NHS Chorley and South Ribble Clinical Commissioning Group NHS Greater Preston Clinical Commissioning Group
Out of Hospital Strategy 2 Out of Hospital Strategy
Contents
04 Foreword 19 Our plan for the future 05 Introduction 20 Locality model 07 About us 21 Our journey 09 National context 22 Sustainable care 11 The challenges we face 23 The case for change 13 Population 27 Delivery 18 Our guiding principles 29 Enabling work streams
Out of Hospital Strategy 3
Foreword
As Chairs of Chorley and South 2017 marks the 70th anniversary of the National Ribble, and Greater Preston Clinical Health Service. Over the last 70 years we have seen lives transformed as a result of the medical Commissioning Groups, and as general advancements. However, the founding principle practitioners, we fully understand the of the NHS remains that it should provide care for significant challenges facing primary all on the basis of need and not ability to pay. We care, and general practice in particular. believe that more than ever we need to mobilise our primary care workforce to work together to achieve The increases in workload and the a clear vision for our population. need to manage more patients with As working GPs we personally experience the multiple and complex health needs, multiple pressures and challenges faced in respect combined with the uncertainty of of workforce, premises, facilities and technology, all future workforce, means we need to of which are key enablers to delivering high quality radically rethink our delivery model if care for all closer to home. We also recognise the changes in the types of patients we see in our we are to remain sustainable beyond practices, with large numbers of patients having the next decade. multiple complex conditions that require careful management and monitoring and we recognise that some of the traditional methods of delivering primary care are no longer fit for purpose. This strategy is not an attempt to reinvent the wheel. We recognise there is a huge amount of good practice, collaboration and service transformation that has occurred in general practice since we were authorised as Clinical Commissioning Groups. But if we are to deliver at speed we need to refresh and refocus a framework on which we can underpin our entire decision making in an effective and efficient way. Given the challenges Dr Gora Bangi Dr Sumantra Mukerji currently facing local services, we recognise the Chair Chair need to do this quickly, transitioning to a sustainable Chorley and South Greater Preston primary care offer and new model of out of hospital Ribble CCG CCG provision that delivers our vision. This strategy aims to support and enable our members as key health providers to deliver effective healthcare to patients, in a timely fashion, in the most appropriate setting. It also outlines our intentions for an integrated approach to delivering out of hospital services for the local community.
4 Out of Hospital Strategy
Introduction
This strategy sets out our vision for out of hospital care in Chorley, South Ribble and Greater Preston. It sets out the principles on which we will seek to transform community and primary care (general practice) and bring together our vision and priorities to support investment, redesign services and to improve access and outcomes for our patients in central Lancashire.
General practice is the foundation of healthcare delivery in the NHS. It is central to bringing care closer to home, managing long term conditions, preventing unnecessary hospital admissions and helping people stay well and healthy. Our patients want to be able to see their GP and general practice when they need to. We have seen a steady rise in demand for general practice and patient expectations have grown. Alongside this has been a growing shift of work from secondary care to primary care, and all of these factors have placed unprecedented pressure on practices. These pressures impact on staff and patients, and it has been recognised that the need to support and develop general practice has never been greater. Therefore, the focus of this strategy is sustainability. This strategy has been co-produced with local general practitioners, and is aligned to a number of strategic plans, including our local Our health Our Care transformation programme (local delivery plan) and those principles set out in both the Five Year Forward View and General Practice Forward View. Other CCG-produced strategies linked to this document include the health economy workforce strategy, the estates strategy, and the internal and external relations strategy. Out of Hospital Strategy 5
General practice is the foundation of healthcare delivery in the NHS. It is central to bringing care closer to home, managing long term conditions, preventing unnecessary hospital admissions and helping people stay well and healthy. 6 Out of Hospital Strategy
About us
NHS Chorley and South Ribble Clinical Commissioning Group (CCG) and NHS Greater Preston CCG are clinically-led, GP membership organisations that plan, arrange and buy a range of healthcare services on behalf of our local population. The CCGs are made up of the 31 GP practices in Chorley and South Ribble and 31 GP practices in Greater Preston. Vision Together, they serve a combined registered population of almost 400,000. Our vision is to ensure equal and fair access to safe, While the CCGs are two separate statutory organisations, we work very closely effective and responsive together, sharing a management team, health and social care for staff, vision, and have a single operational our communities that and strategic plan. represent value – now and We also share the same vision, values and in the future. strategic objectives.
Combined population 400,000
Combined number of GP Practices 62
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Values The values, which should be at the heart of everything we do, are TO CARE, TO LISTEN, and TO ACT.
In more detail, the values have the following ethos:
• Be open and accountable to our patients, their carers and the local community • Be professional and honest • Work in partnership with others to achieve our goals Open and Professional and • Listen and learn, and be accountable honest willing to change based on what we hear • Respect and care for our staff, the people we work with and our local community • Protect and invest the public funds that are given to us in a well-managed way
We have a legal duty to make sure that the healthcare services Partnership Listen and we buy are safe, effective and working learn of the highest quality, but also that these services provide value for money.
Respect and Invest care wisely
8 Out of Hospital Strategy
National context
The Five Year Forward View (FYFV) published in 2014 sets out a new road map and expectations for the NHS. While setting out a whole range of changes, primary care is prominently placed.
