Staffordshire and Stoke-on-Trent Five Year Strategic Plan

2014 -19 CONTENT

EXECUTIVE SUMMARY ...... 1 How we will get there ...... 71 SECTION A – KEY CHARACTERISTICS OF 8. SPECIALISED COMMISSIONING ...... 75 STAFFORDSHIRE AND STOKE-ON-TRENT ...... 4 Aims ...... 75 1. INTRODUCTION ...... 4 Impact on the health and social care system ...... 75 Vision, ambitions and expectations ...... 5 Key barriers to success ...... 75 Ambitions ...... 6 What it will look like in 2018/19 ...... 75 The case for change ...... 10 How we will get there ...... 76 A sustainable future – things that will be different ...... 20 SECTION C – KEY ENABLERS ...... 80 How this will be achieved ...... 22 9. ENGAGEMENT AND PARTICIPATION ...... 80 There will be radical redesign ...... 22 Overview ...... 80 The immediate priorities ...... 23 Individual CCG approaches ...... 81 2. SYSTEM PLAN ON A PAGE...... 24 North Staffordshire CCG ...... 81 SECTION B – ACHIEVING OUR VISION ...... 27 Stoke-on-Trent CCG ...... 81 3. INTEGRATED CARE ...... 28 East Staffordshire CCG ...... 81 Aims ...... 28 South East Staffordshire and Seisdon Peninsula CCG 82 Impact on the health and social care system ...... 28 Cannock Chase CCG ...... 82 Key barriers to success ...... 31 Stafford and Surrounds CCG ...... 83 What it will look like in 2018/19 ...... 31 The way forward and independent assessment of How we will get there ...... 31 engagement to date ...... 84 4. PRIMARY CARE AT SCALE...... 37 Developing the vision for future engagement ...... 84 Aims ...... 37 Detailed engagement requirements of each programme Organising Primary Care for the Population ...... 37 ...... 87 Impact on the health and social care system ...... 38 10. ORGANISATIONAL DEVELOPMENT AND Key barriers to success ...... 38 WORKFORCE...... 89 What it will look like in 2018/19 ...... 40 11. INFORMATICS ...... 95 How we will get there ...... 44 12. ESTATES AND FACILITIES ...... 101 5. PREVENTION AND SELF CARE ...... 47 SECTION D – IMPLEMENTING THIS PLAN ...... 102 Aims ...... 47 13. TIMELINES FOR IMPLEMENTATION ...... 104 Understanding the challenge for Stoke-on-Trent 14. BENEFITS AND MEASURES FOR SUCCESS and Staffordshire ...... 47 109 Impact on the health and social care system ...... 47 15. IMPLICATIONS FOR PARTNER Key barriers to success ...... 47 ORGANISATIONS ...... 110 What it will look like in 2018/19 ...... 50 16. GOVERNANCE ...... 111 How we will get there ...... 56 17. PROGRAMME MANAGEMENT ...... 112 6. THE EMERGENCY AND URGENT CARE 18. RISKS AND MITIGATION...... 113 SYSTEM ...... 58 APPENDICES ...... 117 Aims ...... 58 APPENDIX 1 – CONSTITUENT CCG PLANS ...... 118 Impact on the health and social care system ...... 60 APPENDIX 2 – INDEPENDENT ENGAGEMENT Key barriers to success ...... 60 REVIEW ...... 134 What it will look like in 2018/19 ...... 60 APPENDIX 3 – KEY LINES OF ENQUIRY ...... 141 System before hospital ...... 60 APPENDIX 4 – GLOSSARY ...... 145 Access to hospital ...... 62 APPENDIX 5 - REFERENCES ...... 150 The system post hospital ...... 63 APPENDIX 6 – CROSS REFERENCING BETWEEN How we will get there ...... 65 THIS STRATEGY AND “EVERYONE COUNTS” .... 151 7. ELECTIVE PRODUCTIVITY ...... 68 Aims ...... 68 Current situation ...... 68 Impact on the health and social care system ...... 70 Key barriers to success ...... 70 What it will look like in 2018/19 ...... 70

0 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

‘Staffordshire and Stoke-on-Trent will be vibrant, healthy and caring places where people will be as independent as possible and able to live happy and healthy lives, getting the necessary health and care support when required.’

1 (FRP), evidencing how each CCG will meet its EXECUTIVE mandatory financial duties to achieve a 1% surplus in year by the end of 16/17 and payback of historical deficit SUMMARY by 18/19. . This document now reflects not only the original intentions of the CCGs, but the intended and ongoing This document has been a joint effort actions detailed in the FRP. between the following CCGs and their Clearly providers will be developing their Integrated partners and providers. Business Plans in collaboration with Monitor and the Trust Development Authority We are not yet at a stage  East Staffordshire  South East Staffordshire and Seisdon where commissioner and provider plans are fully aligned Peninsula. but we have made good progress in developing the  Cannock Chase dialogue and governance infrastructure.  Stoke-on-Trent .  North Staffordshire  Staffordshire and Surrounds We originally identified some key drivers to balance demand and our need for improvement. These aims As a Unit of Planning, the CCGs recognise the have been captured and refined in the FRP submitted compelling case for change. In collaboration with our by each CCG at the end of November 2014. While these partners and providers - we must improve safety, plans are evolving, they clearly recognise the need for quality, patient experience, engagement, training, and collaborative working and delivery as an essential deliver a transformed model of care. . We want to dependency for success. Equally the principles support our citizens to take control of their own health identified in the Distressed Economies report of “do and live healthier lives. We know that the financial once and share” resonate in the shared initiatives challenge facing us is immense. The “do nothing” around the drivers recognised in the report, while still scenario will create a gap of £216m as stated in the recognising the variance in local requirements of each Distressed Health Economies Report, due to the ever separate CCG. increasing demand on services. Changing the fundamental offer to the public in a way which delivers These drivers are better outcomes needs to form the basis of our shared  Integrated care – to improve cross strategy across the health and care system. organisational working and optimise value  Prevention and self-care – to support a

reduction in demand, particularly on acute The strategic aims expressed in this 5 year plan, services originally submitted in June, are still absolutely valid. We  Delivering primary care at scale in order to have made good progress in some areas. The ‘Intensive optimise the use of resources as a means of delivering consistent care in a more flexible Support for Planning’ Review in the summer of 2014 operating model. recommended a single pathway to support frail older  Changing the delivery models for urgent and people. We now have a strategic pathway signed off by emergency care to reduce demand on A&E all the CCGs which moves us on the journey to getting a and to reduce the number of non-elective parity of and improvement in outcomes for this group. admissions We have also refined our thinking around changes to  Improvements in the productivity of elective urgent care and planned care. care  Responding to the national direction for The need for financial stability in the system is a given. specialised commissioning As a result of the level of challenge faced by the Local  Ensuring that we use our workforce, technology Healthcare Economy, the CCGs have recently been and infrastructure to enable the delivery of required to each complete a Financial Recovery Plan care.

1 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

Across Staffordshire and Stoke-on-Trent we will Stoke-on-Trent will play their role in improving the integrate care so as to connect people with the care quality and affordability of care. they need, when they need it. This aspiration works The projected financial situation across Staffordshire across organisational boundaries and is shared by the and Stoke-on-Trent is bleak. This will also be whole workforce. compounded if there is no change to how services are All partners across the health and care economy are delivered, and if demand is not controlled and clear on the critical importance of getting integrated care decreased. In addition, our local authority colleagues right. This will make a significant impact to the short and face considerable pressures adding to the overall deficit long term health and social outcomes for people who in the health and social care system. have or will develop long term conditions. It will also So how will we approach this aspiration? The Better prevent future avoidable demand for services and Care Fund (BCF) agreements will be a key first step for reduce unnecessary costs. developing integrated commissioning and This key aspiration is the means to better quality health transformational programmes, which will integrate the and social care, that is safe and effective, demonstrated whole system of delivery of care and support. In by improved outcomes for people, and evidenced by the 2014/15 the BCF work stream will establish the experiences that people describe and by the best use of strategic, financial and governance framework and the public funds. This will create a sustainable economy for mechanism for pooling of c. £244M across all of now and the future. Staffordshire. This is just the start of a wider strategy to join up care into shared outcomes, joint pools of funds Both Staffordshire and Stoke-on-Trent Health and and to connect the outcomes for people into what is Wellbeing Boards have given their agreement, in commissioned and delivered for them across currently principle, to take an integrated approach to separate providers. commissioning. This is just the start of a wider strategy to create the arrangements needed to commission and The CCGs have also committed to collaborative deliver integrated care that delivers shared outcomes commissioning and working through the Contract Board, across the system. the evolving Commissioning Congress as well as the Joint Accountability Board to join up our planning and To achieve our ambitions for a sustainable health and achieve a genuinely joint plan with social care, public social economy, we have to bring our citizens on the health and providers. .. journey with us so that prevention and self- care become the norm. We have to engage with them in The future health and social care system needs to changing behaviours so as to improve their own health. address the significant projected growth in demand This requires a long term commitment to education and through a deep understanding and influencing of awareness to prevent ill health e.g. by enhancing good people’s health, well-being and how illness can be parenting, promoting mental health well-being, prevented. Our vision describes our integrated health encouraging the cessation of smoking, improving and social care system as one which is centred on lifestyle choices particularly around diet and exercise individual needs and more personalised community- and promoting self- care for those who have long term based care and support; and one which recognises that conditions. the wider determinants of health i.e. warm, well maintained housing, access to education jobs and safe The citizens of Staffordshire and Stoke-on-Trent expect communities are also important factors in achieving significant improvements now and in the next five years positive health outcomes for our citizens. to the health and care system. The importance of safety, positive experience and quality outcomes are clear. This The 6 CCGs have set ambitions and annual targets for is especially pertinent to people following the tragedy areas within the NHS Outcome Framework. These are and harm to patients at Mid-Staffordshire. Considerable described in local operational and strategic plans in line lessons have been learned since the Francis report in with this strategy (summarised in section B of this 2013, but there is a national crisis in the ongoing viability document). Although the FRP has now galvanised focus of health care, as people know it. Staffordshire and towards financial recovery, the Outcomes Framework is

2 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19 still embedded in it’s principles and will be facilitated This will require alignment with all the other components through achieving economic balance. The expectations of our strategy particularly integrated care and and features of the innovative and responsive health prevention and self care. and care system in Staffordshire and Stoke-on-Trent Similarly, CCGs and local providers are working include 24/7 access, co-design of services, improved together to the national requirement of a 20% quality, modern models of care including enhanced use productivity improvement in elective care by 2019/20 of technology and a drive for efficiency. We want to through a variety of Staffordshire wide initiatives which support our communities to take control of their health will be outlined. The Staffordshire and Stoke-on-Trent and strongly support the concept of ‘patient activation’. CCGs recognise that this is a shared system-wide Section B describes the existing programme of change challenge and can only be achieved by commissioners, and transformation in progress at CCG level. These primary care and acute providers working together. A strands of work have a local focus and are at different step change in the way that planned care services are stages of development. . A clear blueprint of what organised and managed aims to improve access, services should look like and how they will work is being decision making, recovery times and eliminate errors developed with all stakeholders. whilst improving productivity. This will mean using The model of primary care at scale links to and has a alternative settings of care and stopping some activities. coordinating role for integrated care, urgent care, The plans for specialised commissioning for elective access, prevention and maximising self-care Staffordshire and Stoke-on-Trent will be informed by the capability of citizens. 7 day working, to provide a local and national strategic review. seamless wrap-around service, is an expectation for delivering sustainability of the health and care system in We recognise that delivering this strategy will require a the next 5 years. The operational model will include new number of enabling factors to be managed effectively. roles to ensure a flexible workforce, working alongside In particular we will have teams ensuring that the Primary Care Physicians, including, Assistant organisational and work force issues and estates and Practitioners, Physicians Assistants and Advanced technology changes, supported by effective Clinical Practitioners (e.g. Nurses, Pharmacists and communications and engagement are aligned. This will Therapists). There are seven programmes of work to underpin the successful delivery of the outcomes deliver this aspect of our strategy. expected by our citizens. The urgent and emergency care system across our area is under severe pressure and we need to address We recognise the system has more work to do, the ever increasing demand a develop new models if we however, we do have the governance infrastructure, are to deliver on key targets and expectations. . This largely through the Commissioning Congress and Joint strategy sets out ambitious intentions to reduce A&E Accountability Board. This gives an opportunity for attendances to best in class performance and commissioners to come together and for the wider emergency admissions by 15% and will evidence plans system, coordinated through a subgroup of the two to achieve this. We will implement, in collaboration with Health and Wellbeing Boards to address the issues on a our partners across the system, radical changes to system wide basis. interventions before hospital, within the acute setting and post hospital within the community.

3 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

CCGs North Staffordshire CCG East Staffordshire CCG South East Staffordshire and Seisdon 10 Peninsula CCG Cannock Chase CCG 14 Stafford and Surrounds CCG Stoke-on-Trent CCG 13 Acute Trust Sites 1 7 12 11 1. Royal Stoke Hospital 2. Queens Hospital & Burton Hospital NHS Foundation Trust (Burton HFT) 3. The County Hospital 4. Royal Wolverhampton Hospital Trust. 5. Samuel Johnson Community Hospital (Burton HFT) 8 3 2 6. Sir Robert Peel Community Hospital (Burton HFT)

Mental Health Trusts 7. Harplands Hospital (NSCH) 8. South Staffordshire and Shropshire 4 9 Healthcare FT 5 9. St Michael’s Hospital (S Staffs & SH)

6 Community Trusts 10. Leek Moorlands Hospital (Staffs & SoT PT) 11. Cheadle Hospital (Staffs & SoT PT) 12. Longton Cottage Hospital (Staffs & SoT PT) 13. Bradwell Hospital (Staffs & SoT PT) 14. Haywood Hospital (Staffs & SoT PT)

4 SECTION A – KEY CHARACTERISTICS OF STAFFORDSHIRE AND STOKE-ON- TRENT

1. Introduction

The six CCGs within our unit of planning serve a total  Population growth population of over 1 million citizens (See appendix A)  Social and demographic factors Table 1 : Population served by CCG  Obesity See detailed map on page 5  Patients registered with some of our CCGs who CCG Population receive their acute care outside of Staffordshire East Staffordshire 135,200  High levels of A&E attendances and Non elective South East Staffordshire and the Seisdon 210,000 admissions Peninsula.  Alcohol related health issues Cannock Chase 132,000  Cancer Stoke-on-Trent 258,000  Life expectancy North Staffordshire 213,000  High rates of elective activity Staffordshire and Surrounds 144,000 Work is already underway in these areas but the Total population served 1,092,200 financial challenges that face us cannot be underestimated. Our recent distressed economy review,

carried out by an independent organisation has brought As a Unit of Planning, Staffordshire and Stoke-on-Trent into focus the situation of the “do nothing” option. Left is a complex area, with multiple providers, two upper tier unchanged, our economy will be more than £216million and 8 district councils as well as six CCGs. in deficit by 2018/19, as quoted in the Distressed Economies Report. Whilst the diversity, in needs, across the area is significant, there are many issues where, by working However, the people of Staffordshire and Stoke-on- together we can make a big impact on the safety, Trent trust the staff and managers who organise and quality, patient experience and outcomes for the deliver services, and this is a huge asset. As in other people we serve. parts of the country, we have a model of health and social care that is strongly reliant on professional Some of the key characteristics of the area include support and has created high dependency on public  An ageing population with increased demand for services. This balance has to shift to one where people Long Term Condition Management feel informed about staying well, and empowered to do things for themselves with support when they are poorly  Teenage pregnancy or in need.

4 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

This involves a different mind-set for clinicians and Vision, ambitions and expectations practitioners as well as for the public, and will only be achieved through transparency, engagement and Vision working together. ‘Staffordshire and Stoke-on-Trent will be vibrant, healthy All health, social care partners and the public have been and caring places where people will be as independent involved in the development of this plan, which as possible and able to live happy and healthy lives, coincides with the NHS England strategic review during getting the necessary health and care support when 2014. This strategy has been put in place to accomplish required’ recovery and sustainability for the future; it aims to make Our vision is underpinned by the commitment from each the best use of resources, through the best-fit-structure partner organisation to work together to achieve our joint of organisations, - tasked with delivering the best strategic priorities as laid out in the Staffordshire Joint healthcare system possible within the available budget. Health & Wellbeing Strategy, ‘Living Well in This document describes the agreement and Staffordshire’, Stoke-on-Trent, Joint Health and responsibilities held by strategic leaders across the Wellbeing Strategy 2013-2016 and local ‘Better Care health and social care organisations, who, by making Fund’ Plans. This is now underpinned by the pan CCG significant changes, will deliver a high quality, governance principles outlined in each CCGs FRP sustainable health and care system within the next 5 through the Commissioning Congress, and articulated years. It is informed by a series of reviews undertaken more fully in the appendix. by independent organisations to ensure that we have Our vision gives focus to our intention to create an insight into demand, capacity and best practice and integrated health and social care system which is latterly through the work on the Distressed Economies Report and the Financial Recovery Plans.  Centred on individual needs and more personalised community-based care and support The key outcomes expected by our communities and reinforced through engagement activities such as “You  Cognisant of the wider determinants of health i.e. said, we did” and a “Call to Action” are:- warm, well maintained housing, access to education and jobs, emotional well-being and resilience and  People feel supported, safe and well in their own safe communities homes, promoting self-care where safe and There is an overwhelming and sincere intention among practical to the lowest point of dependency our clinicians and practitioners to provide a health and  People can be part of their local community and be social care system where citizens feel safe. We intend supported to access a range of support solutions to to place great emphasis on quality, patient maximise their independence for as long as experience, engagement, training, feedback, possible improvement and delivering care closer to home.  People are empowered to make their own choices Our intentions for integrated care will be challenging but and, as appropriate, have more control over their are critical to the overall delivery of our strategy. We own health and lives intend to gain role model status for our management of integrated care. To do this we will continue to work with  People are treated with dignity, fairness and respect our partners and providers to re-visit and refine our  People have universal access to information & plans to ensure that we are on track. Where appropriate services which allows them to receive the right care, we will do this as the Congress as expressed through at the right time this may be urgent, emergency or the formation of the Commissioning Congress. We will planned care take a more local approach based on community and

5 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

population need where this makes sense. This will Ambitions include continuing the necessary dialogue around the Health and Wellbeing Strategy and Joint Accountability The 6 CCGs originally set ambitions and annual targets Board (JAB) which has been set up to oversee the for areas within the NHS Outcome Framework (Fig.1). deliviery of the BCF. These are described in local operational and strategic plans in line with this strategy which are summarised in This document defines not only how we address the 5 section B. The workstreams and FRPs are still focussed domains and 6 characteristics at an aspirational level on achieving these ambitions. Although these ambitions but in section B, defines ambitious outcomes and the are still valid, the over-riding and immediate objective of interventions necessary to achieve them. This document the CCGs is to achieve financial stability. It is still the encompasses the required actions to achieve financial firm intention of the CCGs to deliver the ambitions laid stability as laid out in the FRP. out below within the new framework of the FRPs. In addition to all of our CCGs, partners and providers The FRPs will continue to be recalibrated over the committing to the delivery of these ambitions, we also coming quarter. accept the need to hold organisations to account for delivery. This is why we have established a multi- organisational governance structure and programme management arrangement to ensure delivery (see Section 16).

NHS Outcomes Framework

6 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

‘Staffordshire and Stoke-on-Trent will be vibrant, healthy and caring places where people will be as independent as possible and able to live happy and healthy lives, getting the necessary health and care support when required.’

7

Our strategic objectives as reflected in the original plan By 2018/19, the CCGs collectively commit to make the following impact for our citizens through a number of strategic objectives. We believe the following set of objectives and our subsequent responses to the five national domains are still a good indication of our intent of delivery. This will be further validated through the collective management and ongoing measurement of the workstreams in the FRPs although the direct reconciliation of the objectives in light of these plans is to be completed.

We will improve the life expectation of our residents by 8% (for conditions that are Objective 1 improved by healthcare) by delivering prevention and early intervention, using risk identification to enable proactive engagement.

We will improve the reported health related quality of life outcomes for people with a Objective 2 long term condition by 3.7% (on the validated measure EQ-5D).

We will reduce emergency admissions by 11.5%, by helping people to manage their Objectives 3 and 4 own conditions and supporting them earlier, providing better and more integrated care in the community

We will improve care in hospitals so that the proportion of people who perceive their experience to be poor will fall by 9.3%. User/Carer feedback will be proactively Objective 5 sought and acted upon, using their experience to identify improvement opportunities.

We will improve general practice and community care by working with GPs and the Objective 6 Area Team around experience of care in general practice, so that the proportion of people who perceive their experience to be positive will improve by 8.4%.

The following ambitions outlined in Table 2 below state our collective level of ambition at the point the Five Year Plan was originally submitted. This continues to set the direction of trave

l within the financial recovery plan.

8 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

Table 2 : Ambitions – What are we Going to Achieve? – Please also see Appendix 1 for the individual CCG plans on a page.

E.A.1 PYLL (Rate per 100,000 population) Average change 8% i) What is your ambition for securing additional years of life from Range of 18/19 outcome 1810 2200 conditions considered amenable to healthcare?

E.A.2 Average EQ-5D score for people reporting having one or Average change 3.7% more long-term condition ii) What is your ambition for improving the health-related quality of life Range of 18/19 outcome 71.8 76.5 for people with long-term conditions?

E.A34 Emergency admissions composite indicator Average change -11.5% iii) What is your ambition for reducing emergency admissions? Range of 18/19 outcome 1461 2668

E.A.4 The proportion of people reporting poor patient experience Average change -9.3% of inpatient care iv) What is your ambition for increasing the proportion of people having 115 128 Range of 18/19 outcome a positive experience of hospital care?

E.A.5 The proportion of people reporting poor patient experience Average change 8.4% of primary and community care. v) What is your ambition for increasing the proportion of people having Range of 18/19 outcome 4.50 5.70 a positive experience of care outside hospital, in general practice and the community?

Successful delivery of the outcomes above is heavily  High quality and appropriate urgent and emergency reliant on the realisation of benefits within the cross care – right care, right place, right time economy transformation programmes already in  Specialist centres with modern equipment providing progress, and those planned for the future. In addition, the best care this must be aligned with the outcomes of the strategic review and effectiveness of financial sustainability and  GP and Primary Care services at scale FRPs.  Efficient elective services with the best outcomes, In Staffordshire and Stoke-on-Trent we are creating a reflecting county-wide clinical prioritisation modern model of integrated ‘coordinated’ care for strategies people with complex needs, which includes  A co-ordinated strategy to address the needs of our frail elderly population  Access to services 24/7 including Mental Health The rate of change will be rapid and will need to  Engagement with citizens to improve services maintain momentum during potential changes of  Health, Wellbeing and Self-Care Programmes

9 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19 government and senior local leadership. All partners The result is an increased demand for elective (Fig.2) have signed up to the Memorandum of Understanding / and non-elective (urgent & emergency care – Fig.3) Concordat which sets out the direction and commitment services across the whole system. The graphs below to deliver successful delivery. show what the expected impact could be if there were no changes to the service configuration A ‘do nothing’ Accountability and governance arrangements have been option would result in a significant increase in the cemented through the internal and external demand for services, be unaffordable and lead to arrangements specified by the CCGs within the FRPs, system collapse.. broadly reflecting internal PMO mechanisms for delivery and external governance through the Commissioning Figure 1 : Increasing elective spells Congress and supporting PMO. These are reflected more fully in Section 16.

