus on harm-free care after the Mid Staffordshire report will require both rigorous monitoring and reporting of safety. LTC, end of life, disabilities, early discharge and transition LTC, end of life, disabilities, early discharge and transition All segments 29
Innovate and tailor packages of care around patient needs to empower the patient and ensure patient centricity Provide 24/7 patient access to reduce overall cost of the system and improve patient experience Expect increase of personal health budgets from current pilots and integration of health and social care budgets. Opportunity to more fully leverage technology mobile health, telehealth and advances in med tech devices enabling increased care at home. Requires more coordination with primary care and social care to link education and prevention with treatment. Will drive demand for easily accessible, timely and transparent performance quality Greater choice for individual patients as to where and how they are treated. Healthcare providers will need to appeal directly to the patient and better understand their individual needs. Branding and marketing will become necessary organisational competencies. Back office systems and processes will need to be streamlined to support value for money delivery of bespoke packages of care. Requires staff that truly prioritise the patient values and behaviours must be aligned. Requires material changes to current operating models, with (i) (ii) (iii) (iv) structured demand/capacity planning beyond current norms reliable support systems such as 111 with compliance to prescribed sign-posting, much more coordination across organisations changes to job descriptions and flexible working arrangements (v) increased capacity. LTC, universal children, disabilities LTC, end of life 10.4 CLCH will respond to these intentions and work with commissioners to ensure the success of their strategies through ensuring our strategy is aligned with theirs. By way of example, Hammersmith & Fulham s Strategic plan 2012-2017 states its strategic aims as to increase the role of the patient, improve integration, improve governance, reduce unscheduled care and the building of empowered teams with the right intelligencep18f3p. CLCH has heard this intention and responded through, for example, its focus on quality, its approach to adaptive governance that will always ensure we use the best model possible for each situation, and our roll-out of QlikView, which gives 3 Hammersmith & Fulham CCG: Strategic Plan 2012 2017 30
teams at the front line the data they require to run their business units supporting work in integrated shared records. 10.5 Other changes to the commissioning landscape With a significant shift in the Trust s income from NHS England to local authorities, CLCH faces a major change in its commissioning landscape over the coming years. The intentions of CLCH s non CCG commissioners are shown in Table 6. Table 6 Non CCG commissioning intentions Commissioner Local Authorities NHS England Services affected Older people services and social care Children s public health (5 19) (e.g. school nursing) Public health Offender health Commissioning arrangements/intentions Through the introduction of Health and Wellbeing Boards, councils have a greater role in joining up services for older people across housing, health and social care Councils are increasingly coming together to commission services in partnership with healthcare e.g. West London Alliance, Tri- borough arrangements and the Better Care Fund Local authorities receiving ring-fenced public health grant to deliver against Public Health Outcomes Framework On going work to disaggregate public health budgets and contracts Contract efficiencies being sought (e.g. Barnet 5% savings in drug and alcohol services; increased productivity in school nursing) Some investment in new services (e.g. Barnet weight management, childhood obesity) National team sets budgets; services commissioned by 10 regional area teams Single national service specification under development, aiming to reduce inequalities of access. This will make it harder for providers to differentiate their service provision in tender responses Key commissioning principle is to ensure the same standard and quality of care is provided in prisons as can be expected in the community Children s public health (0 5) (to transfer to LA by October 2015) Commitment made to increase the number of health visitors by 4,200 against May 2010 baseline of 8,092 and to transform health visiting services by April 2015 (1,151 to 1,842 in London) April 2013 New service specification for children's public health services (0 5) issued Single child health record Immunisation programme development opportunities 31
GPs Dental care More consistent approach to improve standards of primary care and tackle unwarranted variations Ensuring common, core offer for patients Payment for quality through QOF Co-commissioning of primary care Addressing longstanding access problems Drive for quality and consistency 10.6 Whole Systems Integrated Care (WSIC) Whole Systems Integrated Care is a pan-system approach that aims to integrate the various agencies from differing sector backgrounds into a stronger and more streamlined multi-disciplinary team (MDT) driven care delivery model, centred on primary care registered populations. WSIC will challenge and inform developments in the predictive management of high-risk patients focused on care co-ordination, case management and early intervention. It will also reduce the pressure from unplanned episodes on acute providers whilst increasing the acuity and complexity of care delivered within the home. The WSIC services are available described separately for each location in the IBP. 10.7 Case Manager The new Case Manager (CM) and Health and Social Care Assistant (HSCA) roles will provide a single point of contact for patients and their carers to deal with both health and social care aspects of their lives. These roles will work to coordinate care across health, social care, and the voluntary sector to make it simpler for patients and their carers to access information and understand the various services involved in care of the individual. 10.8 Community nursing Tri Borough Transformation programme Community nursing is a core service for CLCH and a key element of all community care for patients in the Tri Borough. Over the last few years, a number of challenges have arisen for the service, including the impact of QIPP programmes, unreliable data collection and performance information, changes in systems and technology, the advent of the WS programmes within the three CCGs, recruitment and workforce challenges and an increasing focus on community nursing by commissioners. In response to these challenges, improvements have been put in place within the service, including implementing system 1, developing new case manager roles, reconfiguring services around CCG and GP structures, and a divisional workforce plan alongside the CLCH Achieving Excellence Together programme for community nursing. The nursing transformation programme is described further in section 12. 32