“The foundation of NHS care will remain list based primary care” This strategy has been co-produced with local general practitioners, and is aligned to a number of strategic plans, including our local Our
health Our Care transformation programme (local delivery plan) and those principles set out in both the Five Year Forward View and General FIVE YEAR Practice Forward View. FORWARD VIEW Other CCG-produced strategies linked to this document include the health economy workforce strategy, the estates strategy, and the internal and external relations strategy. The FYFV points out that England is too diverse for one model but nor is the answer to simply let a “thousand flowers bloom”. Health economies instead will be supported to choose from a small number of October 2014 radical new delivery options. In early 2015, the vanguard programme commenced, with these new emerging models of care being tested within 50 sites across England, including:
9 6 8 13 Primary Acute and Enhanced care in Urgent and emergency Acute care Care Systems care home pilots care schemes collaborations
More details on the Vanguard Programme can be found at: www.england.nhs.uk/futurenhs/new-care-models/
Out of Hospital Strategy 9
The Next Steps on the NHS Five In April 2016, NHS England
Year Forward View published published the General Practice
in 2017 outlines that the NHS GENERAL PRACTICE Forward View. The document
NEXT STEPS ON THE FORWARD VIEW AP RI L 20 16 NHS FIVE YEAR FORWARD VIEW needs to evolve to meet the sets out a range of measures
new challenges as we live longer to support general practice,
with complex health issues, addressing the evidence
sometimes of our own making. It presented by the British Medical
#GPforwardview March 2017 focuses on how we deliver more Association, the Primary Care responsive services, covering the Foundation, the NHS Alliance issues that matter most to the public, including: and others. The document announced: • Providing urgent and emergency care 24 hours a • Investment of an additional £2.4 billion a year by day, 7 days a week 2020/21 in general practice • Improved access to GPs in the evenings and • A further £0.5 billion of non-recurrent weekends Sustainability and Transformational Plan • Speeding up cancer diagnosis investment • Increased investment in psychological therapies • A practice resilience programme • Supporting the frail and older people stay healthy • A range of workforce measures including: and independent • 5,000 new general practitioners • Fully integrated services and funding • Practice nurse development www.england.nhs.uk/wp-content/ • Practice manager development uploads/2017/03/NEXT-STEPS-ON-THE-NHS- • Supporting new models of care FIVE-YEAR-FORWARD-VIEW.pdf • A £30million three year programme: “Releasing Time for Patients”, which will support implementation of “Ten High Impact Actions” (shown below).
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The challenges we face
Together with local clinicians, staff and wider stakeholders we have identified five key challenges to delivering high quality care:
Constrained funds Clinical Workforce care pressures
Primary Patient and Estate experience community pressures care
Patient experience There is a need to integrate records and communications systems so that Community, social and primary care are too patients do not feel the ‘bumps’ in their boundary focused and disparate, and services are journey. Care should be delivered as too reliant on hospital provision. This makes it close to home as possible, and there is an hard to provide real choice for patients, and can mean that patients are frustrated by the lack of imperative to treat mental health with communication between services about their care. real ‘parity of esteem’.Clinical care The current system is complex and confusing to access, making it difficult for patients and staff Clinical care alike to navigate. Mental health services are often Clinical care needs to be modernised to adapt to the delivered separately to physical health services, continually changing needs of the local population, rather than being arranged to provide integrated who are living longer and experiencing more and holistic care. Services are delivered specific complex or multiple conditions. Care also needs to healthcare sites and settings, and are not as to reflect changes in technology in order to deliver individualised, bespoke or as responsive to patient evidence-based and effective care. More people and carer needs as they should be. should be able to manage their own conditions at
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home or in the community with support to help Quality and safety of services remains them live independently, but the current system is top of the agenda, while finding arranged in such a way that people have longer productivity and efficiency improvements stays than necessary in hospital. Medical and across the whole system to enable the technological advances mean that far fewer best use of the limited resources held. people should need to go to hospital for routine treatment. Keeping people well is reliant on support for people to be able to look after themselves, and Workforce pressures with public health budgets and services increasingly People are less likely to want a career in medicine under pressure, the prevention agenda has lost or wider healthcare, and certain clinical roles are focus and ‘healthy lifestyle’ messages are often experiencing national shortages, including general confused and unclear. Getting patients to present practice. Lancashire in particular has problems early can be difficult, and it can be hard to measure attracting clinical trainees when faced with real clinical outcomes. Developments in clinical competition from large cities such as Liverpool practice and treatments often move quicker than and Manchester. There is a high vacancy rate for services can keep up. health and care roles, which is managed through the employment of agency or temporary Local providers and commissioners wish workers, but this is costly and can affect the to arrange health and care services in a quality of care. The current workforce model is way that makes them agile and able to not sustainable for the future. move with the times so that outcomes There is a need to look at the current continually improve, and patients, their skill mix, the skill mix needed, and think carers and families are empowered to radically about how the workforce could make choices about their care. be arranged differently in the future Constrained funds to accommodate a new generation of workers who want flexible careers. The demands on health and care services are increasing and the budgets are not keeping pace. The cost of providing these services has risen for Estates and infrastructure reasons such as providing care by more highly The estates and facilities used for health and care trained specialist staff, funding the latest drugs, and delivery are no longer fit for purpose. They were keeping pace with technological advances, all of built for different times and needs, are often old, which are necessary as they are enhancing patient energy inefficient and financially inefficient for care and improving health and wellbeing outcomes. the health and care economy. The outcomes for To ensure services become sustainable, demand complex care are better if people are treated in a must be rebalanced by modernising services to specialist centre, particularly for emergency care accommodate empowered patients, or major illness, however, many services could be who are supported to make decisions and are provided close to, or within people’s homes where provided with opportunities to manage their own possible, so that when hospital stays are required, care. The financial challenge facing the whole they are much shorter. Lancashire and South Cumbria health and care economy has been estimated at £800 million over There is a need to invest and the next five years. The residual gap that must be modernise in the local estate by using covered by the central Lancashire locality, even after a collaborative and forward thinking any current savings plans are taken into account, approach that meets the needs of more is £150 million by 2021. effective health and care models.
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Population
The Joint Strategic Needs Assessment (JSNA) produced by Lancashire County Council provides a comprehensive analysis of the current health and wellbeing needs of our population, and we use this to inform our planning.