The case for change In Staffordshire, we have a complex environment, with significant financial challenges and some challenges around delivery of Constitution promises. In some parts of the local health and care economy, securing an appropriately skilled workforce in sufficient numbers remains a profound challenge. We have a legacy around Mid Staffordshire NHS Foundation Trust, which pervades the area and the work Figure 2 : Non elective spells to resolve this is not complete. We have worked hard to focus on quality and lessons have been learned. All this creates a particularly unique environment in Staffordshire and Stoke-on-Trent. That said, healthcare systems in the developed world are facing the following challenges which are applicable to Staffordshire and Stoke-on–Trent

 Increased population – people living longer, with 2 or more long term conditions  A mobile population from overseas with new or existing health needs  Explosion of lifestyle and obesity related conditions The graphs also show that in order to meet performance e.g. diabetes & heart disease challenges, things need to change. In terms of current performance, there are significant issues around A&E  Expectations of the public regarding access, safety waits and although as a patch we are meeting waiting and standards of care and outcomes list targets (RTT) overall, we know this is not  Expectations that technological advances in sustainable. medicine keeps people alive and active for longer; this comes at a cost for medicines, procedures and The demand and capacity modelling based on changes ongoing monitoring to settings of care and people living longer, using more community based services and being cared for closer to Increasing demand home with LTCs, suggests a major gap in capacity. A ‘do nothing’ scenario shows the potential for demand to

10 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19 outstrip appointments and visit capacity by at least 40% People have the right to expect universal access to in the next 5 years. There is existing evidence of 20% of advice and services regardless of their presenting unnecessary acute admissions that could receive out of problem or history. Historically people with psychological hospital care, coupled with the expected demand for conditions have not received sufficient care for their urgent care across all primary care .services. physical well being and treatment for underlying conditions. This document, in section B, illustrates some of the challenges we are facing and how we aim to address Parity of esteem recognises this inequality and them e.g. we have detailed transformational approaches promotes the careful attention to both mental and to improving discharge processes, prevention activities, physical health regardless of which care environment self-care and greater collaborative working with partners the person is accessing services. and providers. The Care Bill will create a single, modern framework for Improving safety, quality and patient experience adult care and support. The new statute will be clearer, fairer and built around the needs and goals of people. We have a mandate to make a positive impact on The well-being principle and focus on individuals’ needs quality, safety and patient experience. and outcomes creates a defining purpose for care and The Francis, Keogh and other reports are further drivers support. For the first time the law will put carers on the of change e.g. we will need to same footing as the people they care for.  Genuinely listen to patients, carers and staff The future health and social care system needs to  Use data to drive improvement address the projected growth in demand through a deep understanding and influencing of people’s health, well-  Learn geographically, professionally and being and how illness can be prevented. Use of detailed academically analytical information is at the centre of designing this  Use the voice of junior doctors, nurses and front strategy. line staff to stimulate innovation and creativity The Better Care Fund (BCF) agreements are a key  Reduce the dependency on locums and agency driver of future arrangements for integrated staff commissioning and for the development of − Drive out blame whilst retaining transparency transformational programmes to integrate the whole- system delivery of care and support. As part of the five- − Understand and prevent avoidable deaths year planning process, the BCF work stream seeks to − Co-design services with patients, carers and establish the strategic, financial and governance clinicians framework and mechanism for the pooling of funds. − Improve the use of inclusive quality BCF plans are in the process of being recalibrated. assessments However their overarching intent and strategic direction remains as described here. − Invest in organisational development to improve staff morale The Staffordshire BCF seeks to pool £150m frail elderly spend in order to facilitate integrated care for this cohort The need for integration and is targeted to result in transformational savings as The integrated commissioning approach also recognises well as improved service provision. that 1 in 3 people with a long term condition may Similarly for Stoke-on-Trent, the BCF pool amounts to experience a significant impact on their motivation, £94m, focussing on frailty, complex needs, long term esteem and psychological wellbeing. Addressing this will physical and mental health conditions, as well as be instrumental in empowering people to have full additional support to live at home and support for carers. control of their independence and make progress towards recovery and stability.

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A targeted strategy for frail elderly  Alignment with other CCGs Over and above our BCF plans, we have recognised the need for a rounded strategy across Staffordshire to address the needs of frail elderly. - Over 65s account for 65% of hospital users - Frail older people in the acute setting represent a low volume but high impact group; they have the longest length of stay, the highest rate of inpatient complications and highest rate of subsequent readmissions. This group account for 70% bed days. - Hospital admission reduces the probability of independent living following the incident or episode. - As a subset, dementia patients occupy up to one quarter in patients beds and have longer lengths of stay than others coming in for the same procedure.

This shared issue has led to a Staffordshire wide Frail Elderly strategy to be developed with the explicit intent of implementing a coherent integrated model of care that is consistently available across the County while being locally responsive to the needs of the communities and individuals. The financial situation The original five year plan submission reviewed the range of info-packs and directories of opportunities (e.g. Commissioning for Value, Any town) which has informed our decision making and local plans. Through the work resulting from KPMGs Distressed Economies Report and FRPs, existing interventions have crystalised and new programmes scoped. CCGs have worked together through a series of workshops, through which a list of Staffordshire-wide initiatives are being collaborated on. Additionally local schemes have been scoped, sharing good practice amongst CCGs, which align well with the overall strategic intentions of the local health economy. These have been developed through:

 Benchmarking  Prioritisation  Stakeholder engagement  Internal sign off

12 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

Significant savings have been achieved on an annual If we fail to deliver existing transformation plans, the basis using the Quality Innovation Prevention and deficit will be greater. A radical approach is required to Productivity (QIPP) Programmes, which will continue. In improve health outcomes and appropriate use of some cases these programmes sit alongside the FRP services; incremental change is not going to resolve our workstreams, and on occasion within them. The table current issues. We need to look across health and social below (Fig.4) describes the impact of both QIPP and care organisations to create the solutions. FRP on the deficit for each CCG at the three year point beyond which QIPP is a balancing item.

In addition to health, local authority colleagues face considerable cuts in funding throughout this period, creating greater tension in the economy.

Figure 3 : Surplus/(Deficit) in year movement defined in the Financial Recovery plan – to 16/17. In year (Deficit)/Surplus movement £m TOTAL ES SAS SESSP CC STOKE NS FY14/15 (36.4) (4.8) (9.2) (12.2) (8.6) (0.5) (1.2) FY15/16 (19.8) (3.9) (6.0) (10.4) (5.2) 3.2 2.5 FY16/17 7.3 1.5 1.7 2.3 1.6 0.1 0.1 NB please note that movement for Stoke and NS represents a change in surplus. Both CCGs remain in surplus thoughout.

13 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

Collaborative working is essential the effectiveness of the public sector purse, to deliver both greater community-based care and a wider health The challenge that lies ahead is about partners working and care economy which is safe, strong and together, changing behaviours in order to strengthen our sustainable. population’s capacity and desire for personal responsibility, independence, choice and control. The FRPs align to these principles

Improving commissioning  Continuing Healthcare We recognise that the task ahead is too great for each  Specific service redesign CCG to tackle individually and the fundamental need for  End of life and cancer care alignment across the commissioning and provider landscape. Therefore we will be strengthing our  Primary care as an enabler commissioning arrangements through the following with each workstream supported by a lead means: commissioner, along the lines of ‘do it once and share’ 1. Commissioning Congress The importance of primary care An inaugural meeting is scheduled for 11th Primary care is central to bringing care closer to home, December 2014 whose purpose is to set out the preventing unnecessary hospital care (access to urgent form, function, aims and objectives of a county-wide care and integrated care) and identifying which people commissioner body, to oversee the delivery of the need specialist services. GPs see the majority of all FRPs and strategic intentions of the local health healthcare contacts, but the funding allocation is only economy. Its primary purpose is one of oversight £170 billion (9%). There are an increasing number of and governance. patient contacts due to the 25% growth in people with 2. Commissioning Board Long Term Conditions (LTC Dementia, Cancer, Cardiac, Stroke, Diabetes & Mental Illness) expected by 2020, Commissioners are working together to ensure with a greater proportion of people being managed at cohesiveness of purpose in their commissioning home. intentions, specifically around shared providers, working well as both lead and associate NHS England has identified the following six commissioners. It will be a working group to underlying objectives for general practice operationalise the commissioning strategy, and 1. Proactive co-ordination of care (or anticipatory ensuring productive relationships with providers. care), that is planned together with people, 3. Contract management particularly people with long term conditions This is delivered through CSU, through their and more complex health and care problems. engagement and emerging leadership of that process. 2. Holistic care: working with people as partners in their care to plan their physical, mental and These structures will be underpinned by a PMO and social needs together. supporting BI function.

The CCGs have also focussed their collaborative efforts 3. Ensuring fast, responsive access to care and into the following areas of common focus: preventing avoidable emergency admissions  Frail elderly, including work on and A&E attendances.

- Integrated care 4. Promoting health and wellbeing, reducing - Long term conditions inequalities and preventing ill-health and illness progression at individual and community level. - A&E/urgent care avoidance

 Clinical prioritisation in planned care

14 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

5. Personalising care by involving and supporting Patients’ expectations are more informed through the patients, their carers and supporters fully in internet and the elderly population is expected to grow managing their own health and care. by 22% (Technology Strategy Board, 2103). This puts the system under great pressure in a very short period 6. Ensuring consistently high quality and value of of time. A major transformation is required to ensure the care, effectiveness, safety and patient demand does not outstrip the capacity and delay the experience. delivery of accessible services.

Figure 4 : The population affected by long term The current resource profile across Staffordshire and conditions is expected to increase by over 50% in the Stoke-on-Trent is outlined below, illustrating significant next 30 years, significantly increasing the demand on variation across the health economy. primary care services.

15 Table 3 : Primary care resource profile

No GP No of WTE GP to Patient Ratio GMS PMS Contacts APMS Practices GPs Contracts Contracts

Staffordshire 124 428 1974 54% 43% 3%

Stoke 53 150 1981 70% 23% 8%

The importance and preference for out of hospital care necessary to ensure successful delivery of and a reduction in acute demand will further increase improvements and realisation of benefits at a the pressure on primary care and community services. citizen/patient level. Across Staffordshire this pressure is amplified through a A clear vision for our frail elderly population pending workforce challenge. We know that there is a sizable cohort of GPs retiring in the next 10 years. There We have recognised the need for a single frail elderly is also a high number of single-handed practices which pathway across the health and care economy to replace prevent delivery of primary care at scale. We need to the two pathways that currently exist, to remove approachfuture workforce planning with new innovative duplication of resources and improve the quality of care solutions essential to ensure a sustainable primary care for patients. infrastructure. Our Staffordshire Frail Elderly Strategy outlines our NHS England currently has the primary care statutory shared intent to commission integrated services that addresses: commissioning responsibility for the population which is  the need to provide compassionate care, preserving shaped by international evidence and guidance by the dignity, respect and privacy Royal College of General Practitioners.  an appropriate and rigorous assessment of needs, Unless a whole system redesign occurs, which focuses wherever people present on the level of service and outcomes for our communities, only minor improvements will be achieved  the management of people before their needs and it is likely that the distressed health economy could escalate, with an emphasis on prevention and living lead to a significant deterioration in services due to well and supported reablement to optimise recovery demand outstripping capacity by over 100%.  a response to individuals’ needs in an anticipated Health and Wellbeing boards have recommended GP and planned way, surgeries should review their appointment systems, to  reducing the need for expensive crisis responses deliver improvements so that more patients are able to and unscheduled care book appointments “online”, “quickly” and sometimes  improving coordination between health, social care “more than a day in advance” (Staffordshire JHWB and mental health support, to deliver a whole Strategy, 2013). system approach The national picture (LMC conference), potential uplift  valuing the potential contribution of a vibrant third on funding may only address part of the funding gap, sector, community and voluntary organisations and alone it will still not be sufficient to address the necessary transformation required to achieve primary  information to be shared readily between professionals, patients and their carers, to make the care at scale. The importance of more effective and most of the valuable contribution made by families efficient use of resources in conjunction with productivity and carers, and support informed decision making. and efficiency gains will be necessary. The Staffordshire & Shropshire Area team are planning the programme  better use of technology to support self- outlined in section B4 of this document – this will be management overseen by the PCJCB and will be managed through  offering alternatives to acute hospital attendances the annual programme of work. A coordinated work plan and admissions and programme management structure will be

16 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

 recognising the need to address health inequalities across our communities Workforce constraintsService delivery cannot be It promotes the aspiration of securing the right care in effectively moved from acute to the community setting the right place for the individual at the appropriate level unless there is the workforce, capabilities, capacity and of care while enabling people to live well, live infrastructure to manage this operationally to the right independently and live confidently. standards and safely. Each of the following key components of the strategy, Health professional and support staff training will be led by a lead developer: programmes are not yet sufficiently structured to produce the volume and skill sets required in the near  Achieving personal responsibility (patient education and empowerment and carer resilience) future.A significant amount of ‘in-service’ training and  Single Assessment (trusted assessment) work-based support / clinical assessment will be  Intermediate Care necessary to ensure people have the right skills. Step up and step down practice  The current distressed health economy has a single  Frail elderly assessment activity (including opportunity to transform in the next 0-5 years and comprehensive geriatric care assessment)  Parity for mental health and approach to dementia provide an affordable and sustainable solution.  Access to diagnostics including access to specialist It is critical that the inevitable change in work distribution interpretation and advice enhances recruitment and retention of an experienced  Care Facilitation, co-ordination and navigation and effective primary care workforce, including GPs.  Making effective use of Technology Enabled Care The need to address the immediate crisis in GP capacity (TECS)  Information Management is key to delivery of this strategy. Proactive and robust action will be required by the commissioners, Local Within the vision is the latitude for innovation at a local Education & Training Committee / Board and primary level where this builds the local capacity to deliver care providers to achieve this. services effectively within financial and other resource constraints. The maxim is ‘centralise where possible and localise where necessary’.

This joined up strategy will be integral to the ongoing work across the CCGs. It will be informed by the 6 themes around which this five year plan is formed: integrated care; primary care at scale; prevention and self care; the urgent and emergency care system; and elective productivity. It will be shaped as part of the Health and Wellbeing Boards’ strategies, and is clearly very much aligned to the intent of the Better Care Fund.

17 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

Social challenges The Public Health Outcomes Framework identifies a number of indicators related to wider determinants of Social Determinants of Health (Fig. 6) - the conditions in health and lifestyle choices that will be used to which people are born, grow, live, work and age understand the context of the prevention workstream. combine to influence wellbeing and are dependent on These are presented in the table below, across the the quality of housing, education, employment and, for lifecourse, with the most recent data for England, example, a nurturing environment in childhood. The Staffordshire and Stoke. The RAG (red , amber, green) negative influences associated with poverty are twofold rating indicates where the Staffordshire and Stoke data  People living in poverty are more likely to be differs significantly from England. These characteristics exposed to conditions that are adverse to their are recognised in the Joint Strategic Needs health (crowded living conditions, unsafe Assessments for both Staffordshire and Stoke-on-Trent. neighbourhoods) The importance of prevention  People living in poor circumstances are more likely to be negatively affected by these adverse The potential impact for the CCGs of effectively conditions. improving prevention and self-care was modelled through the Anytown national modelling tool to provide the potential savings set out in the table below.

Figure 5 : Determinants of health Table 4 : Potential impact for the CCGs Cannock Chase primary built prevention secondary CCG £2,339,060 environment genes and East social and biology managing Staffordshire education cultural health acute characteristics behaviours CCG £623,007 economy conditions North early Staffordshire interventions CCG £747,297 medical managing total care long-term South East safety ecology conditions Staffs CCG £1,019,581 Staffordshire and Surrounds CCG £625,695 end of life Stoke on Trent care CCG £798,637 The Marmot Review1 showed how inequities in health Totals £6,153,277 are related to social and economic policies that lead Research into ‘Patient Activation’ has demonstrated that generally to better health for those with higher incomes for every 10 point improvement in the patient activation and better education and highlight a number of core measure, risk of A&E attendance reduces by 1%, influences at neighbourhood or community level readmissions reduce by 20% and LOS reduces.  Early child development and education Harnessing people’s own assets is an important part of  Healthy places delivering a sustainable health and care system.  Fair employment Performance needs to improve  Social protection Our current performance across the area gives further  Universal health care weight to the case for change. See Table 5 Many of these “causes of the causes” of poor health & wellbeing, which probably account for 80% of improvement in life expectancy, can be influenced locally, mainly through the local authorities and partners acting in partnership.

1 Fair Society Healthy Lives, 2008

18 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

Table 5 : Public health outcome framework Indicator and benchmarks

Indicator England Staffordshire Stoke

School readiness (2012/13) 51.7 53.6 52.0

Low birth weight of term babies (2011) 2.8 2.6 3.4

Breastfeeding initiation (2012/13) 73.9 68.5 62.8 Start Well Start Smoking status at time of delivery (2012/13) 12.7 15.2 21.1

Infant Mortality (2010-12) 4.1 4.9 6.9

Pupil absence (2011/12) 5.11 4.90 5.80

First time entrants to the criminal justice system (2012) 537 332 616

16-18 year olds not in education, employment or training (2012) 5.8 5.4 9.1

Excess weight in 4-5 year olds (2012/13) 22.2 23.9 24.2

Excess weight in 10-11 year olds (2012/13) 33.3 33.5 38.2

Grow Well Grow Hospital admissions caused by unintentional and deliberate injury in 0-14 year 103.8 114.9 117.9 olds (2012/13)

Emotional wellbeing of looked after children (2012/13) 14.0 14.5 14.1

Under 18 conceptions (2012) 27.7 28.9 51.3

Chlamydia diagnosis 15-25 year olds (2011) 2125 2111 2521

Sickness absence (2009-11) 2.2 1.9 1.9

Domestic Abuse (2012/13) 18.8 16.8 16.8

Violent Crime related hospital admissions (2010/13) 57.6 29.2 27.7

Reoffending levels (2011) 26.9 23.1 28.0

Homelessness (2012/13) 2.4 1.1 2.3

Utilisation of outdoor space for health reasons (2012-13) 15.3 18.9 13.5

Fuel poverty 10.9 12.9 15.4

Live Well Live Excess weight in adults (2012) 63.8 67.9 66.5

Physically inactive adults (2012) 28.5 30.0 35.1

Smoking Prevalence (2012) 19.5 17.0 28.0

Recorded diabetes (2012/13) 6.01 6.39 7.16

Alcohol related admissions (2012/13) 637 703 996

Take up of NHS Health Checks (2012/13) 49.1 52.4 50.7

Self reported wellbeing – happiness (2012/13) 10.4 10.0 14.9

Social isolation (2012/13) 43.2 35.3 43.3

Injuries due to fall in people 65+ (2012/13) 2011 2071 2418

Age Well Age Population coverage – flu 65+ 73.4 70.5 73.8

Mortality from causes considered preventable (2010-12) 187.8 176.2 249.8

19 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

development, selection and appointment of providers A sustainable future – (procurement). The use of innovative care and support things that will be arrangements aims to maximise choice and independence. different There are a number of changes expected over the next National Voices (2013) uses patients’ and citizens’ own 5 years regarding the delivery of service words to clearly articulate what needs to change and  A significant shift to home, community or locally how people will identify with a better health and social based care, particularly for intermediate care care system. This is how we want Staffordshire and services Stoke-on-Trent citizens to identify their health and care  Greater use of digital technology to support care system in five years time. that is not invasive to individuals and fits their life We state that integrated care must styles  Be organised around the needs of individuals  Increased use of mobile services and community (person-centred) settings to deliver care  Focus always on the goal of benefiting service  The development of ‘General Practice Plus’ where users the delivery of care closer to home (or at home, or in local community venues) for older people and  Be evaluated by its outcomes, especially those people with long term conditions which service users themselves report  The commissioning of management plans for  Include patient, carer, community and voluntary patients following specialist opinion which will sector contributions reduce the amount of follow up care delivered in  Be fully inclusive of all communities in the locality hospital settings  Be designed together with the users of services and  Together with community and partner organisations, their carers the CCGs will be considering the future use of local  Deliver a new deal for people with long term community hospitals. These are valuable assets but conditions their focus and the services offered in them are likely to change  Respond to carers as well as the people they are caring for  The building systems which are based on improving the quality of experience, which properly safeguard  Be driven forwards by the commissioners vulnerable people  Be encouraged through incentives  Creating a focus on prevention and early  Aim to achieve public and social value, not just to intervention save money  Supporting people to live independently, with choice  Last over time and be allowed to experiment and control, in their own homes for as long as possible, thus reducing the need for long term Our leadership challenge is to work collaboratively to residential care meet these needs, in a modern joined up way that improves outcomes, the safety, quality, patient  Promoting individual responsibility to safeguard experiences and outcomes whilst increasing value health for money. We have outlined how we will manage this  Developing more seamless, personalised and co- through our improved governance and delivery ordinated care pathways which are centred on the framework. individual and not the condition Throughout the improvement process, leaders, staff,  Shifting a significant amount of resource presently patients, carers, families and communities are and will committed to non-elective urgent care services in continue to be actively involved in the design, the acute sector to more community based support

20 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

 Developing community based services which are  In the last five years Emergency Attendances at centred on General Practice and allow for local care Accident and Emergency Departments have and co-ordination increased by 50% over the last decade (Department of Health). Emergency Admissions  Making the best specialist services available to continue to rise – 27% percent of all emergency people when they need them patients can expect to be admitted, on average,  Integrating, where possible, our commissioning across acute providers in Staffordshire. This arrangements in order to achieve maximum value compares with around one A&E patient in five for money and incentivise community based care nationally2 (i.e. 20%).  Giving a much greater emphasis will be given to  Last year (2013/14) there were 260,094 Accident addressing support and training needs for carers. and Emergency attendances and 155,870 (60%) For example, this is reflected in the Better Care emergency admissions, of which 77,000 (30%) Fund allocation of resources. came through the A&E departments. Over and  The Emergency and Urgent Care System across above this there is a significant amount of activity in Staffordshire and Stoke-on-Trent; similar to many walk-in-centres, minor injuries units, primary care healthcare systems across England has seen centres and Out of Hours Services. significant growth in patients accessing services in  The conclusion many draw from these figures is an unplanned way, through many access points that we have a chaotic system of care where that have developed through government policy and patients will access a service which is least local initiatives. resistant, but ultimately will default to the Accident  Patients continually cite lack of GP access and and Emergency Department of the local acute trust confusing messages about what is available as if no other service is available. reasons for choosing a visit to A&E over primary  Over the last 14 years significant attempts have care. This is compounded by the widely held view been made to change the system, persuade that the health service is there to treat any patient patients to behave differently, develop new service with any perceived illness at any time. Conversely, offerings aimed at prevention and change the the evidence suggests that many patients can pattern of care. However, many of these adequately treat and look after themselves. approaches have been piecemeal, uncoordinated However, the paternalistic nature of healthcare has and not at the scale required to switch the seen a rising tide of patients using Emergency and unplanned system to a more planned approach. Urgent Care services rather than planned provision. Added to this is the lack of understanding of how  Add to this the increase in life expectancy and the different populations access healthcare, no idea increasing number of Older People (over 65s) with who will be the next patient through the Emergency an increasing range of conditions. This has created and Urgent Care Door and paucity of data which a mix of challenges which the present system will helps to identify patients proactively and tackle the be unable to meet in the future. problems patients have before they become problems, leaves the health service with the ultimate wicked problem.

2 Health and Social Care Information Centre (HSCIC), Focus on Accident and Emergency, December 2013

21 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

 However, there is no doubt that in times of crisis  Primary care at scale when a patient needs Emergency and / or Urgent  Prevention and self-care Care the NHS, in most cases, delivers health quality interventions which lead to good patient outcomes.  Emergency and urgent care systems The crisis model of healthcare for patients works.  Elective productivity Therein lies the problem - because the patients value the system as it is. They see their loved ones’  Specialised commissioning lives being saved in many cases and therefore Some of the initiatives within these strategic themes believe any change will have an adverse effect on span across Staffordshire with joint working across this. They don’t really understand what is wrong CCGs, delivered through the emerging collaborative with the current system and why would they? All commissioning practices as already defined. Others are they want is high quality care that is safe and has more specific to one or a group of CCGs and where this the best possible outcome for them and their is appropriate and relevant will be worked on families. individually.  The NHS has to prove that change will be for the better, the partnership with the patients, carers and the public will be important to enabling the system A programme is also being developed to ensure the to transform. Mental Health Crisis concordat is implemented to improve outcomes for people experiencing mental  The A&E or Emergency Department is a publicly health crisis. This applies to health, social care and trusted service and is often used when other police and other providers; ensuring a joined up services may be more suitable. This places approach and responsibilities for safety and support in unnecessary demand on busy units and affects the most appropriate environment. waiting times. The BCF will enable us to better align the whole of the health and care system around the strategic ambitions How this will be achieved of the two Health and Wellbeing strategies in a way This 5 year strategic plan has been developed and never tackled before. This framework will be the basis agreed by the people who are using services and those for increasing levels of integrated commissioning in who are charged with the accountability for its future years. The pooling of budgets with partners successful delivery. The key people in leadership through the BCF affords an unparalleled opportunity to positions do change over time and so the governance build on the progress we have made on prevention, arrangements for the delivery of this strategy have been early intervention and integrated care in the carefully structured, centred around our Commissioning community. Congress, to ensure the commitments and promises are fulfilled over the duration of this plan. All CCGs are signed up to delivering this coherent approach which There will be radical addresses the overlaps in geography, provider redesign catchment areas and the need for people to travel across the county (and wider) for services and A clear blueprint of what services should look like and employment. how they will work will be developed with all stakeholders. The staff who work tirelessly to safeguard, Section B describes the existing programme of change protect and support the most vulnerable people of our and transformation in progress at CCG level. These are communities will continue to be involved in efficiency now updated to align the workstreams in the FRPs and improvements. This includes new roles to fit around the existing workstreams for QIPP to the core strategic needs of people using services rather than historical themes: boundaries of what people can and cannot do within  Integrated care organisational or role boundaries.