11. CLCH New Model of Care Consideration of the Case for Transformation (external and internal) in section 9, along with the Clinical Commissioner Plans in section 10, have influenced the way CLCH has developed its new Model of Care, a key feature of this strategy. 11.1 The care provided by CLCH has focussed on the delivery of quality care for patients receiving core services. This was supported by the CQC in awarding the Trust the status of Good following its visit in April 2015. The focus of this is to help to transform services to meet national and local priorities in a patient focussed and effective way. Provision and delivery of the enablers required to implement the clinical priorities through the new model of care are essential. 11.2 CLCH, like all national healthcare organisations, is facing the combined challenges of increasing demand for healthcare service during a time of funding constraints. This theme is a golden thread within national guidance, commissioning intentions and our organisational plans. 11.3 The core activities, described in the current model remain constant, and these are the provision of care to adults and children in the following domains: Primary prevention Secondary prevention End of life care Medicines optimisation Management of ambulatory conditions Care coordination Supporting self-management 11.4 However the drivers described above have led CLCH to increase our focus on maximising value for our patients and clients that is achieving the best outcomes at the lowest cost, (Porter, Lee, 2013) as the pattern of care delivery changes. CLCH is committed to improving quality and improving efficiency across our organisational teams and within the local health system. Some of these efficiencies will be delivered by improved managerial activity such as smarter procurement and the control of the cost of agency staff. CLCH is building on the work of the Carter review (June 2015), to identify these efficiencies. 11.5 The new model will have the following characteristics: Multidisciplinary team working New kind of Partnership working Supports new specialist/generalist relationships A holistic lens and proactively enabling patient engagement Figure 8 depicts this new model of care. 33
Figure 8 New model of care 11.6 This model has a number of enablers which include: 1. Engagement with Patients 2. The adoption of enabling IT 3. Establishment of CBUs 4. Leadership and Engagement 5. Skills Behaviours and Training 6. Quality Improvement Methodology 11.6.1 Engagement with patients Activities taking place with the formal engagement of patients is well documented in Section 8 and Appendix 1. We will endeavour to develop more actives over the next 3 years throughout the patients care delivery process, putting them at the centre of the pathway. 34
11.6.2 Enabling IT There are a number of IM&T enablers that will support delivery of the clinical strategy, these include: The development of a clinical system as the core patient record ensuring the clinical picture is available in electronic form Interoperability to allow the seamless sharing of information between Trust and partner systems in the delivery of integrated care Mobile working using a Virtual Desktop Infrastructure that is device and operating system agnostic meaning that all clinical and corporate applications can be accessed and recorded in the community supporting a timely electronic patient record, working with partners and maximizing the time spent delivering care to patients Assistive technologies to empower patients to take greater control of their care, increase access and to deliver this in the most effective manner Business Intelligence available to operational staff to improve service delivery Having IM&T as a service that allows it to be easily scaled in mobilizing new services In order to achieve data sharing across organisational boundaries CLCH has procured and implemented TPP SystmOne to replace RiO as its core clinical system. This change receives the support of the tri-borough commissioners and enables GPs and community health practitioners to share patient records, giving easy access to changes in medicines, test results and appointments. The next step is to have a single patient record with direct access to clinical diagnostics. 11.6.3 Establishment of Clinical Business Units CLCH has been preparing for these challenges, and one change which has already taken place in the trust has been the introduction of the distributed leadership model. This model allows for those with clinical as well as managerial experience to lead the development of care from the patient-facing service level upwards. In 2014/15 the Trust re-organised its frontline services into clinical business units (CBUs.) The CBU structure encourages clinically-trained staff to take on managerial responsibility and assume greater control and decision-making authority and clusters together similar service lines. This structure also allows for the maximisation of the experience effect and the development and rapid sharing of innovation across the Trust. A key purpose of CBUs is to allow clinical leadership to flourish and develop, and give room for ambitious and talented professionals to grow. Figure 9 below illustrates the CBU structure. 35