Out of Hospital Strategy 13
Greater Preston population 213,690
Greater Preston
Preston Chorley and South Ribble population
181,929
Leyland
Chorley and South Ribble
Chorley
14 Out of Hospital Strategy
Why we need to change
If Chorley and South Ribble was a village of 100 people...
The people
Life expectancy at birth Children Living in areas descibed aged 'most deprived' Male under 5
(20% most deprived 6 areas 79 nationally) Children and 10 Females young people aged 5-18 Long term 81.7 unemployed 16 Spent on persons People aged 19-65 1 Healthcare per annum 60+ persons £1,166 60 living in 4 pension People aged 66-80 credit housholds 1Adults who 14 are obese
People aged 15+ who smoke 2 over 80 Under 16 year olds in low income 15 4 families
Out of Hospital Strategy 15
The health
People aged People 5 year old children with 65+ with recorded with one or more decayed, Dementia severe missing or filled teeth 1mental illness
1 0
9 Adults with diagnosed depression 6 0 People over 17 years 12-17 diagnosed with diabetes year olds Additional people who are 3 teenage with undiagnosed People with mothers diabetes Cancer 1
People with dignosed hypertension 2 0
People who Reception have had a year 15 stroke children who are obese People with Asthma 0 Year 6 4 children People with who are Heart disease 7 obese
16 Out of Hospital Strategy
Why we need to change
If Greater Preston was a village of 100 people...
The people
Life expectancy at birth Children Living in areas descibed aged 'most deprived' Male under 5
(20% most deprived .6 6 areas 78 nationally) Children and 26 Females young people aged 5-18 Long term 82.1 unemployed 16 Spent on persons People aged 19-65 2 Healthcare per annum 60+ persons £1,154 63 living in 3 pension People aged 66-80 credit housholds 1Adults who 11 are obese
People aged 15+ who smoke 3 over 80 Under 16 year olds in low income 16 4 families
Out of Hospital Strategy 17
The health
People aged People 5 year old children with 65+ with recorded with one or more decayed, Dementia severe missing or filled teeth 1mental illness
1 0
8 Adults with diagnosed depression
5 0 People over 17 years 12-17 diagnosed with diabetes year olds Additional people who are with undiagnosed People2 with teenage diabetes Cancer mothers
2
People with dignosed hypertension 2 0 People who Reception have had a year 13 stroke children who are obese People with Asthma 0 Year 6 3 children People with who are Heart disease 6 obese
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Chorley and South Ribble Greater Preston Chorley and South Ribble are relatively affluent The health profile of Greater Preston CCG is when compared to the national average. The profile complex in that the boundary encompasses the of deprivation shows that Chorley is becoming entire district of Preston, and parts of South Ribble slightly more deprived and South Ribble slightly less and Ribble Valley. Preston has significantly higher deprived. There are currently about 2,900 children levels of deprivation than the England average, and living in poverty in Chorley and about 2,650 children a significantly higher proportion of children living living in poverty in South Ribble. in poverty than the England average. South Ribble Life expectancy for women is lower in Chorley than and Ribble Valley have significantly lower levels of the England average. It is 8.7 years lower for men deprivation than the England average. and 7.2 years lower for women in the most deprived The health of people in Greater Preston is areas of Chorley than in the least deprived areas. varied compared with the England average. Life Life expectancy for men is higher in South Ribble expectancy for both men and women is lower than than the England average. It is 8.9 years lower for the England average. It is 10.7 years lower for men men and 6.5 years lower for women in the most and 6.7 years lower for women in the most deprived deprived areas of South Ribble than in the least areas of Preston than in the least deprived areas. deprived areas. The suicide rate in Preston is significantly worse than The population in Chorley and South Ribble is the England average, and the under 75 mortality rate for cardiovascular disease and cancer are worse relatively older compared to the national profile. than the England average in Preston. The population overall is expected to get relatively older and increase significantly in number over The biggest population growth by 2021 will be the next 10 years. in the 65+ group, although it is projected that there will be a smaller population growth than the England average in Greater Preston.
Projected population growth by 2021, by age
16.0% Chorley & South Ribble 14.0% 12.0% Greater Preston 10.0% England 8.0%
6.0% 4.0% 2.0% 0.0% Source: ONS, 2012-based -2.0% Subnational Population -4.0% Projections for CCGs <19 20-44 45-64 65+ all ages
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As the population ages, the demand on health services within the area will increase disproportionately. For example, people over 65 make up 17% of the present population within the region, but the latest 12 month full period for unplanned admissions to hospital shows that patients over 65 account for 38% of those admissions. This illustrates the relative demand that an ageing population will bring. The prevalence of conditions such as chronic obstructive pulmonary disease, chronic heart failure and diabetes are relatively higher in this age group, and dementia prevalence is also predicted to increase within our population. people over 65 make up Some specific disease areas have been identified, as part of the ‘RightCare’ programme, as areas where there are opportunities to provide the biggest improvements in health outcomes and reduce inequalities. 17% These areas inform our priorities, and are: of the present population
Circulation Musculoskeletal Cancer and problems (CVD) system problems tumours
Endocrine, nutritional Neurological Gastrointestinal and metabolic system problems problems
Respiratory system Mental health Genitourinary problems problems
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1. Preston Central
Population approx Males 3 1 % 2 60,932 51 Females 5 12 The largest age group is 4 GP Practices 25-39 and 30-34 49%
6 Covering: Larches, Ingol, St Matthews, Fishwick, lea, Town Centre, Tulketh, Ashton, 8 Deeldale, Ribbleton, Greyfriars, St Georges, Riversway, Sharoe Green, Cadley, 7 Brookfield, University, Preston Rural North, Garrison Moor Park, College and Preston Rural East
Prevalence of recorded Coronary Heart Disease, 39% 1/10 Heart Failure and Asthma registered patients reside in the patients have a recorded BMI of is significantly higher 20% most deprived areas in 30 or above. This is significantly than the national average England. This is significantly above higher than the national and the similar to the Greater the Greater Preston average. Greater Preston CCG average. Preston CCG average.