22 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

Information systems and technology are central to  Reconfiguring our approaches to community based providing the most efficient and modern systems care in order to support the frail/complex supporting services. Informatics (the use of information, population, who often have a number of long term intelligence and technology) will be used to best conditions advantage both for citizens and people providing  Recognising the role of carers and supporting services and care. Plans are in place to create new IT carers to continue in their caring role hubs which will facilitate joint working across health and social care.Significant improvements have taken place  Developing integrated approaches to the provision to the buildings and environment where services are of equipment delivered and people work. Further work is required to  Improving access to community mental health ensure all facilities are fit for purpose and flexible. This services which focus on prevention can be achieved by integration and shared use of all  Transforming end of life and cancer care available health and social care estates, which also brings teams to patients and support for carers closer together; for more effective communication and care coordination. It can also result in significant cost  Developing integrated commissioning arrangements savings. to deliver services for people with a learning disability in Staffordshire  Providing Urgent Care services whenever people The immediate priorities need them and addressing their needs quickly and efficiently There are big ambitions and equally significant economic constraints which make delivery of the  Providing Stroke Services that give rapid treatment proposed transformation of the health and social care to people and help them achieve the best recovery system exceptionally challenging. The Government has  Delivering Acute Hospital services with the right recognised this and is helping by providing intensive flow of patients and capacity to deal with day to day support to make some really difficult decisions that will activity and surges in demand bring the most sustainable health and care systems for We have summarised our overall vision, objectives, people in our communities. delivery mechanisms, governance arrangements, The CCGs have worked to formulate the FRPs in order measures, values and principles on our ‘Plan on page’ to create a sustainable financial platform from which to in section 2. safeguard the future care of our population. Despite the financial pressures, we continue to focus on our immediate care priorities, which include:

23 Staffordshire and Stoke-on-Trent Five Year Strategic Plan 2014-19

2. System plan on a page

Our Vision: Staffordshire and Stoke on Trent will be vibrant, healthy and caring places, where people will be as independent as possible and able to live happy and healthy lives, getting the necessary health and care support when required

Objective One Delivered through Improving quality and outcomes Governance arrangements Improving population health – To support changes to the local system to deliver prevention HWB - Higher level strategic direction of the system and will hold to account a improving health outcomes, and early intervention, using risk identification / stratification number of partnership boards. health related quality of life systems to enable proactive engagement. Using technology, Strategic Officers Group Ongoing coordination ensuring issues are identified and outcomes for people with LTCs enhancing knowledge and support to facilitate patients' raised, being aware that County and City may progress at a different pace at times. inc MH and reducing health capacity to self-manage. Enabling people and carers to play a Integrated Executive Group System –wide leadership and robust programme inequalities more active role in their own health and care. management to facilitate delivery of the Staffordshire Health and Well-being strategy (JHWS). Board Formal Board to include, CCG and Local Authority membership to deliver Delivered through Integrated Commissioning / Integrated transitional and transformational change. Objective Two Care CCGs & LAs Commission and monitor services as appropriate for their local Reducing the amount of time Partnership working to deliver comprehensive pathways, population and will respond as necessary. people spend avoidably in ensuring appropriate support in the community; which will, Local Continual use of national tools and local performance frameworks ensuring hospital through better and reduce avoidable admissions, delayed discharges and that national and local targets are attained and surpassed wherever possible. more integrated care in the readmission rates. This will build on current work to reduce community overlap and duplication. Adopting a collaborative approach to commissioning services (as appropriate), with a stronger focus Sustainability / success criteria / measures Objective Three on local clinical leadership and allowing more optimal Workforce – collaboration to ensure that staff receive training to undertake new Increasing the proportion of decisions. Supporting the development of integrated services, roles. older people living through the Better Care Fund initiatives. Supporting a shift of Premises – work with NHS PS to deliver the best use of the premises. independently at home resources towards ‘wrap around’ community services and the Communication – work with the public and partners, to redesign services and following discharge from development of primary care at scale. Working with the Area ensuring effective communications so that to people can understand the benefits. hospital Team and GPs to support appropriate use of, and ease of Results – More people are supported to remain healthy and in their own home, access to, quality urgent and emergency care services receiving appropriate packages of care when required. Quality and user experience Objective Four and Five evidence demonstrates improvement in care and services Increasing the number of The predicted increase in need is met by appropriate service provision within the Delivered through Service redesign financial envelope available. positive experiences for people, Involving local communities in shaping services, in partnership with mental and physical health Obj 1: 3.3% additional years to life. 2.1%increase in self reported QoL (GP survey) with the CCGs, LAs, PH and other stakeholders to ensure Obj 2,7: 17.4% reduction in hospital admissions, By 2015 there will be 24 fewer conditions; in hospital, out of service development initiatives will drive existing services to delayed transfers of care per 100,000 hospital, general practice and better support elective, urgent / emergency and community Obj 3: 17.4% (85.9% still in own home after 91 days, 2 yr plan)BCF community experiences. care, both in and out of hours. This will link to the work being Obj 4,5&7: Reduce poor experience by 0.6%. Increase hospital experience by 8.8% delivered though the Better Care Fund. BCF Objective Six Supporting a shift of resources towards ‘wrap around’ Obj 6&7 Eliminating avoidable deaths in hospital . To significantly reduce avoidable community services, delivering primary care services at scale Obj 8:Financially and clinical stable health economy deaths in hospital – caused by and where relevant delivering specialised services Plus locally agreed mental health measures: be healthier and more independent; problems in our care concentrated in centres of excellence. feel safer, happier and more supported in and by their community and be able to access more good jobs and feel the benefit of economic growth Objective Seven Delivered through Continuous quality monitoring and Commission safe, high quality improvement including using user / carer feedback System Values and Principles and sustainable services Ensuring robust quality / performance monitoring is in place A greater number of providers performing in the upper quartile across a range of alongside improvement strategies. User / carer feedback will clinically relevant metrics. Proactive coordination and personalisation of care. be proactively sought and acted upon, using their experience to Promoting health & wellbeing and citizen involvement. Ensuring fast, responsive Objective Eight identify improvement opportunities. Working with GPs & the access to appropriate elective / non elective and community care. Ensuring parity of Achieve value for money and Area Team re: experience of care in general practice. Ensure esteem. Ensuring consistently high quality and value of care, effectiveness, safety 24 financial balance QIPPs are managed and delivered. and patient experience.

SECTION B – ACHIEVING OUR VISION

The plan on a page in section 2 provides the headlines These working arrangements underpin the delivery of for this strategy. In this section, we provide the detail the strategic vision. showing how we will deliver the objectives of our strategy by addressing the following key themes of:

 Integrated care  Primary care at scale  Prevention and self care  The urgent and emergency care system  Elective productivity  Specialised commissioning

We have used detailed numerical modelling to forecast the activity and financial impact of a range of scenarios, depending on the levels of performance improvement we intend to make across the system. This modelling has been built on with further analysis as part of the CCGs’ Financial Recovery Plans (FRPs). From this work there is agreement across the Staffordshire CCGs to meeting their mandatory financial duties by the close of the financial year 2016/17, and repaying deficits by 2018/19. This does not diminish the responsibility to meet the ambition to reach the original objectives outlined in this paper. . In the initial submission there was an intent to establish ways of collaborative working in the health and social care economy. Since the original submission:

 the Joint Accountability Board has been established  engagement with providers has increased, as demonstrated through our series of ongoing working groups (e.g. CELG - Cross Economy Leadership Group)  groups have formed around specific areas such as frail elderly and POLCV  A Commissioning Congress is being established to lead the governance of the transformational programme of change across Staffordshire.

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3. Integrated care Impact on the health and social care system Aims Integrated care has considerable implications for In Staffordshire and Stoke-on-Trent we believe that the providers of health and social care. We need staff to key to improving the quality of care and support for work across organisational boundaries in networked people, and to achieving a sustainable health and social solutions with good team working and good data care system, is to integrate what we do. This is our sharing. commitment as commissioners and one we seek to Evidence based on the Torbay case studies is engender with providers to deliver the best experiences compelling in convincing well-meaning but stretched of care that we can, and to use public funds to the best organisations and professionals that to organise of our ability. themselves differently to deliver a more effective and This is key because people tell us that is what they need improved set of experiences for people is the to happen to better support them. improvements that are needed. Our measure of success will be understood through the A typical case study sees an older person visited by 4 experience and outcomes as articulated by citizens, different social care staff and 2 different nurses per patients and carers. Each CCG has defined these week. This increases during and after each measures locally. exacerbation in one of the long term conditions. In economic terms, each of the interventions adds some ‘My care is planned with people who work together value to the person, but that is rarely helpful over the to understand me and my carer(s), put me in longer term because no one builds on the interventions control, co-ordinate and deliver services to achieve in a way that focuses on the whole person and their long my best outcomes.’ term needs, This creates a failure to build a chain of (National Voices 2013) support to maintain a person’s health wellbeing and independence. In one typical study a stay in hospital of Our overarching aim therefore is to connect people with 30 days was due to the home not being made safe to the care they need, when they need it. All partners manage the person’s long term conditions. In another across the health and care economy are clear on the study, a spell in hospital was 20 days longer due to critical importance of getting integrated care right. On failing to recognise a comorbidity of diabetes, when the average 20% of adults in this area suffer from a long originating concern had been breathing problems. term condition.

Table 6 : Proportion of patients by CCG with long term conditions Adults % of Total Population

Cannock Chase 103,431 20%

East Staffordshire 105,781 20%

North Staffordshire 207,608 20%

South East Staffs 165,530 19%

Stafford & Surrounds 113,184 19% Stoke-on-Trent 179,514 13%

Totals 875,048

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‘Our measure of success will be understood through the experience and outcomes as articulated by citizens, patients and carers.’

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A different scenario is being built - to one where  Experiences that staff report about their satisfaction separate professionals, attend to a person as and when with the care we provide and their overall morale they can within their own organisation’s requirements – which has a direct correlation to their ability to do to one where their needs are understood, the responses the right thing for people co-ordinated and the best use of resources is made. The journey towards closer integration is already Commissioners are developing arrangements for underway. Staffordshire-wide programmes have been accountable lead providers to join up a person’s care established to focus on frail elderly, aided in delivery and this can be incentivised to ensure that all public through the BCF, the local impact of which includes, for services add to the person’s capacity to be independent. example: This requires organisations to  In Stoke-on-Trent CCG, an Integrated Intermediate care initiative has been implemented, responding to  Work together to identify those at greatest risk the needs of people requiring rehabilitation, re-  Develop joint plans to support the person health ablement and recovery in the least dependent and wellbeing settings appropriate to their needs. This is resulting in improved outcomes for patients, reduction in  Work side by side to deliver those plans in unplanned attendances and admissions and with a partnership with individuals , their families and greater emphasis on community rather than bed carers based services.  Build capacity in the community to provide early  Through Stoke and Stafford CCGs, unplanned and effective support attendances and admissions are being targeted,  Be able to focus on shared goals and outcomes for through a series of in-community alternatives. The the person focus will be on two cohorts – those with no  Agree monitoring and governance arrangements investigations and no treatment, and those with category 1 investigation and category 1 and 2  Enable the funding to follow the outcomes treatment. The expectation is for a 40% reduction The effectiveness of such an approach, and the for both categories. measures that each organisation and Health and  East Staffordshire CCG as part of the Staffordshire Wellbeing Board will focus on for the cohort of case wide work has developed a Frailty Pathway, managed people are the reducing length of stay and streamlining pathways  Reduction in delayed transfers of care using existing services that are under utilised. Targeting people 75 and over; a team of social care  Reduction in emergency admissions workers, nurses and clinical professions will identify  Effectiveness of reablement ( as a joint intermediate needs whilst in hospital and facilitate an easy care and reablement service) in preventing discharge from hospital. admissions and facilitating discharges and  Connecting patient records across the Health and avoidance of readmissions Care Economy is already in place and is gathering  Reduced average length of stay in hospitals pace to deliver across Staffordshire and Shropshire as an ‘Integrated Health and Shared Care Record’.  Reduced admissions to nursing and residential care  Experiences that people report about their care and support

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 An overall Integrated Health-Economy System  Be able to access quick and responsive services, strategy is in development. This includes a scheme and they will only have to tell their story once. This to reduce the volume of unnecessary A&E visits will form an integral part of our multi-sector training through better education of service users, a drive to and organisational development work. make 111 the primary route to access community  Have a set of services that work in a coordinated resource & more effective identification of needs/ way with them to understand what matters most in treatment capability within the community. their lives, and to build support around achieving These initiatives respond to the strategic aim of the outcomes that are important to them. ‘Right care, right place, right time’. The heart of working in this way is about building reciprocal relationships between professionals, and between professionals and people, so that they feel in Key barriers to success control and confident to direct their care and support. The aspirations for people for themselves are as The key barriers to the success of implementation are identified by “A Call to Action” are likely to focus around the sheer scale of change:  Engaging all key partners and stakeholders through  Being respected as an individual effective channels and working collaboratively.  Being helped to stay fit and healthy  Measuring the system-wide impact  Being able to set and meet personal goals  Effective contract management  Staying independent and active  Effective identification and mitigation of risks to  Staying out of hospital except for planned care that delivery is best delivered in that setting  Maintaining momentum and strength of leadership  Having at all times high quality tailored support over the life course of this long-term transformation available where and when it is needed  Improving alignment of systems, structures and  Having care that is developed and joined up around processes across health and care. This will involve the person, not the system or an organisation a major redesign of services, standardised across a  Having care that is provided in a proactive range of partners. consistent and sustainable way What it will look like in  Being able to live and die with dignity 2018/19 How we will get there We are keen to describe the differences in individual Simplifying care services – this requires a terms. So for a person with a long term condition, they fundamental shift in the way needs are understood, will outcomes for people are met, and how separate organisations design and procure services to meet  Have one responsible person to support them to coordinate their care. The professionals who those needs. The Staffordshire and Stoke-on-Trent support them will talk to each other and be able to Health and Wellbeing Boards have agreed in principle to see one integrated care record, irrespective of outline how to integrate commissioning. The Joint which organisation they work for. Health & Wellbeing Strategy (JHWS) has set out an

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ambitious vision of the future, based on a need to Coordinating service delivery – by the end of redesign the current model of care. This aligns to the 2015/16, 24,000 people with long term conditions in programmes supporting the FRPs. The scale of change Staffordshire and Stoke-on-Trent will be actively case required is dramatic. It has been estimated, for example, managed. This means each person will have a lead that this will involve a shift of some £200m currently professional as their case manager (a GP, therapist, spent in the acute hospital and residential social care nurse, community matron, social worker etc) who system (equivalent to perhaps 400 beds), such that it is coordinates their care under a single care plan. The instead used to support more effective preventative case manager will ensure all the other professionals services in the community. The combined values put the involved in the person’s care, are linked in and act as a BCF are £150m for Staffordshire and £94m for Stoke, point of reference and navigator for their care. People indicative of the scale of funding covering the cohorts with long term conditions will be risk profiled to ensure targeted. they can benefit from a case managed approach. This cannot simply involve a shift in the geographical Through this approach people can seek subsequent location of services, doing in the community what used advice, guidance and access to other services. Integrated health and social care aligned to GP to be done in hospitals. Instead, what is required is a practices are already implemented in many areas, with major redesign of the very nature of the care system, the rest underway. A specific responsibility for people doing different things in the community so that needs who are case managed is to support people during a are met effectively which in turn means there is less crisis, to prevent unnecessary access to services, and to demand for bed based acute hospital and residential put in place intensive support where required to manage social care services. any exacerbation. The attendances at A&E centres, We have strengthened our approach to more integrated where attendance converts into an admission will be commissioning, bringing partners together across the reduced as a direct result of the case management system. approach. All six CCGs are agreed to a Commissioning Congress This requires that we define the organisational form and and each Accountable Officer is responsible for a single operating model to deliver the service that we co-design piece of work on behalf of the whole county and each with all partners. We will need to consider factors such has agreed to their portfolio. They have also approved as of the principle of having key contractual elements applied to the contracts of all the providers. Thus we  Co-location of teams would all be speaking with one voice through the  Governance congress initially made up of the CCGs and then in time the other commissioners. The congress would also be a  Data sharing vehicle for having one CCG voice on the Joint Accountability Board.  Aligning priorities  Cultural alignment Governance arrangements are more fully articulated in  Staff and clinical engagement Section 16. Redesigning our approach to prevention, self-care and support – the means to achieving this is to understand the most effective range of responses at the universal, early intervention and targeted intervention level, and a Prevention Strategy has now been agreed at Health and Wellbeing Board level

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- For those with mental health needs (diagnosed sector. Such an approach will be enhanced by providing and undiagnosed) the response enables the multi-sector training for shared learning and networking. person to be “treated as an individual and  Developing responsive and intensive helped to stay well.” community based services - For people who have unsuitable housing which There is a plethora of such services in place exacerbates their conditions or capacity, it is already but they currently operate in isolation of supporting a person “to live safely and well, each other in many cases and without clear agreed where I want to be.” care pathways to offer the right level of - For people in need of intensive support intervention. CCGs together with Staffordshire (intermediate care /reablement) it means “my County Council and Stoke City Council are independence is respected.” currently re-specifying the intermediate tier of - For people who have mobility, transport or support for the majority of the populations they social isolation concerns, local community and serve. This is requiring providers to collaborate voluntary sector organisations are encouraged more, to focus on the outcomes for people, to to be part of the networks of supporting people, create services which align and coordinate. CCGs so that “my neighbours help me and I feel part and the Local Area Team Primary Care director of the community.” are coordinating the commissioning requirements for primary care to make this a pivotal part of the - For those who undergo a significant life event, local and responsive set of services to manage such as bereavement, they feel “supported those who are frail/elderly and those with long term through difficult times.” Many people are conditions. The work plan for integrated frequent and unplanned users of multiple commissioning is to deliver cohesive services, services, and they need care and support to be including those out of hours, for district nursing, “built around me and my real needs.” ambulance, 111 advice and referral, intermediate - For the tens of thousands of people with long care (step-up step-down beds),reablement term conditions, they can manage because “my (already underway), and items under ‘big ticket’ healthy conditions are under control.” initiatives. The Macmillan Cancer and End of Life Pioneer programme is taking a joined up approach A range of programmes have been articulated to for service responses based on needs and respond to the needs of these cohorts, such as: outcomes too, with a major re-procurement due in  ‘Frequent Fliers’ for people who have a high level of 2015. non-elective attendances at hospital  Frail elderly (underpins ambitions to reduce non- elective and urgent care attendances)  Dementia care  GP education programme We intend to take innovative approaches based upon best practice, to address challenges faced by caring for frequent users of services. These approaches will involve a level of collaboration with other partners in our economy e.g. criminal justice, police, schools, voluntary

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 Understanding individual needs – we believe that Using integrated commissioning understanding individual needs and putting in place the best means of responding to those for the whole Both Staffordshire and Stoke-on-Trent Health and person/family is fundamental to improving the Wellbeing Boards have given their agreement in experiences of care and support, and achievement principle to take an integrated approach to a long term affordable health and social care model. commissioning. Building on the success of this This will be achieved through a focus on outcomes elsewhere (in respect of joint governance, joint where CCGs and local authorities commission for outcomes and shared public and patient engagement whole populations (see the section on integrated strategies) there is a work programme underway to commissioning). It is underpinned by the enabling design strategies of a single integrated health and social  The powers delegated to the joint teams by the care record (see the ICT section) where information partners and the governance of these, to ensure about an individual is accessible and shared across actions are taken on behalf of all the partners organisational boundaries. It is based on the equally and differences of direction or context are principle of the lowest level of intervention required explicitly acknowledged and addressed (see prevention and self-care) for example the increasing use of technological based support. It is  The use of the funding allocated by the partners, also highly dependent on the organisational both for the operation of the joint teams and for the development (see Organisation Development and commissioning of services workforce section) work programme of a flexible  The engagement of partners in setting the strategic and engaged workforce who are supported to direction for jointly commissioned services and in understand real need, for example through the holding the joint teams to account for delivery of Community Plus Teams in Stoke. those intentions, with agreed arrangements The following table shows the numbers of patients that operated in practice the CCGs are considering for alternative care responses  The resources required to undertake the joint through active case management. commissioning function, not only those within the Table 7 : Age bands and potential for case management joint teams but also more widely to enable them to deliver the goals, such as support from Finance, Age Band Cohort Activity Procurement, Business Intelligence, etc. Paediatrics (under 19 years As part of the 2013 Spending Review, DH and DCLG of age) ACS Acute 1560 agreed the creation of the Better Care Fund (BCF - ACS Chronic 1721 originally called the Integration Transformation Fund), Other 50004 recently confirmed as an element of the national Elderly (65 years and over) ACS Acute 12250 infrastructure. From 2015/16, this will bring together a ACS Chronic 13108 range of existing funding streams, currently allocated End of Life 2019 separately to CCGs, social care commissioners, and Housing Authorities, along with a major shift of Falls 7995 resources from CCG allocations. This will create a Other 154615 £3.8bn fund, to be signed off by Health and Wellbeing Adults (19 to 64 years of age) ACS Acute 11890 Boards and held under clear (s75 NHS Act) ACS Chronic 6884 arrangements. Other 219654 The planning and delivery of our jointly agreed BCF

schemes, with its associated pooled budget provides us

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with a mechanism for closer integration of health and  The powers delegated to the joint teams by the social care, specifically around frail elderly. The size of partners and the the pooled budget will be £94 for Stoke and c. £150m for Staffordshire. We will ensure that BCF governance and delivery arrangements form part of a coherent Transforming cancer and end of life care whole with our wider initiatives that support integrated Parts of Staffordshire and Stoke-on-Trent CCGs, NHS service provision. England, jointly on their combined behalf, (with the support of Macmillan Cancer Support, Staffordshire Commissioners are strengthening their ability to County Council, Stoke-on-Trent City Council and Public commission collaboratively and engage cohesively and Health England) in April 2013 launched the decisively with partners through the following Transforming Cancer and End of Life Care Programme. 1. Commissioning Congress This Programme intends to transform the way services 2. Commissioning Board are commissioned and there after delivered for people with cancer and for those at the end of life for all long 3. Contract management term conditions across the County of Staffordshire These structures will be underpinned by a PMO and including the unitary authority area of Stoke-on-Trent. supporting BI function. Commissioners are wishing to shift their approach to commission whole pathways built around the patient Both Staffordshire and Stoke-on-Trent Health and journey. To achieve this they are using the Prime Wellbeing Boards have given their agreement in Provider model. It will enable a transformation in service principle to take an integrated approach to design and delivery focussed on the patient and commissioning. Building on the success of this outcomes along an integrated pathway, and not on elsewhere (in respect of joint governance, joint individual providers. outcomes and shared public and patient engagement strategies) there is a work programme underway to design

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‘ Primary care at scale is one of the linchpins for ensuring a sustainable and integrated health and care system for the future, so that the people of Staffordshire and Stoke-on- Trent can achieve their health and wellbeing needs; by accessing the right preventative, treatment, rehabilitation and recovery services.’