Figure 9 The appointment of Assistant Directors of Quality (ADQs) to each of the four divisions has supported the Trust, and in particular its staff, to embed quality of care into each of the services throughout the divisions. 11.6.4 Leadership and Engagement Three quarters of the 3000 staff employed by CLCH are clinical and they are often the first point of contact for patients. Effective leadership for improvement requires engaging clinicians to participate in change efforts and to build support for these activities among their colleagues. Leadership development therefore needs to extend from the board to the ward. Working together, managers and clinicians jointly solve these problems and drive improvement, culminating in better patient outcomes and experience. CLCH is committed to the development of clinical leadership in three ways: 1. The development of a forum where organisational clinical leaders meet to review strategic information and inform strategic decisions through a clinical leadership group. 2. Enhanced medical/doctor leadership throughout the organisation through the appointment of clinical directors. 3. Divisional level clinical leadership of our Clinical Business Units (CBUs). A fuller description of the CBUs is held in the IBP. 11.6.5 Skills, behaviours and training The education and development of CLCH staff, described in the education strategy, is essential in ensuring that the workforce has the right skills, behaviours and training, and that they are available in the right numbers to support excellent healthcare and healthcare improvement. It is also essential that the clinical workforce meets their statutory requirements for training and is responsive to the changing needs of our services. 36
These enablers ensure the strategy links education to improvements in patient outcomes through focusing on 5 domains of: Excellent education A competent and capable workforce, A flexible workforce that is receptive to research and innovation, Professional practice which is underpinned by our organisational values and behaviours Enabling and supporting participation. 11.6.6 Quality Improvement methodology Quality improvement methods are an essential enabler for any organisation looking to increase the value of service delivery. Improvement methods such as Lean and Six Sigma have been widely adopted by high performing organisations in the engineering and manufacturing industries as a way of increasing quality whilst simultaneously reducing costs. The NHS has been slower to embrace the quality improvement movement due to the challenge of translating these established approaches within a more complex, service based environment. As a result, there is a degree of uncertainty about which approach is best for NHS organisations to adopt. Over the past 15 years, research into the development and application of improvement methods in healthcare organisations has concluded that there is no single best approach. Researchers have concluded that, in healthcare, it is less important to focus on methodology than on how this is implemented. CLCH has therefore adopted a flexible improvement methodology which contains the core elements of the traditional improvement approaches, but which is best aligned to existing models and language. The approach to implementing this method will be detailed within the CLCH Continuous Improvement and Innovation strategy. The methodology itself covers the four basic elements which should be considered when attempting to make improvements: 1. Involve the right people Curiosity is the precursor to improvement. Unless we think there is a better way of doing things, we won t try to improve. Diverse perspectives inspire curiosity. The involvement of patients, carers, staff, public and partners enables us to identify: What is important/what matters How it feels now What changes could make things better Whether anything improved after we make changes 37
2. Take a systems/process perspective The NHS is one of the most complex systems in the world. An appreciation of how complex systems work and how care processes operate within complex systems is fundamental to identifying effective ways to make efficient, sustainable improvements. 3. Plan for the human impact of change Most change efforts fail to achieve their intended aims. Typically this is due to a failure to appreciate and plan for the impact of change on the people involved. Understanding and anticipating people s needs when implementing change, can avoid generating unnecessary anxiety, frustration and resistance. 4. Use a robust implementation model All improvement requires change, but not all change leads to improvement. A robust method for testing and evidencing the effectiveness of ideas before implementation ensures a safe, efficient and effective approach to introducing changes. 11.6.7 Measurement of outcomes The act of systematically measuring outcomes aligned with costs invariably leads to improvements in patient outcomes and value for money However, in previous years, significant effort has been applied to measuring processes and process outputs that capture compliance with contractual requirements. This is focusing on what we do, rather than the impact that it makes on our patient population. Donabedian suggests that to ensure high quality service delivery, we must monitor all aspects of the care process. 38
Donabedian model for quality of care The current challenge therefore, is to define outcomes that matter to the patients they apply to and that cover the full cycle of care for a condition or an episode. Significant work has been done in 14/15 to begin defining and measuring outcomes that matter in services across CLCH. Further work is required to engage with our patients to ensure they are meaningful to them and to develop a reliable IT platform that clinicians can use in their day to day practice that matter to services across CLCH. This work is beginning to highlight areas of variation in care that will drive the Trust s improvement activities. Analytical skills training is also required so that appropriate interpretation of this data occurs driving the identification of opportunities for improvement. CLCH continues to explore opportunities to work with other system stakeholders and their commissioners to develop a wider framework of outcomes across the organisation s care pathways. 11.6.8 Measurement of cost Traditionally community trusts have been paid using a block contract mechanism that does not account for increases in demand or suitably align payment to either clinical outcomes or clinical delivery. This means that there is very little scrutiny of the cost of care to an individual. The development of a Business Intelligence (BI) team is allowing data presentation to operational staff which includes both cost and outcome, so that that action can be taken to identify and deliver service improvements and improve those clinical outcomes. {Very recently national bodies have launched a two year programme to develop currencies capturing relevant outcome and costing measures for community healthcare services equivalent to those developed for mental health care services.} 39