Prevalence of Dementia, Stroke and Transient 10% 1/8 Ischemic Attack is similar of the registered patients reside registered patients have been to the national and the in the 20% least deprived areas diagnosed with hypertension. This Greater Preston average. in England. This is significantly is significantly below the national Prevalence of COPD and below the Greater Preston CCG and similar to the Greater Preston Diabetes is significantly average (26%). CCG average. higher to the national
and Greater Preston CCG average. 23.9% 1/9 Prevalence of Cancer is of patients (15+) are recorded patients aged over 18 years have significantly below the as current smokers. This is been diagnosed with Depression. national the Greater significantly higher than the This is significantly higher than Preston CCG average. national and Greater Preston the England and Greater Preston CCG average. CCG prevalence.
Emergency admission rate for 18+ is significantly higher than the national average and similar to the Greater Preston CCG average
(Recorded prevalence source – QOF 2015/16)
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2. Preston North
Population approx Males 3 1 % 2 52,309 50.3 Females 5 8 The largest age group is 4 GP 0-4 and 5-14 49.7%
6 Covering: Garrison, Sharoe Green, Deepdale, Greyfriars, Moor Park, Cadley, College, 8 Tulketh, St george’s, St Matthews, Brookfield, Preston Rural East, Ingol, Ribbleton, 7 Preston Rural North, Lea, University, Fishwick, Town Centre, Larches, Chorley East, Adlington and Anderton, Brindle and Hoghton, Euxton North, Chorley South East
Prevalence of recorded Coronary Heart Disease, 1/4 1/2 Heart Failure, Stroke and registered patients reside in the patients have a recorded BMI of 30 Transient Ischemic Attack, 20% most deprived areas in or above. This is significantly below COPD and severe mental England. This is significantly above the national average and similar to health are significantly the Greater Preston CCG average. the Greater Preston CCG rate. higher to the national
average and similar to the Greater Preston CCG 29% 8.5% average. of the registered patients reside in registered patients aged over 18 Prevalence of recorded the 20% least deprived areas in years have been diagnosed with Dementia and Asthma England. This is significantly above Depression. This is similar to the are similar to the national the Greater Preston CCG average. England prevalence (8.3%) and and Greater Preston average. significantly below the Greater Preston CCG prevalence (10.4%). Prevalence of recorded
18.5% Diabetes are significantly Prevalence of recorded higher to the national of patients (15+) are recorded as and Greater Preston CCG current smokers. This is similar to hypertension is significantly below average. national average but below the the national and Greater Preston Greater Preston CCG average. CCG average. Prevalence of recorded Cancer is significantly below the national average and similar to the Greater Preston CCG Emergency admission rate for under 18s is significantly above the average. national average but below the Greater Preston CCG average
(Recorded prevalence source – QOF 2015/16)
22 Out of Hospital Strategy
3. Preston East
Population approx Males 3 1 % 2 34,500 50.7 Females 5 6 The largest age group is 4 GP 45-49 and 50-54 49.3%
6 8 Covering: Ribbleton, Preston Rural East, Town Centre, Preston Rural North, Derby and Thornley, Brookfield, Alston and Hothersall, Dilworth, Ribchester, Chipping, 7 St Matthews, Fishwick, Aighton, Bailey and Chaigley
Prevalence of Coronary Heart 1/3 8.2% Disease and diabetes registered patients reside in of patients have a recorded BMI of 30 is significantly below the 20% most deprived areas in or above. This is significantly below the national average England. This is significantly the national average and similar to and the Greater above the Greater Preston CCG the Greater Preston CCG rate. Preston CCG average. rate of 26%.
Prevalence of Stroke and Transient Ischemic 1/8 Attack, Hypertension 25% registered patients have been and Dementia is of the registered patients reside diagnosed with hypertension. This similar to the national in the 20% least deprived areas is significantly below the national and Greater Preston in England. This is similar to the and similar to the Greater Preston CCG average. Greater Preston CCG rate of 26%. CCG average. Prevalence of COPD,
Asthma and severe mental health is 1/5 1/9 significantly above the patients (15+) are recorded registered patients aged over 18 national and similar as current smokers. This is years have been diagnosed with to the Greater Preston significantly higher than the Depression. This is significantly CCG average. national and the Greater Preston higher than the national and Greater Prevalence of Cancer CCG average. Preston CCG average. is significantly below the national average and similar to the Emergency admission rate for under 18s is significantly higher than the national average but below the Greater Preston CCG average Greater Preston CCG average.
(Recorded prevalence source – QOF 2015/16)
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4. South Ribble West
Population approx Males 3 1 % 2 58,900 50.5 Females 5 10 The largest age group 4 GP is 20-24 49.5%
6 8 Covering: Middleforth, Howick and Priory, New Longton and Hutton East, Longton and Hutton West, Broad Oak, Hoole, Riversway, Lostock Hall, Charnock, 7 University, St George’s, Town Centre, Farington West and Moor Park
Prevalence of recorded Coronary Heart 12% 8.1% Disease and Asthma registered patients reside in the of patients have a recorded are significantly above 20% most deprived areas in BMI of 30 or above. This is the England average England. This is significantly above significantly lower than the but below the Chorley the Chorley & South Ribble CCG England average and Chorley & & South Ribble CCG rate of 10%. South Ribble CCG rate. average.
The prevalence of Stroke, Transient Ischemic Attack 43% 1/10 and Dementia are similar of the registered patients reside in registered patients aged over 18 to the national average. the 20% least deprived areas in years have been diagnosed with Prevalence of COPD England. This is significantly above Depression. This is significantly and Mental Health the Chorley & South Ribble CCG higher than the national average are significantly below rate of 21%. and below the Chorley & South national and CCG
Ribble CCG average. average.