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4. Primary care at scale

 Manages risk safely; and to share complex decisions with patients and carers, while adopting Aims an integrated approach The Royal College of General Practitioners (2013) has Organising Primary Care for the Population outlined 6 key tasks to achieve a ‘2022 GP Vision for The model of primary care at scale links to and has a General Practice in the future NHS’ and we aspire to crucial and coordinating role for integrated care, urgent this for Staffordshire and Stoke-on-Trent, to care, elective access, prevention and maximising self  Promote a greater understanding of generalist care care capability of citizens. 7 day working will provide a and demonstrate its value to the health service seamless wrap-around service and is expectation for  Develop new generalist-led integrated services to delivering sustainability of the health and care system in deliver personalised, cost-effective care the next 5 years but has the potential to further dilute continuity of care and destabilise Out of Hours Services  Expand the capacity of the general practice unless managed effectively. workforce to meet population and service needs  Enhance the skills and flexibility of the general Table 8 : Primary care access descriptors practice workforce to provide complex care Stoke- Access descriptor Staffordshire  Support the organisational development of on-Trent community-based practices, teams and networks, to Number of Practices support flexible models of care open 8am- 6.30pm (52.5 48% 13% hours)  Increase community-based academic activity to Practices open more than improve effectiveness, research and quality 16% 5.8% 52.5 hours The generalist-led integrated service is defined as Average number of hours 49.3 hours 45.8 hours open  Led by an appropriate health professional (Doctor, Number of Practices with Nurse, AHP) 25% 62% half-day closing (PLT)  May be a health professional from an Practices using more 19% 40% acute/specialist base (e.g. acute) than one 00H Provider  Fits the principle of a value for money, patient focussed generalist health service for a changing ‘Healthcare should never be allowed to stand still. population It should never be permitted to accept that care is  Healthcare professional with highly developed not as good as it could be. If there is good generalist skills is able to apply his or her medical evidence from clinical research and patient expertise to the growing range of long-term experience for changing healthcare, to improve it conditions and deliver it in a more consistent and sustainable way, we must be at the forefront of the discussions  Incorporates this knowledge into ‘whole-person’ understanding of the patient and their family of how to do so.’ The NHS Confederation, The Academy of Medical Royal Colleges, National Voices (2013)

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Some difficult discussions and contractual changes will be necessary to challenge the traditional working Impact on the health and patterns and opening hours of services. This will be social care system addressed in our OD plan (Section 10). An approach to commissioning will be developed, considering prime Primary care at scale is one of the linchpins for ensuring provider models and covering all primary care a sustainable and integrated health and care system for contractors including general practitioners, optometry, the future, so that the people of Staffordshire and Stoke- dentistry and pharmacy. on-Trent can achieve their health and wellbeing needs; by accessing the right preventative, treatment, Strong leadership, a clear direction and a consistent rehabilitation and recovery services. approach is necessary to achieve the scale of change required. This has to have clinical leadership at it’s heart Primary care will actively participate in ensuring which acknowledges the dedication and expertise of the universal access for all and an up-lift in access/ flexibility Doctors, Nurses, Allied Health Professionals and for people with learning disabilities, outreach for difficult support staff and the need to ensure that they are fully to reach groups and areas of deprivation and non-health engaged with in this process. seeking behaviour (e.g. Mobile screening unit with food incentives for homeless). It is the aim of all partners The operational model will include new roles to ensure a (providers, public health, education, police and crime, flexible workforce working alongside the primary care housing) to reduce the overall spend on unplanned care physicians, including, assistant practitioners, physicians and preventable conditions/illnesses whilst improving assistants and advanced clinical practitioners e.g. quality and citizen experience. Most of the contacts with nurses, pharmacists and therapists. health services for the population are via the primary We have already achieved success in developing walk- care system and so it has a central role in prevention in centres in Stoke and North Staffordshire, reducing and addressing inequalities. The use of health and care unnecessary A&E attendances and admissions, and risk / complexity stratification will be standardised across paves the way for further innovation. This has formed a larger footprint, and eventually the whole health one of the key schemes for these CCGs, which involves economy. This aims to prevent patches of concentrated investment into primary care in order that the demand resulting in an inequality and higher access requirements can be embedded, tracked, monitored and threshold for people in the ‘high’ and ‘very high’ profile. result in appropriate referral patterns. This will be There are opportunities to pool budgets and achieve communicated and discussed with the wider GP integrated working and focus on needs rather than community during January 2015 and implemented as services. The Better Care Fund (BCF) is an important part of contract agreements in February. lever for this. Staffordshire wide, CCGs are implementing similar programmes to aid GPs, through education and funding to improve their role as key care co-ordinators and as a Key barriers to success result improve preventative care, self care and referral The key barriers to the success of implementation are rates. likely to focus around people and resource. Potentially difficult discussions around contractual changes will be required to facilitate the necessary changes to working patterns and opening hours of services. There is also currently a drain on UK doctors to overseas posts, whilst

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GP levels are no longer being boosted by migration from Our mitigation for these challenges will need to be India and Pakistan to the levels seen previously. developed through our organisational development and with the Local Area Team.workforce strategy (see Our current challenges are around: section 10), working closely  The numbers of single-hander GP practices, which The implementation of new roles and ways of working present a challenge to offering more specialised will need to ensure that sufficient capacity is available primary care services. across the network to deal with the increasing demand.  An aging workforce, where a high percentage of This will take time to implement, as traditionally training the GP population will be retiring in the next 5 programmes take a year or more. years. Potentially, recruiting the necessary resources may be  Our number of GP, primary and community care difficult due to shortages of available nurses. vacancies.

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What it will look like in 2018/19 GPs, people from our communities, commissioners (NHS and Local Authority), providers and health and wellbeing boards, professional/representative and regulatory bodies will work together to co-design the future system which achieves the following outcomes that will be recognised by citizens through changes in the following areas

Table 9 : The interventions, costs and measures associated with acheiving our outcomes for primary care

Citizen Experience High Impact Intervention Cost considerations Measures

1a Outcome Fast, responsive access to care. [also an enabler for Urgent and Emergency Care] 24 hour urgent care with a single number for Centralising acute/urgent home visits Operating a service in an Reduced ambulance calls and conveyance. access. 7 day availability for 48 hour routine (consideration to be given the impact on accessible location; concentrated Productivity & Efficiency and PROM/PREM appointments. Pharmacies providing minor “continuity” of care) primary care facility linked to the metrics (e.g. ‘did you get to see a GP at a ailment and treatment services. Enabling drop-in “appointments” within UEC system and out of hours time convenient for you’?) services. Call to action input from citizens requested reasonable access across 7 extended days Q4 15/16 – GP to patient ratio in line with ‘GPs to have access to other services i.e. for all of primary care (GP, ANP/ PN, national average mental health services, third sector’. Optometry, Dental and Pharmacy) Access metrics Q4 2014/15 Only 5% of Citizens / Patients in future will say; ‘There Reduce the number of practices that have practices with half day closing once a week is more time available for each appointment half day closing to 5%, and when they are (baseline of 25% of Staffordshire and 62% in when needed and it easier to see a GP’ closed there is an alternative available to the Stoke-on-Trent) same standard 1b Outcome Preventing avoidable emergency admissions and A&E attendances Proactive care co-ordination & anticipatory Quick response/ closer working with Once future capacity profiles are Reduced A&E attendances & non elective care, that is planned together with people, residential and nursing home care outlined, then the primary care admissions particularly those with long term conditions Commission additional services from workforce costs along with Patients with complex/high risk conditions and more complex health & care problems. Pharmacists, Dentist and Optometrists. equipment and training will be spend longer closer to home. further defined. Citizens / Patients in future will say ‘I am The scope & capability of response (e.g. Planned primary care practitioner visits to closely monitored by the virtual ward team ANP, acutely skilled GPs & Paramedics) that residential / nursing facilities. which prevents me getting worse and going will provide a wider range of care, Increased final stages of EoLC in the place to hospital’. diagnostics & interventions to prevent preferred by patients. unnecessary A&E attendance & admission.

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Citizen Experience High Impact Intervention Cost considerations Measures Funding allocation. Testing co-commissioning and collaboration.

2 Outcome Holistic and personalised care will be achieved through -Working with people as partners in their care to plan their physical, mental and social needs together, where people are informed and involved in their care they can exercise choice and control. People are supported with their health and Extending the range of ways in which Infrastructure costs will be partly Care plans. care needs, to fully manage their own health primary care practitioners/ practice staff can met through the IM&T projects Self activation scores. and care, as close to home as possible, this communicate with patients – ring back triage agreed through business cases PROM/PREM. includes residential and nursing home when people ask for appointments, video- and the better care fund. Reduction in Elective referrals and high cost facilities. calls e.g. Skype style consultations & email. [Telemedicine/ Telehealth/ diagnostics and interventions. Citizens / Patients in future will say ‘I have Automated follow up information – links to u- Telecare/ SMS prompts e.g. FLO]. Acute savings which are reinvested into been involved in writing and agreeing my tube videos (e.g. asthma) advice care plan. This allows me to feel more in sheet/email/text prompts primary care and community services. [There is also a recurrent cost for control of how my care is organised.’ Up-to-date triage, referral and pathways, GP management of pathways and referrals governance and system security, policies to reduce unnecessary specialist ‘My mental health and wellbeing is always optimise reduction in procedures of limited record keeping and training]. considered as important as my physical clinical value (e.g. surgery) referrals & consultations.

needs’ Use of map of medicine algorithm to support Consultation times – consistent structuring of

Through call to action citizens / patients diagnostic and referral decisions. appointment times based on the profile of would like to see ‘Professionals help people patient needs and complexity. understand what they need to do for themselves in keeping healthy’. [Links to prevention and self care section]. 3 Outcome Ensuring consistently high quality and good value care, effectiveness, safety, patient experience and care outcomes. [This includes reducing unwarranted clinical variation.] Supporting patients, their carers and Sharing of practice ‘safety and quality’ Cost of automated replay of Clinical outcome measures / SI / Incident + families Promote health and wellbeing, scorecard- Primary Care Web Tool (PCWT). quality web tool findings to enable near miss reporting reducing inequalities and preventing ill- local networks and federations to [access, clinical standards – CQC/NHSE, health and illness progression at individual manage the variation in services Primary Care Quality led GP development public health] and community level. and outcomes. team for practices/GPs needing support and Patient / Citizen experience Q4 2014/15-

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Citizen Experience High Impact Intervention Cost considerations Measures Improved satisfaction of consultation, care development. Achieve Unify trajectory for patient and service. Planned resources for ongoing satisfaction Evidence based medicine / healthcare, development of primary care Reduced clinical variation Reduce from 5% to Citizens / Patients in future will say ’It prescribing to ensure that the same minimum teams to achieve the required 2% practices that have 5 or more negative doesn’t matter where I am registered with standards apply across all primary care standards. outliers in the PCWT. the doctor, they have access to my records providers. Reduce prescribing costs. and I get the same standard of service and care’. 4 Continuity of care will be achieved through Case managed patients will have consistent primary care professional; Primary care professionals undertake MDT activities & may be the case manager; Operational management of case load and practice list encourages effective & productive 7 day services. Most complex patients with long term Commissioning the whole pathway for [procurement] Case Management conditions have greater continuity of care, outcomes and can progress over the 24/7 24 hour availability of patient pathway and they will see a more familiar set of primary period. progress information care professionals. Opportunity for Prime Provider model; Patient experience Care coordination will be effective between vertical integration models. Reduction in incorrect prescribing and case primary care, and other organisations direction involved in delivering the care plan / [informatics projects e.g. risk Integrated health and care records that are pathway. stratification tool] Reduction in ALOS accessible 24 hours by authorised members O LOS – NEL admission avoidance Citizens / Patients in future will say ’I have a of the team. couple of long term conditions and I have a [integrated care] [DES unplanned admissions; over named professional (key worker) to organise 75’s named GP; anticipatory care] my follow up and care’ [workforce] [capacity planning & 7 day working] 5 Outcome Sustainable & flexible workforce with new skills and roles Staff are available to meet the demands of Federation/ collaborative practice groupings [demand and capacity step plan Vacancy rates the service, people will have contact with a to provide professional support and and envisaged resources + gaps Skill mix shape change and skills profile wider range of practitioners that can meet supervision whilst developing skills and to be entered here] Training outcomes their needs. training. Citizens / Patients in future will say ’I know Skill mix existing practices to release GP

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Citizen Experience High Impact Intervention Cost considerations Measures that in the future there may well be a time and support areas with vacancies different professional providing my develop/ recruit more advanced nurse consultation, other than my GP’ practitioners and physicians assistants. Integrate nursing and treatment services (PN/DN)

Outcome Productive use of facilities 6 Assurance that resources are being used Encourage shared and scheduled use of demand and capacity step plan Space utilisation / sharing by integrated team wisely and space is not left empty. facilities for the integrated team. and envisaged resources + gaps Cost sq meter/ per 1000 population – metric Citizens / Patients in future will say ’I know Lease out vacant space / consolidate estates to be entered here to be confirmed that wherever I go for services the facilities capacity. Cost of total weekly opening time / will be clean, safe and maintain my privacy denominator number of appointments and dignity, even at the chemist’. Income for estates leased out

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 The GP of the future is likely to be contracted using How we will get there a number of arrangements, including, but not exclusively, as a self-employed practitioner (either Transformation Programme & Governance as part of a larger provider organisation, a federation, foundation or equivalent trust, or an During 2014/15 the development of a formal CCG/Area employee of a third-sector and/or private-company Team Primary Care Joint Commissioning Board chaired organisation) and/or as a salaried practitioner. by the Area Team Director, will be managed on a programme basis to ensure pace and scale of delivery.  Federated organisations will be better able to This aims to promote a stronger focus on local clinical coordinate out-of-hours care and ensure the leadership and allow more optimal decisions about the provision of personalised care for those patients balance of investment across primary, community and who particularly require continuity with their treating hospital services. team, both in and out of hours. Source 2022 GP Vision, RCGP (2013) Programme 1- “At Scale Work stream” Where appropriate we will explore the shift to working at greater The Primary Care Joint Commissioning Board will work scale through networks, federalisation or mergers. to ensure there is both capacity and capability across the federations. Where appropriate we will look to A federation is defined as achieve economies of scale in administrative and  Collaboration between groups of practices and business functions of practices. Co-commissioning of other providers, this may include community nursing services by the Local Area Team and the 6 Staffordshire services and GPs with extended clinical roles. & Stoke-on-Trent CCGs will develop a strong  Such organisations permit smaller teams and sustainable Primary Care service over the next five practices to retain their identity (through the years. This may well be looking at different ways of association of localism, personal care, accessibility commissioning additional primary care either through and familiarity) but combine ‘back-office’ functions, using current providers or opening up the market and share organisational learning and co-develop considering alternative suppliers in effort to stimulate clinical services. improved quality, reduced variation and achieve financial sustainability  Leadership and business management may be shared across groups of practices. Programme 2- Improved access We will explore  Workforce resourcing is achieved due to flexibility innovative approaches to improving access to general and ability to cross-cover and pro-actively deploy practice services. We will look to support the changes to team members where the demand is greater. the urgent care system to make 7/7 working a reality across the whole system  Where possible community services will be collocated with GP services Practices will offer Programme 3- Workforce We will build on existing more community services e.g. dietetic services, good work and look to address the workforce problems podiatry and outreach services dependent on GP facing general practice in Staffordshire and skills (e.g. minor surgery and complex contraceptive neighbouring Shropshire. The General Practitioner services). This will require consideration of the community and health centre teams face great current estates utilisation. challenges ahead where there are a high proportion of GPs leading up to retirement (often earlier at 55yr) and  Some practices will form large federations, incorporating hospital, third-sector, private and some areas are historically difficult to recruit new staff. community providers. Previously, an annual migration from Pakistan/India of about 20 primary care physicians which has boosted the local GP workforce and provided diversity in language skills matching some of the local population. This trend is now receding and there is a drain on UK doctors to overseas posts. A new way of thinking about how 7 day

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accessible Primary Care services will be delivered, This programme will look to develop a coherent primary including greater roles for practice nurses allowing them care estates strategy. We will look at the estates and IT to use a broader range of skills. There will be infrastructure across the health economy and identify opportunities for new roles and ways of working to actions required to ensure that these key components ensure sufficient capacity is available across the enable the delivery of the changes identified within the network to deal with the increasing demand. This needs other programmes. We will ensure that estate is fit for to be sustainable and does take some time to implement purpose and that have compliant disability access fulfils as often training programmes take a year or more. The statutory requirements for clinical environments (CQC). proportion of patients seen by nurses in primary care Programme 7 –Change in public behaviours increased from 21% in 1995 to 34% in 2008. Although continuing to improve the skill mix in general practice is We will work to support the development of a culture of important, it should absolutely not be seen as a ‘catch- self-reliance and self-care with our population in all’ solution to the workload problems that GPs are Shropshire and Staffordshire. There is evidence that facing. (Professor Nigel Mathers, Royal College of patients are seeing the primary care team for support General Practitioners, 2013). It must also be recognised which could have been avoided through self care and that recruiting the necessary resources may be difficult management plans. Our way of interacting with patients due to shortages of available nurses. The profile of will need to change, for example: practice administration and support services will need to  seeing the right patients at the right time, which be redesigned by a modernised practice management may be earlier that is typically done currently by approach. This will in turn minimise the demands on professionals. clinician time but will require a flexible and experienced  changing clinical practice and the guidance given set of practice managers as part of the federated to patients, moving from a paternalistic approach to approach. The CCGs, LMC and AT are taking a more of a partnering approach so that people may feel empowered to self management and take proactive stance on recruitment and retention including control of their care where appropriate. bursaries for relocation to the area, re-starter schemes ,  the primary care clinician still needs to assess and innovative training posts etc treat but should also enhance the focus on Programme 4- Unwarranted clinical variation. We providing information and sometimes challenge to existing behaviours, which assists people to will look to systematically identify and address the navigate the services available. systemic and clinical causes of variation and significantly improve the poorest practices. The importance of maximising self care capability and capacity is outlined in the prevention and self care Programme 5 – Pharmacy, Optometry and Dentistry. section. The programme has been set within key We will look to these professions to play a greater role in design and organisational principles below. treating minor ailments; empowering patients with long term health conditions to manage their own health more effectively; improving the efficiency across the whole system.

It is envisaged that this programme will be intrinsic to the primary care at scale solution, and it is recognised that the inter-dependency of these clinical specialties means they are equal partners in defining and delivering the programme of transformation.

Programme 6 –Infrastructure.

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Clinical Design Principles (Nuffield Trust & NHSE Organisational design principles (Nuffield Trust & 2013) NHSE 2013)

 Patients see a senior clinician, capable of making  Primary care is delivered by a multidisciplinary team good decisions about clinical management, as early in which full use is made of all the team members, in the process as possible. and the form of the clinical encounter is tailored to the need of the patient.  Patient access to primary care advice and support is underpinned by the latest technology.  Primary care practitioners have immediate access to common diagnostics, guided by clinical eligibility  Patients have the minimum number of separate criteria. visits and consultations that are necessary,  There is a single electronic patient record that is  Patients offered continuity of relationship where this accessible by relevant organisations and can be is important and access at the right time when it is read and, perhaps in future added to, by the patient. required.  Primary care organisations make information about  Care is proactive and population-based where the quality and outcomes of care publicly available possible, especially in relation to long-term in real-time. conditions.  Primary care has professional and expert  Care for frail people with multi-morbidity is tailored management, leadership and organisational to their individual needs, particularly in residential support. /nursing homes.  Where possible, patients are supported to identify their own goals and manage their own condition and care.

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5. Prevention and self care

Aims Understanding the challenge for Stoke-on-Trent and Staffordshire To help people have longer and productive lives, reduce The health and care system is based around four tiers of the impact of long term conditions and ensure citizen need and intensity of services provided sustainability of the health economy, is based on three representing different levels of care. See Fig. 7. core functions. The

 Prevention of illness and promotion of health  Promoting recovery and re-enablement Impact on the health and  Encouraging citizens to take responsibility to self social care system care whenever possible The Council and others will, as a priority, develop These are the right things to do and as a consequence systems that enable all providers of tier 3 services will also reduce the dependency on health and social (including housing and support) to measure expected care provision, and in particular the use of A&E and impact across the system, as well as individual urgent primary care services. This is therefore outcomes. This should link to the Better Care Fund fundamental to creating and maintaining a sustainable plans. The priorities for Staffordshire are set out in the health and social care economy. table below. These three core functions are an essential part of the The locality commissioning model is building on the approach to integrated care. existing infrastructure developed by each district’s Local Strategic Partnership (LSP). The commissioning role of In future peoples’ health and independence will be these groups is being tested through a Public Health encouraged by Commissioning Prospectus focusing on improving  Being well informed about their physical and mental physical activity and nutrition. This prospectus builds on health the Community Wellbeing Fund that has been  Taking responsibility for keeping well and avoiding implemented over the past three years and evaluated illness positively.  Actively participating in activities which promote wellbeing .Recognising when there are changes in Key barriers to success their wellbeing and taking action to address this The key barriers to the success of implementation are  Using services closest to home or in the community likely to focus around workforce and existing conditions. whenever possible The workforce redesign and training programmes will  Building up ‘personal assets and resources’ which require time to commission, embed and for results to be help deal with long term conditions seen. This may be compounded by the fact that the  Ensuring that if they are a carer, they gain support evidence base is not strong enough to understand the as well as the person they are supporting size of impact based on resources invested. This will be mitigated through our OD and workforce programme (section 10).

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Population-wide behaviour change is challenging to achieve, and is likely to require a wide range of interventions on many fronts. Together with our primary care, community and acute providers, there will be initiatives we can undertake, to make every contact count in terms of supporting individuals’ behaviour change. Equally, we will need to engage with our partners in the local authority to make use of other levers for change, to make healthier choices easier choices. The relationships across the Health and Wellbeing Boards will be a real asset to support this multi-headed approach.

Figure 6 : Tiered levels of care

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‘The objective of the CCGs’ 5 year plan is to work with partners to improve these wider determinants of health and influence the population’s lifestyle choices.’

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 Provider data will be linked to support integration of What it will look like in services. This shall be available pseudonymised for commissioners to support integrated 2018/19 commissioning. The core health and well being approaches are shared  The impact of early years programmes will see an by both Staffordshire and Stoke-on-Trent. Prevention, increase in mean EDI (Early Development Index) early intervention and targeted prevention are based on scores an understanding of the determinants of health and wellbeing  Smoking prevalence will reduce to 18% by 2020

 A ‘lifecourse approach ’3 focuses on the different  Reduced prevalence of overweight and obesity to elements of the experience of health, from the 55% having halted the year on year increase in the moment of conception through childhood and percentage of those who are overweight or obese adolescence to adulthood and old age. It is not  The recovery Star outcome tool shows increased only physical health but also social well-being which prevalence of mental wellbeing is explained by the lifecourse framework. This is the  The Generalised Self-efficacy Scale to shows basis of considering the needs of the population at increased prevalence of self-efficacy different life stages and ensuring people “start well”, “live well” and “age well”. Efforts to increase the  Overall improvement in quality of life shown by the capacity of individuals and households to self care EuroQol5D for all client groups should begin during childhood and adolescence.  People who engage in wellbeing activities will have As the evidence base is not strong enough to better wellbeing (including lower rates of understand the size of impact based on resources depression) invested, the indicators above will be used as context  Physical and mental health are intimately and reviewed frequently. The objective is to ensure that connected and thus poor mental health can affect these indicators move in the right direction and physical health and vice versa interventions that are evidenced to improve these indicators will be commissioned.  Dependence on services is contributed to by lack of activities outside of services – support to engage in Medical care only contributes around 20% of these activities will reduce dependency and support improvement. Different partners have responsibility for discharge – service users will have an ongoing life influencing the different factors. plan which outlives any care plan  All providers shall have wellbeing and patient Therefore it is logical to assume that this would lead to activation measures incorporated into their  Shorter lengths of stay in service performance management  Reduced readmissions to services  Reductions in A&E attendances

3  Reduction in non elective admissions Evidence for life-course theory comes from longitudinal studies of childhood disadvantage and adult health derived from birth cohort studies. The data collected relates to economic and social conditions, educational achievement and health experiences and conclusions are that outcomes can be predicted statistically - a predicted probability is only that individuals in one group are more likely to experience a given outcome than those in another group. This raises issues about how to enable families and individuals to mitigate the disadvantage, to cope or survive the negative influences –“resilience”.