11.7 The New Clinical Model in the Strategic Context The new model of care has been designed to create the conditions for CLCH to engage successfully with transformational change. The change required will of course be diverse and emergent but will be underpinned by the clinical principles described earlier. The new Clinical Model is illustrated in Figure 10 below. This model, is building on the current clinical model and it links to the Trusts Clinical principles, demonstrating that the Trust is adhering to the Clinical Principles, described in Table 1 on page 5 of this document. Figure 10 11.8 Improving quality and efficiency in the longer term 11.8.1 The focus for improving quality and efficiency will alter over time. Recent thinking from the Health Foundation (2015), describes this shift in Figure 11 as follows: 40
Figure 11 This model has 5 key themes which are: Scientific discovery, technology and skills Focus on population health New ways of delivering care Process improvement for quality and productivity Active cost management 11.8.2 The model shows how the current focus is to drive efficiency using actual cost management. There is no doubt that this focus will continue but needs to be augmented with an increase focus on clinical redesign that delivers improved quality and efficiency. The plan to achieve this will be set out in CLCH s quality improvement strategy. 11.8.3 The Forward view and our commissioner s intentions clearly set out a requirement to deliver increased caseload within primary and community care settings. Currently CLCH is involved in the development of localised changes, such as the implementation of care navigators and the PACE scheme, but will strengthen its involvement in wider integration initiatives as wider networks and collaboratives develop, fulfilling its role as a key stakeholder within the wider system. 11.8.4 As a key service provider within this emerging health system CLCH is required to strengthen its focus on transforming population health so that the people we deliver care to can be supported to live longer healthier lives. The development of a prevention strategy will set out how the Trust will respond localised public health data, will 41
contribute to the wider prevention agenda and align service capacity to demographic need. 11.8.5 Finally the Trust will continue to encourage and support the use of innovation and technology in the delivery of safe and effective services including supporting research and experimenting with innovative care technology 11.8.6 The five themes, set out above, have been used to develop a matrix that sets out how CLCH will respond these components across the 3 years time span of this strategy. Component Part Active cost management Process Improvement New ways to deliver care Focus on population health Innovation Year 1 Year 2 Year 3 QIPP Non-clinical support service transformation Development of desktop clinical outcomes dashboard Training in management of variation Work with stakeholders on experiments in integration Produce a CLCH prevention charter Produce Innovation strategy Ongoing Ongoing System wide training in quality improvement methodology Data driven improvement Participate in collaborative system redesign Systematically analyse need to align with outcomes Embed processes to identify and experiment with innovation QI is Business as usual Established new models of care Deliver flexible outcome focused health system Track record of innovation 11.8.7 Beneath this overarching strategy the annual business planning process will capture the strategic plans of the divisions within CLCH, for the next 5 years and will demonstrate alignment with the clinical principles. This will create a layered strategy with a series of interlinked plans that reflect the clinical specialty of the division and their direct influencing factors. 42
12. Developments in Clinical Nursing A Community nursing Tri Borough Transformation programme is underway to address challenges that have arisen for the service. Community nursing is a core service for CLCH and a key element of all community care for patients in the Tri Borough. Challenges and concerns have identified the need to: address concerns relating to the need for further enhancement of the service, in particular to ensure the highest standards of clinical and operational performance (and its measurement and visibility), explore new models of care and collaborations, and to build strong relationships between the service and clinical commissioners, demonstrating its crucial role in future community care delivery There may be an opportunity to build on the work started by the Whole Systems programmes of the three inner London CCGs. Aims of the transformation programme The programme proposes to: bring together a number of existing initiatives within the service to provide structure, support and sustainability to these as a more coordinated programme of improvement (Year 1) build on this foundation a transformational new service model, benchmarked to the highest standards, delivering true whole systems care (design Year 1, implement Year 2) 43
13. Clinical Service Planning In terms of taking the strategy forward, a number of service developments have been initiated by Clinical Divisions, they are: Managing long-term conditions in the community Early discharge and transition services Integrated children s care Delivering improved care through technology These service developments are illustrated in Figure 12 below. The service developments are described more fully below and in the IBP. Figure 12 - CLCH Service Developments 44