Prevalence of Cancer is 1/7 significantly above the patients (15+) are recorded national average. as current smokers. This is significantly lower than the England average.
Emergency admission rate for under 18s is significantly above the England and Chorley & South Ribble CCG average
(Recorded prevalence source – QOF 2015/16)
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5. South Ribble East
Population approx Males 3 1 % 2 30,311 49.3 Females 5 3 The largest age group is 4 GP 40-49 and 50-54 50.7%
6 8 Covering: Coupe Green and Gregson Lane, Walton-le- Dale East, Bamber Bridge West, Samlesbury and Walton, Walton-le-Dale West, Lostock Hall, Bamber Bridge East, 7 Brindle and Hoghton, Clayton-le-Woods North
Prevalence of recorded Coronary Heart 1% 9.2% Disease and Stroke registered patients reside in of patients have a recorded BMI of and Transient Ischemic the 20% most deprived areas in 30 or above. This is similar to the Attack and Cancer England. This is significantly below national average and below the are significantly the Chorley & South Ribble CCG Chorley & South Ribble CCG rate higher to the England rate of 10%. CCG rate. prevalence and similar
to the Chorley & South Ribble CCG 24% 9% prevalence. of the registered patients reside in registered patients aged over 18 Prevalence of recorded the 20% least deprived areas in years have been diagnosed with Asthma and Diabetes England. This is significantly above Depression. This is significantly are similar to national the Chorley & South Ribble CCG higher than the England average average but below rate of 21%. and below the Chorley & South the Chorley & South
Ribble CCG rate. Ribble CCG average.
Prevalence of recorded
Dementia is similar to Prevalence of recorded hypertension 1/6 the national average. patients (15+) are recorded as current and COPD is significantly higher smokers. This is significantly below than the national average and Prevalence of recorded the England and Chorley & South similar Chorley & South Ribble CCG severe mental health Ribble CCG average of 18.1%. prevalence. is significantly below the national and CCG average. Emergency admission rate for under 18s is significantly above the national average
(Recorded prevalence source – QOF 2015/16)
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6. Chorley East
Population approx Males 3 1 % 2 35,329 50.3 Females 5 7 The largest age group 4 GP is 30-34 49.7%
6 Covering: Clayton-le-Woods, Whittle-le-Woods, Clayton-le-Woods North, Wheelton 8 and Withnell, Astley and Buckshaw, St. Ambrose, Pennine, Clayton-le-Woods West 7 and Cuerden, Chorley North East, Chorley East, Adlington and Anderton, Brindle and Hoghton, Euxton North, Chorley South East, Chorley South West
Prevalence of recorded Coronary Heart Disease 24% 8.4% and Stroke and Transient of the registered patients reside in of patients have a recorded Ischemic Attack, Cancer the 20% least deprived areas in BMI of 30 or above. This is and COPD are similar to England. This is significantly above significantly below the England the England prevalence the Chorley & South Ribble CCG (9.5%) and the Chorley & South and below the Chorley rate of 21%. Ribble CCG rate (9.8%). & South Ribble CCG
prevalence.
Prevalence of recorded 1/6 1/8 Diabetes and Heart patients (15+) are recorded registered patients aged over Failure is significantly as current smokers. This is 18 years have been diagnosed below the national significantly below the England with Depression. This is average and Chorley and Chorley & South Ribble CCG significantly higher than the & South Ribble CCG average of 18.1%. national and Chorley & South average. Ribble CCG average. Prevalence of Asthma is
significantly higher than Prevalence of recorded the England average but hypertension is significantly below similar to the Chorley the national average and Chorley & South Ribble CCG & South Ribble CCG prevalence. prevalence. Prevalence of recorded severe mental illness and Dementia is similar to the Emergency admission rate for under 18s is similar to national national average. average but below Chorley & South Ribble CCG average
(Recorded prevalence source – QOF 2015/16)
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7. Chorley Central
Population approx Males 3 1 % 2 63,044 49.7 Females 5 8 The largest age group 4 GP is 45-49 50.3%
6
8 Covering: Chorley South West, Chorley South East, Coppull, Chorley East, 7 Adlington & Anderton, Chorley North West, Chorley North East,
Prevalence of recorded Coronary Heart 1/7 1/10 Disease, Heart Failure, registered patients reside in the 20% patients (18+) have a BMI of 30 Stroke and Transient most deprived areas in England. This or above Ischemic Attack is is significantly above the CCG rate. significantly above
national average
Prevalence of recorded registered1/6 patients have been 1/6 Cancer, Diabetes patients (15+) are recorded as diagnosed with Hypertension. (17+), COPD and current smokers This is significantly above the Asthma is significantly national average. above national
average.
Prevalence of recorded severe mental illness is 1/9 similar to the national registered patients aged over average. 18 years have been diagnosed with Depression. This is significantly above the national average.
Emergency admissions rate for under 18s is similar to national average.
(Recorded prevalence source – QOF 2015/16)
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8. Leyland
Population approx Males 3 1 % 2 52,867 50.7 Females 5 9 The largest age group 4 GP is 50-54 49.3%
6 8 Covering: Seven Stars, St Ambrose, Leyland Central, Eccleston and Mawdesley, Moss Side, Lostock, Clayton-le-Woods West, Cuerden, Farrington East, Buckshaw and 7 Worden, Earnshaw Bridge, Farington West, Broadfield and Chisnall
Prevalence of recorded Coronary Heart Disease, 8% 1/11 Stroke, Transient Ischemic registered patients reside in the patients have a recorded Attack and Heart Failure 20% most deprived areas in BMI of 30 or above. is significantly higher than theEngland. Chorley This & is Southsignificantly Ribble below CCG the national average. average (10%). Prevalence of Dementia 1/7 is significantly below the registered patients have been England and Chorley & diagnosed with Hypertension. South Ribble CCG. This is significantly higher than the 1/6 Prevalence of recorded patients (15+) are recorded as national average. Cancer, Diabetes (17+), current smokers. COPD and Asthma is significantly above 1/10 national average. registered patients aged over 18 years have been diagnosed with Depression. This is significantly higher than the national average.