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The impact of measures to improve life expectancy will The ambition is, by 2020, to harness the assets of also be seen in two dimensions; improvement of quality neighbourhoods and mobilise our communities to of life and the “compression of morbidity”. increase healthy lifestyle choices, reduce levels of social isolation and improve mental wellbeing by There are a number of validated measures of quality of supporting 20 communities to set up neighbourhood life which look at domains such as wellbeing, functioning partnerships. in daily living and patient activation. The CCGs and partners will identify one or more specific measures and  Healthy Food City to tackle high levels of food ensure this systematically across all contracts. poverty and the lack the knowledge and skills Systematic use of these measures will tell us how well needed to shop for and cook nutritious meals for interventions are achieving the goal of improving quality themselves and their families, a situation of life and allow comparison across different compounded by poor access to healthy food locally. interventions. The consequent impact on health in Stoke-on-Trent encompasses long-term conditions, such as Stoke-on-Trent diabetes and heart disease, poor mental health and The understanding of the determinants of population potentially malnourishment, for those struggling to health, as described in the case for change, underpin feed themselves in the face of chronic poverty. For the following opportunities to make significant change. Stoke-on-Trent to become a Sustainable Food City by 2020 will require a city-wide plan that will  Healthy places (internal and external built consider activities such as environment) can have a significant impact on  Ensuring the population has access to affordable health and wellbeing with a growing evidence base good food to suggest that it can impact on obesity, mental wellbeing, unhealthy lifestyles, community  Giving people the opportunity to develop the skills cohesion, physical activity & health, educational to feed themselves well attainment. Under Mandate for Change, the city is  Helping producers to sell more of their food locally undergoing extensive regeneration and it is important that positive health and wellbeing is  Public sector organisations leading by example routinely built into the city plans and developments  Creating a vibrant, diverse and fair local food and that effort is made to ensure that negative economy that encourages new sustainable food impacts on health and wellbeing are mitigated as businesses to flourish, providing new jobs and appropriate. There are also opportunities to explore opportunities. the potential use of integrated impact assessments to include issues around safer communities, and Prevention priorities for Stoke-on-Trent are set out in the cohesive communities etc. table below.

 Healthy neighbourhoods can tackle issues such as isolation and loneliness, anti-social behaviour, and unhealthy behaviours, etc. With the right level of

support emergent leaders arise and spearhead positive change, and communities become more resilient. They understand that where there is a problem, the solution lies within that community – whether the solution is to draw on community assets and mutual support or to work with local agencies to improve services.

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Table 10 : Priorities

Priority Objectives Enabler Outcomes

Good Parenting To improve the life The most important modifiable risk factor Reduction of risk of future mental chances of children and and physical ill health (can this result in improved mental be quantified?) and physical health in adulthood.

Promoting mental well To enable a city population implementation of the strategy to promote Good mental wellbeing being to function well and be mental wellbeing across all ages, including • Higher educational resilient interventions such as attainment • Promotion in schools, training of • Better physical health, frontline staff and 2000 Stoke • Fewer missed days of work residents per year, • Reduced use of health • Raising awareness in businesses services increasing participation of their staff Mental wellbeing underpins in the Five Ways to Wellbeing efforts to achieve healthy • Ensuring high levels of participation lifestyles. by vulnerable groups.

Smoking - the most Reduce prevalence from Maintain and enhance smoking cessation Prevalence rate comparable to important cause of 28.0% to 18% (below the services the England average preventable mortality England rate of 19.5%) To target current smoking population

Obesity To reduce the incidence of Reduced levels of obesity obesity and overweight in reflected in improvements in the adults from 66.5% to 55% occurrence of health problems -

(by 2020?) arthritis, sleep apnoea, diabetes, gallbladder stones, high blood (England average of pressure, liver disease, coronary 63.8%) artery disease, cerebrovascular Reduction of obesity in disease, certain types of pregnancy cancers, and infertility. To reduce potential for Reduced obesity in pregnancy premature mortality leading to reduced health complications for the mother, reduced chances of stillbirths

Promoting self-care for To improve levels of Greater use of 111. Encouraging use of More activated population, higher those with long term patient/public activation local pharmacists. levels of understanding in the conditions - 31% of the and to target programmes All round improvement of health community with better ability to Stoke-on-Trent adult in line with people’s level information and public understanding. self manage and avoid population suffer from of activation. escalation of health issues. one or more long term health conditions.

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Staffordshire Figure 7 : 7 ways to target prevention The joint strategic needs assessment for Staffordshire Figure 1 : Seven proposed outcomes for TargetedPrevention informed the Health and Wellbeing Strategy. The plan underlying this focuses in three areas

 Integrated commissioning for care and support, integrated commissioning for prevention and early intervention and influencing other strategic areas.  Integrated commissioning for care and support includes some targeted prevention including maternal health, alcohol and drugs and sexual

health.  All integrated commissioned services shall also focus on improving general wellbeing in their target

population and encourage service users to access wellbeing activities delivered in their local area. Integrated Commissioning for Prevention and Early

Intervention is being developed on a district footprint will all relevant partners. CCGs are taking a leading role in these district partnerships. This shall commission wellbeing activities which will reduce the general populations need for care and support services and support service users to step down from these services. The Health and Wellbeing Board and Senior Officers Group in Staffordshire have agreed the goals of targeted prevention services as part of an integrated commissioning approach which is embedded in the principles of the BCF and the JAB.

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The priorities for Staffordshire are set out in the table below

Table 11 : Priorities continued

Priority Objectives Enabler Outcomes

Healthier Lifestyles Support all people to Reduced investment in upstream Reduction in excess weight live healthier lives and services e.g. adult weight in adults make good lifestyle management, Increase in physically active choice Increased investment in downstream adults activities, first step the public health Reduction in smoking commissioning prospectus. This is prevalence being implemented via the LSP Improvement in self-reported commissioning groups. wellbeing Central support services being commissioned centrally to support locality developments including hub and lifestyle intervention services. NHS Health Increasing invitation to Continue with current system 20% of eligible patients identifying people at 20% of eligible delivered through GPs or alternative offered health checks risk of cardiovascular population per year to providers 60% of those offered taking disease and health checks with an CCGs to take an active role in up health check encourage adoption uptake of 60%. encouraging GPs to participate and Increase uptake of wellbeing of healthier lifestyles achieve consistently high levels of activities and if needed activity. lifestyle interventions. Pathways into healthy lifestyle activities and interventions strengthened and increased as these are developed. Mental Wellbeing - The Ambitions are for Focus of LSP commissioning groups Improved self-reported promote Mental the connection between is to pool partnership resources and wellbeing. Wellbeing across the mental wellbeing and commission activities to improve Increased patient activation. lifespan & through all self-care to be well wellbeing of general and target Reduced demand for care commissioning established and populations and support services activities commissioned to achieve both Shorter length of stay in care outcomes, whilst all and support services. commissioned services Reduced fear of crime will include outcomes Reduced antisocial behaviour related to mental well- being and designed to take advantage of opportunities to support people to connect. There will also be work to consider the potential for social bonds to support investment in self-care, wellbeing and lifestyle improvement

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Priority Objectives Enabler Outcomes

Children’s Consider the scope of integrated Reduced excess weight in Commissioning - children’s commissioning. children. support best start in Ensure best value is achieved from all Reduced smoking life for all children children’s services including healthy prevalence (15 year olds) and young people child programme and Health visiting Improved emotional wellbeing of looked after children Self care Interventions to support Lay-led self care support groups to Improved patient activation improve self-efficacy and raise energy patient self-care of their Improved wellbeing condition aim to levels among patients with long-term improve patient health conditions Improved lifestyles in target groups and reduce health Support for individuals and their service costs. carers through Reduction in A&E attendances • Practice nurses in providing education and support Reduction in readmissions • Access to appropriate and up-to-date Reductions in length of stay information in a timely way • Psychosocial support through organised activities Prevention • Working with planners to maximise Improved use of green space for physical activity the ways in which the built environment increases participation Reduced excess weight in in physical activity children/ adults • Using behavioural interventions to Reduce variation in quality reduce screen time with a view to and outcmes framework weight management indicators • Providing worksite programmes to address lifestyle change • Addressing the variations in primary care, in the management of e.g. hypertension

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Commissioning for prevention and self-care How we will get there The commissioners will include in all specifications  Mental wellbeing - There will be a focus on The Health and Wellbeing Board Strategy has an commissioning for mental wellbeing as part of all emphasis on integrated services and a shift of existing provision. Providers will be required to investment towards prevention. Thus the ambition is to promote wellbeing of the target population and develop integrated prevention commissioning using the encourage uptake of wellbeing activities developed following principles through district/ locality partnerships.  Decision making delegated to the district/ locality This can be encouraged by including a wellbeing partnerships outcome in specification e.g. recovery star/  Funding distributed between the district/localities WENWBS. Involvement in activities to improve based on need wellbeing (i.e. opportunities to connect, keep active, learn, take notice and give) should be incorporated Funding decision based on addressing local need  into integrated care plans. This can be supported utilising local assets and contributing towards the by appropriate activities being commissioned in the joint Health and Wellbeing Strategy. community by district/ locality partnerships. As integrated commissioning becomes successful,  Innovation and technology - Providers will be resource will move from acute services to prevention, expected to develop the use of technology to give and lifestyle and wellbeing interventions will be people information and independence. This is to integrated into long term conditions, mental health and become widely used and built on the interactive text learning disability pathways. There will always be a messaging service (e.g. FLO) for people with need for alcohol and drug treatment and for ongoing health needs that need monitoring (e.g. genitourinary medicine, but over the five years, it is COPD and Diabetes). Increasingly people have anticipated that this proportion will reduce. In a shorter modern mobile telephones and devices which time period, resource currently invested in upstream provide an interface for self- monitoring, and lifestyle interventions will be re-invested in more communication with health professionals. There is preventative activities. great potential for the use of ‘apps’ which guide Assessment and intervention around lifestyles and people in their health/medical condition wellbeing will be a core part of the care planning management. process. Staffordshire Public Health will commission an Health and care can learn much from other integrated lifestyle support service to maximise the industries by translating approaches to managing impact of evidence based interventions across the and delivering services to people. This assists with population, providing vital support to primary care. stepping down/up of care intensity and methods of communication and engagement. All patients will be The CCGs along with their partners will aim to increase offered support using technology/apps (e.g. FLO- the impact of prevention measures and interventions to LTC monitoring by text message, Health Fabric) to increase self care by focusing on areas where there is support changes to develop a healthier lifestyle and good evidence for efficacy. identify problems. This is about putting people in control of their own health.

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 Workforce - The skills, competencies and capabilities of the workforce will be quite different to the last decade and need to focus on starting the right conversations with citizens and patients. Health and care professionals’ knowledge of motivational interviewing, tailored coaching and signposting to resources or community assets requires a different approach when interacting with people. These behavioural skills need to work in synergy with the use of technology and delivering interventions which were traditionally the domain of acute care within a hospital. The workforce redesign and training programmes will take a while to commission, embed and achieve the impact on how services are delivered. Attention should be given not just to new undergraduate programmes but how the existing workforce will need leadership and training to become more effective at promoting prevention, empowering individuals to build their own capacity and capabilities. The delineation of roles and responsibilities will flex appropriately to support people along their care pathway, minimising handoffs and focussing on outcomes rather than just tasks to deliver health and care interventions. Practice and community nursing services will work much more closely to provide seamless services to people with long term conditions and complex needs. Costs, financial investment and benefit from the identified interventions.

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 Social marketing has to be systematic and well 6. The emergency developed to ensure health messages have a positive impact on community behaviour and urgent care  Service providers will work differently so it will be the norm for the ambulance service to treat patients and system leave them at home rather than convey them to hospital (when unnecessary)  We must meet all the targets for urgent and Aims emergency care on a routine and consistent basis Over the next five years there needs to be a dramatic To deliver this vision, a root and branch review is required change in the emergency and urgent care system cross of emergency and urgent care which takes account of the our unit of planning. Addressing the current over- review by Sir Bruce Keogh and the future report from Keith performance and future demand in this area is the focus of Willetts. The Keogh recommendations to improve access, the programmes in FRP with at least £23m of savings service quality and outcomes have far reaching earmarked by 15/16. This needs a strong focus on the implications; these are being addressed through the Urgent reasons people attend A&E centres and an equally strong Care Board and working groups. This will be supplemented focus on how people become admitted when the by recommendations regarding service configuration from Staffordshire and Stoke-on-Trent rates for admissions are the strategic review which is currently in progress. higher than the national averages so that: Ultimately it will be delivered by the organisations, within  The unplanned has to become planned the system, working differently, with the population, to change the present broken and fragmented system.  Service provision needs to be more consistent and layered so it is easily explainable to patients and The vision has to be that for change to occur across provides consistent quality and safety for those Staffordshire and Stoke-on-Trent it will not occur in individuals requiring treatment Stafford, Burton or Newcastle-under-Lyme separately - the  Prevention needs to become the first line of action, footprint is not big enough - consistency would be lacking; rather than an after thought organisations would continue to compete for a reducing  Patient data needs to be available in a format which workforce and there would be no ability to produce the allows targeting of the at risk more effectively layered approach to emergency and urgent care access where the first level is self-care.  Primary care needs to change - access to the Primary practice needs to be easier seven days a week Finally without this vision and the development of the new through the development of larger GP Federations model, plans set out by commissioners will not be  Networked systems between hospitals, community, delivered. The Better Care Fund, individual CCG mental health and primary care need to be slicker. strategies, QIPP delivery rests on this fundamental system This will allow for ensuring that all patients with wide change. whatever condition, medical or mental health, get the treatment that they need achieving parity of esteem Over the next five years the three executive level Urgent for all Care Working Groups (UCWG), which include Emergency Department (ED) specialists and input from all strategic  We will commission emergency/urgent care pathways to support people with emotional distress and mental partners will focus on illness  The oversight of the whole urgent care system  The third sector need to be embraced to provide  The delivery of priority projects and approval of a long targeted tender, loving, care (TLC) services term strategy to deliver a safe, effective, simple and high quality service for the benefit of patient care

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‘To deliver this vision, a root and branch review is required of emergency and urgent care which takes account of the review by Sir Bruce Keogh and the future report from Keith Willetts.’

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Impact on the health and Key barriers to success social care system The key barriers to the success of implementation are likely to focus around the risk appetite of doctors. Delivery of the six key interventions will have a Incidents such as mid-Staffs could make them more significant impact on the Health and Social Care system likely to admit borderline cases. There is also the over the next five years, which will include potential for unnecessary admissions due to lack of  The refocusing of the system to self-care and support systems in the home. This will be mitigated to self-management some extent by our programme of engagement with  A change in the pattern of care from acute to acute and primary care clinicians, to clarify protocol and community provision thresholds for appropriate emergency admissions.  The delivery of the aspirations through the Better Care Fund The cost of the interventions is yet to be determined.  The delivery of the Staffordshire County Health and Well-Being strategy  The financial sustainability of the health and What it will look like in social care system

In the original submission of this plan, reduction of 15% 2018/19 The UCWG has agreed strategic principles of the urgent emergency admissions was indicated to be possible care system which will guide the delivery of key projects with an average of 11.5% over the next five years in and improvements across the whole system for patients line with the Clinical Commissioning Group UNIFY and the public. Over the next five years, increased submissions which are in total 77-79,000 per year. This demand and concentration of specialist services will ambition has now been superseded by the FRP which have an impact on how ‘the system’ will need to respond seeks a significant reduction in spend in this area. and how it will be configured. The emergency and Additionally the BCF, which is still developing, refocuses urgent care system can be divided into three parts the provision of care for the frail elderly by reducing over-reliance on urgent care and will be impactful in  The system before hospital reducing the activity in acute settings. Furthermore the  The access to hospital CCGs have committed to collaborative working around an approach to frail elderly care and each have a  The system post hospital commitment on preventative programmes in primary Our rationale, response and interventions are explained care. below. There is support of a unified approach through A fully integrated and responsive system will be the Commissioning Congress, however consideration of implemented to ensure wherever people access local demography, geography and pre-existing models services for urgent and emergency care, they will of care will be made by each CCG in implementation, receive the response commensurate with their needs therefore emphasising the needs of and commitment to and be directed to the right place, first time. the care of the local population. Partnership working with all ‘points of service’ will strengthen the structure and availability of help when System before hospital people need it. We will ensure GP services are organised and out of hours support is available every Almost half of patients who attend A&E in England do day of the week. not need medical treatment. One third (34 per cent) are given advice, while a further 12.8 per cent need neither

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advice nor treatment. Nationally, the majority of  An understanding of who requires support attendances are during normal working hours of 9am to  Access to community based support, for example 6pm. 4 the third sector that can support people who This means we could avoid, just in Acute Hospitals, become vulnerable and socially isolated. The 125,000 attendances based on 2013/14 levels. The campaign about loneliness recently highlighted that added benefit would be to release significant time to living alone and being isolated is the equivalent to deal with patients who require treatment. smoking twenty five cigarettes per day Intervention 1 - To reduce, over five years, the  Programmes which support people to understand number of patients attending level 1 and level 2 their condition emergency and urgent care centres to national  Technology which underpins support to individuals benchmark levels and gives them confidence to self-care

Fig 9 Targeted interventions as expressed inQIPP and FRPs will  Access to urgent advice and support where action reduce A&E attendances by 30% resulting in an approximate £8 can be taken to support the individual m in year saving by 16/17. An understanding of how people access healthcare now and appropriate social marketing to ensure messages are well developed for different populations. It has been 30% Nationally Benchmarked saving well researched that segmenting populations aids the by CCG development of self-care. 9,000,000 8,000,000 Intervention 2 - To increase the numbers self-caring 7,000,000 North Staffs 6,000,000 SoT by 20% per year as a support to reducing the overall 5,000,000 Staffs and Surrounds number of attendances across the emergency and 4,000,000 Spend £ Spend Cannock 3,000,000 urgent care system. 2,000,000 SESSP 1,000,000 East Staffs The Expert Patients Programme document “Self-care - reduces costs and improves health –the evidence” 13/1414/1515/1616/1717/1818/19 suggests that across the Staffordshire and Stoke-on- The FRPs detail a number of interventions being put in Trent emergency and urgent care system that if you place by the CCGs which include: arrive at any of our accident and emergency departments you have a one in three chance of being  Prevention through integrated care admitted. There are also a proportion of patients being  Prevention through provision of in community/primary alternatives directly routed to admission portals by their GPs. Self  Addressing the care needs of regular attenders care may provide an opportunity to significantly reduce and ACS this number. The report indicates this number could be  Creating walk in centres to divert activity away as high as 16%. The table below shows the volumes of from A&E admitted patients and the impact of reducing this  Investment in rapid response services activity. International evidence suggests that we can also increase the self-care of patients but we need to ensure that the following are in place

4 Health and Social Care Information Centre (HSCIC), Focus on Accident and Emergency, December 2013

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Although admitted care can be appropriate for some it This intervention item will support the aspiration to can be the last thing required for others who can reduce unplanned emergency admissions up to a immediately become institutionalised and as we know, possible 20% according to benchmarking. for many, returning home immediately is not what The programme for urgent care centres in South East happens across the system. The problem of course is and Seisdon CCG is example of this type of intervention multi-factorial but the simple fact is the system does not being put into place. It looks to simplify an often complex know who will enter the system next, yet there is good Urgent care service and focus on improvements in evidence to show that populations can be identified and community, primary, ambulance services and MIU and supported into active programmes of care to avoid an to signpost better for patients to reduce unplanned admission. For many, an admission will be inevitable as interventions. their condition progresses but it should not be beyond the system to plan these interventions rather than let us . continue with the emergency admissions lottery we have Figure 10 - By 18/19 Staffordshire and Stoke-on-Trent could at present. achieve a saving of £35m by reducing the level of all unplanned admissions by 20%.. FRPs indicate that by 16/17 NEL spend The above requires all populations to be stratified for should be reduced by £17.4 as a result of articulated risk, although we will start with the over 85s frail elderly programmes, with an additional £23m of QIPP savings who have been identified as a key group through the earmarked but yet to be fully scoped. Staffordshire and Stoke-on-Trent strategic review. We will then move to more of the population as we start to 20% Benchmarked Saving NEL manage the first group proactively.This risk stratification 60,000,000 50,000,000 must link to social care data to give as full a picture as North Staffs 40,000,000 possible of the care presently being received and what SoT

further support is required. This is being tested at 30,000,000 Staffs and Surrounds Spend £ Spend present. In many cases local and practical support will 20,000,000 Cannock be required to ensure effective diversion and others will 10,000,000 SESSP East Staffs require primary care to deliver a different type and - different level of service “to avoid the crisis” , which is what local people have identified through “Call to Action” events. Of the total NEL admissions over the CCGs approximately half originate in admissions from A&E. Reducing this rate to We are working with the ambulance service to reduce benchmarked ratio levels would be equivalent to reducing NEL variation in the inclusion/exclusion criteria for urgent admissions by 15%. care centres e.g. “walk in centres” as described in the FRPs. This will facilitate the use of the “Pathfinder” project, where patients are signposted to alternative Access to hospital settings of care other than A&E. Intervention 4 - To recalibrate the emergency and Intervention 3 - To risk stratify an agreed set of the urgent care system within hospitals. population of Staffordshire and Stoke-on-Trent and This will use the Keogh report as the basis for change offer programmes of community support to each of but will also consider how we network all hospitals these individuals to enable unplanned interventions together so that workforce (in particular medical) can be to be the exception not the norm. used more flexibly and this is evidenced in the step-up This directly links to care planning which all systems are and step-down model of care being implements in the required to undertake. North of the county.

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Intervention 5 - To streamline and change primary We also know that factors such as what occurred at Mid care access needs. Staffordshire may affect the risk appetite of doctors, particularly junior doctors and therefore they may be The scope, range and style of different centres, opening more likely to admit a borderline patient. We are also times that are similar to other services, create confusion aware that no support systems in the home mean but also create demand. Each CCG, as part of the admission may be the only alternative. system work, has described how primary care will change. The primary care system should have these There continues to be significant focus on this area of consistent features work and it’s the part of the system which continues to remain stressed. The system presently has too many  A methodology for increasing access across seven people at its front-end, too many people being admitted days and therefore requires the discharge process to run at a  Direct and integrated links to hospitals level which has shown in the system to be  A front-end which promotes self-care including NHS unsustainable. The patient experience cannot be good 111 as a large proportion of patients do not go home, in the north they go to community beds in the south they can  The potential for patients to be stepped up, but this go to a mix of residential, nursing home and community could be in their own home, or a unit run by GPs beds. For many this just increases the length of their The programme of interventions detailed by the CCGs stay and escalates costs, when in fact a system which and in their QIPP and FRP support the features listed ensures patients can go home with the appropriate and support the reduction in emergency admissions support in a timescale reasonable for the care needed in over the next five years. hospital must be fundamentally better than the present For example in North Staffordshire and Stoke CCG, system. It would also allow the system to use the Intermediate Care teams have been established to resources better than are achieved at the moment. proactively manage patients within their own homes or Any change in this part of the system would be better for to facilitate a step up model into community hospitals. patients and the staff who work in the system, most of The Hub as the enabler provides expertise regarding the who are “running to stand still”. capacity and capability of community services. This is Therefore the challenge is to support the development equates to a potential 11,900 saved admissions. of better systems to move people out of hospital in a timely manner avoiding readmissions. The North Staffordshire and Stoke model is a good The system post hospital example of a step down model of discharge which will be delivered through the ‘Discharge to Assess’ scheme Intervention 6 - Improving discharge processes which is intended to ensure speedy discharge from As individuals move into the hospital system, which is hospital to home and to deliver assessment in the best under pressure, we understand that this may mean place. more patients are admitted to a bed. This may not be a Each of the interventions rely on the system galvanising bad thing to do but the reality is that acute hospitals are itself not only to work differently but to create a culture running “hot” permanently. that sets out to put the patient, carer and public at the The aspiration must be to reduce the “hot” system to centre of the plans rather than see them as the potential acceptable levels. problem why the system doesn’t presently work.

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The whole system accepts that any attendance / Better Care Fund performance metrics will measure admission within the emergency and urgent care system performance on delayed transfers of care, avoidable which is not planned should be seen as a system failure emergency admissions, Injuries due to falls and the in the future. rehabilitation (re-ablement) of people as gauged after 91 days. Achievement of these is predicated on plans for The model for the future will be similar the one shown the alignment of health and social care services with an below, however the system must be pragmatic enough emphasis and focus on community services, such as to be able to develop a consistent set of services that outlined in Phase 2 of the Stoke-on-Trent and North may have nuanced differences in local populations. Staffordshire admissions avoidance plan.