Emergency admissions rate for under 18s are significantly higher than the national average.
(Recorded prevalence source – QOF 2015/16)
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Our guiding principles
Working with our general practices and partners across central Lancashire, we have identified that in order to deliver our vision we need to improve care for the future by encompassing the following principles:
1 Safe and high quality 5 Population orientated Care will be evidence-based whenever Care will be focused on the needs of the possible and clinical decisions will be population within a locality and or specific informed by peer support and review. patient groups such as those with multi morbidities, frail elderly and those within care and nursing homes. Accessible 2 Patients will be seen in a time appropriate Co-ordinated manner depending on clinical need, 6 by an appropriately skilled person capable Services will work seamlessly together to of making decisions about the correct co-ordinate care plans and deliver the course of action, available to patients support patients need, coordinated across as early as possible in the process. agencies with the minimum number of Services will be delivered 7 days a week separate consultations. where appropriate. 7 Maximising care provision 3 Comprehensive closer to home Primary care professionals will support Delivering services traditionally delivered population-based proactive care working in a hospital setting in the community as integrated care teams providing underpinned by access to specialist advice continuity and coordination across and diagnostics. multidisciplinary teams centred on localities and local patient needs. 8 Sustainable
Services that are fit for the future 4 Person centred and supported by resources committed People should be supported to live well long term when they are well with prevention, self-care, early help and early intervention as a priority.
30 Out of Hospital Strategy
Our plan for the future
The Five Year Forward View outlines and social care partners across central Lancashire that steps will be taken to break working together to determine how out of hospital services will be delivered. The aim is to ensure that down barriers in how care is provided patients only have to access services in hospital between family doctors and hospitals, when absolutely necessary, increasing the number between physical and mental health, of services delivered in the community and closer to the patient’s home. To do this we are working between health and social care.The towards the establishment of two Multispecialty future will see far more care delivered Community Providers (MCPs) in Chorley, South locally but with some services in Ribble and Greater Preston. specialist centres, organised to An MCP is a multispecialty community provider; it is support people with multiple health a new type of integrated provider, combining place based delivery of primary and community-based conditions, not just single diseases. health and care services, including the planning and The CCGs in Chorley, South Ribble and Greater budgets for services. Preston are part of the ‘Our Health, Our Care’ The diagram below illustrates the MCP model change programme, which encompasses health being developed:
Services delivered across both MCPs e.g. hospital sp i
rvi Services delivered across all ICTs re d e.g. Tier 2 services ll I C
Services delivered across one or more ICTs e s d e.g. specialist nursing e or
Fully integrated health and care services, serving populations of approximately 30,000 to 50,000 and delivered through GP collaboratives e d C Population Health, Prevention and Self Care in communities a lth
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Locality model
The building blocks of an MCP are These localities are the practical, operational model ‘localities’ of integrated care teams, of accountable care provision. The wider the scope of services within the MCP, the more localities that may serving populations of approximately need to connect together to create sufficient scale. 30,000 to 50,000 people to deliver Localities will be supported to develop a leadership services shaped around local need and model that enables them to take on responsibility what works best for different groups for their population, to define the services that are of patients. required, and the models by which they are delivered.
Integrated Care Community consultants Teams
Social care Primary care
Signpost
Mental health Therapy
Integrated
care
Wellbeing support Community nursing Triage Treat
Specialist care Acute care
Diagnostics
Improved outcomes Better utilisation Improved utilisation and experience of care of the local health and and sustainability of 1 for patients 2 care workforce 3 local services
32 Out of Hospital Strategy
Our journey
General practice is experiencing unprecedented workload and workforce challenges and when general practice fails the NHS fails. Developing an MCP will provide practical help to sustain general practice now and in the future, supporting practices to work at scale and to benefit from working as part of a larger integrated care team.
To support the direction of travel towards an MCP This will include the investment of £3 per head this strategy focuses on how we support existing of population transformation funding to support general practices to deliver consistent and reliable practices to develop joint working arrangements care, and for those services that require a wider skill and start to deliver the “10 high impact changes” mix, supporting practices to come together and collaboratively, training for non-clinical staff offer these services at scale. processing clinical letters, and non-clinical triage. The first step on our journey is to support practices Building on these collaboratives we will support work together at scale, and through maximisation practices and community services to develop of the opportunities outlined in the GP Five Year integrated care teams in the localities. These teams Forward View, help practices to work jointly in the will work to support the health and wellbeing delivery of general medical services. of their population by focusing on prevention, supporting people to take responsibility for their own health, and delivering services in an integrated and co-ordinated way.
The focus of the Strategy
Primary care Primary care Integrated Care Accountable Care today at scale Teams System
Now 2020/21
Out of Hospital Strategy 33
Sustainable care
This strategy describes how we will devolve the commissioning of a number of services based on population need for delivery in localities and focuses on six key areas.
Working with our practices we have identified the case for change and the outcomes Access we would expect to see in each of the six key areas, and these are outlined in more detail in the next section. New Models Integration of Care
Sustainable Care
Workforce Technology
Access:
Safe and accessible primary care Estates services for all patients .
New models of care: Access to a greater range of services closer to home. Integration: Services from a range of providers delivered by a Estates: multidisciplinary team centred around the needs of High quality primary care estates and facilities the patient and community. that meet the needs of our population now and in the future. Workforce: A valued and motivated primary care workforce Technology: with training and development opportunities for a Maximise the use and benefit of technology to variety of roles, including specialists. support efficient and seamless patient care.
34 Out of Hospital Strategy
The case for change
The current care system across the two CCGs is unsustainable in its current form. Therefore, fundamental change is required. There is a clear willingness across the central Lancashire health economy to address the challenges outlined below in a proactive way.
• Practices working in silos • Long waits for non-urgent New • Duplication of functions GP appointments, especially with a named GP Models of across practices and Access Care community services • In equity in the provision • Variation in clinical practice of evening and weekend appointments across practices • An ageing workforce • Difficulty in access for hard to reach groups • Services are not provided based on population need
• An inability to recruit, • Organisations working including trainees independently
Workforce • A lack of career progression Integration • Poor and confused • An inequity in distribution communication and of the workforce information • A lack of robust workforce • Multiple handoffs for planning data patients across organisational boundaries • Duplication in work load • Inefficient use of clinical expertise
• Poor quality premises that • No single patient record are not fit for purpose accessible by multiple healthcare professionals and Estates • Underutilisation of premises Technology organisations • Services not co-located • Limited use of alternative • Practices do not have room technology to expand • Variable uptake in • Some buildings have utilisation by patients limits on weekend and Utilised in a sporadic and evening opening unsupported way
Out of Hospital Strategy 35
Many practices are now starting to work together and are seeing the benefits for themselves, patients and the wider health and care system. Working at scale is not about merging or relinquishing contracts, but about working collaboratively to maximise the benefits of economies New of scale, workforce development, resilience and service delivery Models of opportunities. Expected outcomes: Care • Practices working • Maximum utilisation of collaboratively on population non-clinical staff to free up footprints of 30,000 + in order clinical time to maximise the benefits of • Efficient management operating at scale of workload through the • A multidisciplinary workforce implementation of the encompassing new roles and “10 high impact actions” best practice • Workforce planning across • Delivery of a greater range of general practice collaboratives services to all patients • Clinical leadership in the • Services delivered closer collaboratives to home • Rationalisation of back office functions
The current care system across the two CCGs is unsustainable in its current form. Therefore, fundamental change is required. There is a clear willingness across the central Lancashire health economy to address the challenges outlined below in a proactive way. Expected outcomes: Access • Safe and accessible services for • Patients can easily access all patients with a focus on: the most appropriate care - Children professional for their needs - Population groups • Access to all general practice - Long term conditions additional and enhanced - Frail elderly services for all patients - Care home and house bound • Provision of support and • New models of care that offer resources to enable patients to patients access to GP services self-care seven days a week • New ways of accessing services • Services provided in a through the increased use of timely way technology • Co- located general practice, community, social, third sector and some hospital services
36 Out of Hospital Strategy
Integration of health and care services underpins all future models of service delivery. Recognising the importance of breaking down organisational and professional barriers; to enable a joint focus on patient need, the removal of duplication and delays in patient care. Expected outcomes: Integration • Integrated care teams delivering • Co-ordinated care, wrapped services to populations of around the person and their approximately 30,000 to 50,000 family/carer • General practice collaborations • Health and care professionals working alongside acute, working within multidisciplinary community and local authority teams to create personalised colleagues to maximise the solutions pivotal role they play in the • Rapid intervention to prevent coordination and continuity of unnecessary hospital admissions care for patients • Integrated support to ensure • The removal of organisational safe and timely discharge back barriers, which prevent a joint in to the community following focus on patient need a hospital stay • Co-ordinated care and services • Focus on ‘home first’ to enable for patients who need health people to live as independently and/or social care support in as possible the community
The CCG is working to deliver a Lancashire wide digital strategy which aims to maximise the use and benefit of technology to support efficient and seamless patient care. Expected outcomes: • All of our population will be • Fully interoperable IT systems Technology ‘digitally enabled citizens’ in to allow seamless information relation to their health and care sharing between organisations • All patients will have the Members of the public same level of access to online participating in a range of primary care services, such as engagement activity have electronic prescribing, ‘real cited technology as a key time’ appointment books and issue for them: viewing of their patient records People said IT and technology • No barriers to patients are particularly important for: accessing technologies that • Patients to be able to access will better enable them to information about themselves manage their own health, care, conditions and treatment • To link the Third sector into health and care information systems
Out of Hospital Strategy 37
It is critical that all public sector organisations locally work together to make the most efficient and effective use of their estate and ensure there is sufficient fit for purpose infrastructure to support service delivery in the required locations. Expected outcomes: Estates • All public sector estate will • All potential avenues of capital be fully utilised to support and revenue will be exploited integrated working to their fullest to help develop • The estates will be fit for the estates – for example purpose now and in the future • Estates, Technology • Primary care estates will Transformation Programme be ‘future proofed’ to • Community Infrastructure Levy accommodate population • Section 106 expansion as a result of • Public Private Partnership initiatives such as the Preston City Deal. • NHS Property Services investment
As we develop new ways of working we need to maximise the existing workforce and embrace new roles, and ensure working environments are flexible and motivating enough to help recruit and retain staff. Expected outcomes: • Locality workforce plans will be • Clinical skill mix and the use of Workforce in place new roles will be maximised • Primary care careers will be • The use of non-clinical staff will prioritised be maximised with the aim of • Training placements within freeing up clinical time primary care will be increased • Opportunities will be in place, such as work shadowing, secondments, flexible working to provide career development opportunities for all
38 Out of Hospital Strategy
Delivery
Delivery of the strategy will be underpinned by three key work programmes
aligned to the MCP care model and supported by six enabling work streams.
Delivery
Delivery of the strategy will be underpinned by three key work programmes aligned to the MCP care model and supported by six enabling work streams.
Out of Hospital Strategy 39
Patients with increased need
OF Urgent care needs
LEVEL
Whole population
PROPORTION OF THE POPULATION
Whole population Urgent care needs Patients with • Providing support for the • Improved access to increased need whole population to stay general practice • Working with community well and to manage their • Ensuring patients are services to develop integrated own health. signposted to the mose care teams that are wrapped • Ensuring patients who have a appropriate service to around the GP collaboratives minor self limiting illness are meet their needs in a delivering services that directed to and seen by the timely manner meet the needs of their most appropriate person for • Effective and co-ordinated patient population. their need. urgent care services • Using risk stratification • Working with partners to to identify those patients ensure we make best use of which may benefit from an existing services, for example, increased level of support pharmacists and dentists. to enable them to remain well and reduce their risk of hospital admission. • Redesigning condition specific services for delivery in the community.