Figure 8 : The ‘new’ urgent care system in Staffordshire and Stoke-on-Trent UOP

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This new system will  Increased discharge of patients direct to home  Provide 24/7 access, support and advice  Create a highly responsive service that delivers Activity care as close to home/in their community as  Reductions in acute activities that are unnecessary possible, minimising disruption and inconvenience for patients and their families  Increase in community based activities involving a number of providers including new entrants  Decrease avoidable emergency attendance, ambulance journeys and unplanned admissions Resource utilisation  Give treatment in centres with the very best  Reduced A&E attendances expertise and facilities, this may mean passing the  Reduced use of non -elective admissions local unit to get to the specialist centre faster  Provide care and services that maximise the chances of survival and a good recovery How we will get there Using the following outcomes framework the expected The system partners will need outcomes of all these changes at a high level are as  To commit to working as a Staffordshire and Stoke- follows on-Trent emergency and urgent care system. This Organisational outcomes could be achieved through the development of a system wide emergency and urgent care network. Providers This network must be given the authority to act and  Systems will be working at optimum levels its leadership must be through one Accountable increased better outcome for patients Officer. This commitment is now being put to action through the emerging commissioning congress and  Meeting key standards (4 Hours etc.) through the leadership being given in Staffordshire Commissioners wide initiatives around specific themes.  Increased number of patients in planned  A programme plan developed through the network, programmes of care signed off by all organisations needs to be agree  Standardise access points and again this is emerging through the new governance framework  Seven day working the norm  Intervention task groups are also evolving to be Satisfaction convened across the system that will take  Increased Patient and Public satisfaction with responsibility for implementing system wide the Emergency and Urgent Care Services work. An example of this would be the work being done around frail elderly and end of life, both of  Increased ability to recruit into level one and level which are also primary focuses of the BCF. two centres because of a networked system Validation of the work clinically could be achieved using  Increased satisfaction of clinicians in job role and the Clinical Senate as a Clinical Advisory Group. content The objectives must be to deliver an emergency and Clinical urgent care system which is responsive to patients but  Patient Outcomes improved by proactive early drives the treatment of patients to the lowest possible intervention level – starting with self-care. A by-product of this work would be the delivery of the reductions in unnecessary  Support for Carers improved by proactive early intervention attendances at level one and level two centres and by definition a reduction in emergency admissions in line  Level one and two centres concentrating on with commissioner aspirations. patients with real need and better outcomes

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Each intervention task group would need to consider the  Ambulatory emergency care centre (AEC) enablers of workforce, estates and information  Admission rates technology.  Ambulatory care sensitive conditions (ACSC) Work is already planned to develop the approach through the Urgent Care Working Group Leads and has  Rapid Assessment Interface and Discharge (RAID) been further progressed through the FRP process. Service Making the significant changes to how services are  Seven day working delivered and encouraging people to use the wider  Ambulance services range of providers requires ongoing engagement and  Winter planning information programmes. The outcome of the review will result in a public consultation which draws attention Some of these elements will be now be addresses to how important this is for the future sustainability of the collaboratively through the Commissioning Congress emergency and urgent care system. Each local CCG and inevitably there is significant cross over with the has committed to contribute via initiatives and system ambitions of the BCF. changes, as follows and as most appropriate to their These plans are continually aligned with the QIPP and locality. These fit well alongside the initiatives which are FRP schemes that relate to the reduction in attendances either in place or planned and documented in the and non-elective admissions. At present the overall recovery plans. impact of these plans on activity has not been collated,  Primary care but as the schemes mature, performance against the overall reduction ambition and benchmarked target will  GP out of hours be monitored and plans recalibrated to achieve the  NHS 111 ambition.  Use of levers in existing contracts for services  Addressing findings of the Keogh Review  Accident and emergency unit (A&E) redesign

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Table 12 : Summary

Outcome Citizen Experience High Impact Intervention Cost Measures

1 Patients understand how To reduce, over five years, the To be determined The number of to access the most number of patients attending level 1 patients attending appropriate service for and level 2 emergency and urgent level 1 and level 2 their need care centres to national benchmark emergency and levels. urgent care centres 2 Patients choose and are To increase the numbers self-caring To be determined The number of confident to choose by 20% per year as a support to patients self-caring alternative options to reducing the overall number of A&E for their needs attendances across the emergency and urgent care system 3 Patients feel assured that To risk stratify an agreed set of the To be determined Reduction in community support is an population of Staffordshire and Stoke- unplanned acceptable alternative to on-Trent and offer programmes of interventions a visit to hospital community support to each of these individuals to enable unplanned interventions to be the exception not the norm.

4 Patients see a seamless To recalibrate the emergency and To be determined Increased flexibility service of care urgent care system within hospitals. of the workforce

5 levels benchmark national to Patients are able to To streamline and change primary To be determined Reduction in access primary care 7 care access needs. emergency days a week admissions 6 Patients are discharged Improving discharge processes To be determined Reduced LOS in a timely and safe manner for the acute

setting

Reduce A&E attendances attendances A&E Reduce 15% by admissions A&E reduce To

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7. Elective productivity

Collaborative working with providers can be evidenced by the work between East Staffs CCG and Burton Aims Hospital, to reduce first to follow up ratio they have CCGs and local providers are working together to agreed four specialties where they believe that deliver the national requirement of a 20% productivity efficiencies could be made without negative impact to improvement in elective care by 2019/20. Whilst this is the trust. triggered by the tariff deflator through which elective Through these changes such as these we aim to tariffs are being reduced by 4% each year over the five maintain and enhance patient safety and improve the year period. The Staffordshire and Stoke-on-Trent experience for patients and carers. Local people expect CCGs recognise that this is a shared system wide to have a high quality and efficient experience when challenge and can only be achieved by commissioners, their care pathway includes episodic elective care (e.g. primary care and acute providers working together. cancer treatments, surgery and therapies). Maintaining A step change in the way that planned care services are quality will be a particular priority in the face of changes organised and managed which aims to to established ways of working.  Doing less – stopping the clinically unnecessary Work is also ongoing by engaging with primary care interventions or delaying procedures where this colleagues. Collaborative working has enabled CCGs to does not have adverse clinical consequences focus plans around preventing outpatient referrals by  Work collaboratively with primary care to shift developing a number of initiatives at a local level on activity into alternative settings referral prevention  Provide appropriate access within a reasonable Additionally, CCGs have focussed on local priorities for timescale pathway change, targeting specific specialties.  Share decision making between the clinician and By March 2015, we also expect to have made progress patient so as not to undertake procedures of limited towards achieving true parity of esteem, in which value everyone, including those with mental health needs, requiring elective physical care has timely access to  Reduce recovery time evidence-based services. Our commitment to quality  Remove errors and safe care, includes keeping to national standards  Improve productivity by making the best use of for example on the referral to treatment times resources expectations.  Shifting some activity into alternative settings Current situation In order to maintain a sustainable health economy, There are existing challenges to elective care commissioners will work with local providers to mitigate performance within the Unit of Planning as shown in the against the loss of income from reduced elective activity table below. through taking on more specialist activity, repatriating work currently referred elsewhere and for providers to sell their freed capacity to out-of-area commissioners.

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Table 13 : Performance against 18 weeks treatments for the 4 top specialties as at April 2014.

Commissioning for value packs have highlighted where consultant capacity to reduce waiting and repatriate there is scope for cost reduction in elective care. For activity from residents who chose to go elsewhere due instance in Stoke-on-Trent the greatest opportunity for to long waiting times. cost reduction has been identified in elective neurology (£1.6m) and in elective trauma and orthopaedics (£1.5m). Specific initiatives are now in train to address performance issues in specialties and develop new pathways where applicable. Contract Management are working with the CCG to enforce these changes through sound contracting. Learning will be shared between CCGs.

East Staffordshire CCG is working towards top 10% performance with regard to the new to follow up ratios with acute providers; with a gain share negotiated with Burton Hospital NHS Foundation Trust to incentivise improved follow up ratios freeing up the hospitals

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A 20% saving by 2018/19 would yield a £58m reduction Impact on the health and in all spend on Planned Care. Of this £17.5m is identified within current plans as acheivable by 16/17. social care system Potentially this could be higher were higher risk elements also included. Better phasing of activity need not mean reduced overall income for Trusts - but there are risks to Trust’s viability . and commissioners need to work closely with providers Elective Spend to minimise adverse impacts. 180,000,000 160,000,000 140,000,000 If managed effectively, providers will be able to free 120,000,000 capacity for complex cases providing this does not lead 100,000,000 CCG Spend with 20% Activity

80,000,000 reduction Spend £ Spend 60,000,000 to increased acute intervention overall. This will CCG Spend 40,000,000 however, have an impact on primary care although 20,000,000 collaboration between practices working at scale should - mitigate the additional workload.

Key barriers to success The key barriers to the success of implementation are There are three areas of focus in improving the likely to focus around mitigation of the extra pressure productivity placed upon Primary Care and any resulting push back from those affected.  Reducing outpatient activity  Increasing the efficiency of specific specialties [East Staffs] POLV were implemented in the 14/15  Clinical Prioritisation contract, with associated reductions, however demand/ treatment is showing that the capacity removed in the Outpatient Activity plan is not being achieved since it is being replaced by By reducing the rate of DNA to an average of 10% there other activity increases, mixture of increased referrals would be additional capacity of 15,000 appointments and quicker treatment. Audits have been carried out to every year, releasing a resourced cost of £1.6m ensure compliance with policies, this appears to be the case. Referral to Treatment (RTT) pressures may require a contingency being factored into the budget to allow for additional activity.

What it will look like in

2018/19 The Outpatient first to follow up ratio is above the The national requirement of a 20% productivity national average in most CCGs. By reducing the ratio to improvement for elective care would result in freeing the benchmark would yield 133,000 appointments and capacity to deal with increased demand and making £11m of saving. There are currently plans in place to savings through more effective utilisation of capacity achieve at least £3.4m saving with further savings and of alternative approaches. embedded within other schemes and not identified separately.

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 Redesigned pathways will be in place with consistency wherever possible over the Unit of Planning  Patients and public will understand the issues  Local clinicians will be committed to working to these aims, and observe protocols and refer appropriately

Clinical Prioritisation How we will get there The reduction of procedures of limited clinical value and We will build on experience to date and the work that clinical prioritisation are one of the main Staffordshire has already commenced to increase productivity in wide initiatives which could result in the reduction of elective care. spend over all CCGs by as much as £8.5m , CCGs and providers meeting as part of the cross The CCGs have applied the principles of ‘do it once and economy elective productivity workstream are share’ as recommended in the Distressed Economies committed to sharing experience, working Report to elect a lead commissioner for workstreams for collaboratively and (through the CPAGs for the north of both Procedures of Limited Clinical Value (POLCV) and Staffordshire and Stoke-on-Trent and for the South of a programme around clinical prioritisation, Oregon. This Staffordshire) to ensure that the same levels of access has been shared among the CCGs, to capitalise on the will apply across the economy and that there will not be benefits in their FRPs (Financial Recovery Plans). any postcode lottery. The table below showing the output of the The areas of most concern both at a Staffordshire wide commissioning for value packs corroborates the and local CCG level include opportunity available through this intervention.  Trauma and orthopaedics  Ear nose and throat  General surgery

 Ophthalmology Specialty focused Efficiencies Our attention will focus on  Productivity gains will have been delivered across  Pathway re-design to reduce inappropriate elective the economy as a whole referrals  As a result of redesigned pathways and other  For many health issues, surgery is the last step in a interventions performance improvements will be patient’s pathway and alternative measures should demonstrated in be exhausted before the risk of surgery is - Lengths of stay in hospitals, and reducing the considered. Modern clinical consultation with volume of unnecessary, excess patient bed patients also highlights that undertaking a surgical days during elective stays procedure can sometimes have a major impact on - The number of people treated as day cases their working life. More-often recommendations for repeating therapies that control symptoms is - Achieving referral to treatment targets preferable than experiencing a 3-6 month period - First to follow up ratios when function is reduced and may only return to the level preceding the procedure. People may still  We will be making appropriate use of alternatives to require the surgery at a later date but this deferral inpatient acute care and surgical intervention has improved medium term benefits to peoples’ lives and costs to the system.

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 It is believed that some patients are accessing  Wolverhampton CCG (Commissioning from south hospital care too early and too often, without providers) have launched 13 condition specific exhausting alternative options (e.g. for acute lower pathways back pain where evidence suggests that for 90% of  Targeting Procedures of Limited Clinical Value patients pain will have resolved spontaneously within 8 weeks).  Addressing this requires full support of CPAGs and clinicians and clear referral criteria and thresholds.  We will develop the capacity and capability for such CCGs need to be able to work with providers to patients to be managed in primary care with monitor referrals. Cannock Chase CCG, for alternatives for a period of time before exploring example, has set up quarterly audits with GPs to other treatments options. This also requires assess compliance with inclusion/exclusion criteria working closely with CPAG (as Northern saving £300k in 2013/14. Staffordshire CCG are doing) to be clear about the clinical evidence and cost effectiveness to enable The elective productivity work-stream has identified a the most informed commissioning decisions which number of themes to develop which may have more will be supported by clinicians broad based consequences than the specific actions identified above – these set out to change the overall  Stoke-on-Trent and North Staffordshire have culture and challenge existing practice and will need to prioritised specialties where case mix and tariff be supported through effective engagement and prices mean services cost more to deliver than can discussion with patients and the public be recouped in income  Trauma and Orthopaedics – conversion rates tend  Reduce use of diagnostics by eliminating to be high and this requires heightened GP led unnecessary tests management of care. Cannock Chase CCG has  Reassess the need for follow-up across all clinical worked closely with local GPs and health care areas and eliminating post-operative hospital professionals to develop a model for an integrated outpatient follow-up appointments as the norm. We Musculo-Skeletal service. The outcome based will explore the feasibility of introducing RAG patient specification for this new service has been clinically information cards - red symptoms - come back; led and will ensure that patients are managed in the amber symptoms - call your GP; green symptoms - community where possible, duplication of treatment no further intervention required. across the sectors will be minimised and patients  Reassess the use of skills and workforce in follow- will be expected to have exhausted alternative up and initial diagnosis / support required for treatment options before considering surgery primary care. As part of our intent to change  Gaps in the system around pain management. behaviours through education and awareness, we There is scope for better management of pain in will explore using consultants in the community as older frail people leading to avoidable procedures educators of primary care practitioners, to improve interventions and Important social and the quality of referrals psychological benefits  Further consideration will be given to “one-stop”  Ear Nose and Throat – community services in clinics, where patients do not have to continually Cannock Chase and Stafford and Surrounds return for interim outpatient visits e.g. for involving a consultant working alongside GPs with diagnostics, pre-op assessments special interests to triage referrals and suggest  Explore the elective centre concept where this will containment within primary care – patient promote Productivity. Quality and Outcomes on the satisfaction, has reduced referrals basis of specialty or procedure and taking into  Ophthalmology – initiatives to use ophthalmic account geographical factors optometrists in the community to screen and refer in  We will explore the opportunities available through line with e.g. cataract thresholds has been shown to the use of technology e.g. phone triage, Skype manage referrals for better outcomes appointments to improve productivity

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 The use of tele-health to promote self monitoring and avoidance of routine outpatient appointments including post operation follow ups  Access to specialist advice through help-lines

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Table 14 : Table 9 Summary

Outcome Citizen Experience High Impact Intervention Cost Measures

1 Reduced waiting times Reduce DNAs to national benchmark – To be DNA for appointments include in contracts confirmed

2 Reducing inconvenience Improve new to follow up ratios by reducing To be New to follow up of unnecessary trips to face-to-face follow ups. confirmed ratios hospital Not paying providers for unnecessary follow ups and not commissioning follow ups for specific interventions Introducing one-stop clinics by improving access to diagnostics and improving referrals

3 Avoid unnecessary Improve referrals by introducing peer reviews To be Improved quality of referrals at practice level to reduce referrals and using confirmed referrals undertaken

specialists as educators in the practices. by peer review

4 20% Improved use of Reducing procedures of low clinical value and To be Reduced spend on resources for high value making triage of these a feature of our confirmed PLCV procedures contracts. This may involve some gain sharing arrangements. 5 High quality and service Prepare business case for elective centres of To be Cost of service and

consistency excellence for high volume activity based on confirmed quality indicators up to a Benchmarked a to up service redesign and potential gain sharing particularly T&O, ENT, ophthalmology and gynaecology. 6 Right care, right place, Improve use of map of medicine and To be Cost of service, right time and right technology for self care e.g. tele-health confirmed quality indicators and healthcare professional take –up rates of users.

Improve elective productivity by by productivity elective Improve

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8. Specialised commissioning

The plans for Staffordshire and Stoke-on-Trent will be Aims informed by the local and national strategic review. Nationally, work is underway to change how specialist services are commissioned and configured in the future. Impact on the health and International evidence highlights that outcomes are significantly better when the specialist teams work social care system closely together at a regional level and are linked to It is essential that CCGs work with the Area Team and research and expertise. The aim is for all citizens in the specialised commissioners to ensure that decisions to future to have access to specialist services which are concentrate specialist services minimise impact on local organised to maximise their effectiveness. This is likely organisations and that through networked arrangements to mean a concentration of expertise in some 15-30 local provision and involvement of local clinicians is centres across the UK. The national strategy is not clear maintained. Working collaboratively with providers will at present but it is likely to have large potential help to minimise the adverse impact on finances and implications for local providers especially University other service viability through changes in service Hospital North Staffordshire. configuration. If providers lose income, fixed costs will become a burden for whole community. In addition, if services are lost, the supporting infrastructure may become unviable. Key barriers to success As commissioners in Staffordshire and Stoke-on-Trent The key barriers to the success of implementation are we recognise the need to work closely with Specialised likely to focus around reactions to the financial Commissioning colleagues to jointly plan for services. implications. Although we recognise the need for an increasing move to fewer centres for very specialist services, we will be cognisant of the needs of our patients to receive a local service where required. We will strongly support What it will look like in networked solutions with local providers to ensure care 2018/19 can be appropriately provided locally where possible. In order for our citizens to be able to access high quality, We also recognise that Specialist services mean more effective services when they need them, we will build on than those prescribed by national agreements and work arising from the disestablishment of Mid include services that are local CCG commissioning Staffordshire NHS Foundation Trust and the responsibilities. Similar principles apply for all specialist consolidation of vascular services at University Hospital services in that they of North Staffordshire (UHNS) and vascular and urology  Must be accessible to local people at Royal Wolverhampton NHS Trust. Changes to the neurology pathway have concentrated this activity at  Require a certain scale of operation to make UHNS. We will continue to look at specific areas where provision (especially over 7 days) viable scale and viability are important even if this means using  Need a certain level of activity and size of team to services further afield in order to reduce local waiting achieve the best outcomes times (e.g. we have moved the treatment of sarcoma out of area to Royal Orthopaedic Hospital Birmingham).

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Local people will be assured the best possible access to  Continue work already undertaken to rationalise services that meet the required standards, are local specialist services in order to ensure responsive and timely and deliver the best possible sustainable provision and to enable better outcomes. Local clinicians will be included in outcomes e.g. in the establishment of local hyper arrangements where possible and this helps to ensure acute stroke centres meeting the national maintenance of local skills. performance requirements integrated with appropriate rehabilitation and integrated care down the pathway How we will get there  Focus on areas where there are risks to sustainable We will continue working with Specialised Service quality services including plastics and dermatology Commissioners through the Area Team to (in the latter as more activity shifts to community settings)  Explore where specialised services can link with local provision/commissioning arrangements e.g. how local pooled budgets can support Tier 4 Child and Adolescent Mental Health Services

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‘The people of Staffordshire and Stoke-on-Trent are central to the success of this strategy, both those experiencing the services and those delivering them.’

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SECTION C – KEY ENABLERS

To enable the previous key themes to be delivered, a  Primary care and A&E avoidance number of supporting strategies need to be delivered.  Caring and care coordination These have been defined as follows  Finance – ensuring the limited resources are  Engagement and participation directed appropriately  Organisational development and workforce Good practice examples are being shared between  Informatics organisations such as the patient congress in Stoke-on- Trent, where true engagement through authentic  Estates and facilities conversations is leading to effective strategic decision- making and service redesign. Inclusion of peoples’ real stories and emotions through 9. Engagement and initiatives such as experience based commissioning will define a clearer more recognisable set of services for participation people. The importance of co-design and production of services aims to engage peoples’ sense of control and Overview influence over ‘their’ health and social care services. At the time of writing this strategy there is great concern The people of Staffordshire and Stoke-on-Trent are about the implications of the strategic review and central to the success of this strategy, both those service reconfiguration when Mid-Staffordshire plans are experiencing the services and those delivering them. implemented. It is a critical point in the history of NHS We have reflected upon the independent review of our and social care which needs to be handled carefully. commissioning and engagement plans - conducted in Over the next five years we will be building on the 2014 (see appendix 2). This has been used to influence positive work already underway to embed and sustain our thinking for our future plans. high levels of inclusion and participation as the ‘norm’. People have very clear views on their expectations of The role of communication will be key, but never a health and care, and Call to Action engagement events substitute for true partnership and engagement. during 2014 have set the agenda for discussions and Healthwatch Staffordshire is the new, independent participation of the local community across Staffordshire consumer champion for health and social care in and Stoke-on-Trent. Staffordshire. They have a seat on the local Health and The themes from this work, which are being taken Wellbeing Board (a body that oversees health and social forward using a co-design approach, are care in the county) and aim to ensure the voice of the consumer is heard and acted upon. In the interests of  Integration improved partnership working, and to avoid duplication,  Person centred care we are encouraging anyone who would like to keep in touch with local health issues to join Healthwatch  Education and training for carers and people Staffordshire. delivering services

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By engaging with Healthwatch rather than running local Participation Group (PPG) in place or in progress. CCG schemes, we believe patients and the public will Anyone registered with that practice is entitled to get a better range of information, keeping them up to become a member. date with the latest news from the local health economy Patient Congress in Staffordshire. Patient Congress is has 20 members and is chaired by the Board Member for Patient and Public Engagement Individual CCG (PPE). Most members have a track record of being involved in local health issues and there is a selection approaches process. Each of the six constituent CCGs in our unit of planning have developed bespoke local initiatives to complement East Staffordshire CCG the common approach and achieve appropriate public Patient membership scheme and patient engagement and participation. The main This is the easiest way to get involved. Anyone is ways patients can get involved in each of the CCG entitled to join if they are registered with a doctor within areas are set out below. Burton and Uttoxeter. North Staffordshire CCG Practice patient participation groups Patient membership scheme Many of our GP practices across East Staffordshire have both patient participation groups and virtual patient Regularly receive information and take part in representation groups. consultations. District patient group Patient participation groups Our district patient group is made up of nominated Have a say in how your local GP practice is run. representatives from practice based participation PPG localities groups. The district patient group addresses issues Represent patients in the area where you live. affecting the wider population of East Staffordshire, but not those directly affecting practices. Patient congress The district patient group provides the setting for Brings together patient representatives with a track commissioners to share thoughts, priorities and planning record of involvement in local health issues. intentions on developing services. Representatives contribute to discussions and feedback to their Stoke-on-Trent CCG respective patient participation groups and virtual Patient membership scheme groups, encouraging a two way flow of information Members regularly receive information about local between the CCG and patient, to ensure that their views health developments. They also have chance to take and experiences are taken into account of in planning part in consultations and receive feedback on their and development of services. results. No time commitment is involved. Patient participation groups All of the 53 GP surgeries that are part of the Stoke-on- Trent Clinical Commissioning Group have a Patient

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Patient opinion South East Staffordshire and Seisdon www.patientopinion.org.uk Peninsula CCG

Patient opinion is an independent website where A structured model of engagement has been operational patients can write about their experiences at their local for some time http//www.sesandspccg.nhs.uk/ppi and healthcare provider whether it is good or bad. Providers this will embrace additional components as best practice can respond to comments that are made and it enables from the county wide and national activities is identified. them to make changes to services to improve the patient experience and outcomes.