40 Out of Hospital Strategy
Enabling work streams
Delivery of the strategy will be supported by six enabling work streams:
Working at scale IT Through the investment of the GPFV £3 per head The Lancashire and South Cumbria Sustainability transformation funding, the CCGs are working and Transformation Partnership (STP) are developing with practices to support the development of the digital roadmap to build greater interoperability collaboratives with populations of 30,000 – 50,000. between systems and improve their resilience. Year one of this work is aimed at identifying the Providing all healthcare professionals, irrespective members of each collaborative, developing the of whether they work in a practice, hospital or supporting governance structures and delivering in the community, with a single patient record two of the 10 high impact actions jointly. is the priority. Secondly, we will improve patient Year two will then build on this work in further accessibility to services and ensure all patients have developing the governance and leadership access to the best information to decide which arrangements in the collaboratives and supporting health or social care service is most appropriate for them to take on responsibility for how community their individual needs. Finally the CCGs will start to services are delivered by the integrated care have a conversation with patients helping them to teams to their population. understand how digital technology can help them in their own care, including groups of patients who need to access health services most regularly. Contracting As we change the way we commission services from primary care to being based on population need for Estates delivery in localities we need to ensure that we have To ensure the functional suitability of our estate a contracting mechanism to support this. Building is fit for purpose and is located in areas of need on the work already undertaken in developing the the CCGs have developed an estates strategy. quality contract we will extend its scope to enable The strategy will inform where infrastructure and practices to pool funding and deliver services jointly. investment is needed and the potential projects required to underpin this strategy. Workforce There is a health economy wide workforce strategy that has been developed, following research on clinical workforce in a range of settings, from primary care to secondary care, and also in the community. Workforce planning and development is being undertaken both at an STP level, and also as part of our local delivery plan. In relation to general practice workforce locally, practices will be supported to collaborate to ensure their workforce is sustainable for the future.
Out of Hospital Strategy 41
Investment Primary care medical allocations
Primary Care Medical allocations support primary To meet the funding gap the CCGs have invested in care co-commissioning including primary care primary care services through the recently developed core contracts, Quality and Outcomes Framework quality contract and locality development. This is payments, premises and enhanced services. In only possible where growth in secondary care use line with other CCGs Chorley and South Ribble and corresponding expenditure either levels off or CCG and Greater Preston CCG have received firm reduces. Therefore a key priority for evolving primary allocations up to 2018/19 and indicative allocations care provision is that services and interventions are for a further two years. Both CCGs receive above targeted to stop patients needing hospital stays. average growth monies in 2017/18 and 2018/19. This guarantees secure and sustainable funding for Despite the better than average funding growth primary care services. both CCGs are at almost 5% underfunded The chart shows growth compared to other CCGs compared to what the Department of Health in Lancashire and the gap between the funding identified the CCGs require. required and allocated (referred to as distance from target or DfT).
2017/18 & 2018/19 Growth Monies and Impact on Distance from Target
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
(2.0)%
(4.0)%
(6.0)%
(8.0)%
(10.0)%
(12.0)%
Chorley & West Greater Lancashire England Lancashire East Blackburn Fylde & Blackpool South Ribble Lancashire Preston North Average Average Lancashire with Darwen Wyre
2017/18 & 2018/19 Growth 2018/19 Closing DFT 2016/17 Closing DFT
42 Out of Hospital Strategy
GP forward view funding NHS Operational Planning and Contracting • £3 per head for practice transformational Guidance 2017-2019 describes funding available support over two years 2017/18 to 2018/19. as part of the GPFV sustainability and This investment is funded from CCGs baseline transformation package and to improve access. allocations and is designed to stimulate development of at scale providers, stimulate This includes: implementation of the 10 high impact actions • Funds for initiatives which aim to release time to free up GP time and secure sustainability of for GPs and optimise care provision including general practice training reception and clerical staff to undertake • Funding for CCGs to commission extra capacity enhanced roles in active signposting and to ensure all patients have access to GP services, management of clinical correspondence; including routine and same day appointments at • Funding for online consultation systems to evenings and weekends. improve access and help optimise clinicians time
Chorley & South Ribble CCG Greater Preston CCG
2016-17 2017-18 2018-19 2019-20 GPFV Allocations £000 2016-17 2017-18 2018-19 2019-20
Non Recurrent
16 Clerical and Admin Training 18
31 31 Training care navigators 36 36
47 62 Online general practice software 55 72
181 364 Practice Transformational Support 212 425
Recurrent 610 1,102 Improved access 709 1,276
16 259 1,067 1,102 Total £000 18 303 1,243 1,276
Out of Hospital Strategy 43
Primary care medical expenditure The primary care medical growth monies and GPFV 2018/19 (13% in CSR CCG and over 15% in GPR funding contribute to the increasing investment CCG). 2017/18 and 2018/19 investment plans in primary care medical in both CCGs. Primary include transformation funding to support locality care medical expenditure per weighted patient is development and GP practice sustainability and planned to increase each year from 2015/16 to funding for increased access.
CSR & GPR CCGs Primary Care Medical Spend (£ per Weighted Patient)
£160
£150
£140
£130
£120
£110
£100
£90 2015/16 2016/17 2017/18 2018/19 2015/16 2016/17 2017/18 2018/19 actual actual actual actual actual actual actual actual
Chorley & South Ribble CCG Greater Preston CCG
Locality Development & 7 Day Access Local Enhanced Services GP Quality Contract
GP IT Increased Access PC CoCommissioning
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