Figure 9 : Model of Engagement

Cannock Chase CCG and this will embrace additional components as best A structured model of engagement has been operational practice from the county wide and national activities is for some time http//www.cannockchaseccg.nhs.uk/get- identified. involved/

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Figure 10 : Governance arrangements

Patient participation group (PPG) Members of the Patient Forum attend public events about health and healthy lifestyles; help to design Many of the GP Practices in Cannock Chase have services and care packages alongside health established Patient Participation Groups which provide professionals; give us their views about the quality of an opportunity for patients to get involved at a local services; and help to highlight where there are level. The groups not only enable patients to be kept up opportunities to improve our services and care. to date about their own practice but also to hear about projects being undertaken by the Clinical Stafford and Surrounds CCG Commissioning Group (CCG) including proposals to develop new services in the area. Membership scheme Resident champions Becoming a member enables local residents to Their role is to establish links with existing community  Stay informed about developments in health which and voluntary groups in the area – including the PPGs – are of particular interest to you to extend the range of people the CCG is able to  Find out about special “Our NHS” events, health engage with (including those that are often not engaged initiatives and consultations and how to take part through traditional methods). Resident Champions  Find out more about your local NHS and how the receive financial remuneration and each take money is being spent responsibility for one of the five localities in Cannock Chase.  Have their say in the development and planning of local services. Help us to monitor the quality of our Patient forum health services

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 Receive feedback on changes made in response to available. We will work with local educational YOUR input institutions, particularly Keele University to provide Practice patient participation group (PPG) opportunities for learners to experience working in our health economy.  Many of the GP practices in Stafford and its We have commissioned an external review for each surrounds have established patient participation groups which provide an opportunity for patients to CCG of the communication and engagement work to get involved at a local level. date. The results of this review are in the Appendix and we are using the recommendations to refine local and  The groups not only enable patients to be kept up system wide initiatives. to date about their own practice but also to hear about projects being undertaken by the (CCG) As a result of this independent feedback, A Call to including proposals to develop new services in the Action and the broader capacity and capability provided area. by the recent CSU merger, we have progressed our planning for the future by engaging the full potential of Other opportunities for involvement include becoming a the embedded CSU expertise. resident champion, and joining our patient forum.

The way forward and Developing the vision for independent assessment future engagement This work was initiated in April 2014 through a multi- of engagement to date disciplinary team workshop involving most CCG It is clear that to enable many of the clinical ambitions, engagement locality leads, and led by the Staffs & particularly the desire to reduce the demand on urgent Lancashire CSU. They used the facilitated visual and emergency care, our communication and planning process called PATH (Planning Alternative engagement priorities must focus on contributing to Tomorrows with Hope), focussed on “How to embed changing society’s behaviours. public and patient involvement”. Changes brought about by service transformation and The group described a positive possible future for public redesign, whilst engaging representatives of the and patient involvement in 2019, building the community in co-design, will require consultation and diagrammatic version of the output of the event as extensive communication using all media channels shown below.

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Figure 11 : Output of the planning event

Our ambition for patient involvement in 2019 A positive possible future The groups looked at the shared ambition for Patient The groups were asked to envisage being in 2019, and Involvement and the common themes identified were describe what would have happened over the past 5 years to achieve the ambition. Feedback included  Patients to be involved in every stage of the commissioning cycle with the patient voice being  By 2019 it was envisaged that every service listened to and acted upon and engagement being change or redesign would be able to planned in right at the start of the process demonstrate how patients had been involved  Patients working alongside clinicians and and that commissioners automatically include commissioners to redesign pathways and services engagement within their plans. that really do meet the patients’ needs so that  Patients feel valued and empowered, knowing patients feel valued and listened to that their feedback is important and acted upon.  Effective feedback mechanisms (including  As a result of this, engagement includes wider technology) and “you said, we did” with the knock- aspects of the community and feedback on effect of people wanting to be involved and following engagement is also much improved leading to overwhelming responses to engagement with better channels of communication and and involvement activities innovative techniques being used.  There is a real sense of collaboration, not just  More effective engagement will lead to better- with the patients and public but also with informed patients and patients taking more providers. responsibility for their own health resulting in more  Improved engagement and feedback has also efficient use of services led to patients having a better understanding of health services and where to go for what. This  CCGs will have large numbers in their membership has led to more efficient use of services, schemes; all practices have robust patient including a decrease in A&E attendances, and participation groups and the CCG’s relevant groups commissioners achieving their targets. (e.g. patient congress/council/board/ health round table) will be leading themselves, with people queuing up to be involved when vacancies arise.

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Where are we now?  Make ELC the way to operate i.e. outcomes-based When asked to describe how things are now it was  Have open discussion with CCG about acknowledged that not all commissioners recognise costs/implications of good involvement patient involvement as an important and integral part of  Highlight poor practice and implications the process, despite the risks of not including it. Involvement was regularly seen as a last-minute “add- on” rather than being planned in advance. Other Next steps recurring themes were poor feedback and lack of To start the journey, participants identified actions that communication. they could individually start straight away. These Other comments included included:

 Inconsistency across CCGs  Request for next team meeting an example of good  CCGs not understanding importance of developing or innovative communications/engagement relationships with patients  Measuring impact and preparing fully  Poor at linking with local authority colleagues  Complete census data to enable “targeting” areas  Lack of trust/confidence in purpose of engagement where membership is lacking  Being reactive instead of proactive  Sharing engagement with CCG  Limited sharing  Speak to director of transformation re. decommissioning of services and patient Despite some of these negative comments it was also involvement recognised that some good work was starting to shine through and there were some positive examples of  Discussion with CCG re. expectations of level of engagement work, particularly the recent Experience- service Led Commissioning (ELC) work in East Staffordshire.  Discuss with colleagues different methods of increasing the membership The bold steps we need to take  Contact patient board members at least once a Through exercises envisioning what would be necessary week to achieve this future and identifying the present reality, ‘Bold Moves’ were defined which would be necessary.  Review content and frequency of newsletters to These include members and GPs

 Make link to integration/ transformation from PPI  Have face to face contact with at least one member of the governing board each week.  Demonstrate ROI for work

 Define CSU PPI/ Insight/ Consultation/ ELC services/options Finally as participants have ”enrolled” in the journey, by adding their names to the PATH (Planning Alternative  Define outcomes not services Tomorrows with Hope), we can begin the process to  Do what patients want; act to demonstrate you deliver significantly improved patient and public said/we did; you said/we can’t; you said/we are engagement in the co-design of Staffordshire and thinking Stoke-on-Trent health and social care.

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Detailed engagement requirements of This is a way of developing community activities which each programme could also promote wellbeing for those who access them. The process of developing the activities is an Integrated care and support requires coordination intervention in itself. The activity that is developed may across commissioners, providers, community groups, or may not be an intervention to support health and and the population. The strategic direction is set at the wellbeing e.g. a physical activity opportunity. It will Health and Wellbeing Boards level and the underlying provide opportunities to improve quality of life through delivery structures are being developed with the new increasing participation, personal development and approach to integrated commissioning in the challenge problem solving. economy work. This would include The type of support people may need or want varies depending on their understanding of health and well-  Social intervention in primary and community care being and on their capability and capacity to live pathways e.g. volunteering, exercise, arts and creativity, learning and educational opportunities, independently. People who participated in the “Call to green activity) Action” engagement activity made it very clear that some historically difficult aspects about how people use  Signposting to welfare advice, particularly the health system need to be tackled, including employment, provision of support for benefit uptake, debt advice, financial literacy and information  Help to make best use of resources and keep costs down by only using expensive services when it is  Self help groups necessary e.g. attending the A&E department or  Debt counselling and advice making GP appointments

 Give people information and education so they can

make informed choices  Consider charging for missed appointments or The impact of this would be alternative strategies e.g. text reminders and  Self help groups are effective in reducing social cancellation via text isolation/ loneliness and provide meaningful  Work closely with the community to design services occupation locally, leads to increased quality of life of the future through social interaction and having practical needs met.  Support carers through education and respite.  Improved mental and physical health The primary care system (and education system) is the main point of contact for people who need to access  Increased confidence, sense of community, social health and care services. Every contact with cohesion professional services will need to quickly identify not just  Increased levels of social support and caregiver the immediate response to the presenting request or skills condition, but also facilitate and support people to  Reduced demands on primary care and reduced maintain health and independence as noted above. levels of antidepressant prescribing Every contact counts.  Self-management and healthy behaviours The partners will invest in Community empowerment and development – interventions that encourage  Increase in benefits through providing access to communities to improve physical and social benefits advice. environments, participation and strengthen social Integral to the success of our strategy for urgent and networks. Specific interventions include encouraging emergency care is influencing the decision making active travel, reducing the effects of traffic, functionality behaviour of citizens. of a neighbourhood, safe green environments, community arts and culture, volunteering.

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This will require engagement with them in the co-design A system-wide communication will be developed for of future services and to ensure there is a widespread patients and citizens, to facilitate the process of understanding of how to access the right service most  Managing expectations effectively.  Providing re-assurance about how different We will seek to share a common approach to pathways will operate in the future. engagement across our CCGs. Closer public engagement will follow once ideas have To date we have completed a series of “A Call to Action” become more fully developed through discussion with events and “You said, we did” engagements and we will clinical stakeholders. continue these and other engagement activities in the We are clear that these changes can only be achieved future. through close working with external commissioners and It is essential to keep public, patients and carers on with local organisations and in particular with clinical board – people need proper explanations in order to stakeholders. We will ensure that wherever appropriate understand the reasons why the way in which elective mental health providers will be engaged to ensure that work is undertaken may change significantly (in terms of the emotional and mental health requirements of timing, location and clinical roles). patients and carers are taken into account. This could be particularly important in decisions that result in Discussion of these changes relates closely to provision at locations geographically removed from the continued discussion of Call to Action themes and can local area. be incorporated in to further events. This will depend on improving information, advice and guidance to patients and referrers.

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10. Organisational development and workforce

Health and care is a person centred service industry strengths and weaknesses which once fully understood relying heavily on the competence, behaviour and will need a degree of reshaping for successful delivery capability of the people working in all roles across the of the scale of service transformation planned. whole system. The current workforce has a range of

Figure 12 : Skills, competencies, behaviours and capabilities are core to the success of our strategy

Aligning OD and workforce strategies and actions with  A cultural shift in whole system ‘integrated’ the overall strategy & outcomes is essential. This means leadership and ‘integrated’ transformation that OD and workforce must enable;  A new process/annual cycle for achieving a robust  Success and sustainability of the health economy OD/Workforce plan that is shared across the whole which is predicated on an absolute focus on health economy. prevention and independence (self  A more flexible workforce able to provide a range of care/management) services across a federation of providers  Principles to be agreed by all partners in health and  Value Based Recruitment to build a workforce with care the necessary attributes to provide the best  New operating models and pathways services possible  Innovative contracting and partnerships  Commissioning of education programmes and training to prepare staff for the new operating  Use of the third sector (voluntary ) and independent models providers  Future proofing the workforce skills, capabilities and capacity necessary to deliver the strategy

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 Peoples health and care needs to be met closer to To achieve the building blocks of our future health home and increased intensity /support will be service we will need a workforce and culture that is achieved through step up / step down services and focused on Integrated Care Locality Teams (ICLTs) embracing  Prevention based delivery both physical and mental health needs.  Achieving commissioner and provider plans  The whole system culture and leadership to be focussed on maximising self care to the lowest  Validation of quality, safety and patient experience point of dependency and deliver true integrated It is our combined intention to deliver an organisational care. development model that is responsive to the rapidly The scope includes all people (the workforce changing needs of our communities. paid/unpaid) providing health care and carer support. As the CCGs articulate their ambitions and then work During May 2014 the strategy development group back to the design of the pathways and service solutions gained further input from the local education and training so this will inform the workforce and organisational committee and board. development requirements. Organisational development will be a critical enabler in The most significant change will be gaining collective the delivery of the main interventions required to deliver commitment to keeping organisational and workforce the strategies in each of the key interventions for issues as a priority over the next 3-5 years. This is likely to require a change to how we commission services e.g.  Urgent / emergency care we will consider the need for prime provider / alliance  Productivity of elective care contracts with one set of outcomes and a single owner  Self-care / prevention of provider OD and workforce oversight. We have experience of doing this successfully e.g. the cancer /  Bed base end of life care in north Staffs and drugs and alcohol.  Domiciliary care and rehabilitation Organisational development will require commissioners  Step up / step down care – rather than through A&E and providers to work with the local education and  Primary care at scale and seven day working training board (LETB) in order to access the necessary funding to deliver the skills upgrade we will require. Such service transformation and redesign as is being envisaged will require a different approach to aligning The clear focus on building an integrated system of skills and resources with demand. It will require a care, will undoubtedly require changes in the delivery of cultural shift and extensive consultation and the domiciliary care market. This presents a significant management of change activities. challenge to any successful OD and workforce strategy e.g. because terms and conditions are poor but the staff All workers will need to be aware of people’s emotional will become increasingly critical in our sustainable and mental health needs as well as physical delivery of out-of-hospital care. CCGs and the local requirements. authorities will need to have continual dialogue so that All workers will need to be “dementia aware”. Those actions taken by one partner do not compromise the working with older people will need to be “dementia ambitions of another and fail to optimise cross economy skilled” whilst those in specific dementia services will quality, safety and efficiency. The probable outcome is need to be “dementia specialists”. that there will need to be an increase of resources e.g.

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carers development and support which is key to population that is ageing and creating a critical situation maintaining people as close to their home as possible. - within the next decade requires a different solution. The voluntary sector could inform what is needed. Our We know we will need to support staff to work differently OD strategy may therefore need to extend beyond our with patients and their families and carers, with own organisations for the benefit of the system as a prevention and self-care playing a greater role. We will whole. need to develop training programmes and may need to Across the system, there is a need to embed value refresh role outlines for some of our key clinical staff. based recruitment of staff so that they have the right OD and HR colleagues will support investment in the skills, motivation and engagement to deliver safe future, involving key leaders / shapers (e.g. LMC) in the effective services development of future proof resourcing and OD models. General practice is currently isolated with a reduction of We will consider the different contractual arrangements NHS funding and/ or no investment but GPs are the and how they enable/constrain the transformation answer to many of the issues. General practice will ambitions and agree system wide approaches to inevitably change and integration with other health address the issues identified. professionals is probable e.g. district nurses and mental health workers. Retraining staff will have lead in times and this may also include the need to update / develop new courses We know that some of our focus areas will present OD including using electronic media. implications. In delivering primary care at scale, for example: We will work with our partners, particularly local authorities to develop a strategy for health and social  There will be potentially difficult discussions around care to deliver the future state. This cannot be just a contractual changes to facilitate the necessary workforce plan for the immediate future but must be long changes to working patterns and opening hours of term and include skills and competencies, succession services. planning and a common approach to leadership and  We will have to work with primary care colleagues culture development. We will also ensure that the health to respond to the numbers of single-hander GP and wellbeing strategy is aligned with OD and workforce practices, which present a challenge to offering intentions. more specialised primary care services. Current trust workforce plans have been submitted but  There is an aging primary care workforce, where a will require refinement as the transformation and service higher percentage of the GP population will be redesign becomes clearer. retiring in the next 5 years. Successful delivery of this strategy will be dependent on  We carry a sizeable number of GP, primary and effective and cohesive interactions between all partners community care vacancies. who are responsible for making the improvements. The The implementation of new roles and ways of working content of the OD plan will be worked up in the latter will need to ensure that sufficient capacity is available part of 2014 once agreement on the configuration of across the network to deal with the increasing demand. services is agreed at a strategic level. This will be a GP federations may emerge and this will require a rapid difficult time for organisations across the health response to organisational development and workforce economy as further uncertainty exists. To guide the issues e.g. resourcing seven day working in a GP work on this aspect, key principles, objectives and risks have been identified below.

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OD principles  Identify the future workforce requirements – clinicians, professionals, support staff, voluntary  Engagement of partners and partnership working is sector functions and roles key to delivering successful transformation, there needs to be belief in the plan and that we can  Outline the skills and redesign requirements for deliver it – it has meaning and buy in from the right integrated care and changes to the settings of care people from acute to community (including mental health)  Representation from the human resources  Workforce planning is submitted by providers - organisational development and operational leads CCGs need to sign off with sufficient insight into the from provider organisations requirements  Programme of work will be in alignment with the  Agree joint HR policies (recruitment and retention, strategic review and initial focus should be on employment contracts, management of change tactical decisions and implementation following the including disestablishment of posts, redeployment strategic review. and redundancy)  Subsequent focus will be on preparation of ‘the Such a transition to innovative thinking will take time and system’ to deliver the future model and services no one is underestimating the potential for conflicting priorities to undermine our collective aspirations.  Values and principles are aligned to those agreed across the health economy We have considered the implications of the Cavendish OD objectives Review and for some of the recommendations we will wait to see the national direction. However, there are  Ensure effective and clear Governance of the many of the recommendations can be addressed as part system to enable people to sign up to the strategic of our overall OD and workforce strategy for example plan and programme of work  Ensuring that any certificates or other evidence of  Agree a strategy for enhancing partnership minimum standards of training are written into development across the system provider contracts and that controls are mandatory  Support organisations to work together and deliver for anyone undertaking work unsupervised. Such in a highly complex system of relationships, controls will include financial distress and structural dynamics  Assessment of technical and care skills, including Workforce principles attitudes and behaviours  Integrated care and working will be critical to the  We would aspire to have nurse and healthcare future successful service delivery assistant (HCA) training done together  Use co-design with the workforce as they are  We will undertake audits of provider training closest to operational reality – this will help define provision and records and ensure that reviews to more accurately new roles and ways of working determine the effectiveness of training are completed  Be innovative with proposing new functions and expanding roles such as primary care utilising non-  We will encourage HEE and LET to be innovative in medical advanced practitioners and physicians enabling people to make transitions into more assistants and a range of mental health workers. challenging roles Workforce objectives

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 We will continually work with our partners to build cross organisational development opportunities  We will encourage more clinicians to take leadership roles and aim to engage with partners to share leadership education and training opportunities to accelerate networking opportunities for current and future leaders. We will enhance this through joint project working  We will work together to ensure that there is a consistent and equitable approach to performance management including characteristics related to working with colleagues from different organisations. We will create a shared code of conduct for collaborative working and use an agreed governance arrangement to hold each other to account  We will systematically engage with cross organisational professionals to challenge ways of working and drive continuous improvement - this will underpin any transition to outcome based commissioning and facilitate solutions to 7 day working and changes in shift patterns based on demand and service need. After consultation with our partners and providers, we have defined our overall approach as shown below

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Table 15 : Overall approach to OD and work force

Activity Commissioning Agree delivery System wide Provider Route to market Parallel running Full Ongoing intelligence model triangulation consultation implementation governance

Typical Tasks •Use available •Co-design •Ensure that •Work with •Follow •Run systems in •Performance •Review for data delivery model partners and providers to procurement parallel until new manager delivery effectiveness •Identify and learn using bottom up providers are review options regulations and system is fully of model •Interim course from best practice and prevention sighted on •Providers develop requirements deployed changes •Complete lessons based principles outcomes and OD and workforce •Choose provider •Decommission learned analysis financial impacts plans previous model •Bidder’s day

Accountability •CSU •CCG •CCG •CCG •CCG •Providers •Providers •CCG •HWB •Local authority •Local authority

OD implications •Staff satisfaction •Competency gap •Optimisation of •Providers’ plans •Lead provider •Additional cost •Continually •Reviewing Activity will need •Leading staff •Recruitment resources and for optimised use responsible for •Criteria for aligning dashboard of to consider.... indicators e.g. •Management of competencies of resources and optimisation of ending previous competencies contractual Absenteeism, change across the system competencies resources and model with need measures and recruitment, •Staff consultation and providers across the system competencies •Effective •Tracking driving turnover •Changes in •Potential TUPE •Cost of education •Funding for communications optimised use of improvement in •Complaints, resourcing levels issues and training education and resources use of resources quality and safety •Communications training concerns •Recruitment

Workforce •Known actual •Known changes •Understand •Provider develops •Market test to •Leadership and •Manage to •Performance requirements current state in workforce constraints across workforce optimise managerial workforce management by workforce requirements the system numbers to deliver resources with ownership numbers and providers with numbers and regarding skills, •Agree risks to model outcomes indicators reports to indicators and integrated of workforce of commissioners correlation with teams etc. independent performance activities

Outputs •Options appraisal •Delivery model •System wide •Workforce and •Optimised •Implementation •Decommissioned •Meetings of validation of OD implications workforce plan plan service minutes delivery model understood and •Spec •Performance •Fully operational •Corrective action agreed •ITT reports new delivery plans •Workforce and •Chosen provider •Criteria for model OD model •Contract decommissioning •Performance reports

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11. Informatics

The collection, storage and access to information are and record information about their health and care, key enablers to the whole system redesign ultimately engaging for maximum participation and self effectiveness. This means that the delivery of good care/management. The controlled availability of up-to- health and social care can only occur if the right date integrated care records is necessary for health and information is available for decision making, planning care practitioners to make assessments and decisions and delivering services. on current information which ultimately leads to better care coordination and outcomes. The national strategy is to ‘connect all’ systems within a carefully controlled governance framework and security system. People will be offered the opportunity to view

Figure 13 : Governance framework

CCGs are committed to putting patients, service users The use of remote consultations and monitoring will free and their families in the driving seat concerning their up travel time and provide improved access. The ‘FLO’ care. This is a fundamental commitment which will shift text messaging service for people with long term the balance of control from the professional to the conditions has shown high levels of engagement by person, and is seen as integral to giving people greater patients and helps to increase self-esteem, interaction personal responsibility and making informed choices and self management capability. about the care and support that people need.

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Successful delivery of integrated care, Health and care systems are required to interact at urgent/emergency care and primary care at scale can speed and support patient and information safety. only be achieved if the technology and information Prescribing and medicine management systems aim to management supports the whole health system. eliminate errors and delays to treatment.

Figure 14 : IT Guiding Principles

The priorities for improving the use of technology and The robustness of integrated programme management providing systems which support and enable health and across the health and care economy will be dependent care delivery will be guided by the principles above. It is on strategic leadership linking all health and care particularly important that any funding decisions are partners. The challenge will be to effectively coordinate based on how it will add value and benefit citizens, inter-dependent workstreams to ensure that scarce and patients, carers and staff who are providing services. expensive resources are used to achieve the desired Transforming health and care services should be a outcomes. The Better Care Fund outlines the clinically led and a service level supported activity. importance of technology to support integrated care and Implementation of technological solutions without also clearly states ‘Each stakeholder cannot plan or business change leadership by recognisable team deliver TECS without considering the implications upon members often results in poor embedding of new others, in terms of what is possible and what staff and processes and delivery of expected benefit. The journey service users want and need.’ Future funding streams to a culture of transformational change resulting in for delivering the process and technological sustainable value delivery has some-way to go. transformation are not completely clear or definitive.

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The health and care economy have to bid for national benefits programme is being developed as part of this funding which delays implementation of business cases project and benefits will be identified, agreed and then and adds lead-time. The Integrated Care Record (ICR) measured as the system rolls out. We are expecting project will deploy a shared care record across that the financial benefits of this system will outweigh Staffordshire and Shropshire allowing clinicians and the costs by some margin. carers across the counties to access clinical information High level benefits include when and where it is needed. The project builds on a proven solution already installed at various sites in the  Substantial improvements in efficiency across the area and across the wider NHS. A whole system board, e.g. fewer repeat tests, less time spent approach includes the Staffordshire and Shropshire completing forms and chasing results, a massive health economy, integrating data from acute trusts, reduction in paper primary care, community care and social care. The  Better clinical decision making based on richer and proposed solution will serve a population of 1.47M and more timely information shared between clinicians involve nine trusts and 250 general practices. leads to a reduction in unnecessary A&E attendances The overall aims will be to develop and inpatient stays  A shared system encouraging and facilitating shared,  A single trans-agency portal for care teams in integrated and productive working to improve care Staffordshire and Shropshire  Improved healthcare outcomes for patients, including  A detailed multi-agency record which contains key a better patient experience where the real time data in the pathways of care from acute to community information can be used during patient interactions  A cross-community assessment, alerting and care The programme of work also focuses on the essential management system to provide safer and better care requirement to have a robust infrastructure and for vulnerable patients (initially end-of-life and appropriate equipment available in the field including dementia) mobile devices. The CSU IM&T aims are listed below The proposal extends existing information sharing work which support the key aspects of this strategy, however by adding records from more GP practices, other trusts the challenge is a fully integrated approach to the (e.g. acute, community and social care), targeting the transformation in conjunction with partners across inclusion of data relevant to type of care, and rolling it health, care, statutory agencies and support out to the larger geographical area. The detailed shared organisations. record will include (i) socio-demographic data, (ii) clinical data (biometrics, diagnoses, procedures, investigation  To support the effective running of the CCG & results, medications), (iii) cross-agency working commissioning within the local health & social care (referrals, alerts, and correspondence), and (iv) shared economy, including the infrastructure and systems plans to support transitions in care (e.g. A&E supporting the Business Intelligence to function. summaries, discharge summaries and care  To support QIPP programmes. assessments). The shared care record will provide a  To support interoperability with partner platform for facilitating and encouraging multi- organisations. disciplinary and multi-agency working. The proposal includes specific care management support for  To support primary care. dementia and end-of-life. The system will be extended  To improve internal and external communication to manage other clinical priorities in future phases. A full and collaboration.

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Table 16 : Summary

Theme Aim & Description / Examples Risks Finance

• To support the Aim • Data Availability • Embedded within effective running To ensure the CCG has the necessary including timeliness current CSU Cost of the CCG and information and IT tools to run its • Data Quality Model. commissioning business • Information • Costs associated within the local with Infrastructure • Business Intelligence & Knowledge Governance health and social Management • Change Management, enhancements care economy • Real Time reporting from the Integrated embedding BI within a • Care Record Business as Usual culture • Mobile / Agile Working • Infrastructure limitations • To support our Aim • Lack of collaboration • To be Confirmed QIPP To use the best Information Technology to across partners programme support and monitor the QIPP projects • Maturity of technology (including long • Assistive Technology i.e. Telehealth, • Benefit Realization- term conditions, Telecare, Remote Consultations & Self Difficulty measuring urgent care, Care impact planned care and medicines • Supporting the Long Term Conditions management) Strategy • Supporting Effective Medicines Management & Prescribing • To support Aim • Lack of collaboration • Estimate c£6m interoperability We will work towards safe and effective across partners over 4 years v with partner means of integrating clinical records from • Differing levels of IT c£11.8 benefit organisations a wide variety of sources for the Maturity across • • improvement of patient care partner organisations • Deployment of Integrated Care Record • Information System for health and Social Care Governance • Fallout from Care.Data • Affordability • To support Aim • GPIT National • To be Confirmed Primary Care To fulfil our obligation to member Funding Allocations • practices by supporting them in the most • Infrastructure effective use of IT capabilities • Understanding & responding to the • Impending removal of pressures within practices and delivering N3 effective IM&T solutions • Supporting Information Governance, Date Quality, Disaster Recovery and Innovations • Implementation of National systems • To improve Aim • Public Perceptions • No major direct internal and costs but indirect

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Theme Aim & Description / Examples Risks Finance

external To review our existing CCG and public • Rural Public costs of communication communication strategies and improve Infrastructure embedding and wherever possible • technology collaboration • CCG’s to make better use of existing technologies • Directing patients to appropriate health related information for managing and controlling conditions • Further research into effective ways of communicating to patients and hard to reach groups

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12. Estates and facilities

At the time of writing this draft strategy, there are a wide range of local plans regarding estate. During the development of this strategy in April/May 2014 a plan was initiated and agreed to ensure a strategic understanding of priorities and potential scenarios that will occur following the strategic review. To guide this work a set of principles, objectives and risks have been identified. Principles

 Transparent baseline of estates across the whole health and care system  Involve the workforce in planning changes to usage  Agree systems and ways of working which allow people to share facilities fairly without bureaucracy  Challenge property management and contractual agreements where appropriate Objectives

 Maximise the use of estates across the whole health and care system including primary, community and acute care  Reduce waste in estates, facilities and utilities by using space productively  Identify opportunities for income where estate is available for occupancy but may be required in the future due to growth or changes

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SECTION D – IMPLEMENTING THIS PLAN

Consolidation of the six CCGs five year plans has 5. Where appropriate we may decide that we need helped to draw out commonalities in the high impact more than one commissioning footprint. In interventions across care pathways, and also where particular, this may apply on a north/south basis. there are local areas of focus and phasing of changes. 6. To keep the important localism there may be The FRP process has further supported this and occasions where we have a joint overarching identified similarities in work being undertaken in strategy, but the six CCGs have detailed delivery different parts of the economy. The healthcare economy plans at a local level. partners share a strong commitment to work together, to address the most challenging and complex issues such 7. For each major strategy one individual is nominated as service configuration and how health and care can be as the accountable lead funded within financial constraints. 8. The ‘do once work’ would probably involve resources (people, money or both) being released The plan represents a need for transformational not by each CCG to support delivery. In practice this incremental change and as such will require very should be more effective different approaches and behaviours. All parties recognise this and this strategy moves us on in the 9. The six CCGs remain as sovereign bodies and journey to develop a truly collective solution. therefore need to take their membership with them. The CCGs have recognised the need to work together As well as the CCGs working together, it is critical we as commissioners and have agreed a set of common continue to develop our joint commissioning with local principles in terms of joint work. Since the original authorities. In both Staffordshire County Council and submission of the 5 year plan, this has been evidenced Stoke-on-Trent City Council there are ambitious plans to through the formation of the Joint Accountability Board join up our commissioning and strategic development. (JAB) and the Commissioning Congress. Both provide, We recognise that the overall health and social care from a different perspective, governance and a system has significant challenges and we are committed framework for collaborative working arrangements and to working in a collegiate way to improve outcomes for facilitate oversight of programmes for Implementation citizens. We have a robust governance structure County wide. beneath each Health and Wellbeing Boards and wealso work closely with district councils, police and other To achieve this, the six CCGs will work to the following partners. first principles One of the key challenges in Staffordshire and Stoke- 4. Where possible we will take the approach of doing it on-Trent as a Unit of Planning is the need for an once. This is likely to apply to a range of service ongoing single conversation with provider organisations. strategies where it makes no sense to create more We have tended to work and engage with providers in than one vision and strategy. This can be the three constituent health economies and again this evidenced through the county wide work on frail can already be evidenced through the Cross Economy and elderly pathways, mental health and POLCV.

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Leadership Group (CELG), the Trust Special Administrator (TSA) process and the collaborative dialogue taking place with Burton. There is a recognition that we need to pull some of these conversations together across Staffordshire and Stoke on Trent and indeed with providers on our borders who have significant impact. This will be enacted through the JAB which covers the entire Unit of Planning Area. The JAB will oversee alignment of the strategies of all parties, ensure mutual accountability for delivery and address collectively some of the key challenges or ‘wicked’ problems. Agreed changes will be facilitated through improvements in contract management. In terms of delivery planning, we recognise that we will need some joint resource to oversee the implementation phase of this plan and this is being scope under the arrangement of the Commissioning Congress and discussed through the JAB. . The high level timelines are shown on the following pages.

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13. Timelines for implementation

Figure 15 : Implementation plan for primary care transformation 2014/15 2015/16 2016/17 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Centralising home care visits Enabling drop in appointments Reduce practices with half day closing Improved working with homes Commission additional services from Pharmacists, Dentists and Optometrists Improve the scope and capability of response (e.g. ANP, acutely skilled GPs and Paramedics) Improve the communication channels for clinician to patient, includiing automated follow ups GP management of pathways and referrals optimise reduction in procedures of limited clinical value Use of medicine algorithm map to support diagnostic /referral decisions Sharing of practice 'safety and quality' scorecard - Primary Care Web Tool -PCWT Primary Care Quality led GP devellopment team for practices/GPs needing support and development Evidence based medicine/healthcare prescribing Commissioning the whole pathway for outcomes and can progress over the 24/7 period Prime provider model; vertical integration models Integrated health and care records that are accessible 24 hrs by authorised members of the team 7 day working Federation/collaborative practice groupings to provide professional support and supervision whilst developing skills and training

PRIMARYCARETRANSFORMATION Skill mix - existing practices to release GP time and support areas with vacancies, develop/recruit more advanced nurse practitioners and physician's assistants Integrate nurse and treatment services (PN/DN) Shared and scheduled use of facilities for the integrated team Lease out vacant space / consolidate estates capacity

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Figure 16 : Implementation plan for integrated care transformation 2014/15 2015/16 2016/17 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Capture service User Needs Capture service User Needs Map simplified processes

Casefor change Each person will have a lead professional as their case manager Single care plan

Finaliseorganisational form and operating model Collaborative working for frequent service users Redefinition of intermediate tier of support Use of medicine algorithm map to support diagnostic /referral decisions

EOL reprocurement Benchmark best practices and redesign services e.g. 111, advice, re-ablement

Evidence based medicine/healthcare prescribing

Integrated health and care records that are accessible 24 hrs by authorised members of the team Skill mix, aligning skills and structures to optimise delivery

Joint governance and commissioning

Prime provider arrangements 7 day working

Integrate nurse and treatment services (PN/DN) INTEGRATED CARETRANSFORMATION INTEGRATED Shared and scheduled use of facilities for the integrated team

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Figure 17 : Implementation plan for prevention and self care

SOT Staffs 2014/15 2015/16 2016/17 2017/18 18/ 19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

Healthy Places

Healthy neighbourhoods

Healthy Food City

Smoking cessation and obesity

Self care and use of 111 AND SELF CARE SELF AND Patient activation commissioning and delivery

Locality Commissioning Model commissioning and delivery PREVENTION Sexual Health commissioning

Healthy lifestyles commissioning and delivery

Children’s commissioning and delivery

Figure 18 :

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Figure 19 : Implementation plan for urgent and emergency care

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Figure 20 : Implementation plan for improving elective productivity

2014/15 2015/16 2016/17 2017/18 18/ 19 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1

Reduce DNAs to national benchmark

Improve New to follow up ratios

New to follow up ratios contractual changes

Introduce One-stop clinics

Peer reviews of referrals at practice levels

Specialists working as educators Improve Electiveproductivity Improve Reducing procedures of low clinical value

Business case of elective centres of excellence

Improve use of map of medicine and technology for self care e.g. tele-health

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14. Benefits and measures for success

We are clear that we need to see significant shift in the system. We will clearly monitor Constitution rights and ensure we deliver on our basic commitments to the public, but increasingly we will need to work on measures which mark change in the health and social care system. We will be working with providers to shift measurement to an outcome focus rather that units of activity. For some areas, such as long term conditions and mental health we will look to commission against an outcomes or recovery start. We also need to develop measures to test whether we are supporting people to self care. As such, we will work to focus on measures of self- confidence and broader determinants of good health, such as level of social interaction. In each of the priority areas, we will identify a small number of key measures linked to the interventions. For specific interventions e.g. integrated teams, MacMillan Project, there will be clear measures of success for individuals, carers and the system.

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This is very much a work in progress. The complexity of 15. Implications for Staffordshire and Stoke on Trent necessitate a simple partner and clear goverance structure which has taken some time to develop. organisations We also recognise the need to further build on partnerships developed in the health and wellbeing The strategic recommendations in this plan have boards to ensure we have fully integrated transformation significant potential impact for community, mental health plans between health and social care. The Better Care and acute providers. Fund will be key to this in terms of facilitating change. We have recognised the need for improved alignment This will also articulate how the Better Care Fund will with providers if the plans are to be successful and the alter funding for providers once programmes are in JAB will effectively be the vehicle to hold the ring on place. these discussions. We welcome the Tripartite Accountability Arrangements and will link into NHS The key features should include England, Monitor and the TDA to ensure system  Planning Implications for the providers accountability.  Funding flows . Commissioners are also focusing on improving contract management and appreciating the nature of  Capitation roles as lead and associate commissioners with providers to leverage successful collaboration and negotiation.

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16. Governance

All six CCGs are participants in a Commissioning areas we have agreed there will be a single Congress which allows us to coordinate and share strategic approach across Staffordshire and a commissioning activity. Each accountable officer is single senior lead. They are: responsible for leadership on behalf of the whole county  Strategic Approach to Primary Care and each has agreed to their portfolio. They have also  NHS 111 approved of the principle of having key contractual  Frail Elderly Pathway (a single pathway elements applied to the contracts of all the providers. has been agreed) Thus, increasingly we speak with one voice through the  Approach to Planned Care Transformation Congress, initially made up of the CCGs and then in  Learning Disabilities time with other commissioners. The Congress is also a  ICES vehicle for having one CCG voice on the JAB.  Mental health

 Contract management – a single approach Internal governance arrangements with clearly articulated footprints  Clinical prioritisation Each CCG has established its own internal governance  Children’s / CAMHs structures for accountability and oversight as well as responsibility for delivery. Many of these areas involve integrated commissioning with Staffordshire County Council, and Stoke City For each: Council.  Overall accountability for implementation is held by As a unit of planning within this, for northern the CCG Governing Body, and to ensure alignment Staffordshire there is a well-established Cross Economy with other strategic initiatives, both internal and Leaders Group (CELG) that signs off transformation health economy wide such as the BCF. Clinical, plans prior to approval through individual organisations Financial and Operational leads are appointed for governance arrangements. each project. The governance arrangements and relationship  The CCGs’ Executive management team holds between the Commissioning Congress and the two oversight of the Financial Recovery Plans, and will resolve escalated issues. Health and Wellbeing Boards that operate within the region have yet to be fully cemented, though clearly  With the exception of Cannock Chase and Stafford alignment of strategy, planning and implementation is CCGs, there is an intermediary committee which needed, to create a cohesive and sustainable health monitors progress against milestones, to mitigate and care economy. against risks and approve changes to the programme. In the former, the CCGs’ Executive management team holds this responsibility directly.

 There is a Programme Management Office or equivalent, to track delivery, ensure a consistent reporting method and drumbeat, and to escalate as needed.  Most have produced clear roles, responsibilities and named individuals against their governance arrangements. External governance arrangements  The CCGs have established a Commissioning Congress to strengthen the governance around the partnership working and ensure a vehicle for joined up discussions and accountability. In a number of

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management office (PMO), built upon the 17. Programme existing infrastructure and working across the whole system. The interaction of this office management with the other system bodies will be clarified as the governance is finalised as described in the The outcomes and benefits detailed in the earlier previous section. sections will be delivered through a single portfolio  The PMO will be jointly owned and properly approach for the whole Unit of Planning. This will funded, to ensure it is able to fulfil requirements ensure consistent delivery of each of the programmes  whilst providing best value for money for implementation  . resources and avoiding duplication.

The Commissioning Congress is currently establishing the final structures for this; however they will be formed with adherence to the principles listed below.  The programmes will be structured as one programme for each of the six main aspects described in Section B (Achieving our vision), with additional programmes for the key enablers as required.  Each programme will be owned by an executive sponsor from the system leadership group to ensure continued accountability, focus and championing as required, and a clinical lead for each will also be appointed. Each programme will then be formally described and signed off, including timeline, milestones, benefits and resourcing. The constituent interventions will similarly be described in detail and approved to ensure precise delivery of the required outcomes.  Delivery teams will consist of nominated, multi- disciplinary and cross-organisational staff and suitable assessments and training will be used to ensure the required level of skills and understanding are available to every team. The requirement for each team will be factored into these roles to ensure the resources can provide the dedicated time necessary for successful implementation.  The interventions and programmes will be monitored and tracked during delivery by a nominated lead, and any deviations from plan escalated as necessary to resolve the issues and recover the original delivery targets. The programme sponsors will interlink the progress of these programmes with the engagement and communications work to ensure that stakeholders are sufficiently involved with the work to capture relevant insights and maintain support.  This approach will be supported and administered by a networked programme

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18. Risks and mitigation

Full risk management is used across the CCG group to ensure timely achievement for stated benefits. The key risks to the programmes

are included in the table below

# Risk, with cause and impact Control

Risk Risk Rating

Impact Likelihood Owner Risk 1 There is insufficient capacity in the system to provide the access to and 4 4 16 Demand and capacity modelling with scaling for 5-6-7 day services – delivery of primary care services with current resources and future growth project in progress. expectations. 2 The whole system will collapse if alternatives to A&E attendance and Acute 4 4 16 Radical redesign of operating model Primary Care Specialists e.g. LTC admissions are not found which will achieve the clinical and financial management at sub-acute level for patients in normal place of residence sustainability. (home/residential/nursing facilities). 3 Workforce strategy and plan will have a lead time to implement e.g. new 4 4 16 Confirmed workforce plan and lead in transitional plan until people fully roles and training/ recruitment trained. System wide collaboration on organisational development. 4 The strategy is developed but people and organisations may still work in 4 3 12 Collaborative working across all health and care partners to maximise an silos which inhibits successful transformation integrated approach 5 Unable to make transformational changes due to contractual and funding 3 4 12 High level of collaboration and co-production with Primary Care. model constraints Develop plans to deliver changes to contracting and funding streams through the BCF / Integrated Commissioning/ year of care/ capitated budget and prime provider models 6 The decision making and consensus takes too much time and delays 3 4 12 Progress the strategic debate with primary care and commissioners transformation across the system through the newly formed Joint Commissioning Board. 7 The strategy is developed and Primary Care is commissioned without 4 2 8 Ensure a close link to the Staffordshire and stoke wide working group for considering Inter-dependency for out of hours services UEC. (check title) 8 Misalignment of strategies between commissioners and 5 3 15 Engagement with providers during strategy development Providers

9 Significant recommendations from Strategic Review for distressed health 4 4 16 CCG and Area team forum to resolve issues. Engage with partners where economies impacting on strategy priorities / alignment the findings impact upon them.

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# Risk, with cause and impact Control

Risk Risk Rating

Impact Likelihood Owner Risk 10 Delivering Financial Sustainability 5 4 20 Alignment with BCF, achieve financial savings through efficiency improvements. Monitor economy wide financial performance on a monthly basis. 11 Growth of demand over and above projected activity forecasts 4 3 12 Plans take into account activity levels and are offset by changes in pathway co-design, comms and engagement approaches and collaborative working. 12 Links to BCF and local authority are not sustained 4 2 8 Maintain system wide dialogue through formal and informal channels

13 Public Opposition to service reconfiguration 4 3 12 Effective co-design and comms and engagement

14 Fragmented specialised commissioning 4 4 16 Take proactive role in specialised commissioning dialogue

15 Impact on quality due to financial pressures 5 3 15 Clinical leadership of service reconfiguration. Quality performance an integral part of contractual levers. Regular quality audits. Effective provider selection. Effective organisational development and training programmes. Sharing of best practice 16 Collaborative working is compromised because organisations continue to 5 3 15 Ongoing dialogue. Joint projects, common understanding of context and pursue individual agendas strategic intentions

17 System leaders fail to drive system wide change 5 3 15 Ongoing dialogue. Joint projects, common understanding of context and strategic intentions. Performance management and system wide governance arrangements to ensure individual and collective accountability. 18 No agreement on the models to be used 5 3 15 Agree criteria for selecting models based on outcomes and evidence.

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# Risk, with cause and impact Control

Risk Risk Rating

Impact Likelihood Owner Risk 19 Fail to engage primary care 5 3 15 Provide effective channels of communication and for capturing, prioritising and using primary care input. Review opportunities for incentives and performance management based on evidence and per reviews.

20 Public fail to engage with the new models and necessary changes in 5 5 25 Public and patient engagement. Visibility of the impact, of failing to change, behaviours. on the system. 21 We achieve everything that is planned but still fail to deliver improvements in 5 2 10 Continual review via the governance structure. Adjust interventions, as A&E attendances, NEL admissions and elective care productivity. required, to take corrective action. 22 TSA implementation, Procurements for out of hours, other system wide 4 4 16 Governance arrangements to take this into account priorities create confusions and compromise delivery of overarching strategy

23 The sphere of control and management related to financial flows can be a 5 3 15 Continual review via the governance structure. Adjust interventions, as barrier to effective implementation of radical redesign and ways of working required, to take corrective action.

24 Retirement of GPs and difficulty recruiting to posts in certain areas 5 4 20 Constantly seeking to fulfil the need for GPs through recruitment and alternative approaches to primary care delivery.

25 Recruitment of staff with the right skills and competencies 5 3 15 Constantly seeking to fulfil the need for staff through recruitment and alternative approaches to primary care delivery.

26 Estates rationalisation is not optimised 3 3 9 Work with partners to review plans and options

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Impact Risk 4-5 High 1-7 Low and no immediate action required 2-3 Medium 8-15 Medium and requires preventive action 1 Low 16-25 High and requires collaborative action across the system Likelihood 4-5 Very likely 2-3 Possible 1 Unlikely

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APPENDICES

Appendix 1 – Constituent CCG Plans Appendix 2 – Independent engagement review Appendix 3 – Key Lines of Enquiry Appendix 4 – References

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APPENDIX 1 – CONSTITUENT CCG PLANS

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East Staffordshire CCG Plan on a Page 2014/15 – 2018/19

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East Staffordshire CCG Plan on a Page 2014/15 – 2017

ESCCG system vision is to deliver high quality safe care and radically transform the delivery and outcomes for all Non Elective Care. We will achieve this by maximising self care facilitating the lowest point of dependency delivered in local communities through innovative services with clearly defined outcomes and better use of todays technology through our “Improving Lives” programe. This vision is aligned with the Health & Wellbeing Strategy and is supported by both local and county Health & Social Care Scrutiny Committees

Delivered through a true partnership approach and integrated Governance Arrangements working across East Staffordshire. We will listen to our • Health and Wellbeing Board We will “Improve Lives” with population, examine the evidence and address the factors that • Cross Economy Leaders Group and Collaboration Agreements Improved health outcomes influence Health & Wellbeing, supporting behaviour change and • CCG Commissioning Body and Committees and reduced health promoting self management. Initiatives include a radically new inequalities. way of commissioning, early intervention and support, plus a new model for lifestyle services Overseen through the following arrangements: • New Public Health lifestyle services model supporting people to We will improve the quality of Delivered through radically transforming the way in which care is live well and robust Local Strategic Health and Well Being life for people with Long-Term delivered in East Staffordshire using innovative wholly integrated Partnership Conditions (inc. mental health) systems focusing on improved use of technology better • NHS Assurance Frameworks and Standard National Contracts outcomes and increased self management. • ESCCG’s Patient Engagement & Communications programme • ESCCG’s Membership Scheme, website & Soft intelligence” Delivered at scale through a new model of integrated care and • Introducing new outcome based models of All Adult Intermediate We will reduce the avoidable re-ablement, empowering patients & their families to maximise and Frail Elderly Care to include all long term conditions. time people spend in hospital independent living and actively supporting individuals to attain • Community-based options reducing the reliance on bed-based (promoting quick recovery from optimum levels of functioning. We will reduce numbers of follow care facilitating lowest point of dependency. ill-health + injury) up appointments and procedures undertaken that have limited • Implementation of “Better Care Fund” partnership plans clinical value • Full implementation of “Friends & Family Test” (FFT) across all NHS sectors We will increase the proportion • Proactive management + reduction of all healthcare-associated of older people living Delivered by maximising outputs of current services through a whole system transformation for non elective care. Including infections and reduction of all medication errors independently and support • Continued deployment of the “Safety Thermometer”, innovative discharge back to their own changes to delivery in Primary Care and implementation of the remodelled LTC and Integrated Care Programmes. CQUIN schemes home following an acute • Performance monitoring to ensure the delivery of agreed targets , admission inc VFM aiming to achieve long term sustainable financial balance. Delivered through continuous monitoring of Quality of services and effective performance management of our acute health care providers. Implementation of the NHS “Friends & Family We will increase peoples’ Test” (FFT) and of commissioned service quality requirements positive experience of acute relating to patient experience, including parity of esteem and • With the following key outcome measures: health care actively engaging our community through “Experienced Led • 3.2% reduction in potential years of life lost (conditions amenable to Commissioning”. healthcare) • A stretch target of 6% reduction each year in NEL activity • Up to 75% population coverage of NHS Health Checks Delivered through continuous monitoring and effective We will increase peoples’ • A minimum of 3% increase in the self-reported QoL (GP Survey performance management to ensure high quality Primary + Out positive experience of non- questions) of Hours Care. We will implement commissioned service quality hospital care (those with • In line with Staffordshire our ambition is to increase the proportion of requirements relating to patient experience, including parity of mental + physical conditions) elderly people living independently at home following discharge esteem. from hospital by 17.4% • Improved FFT scores from services implementing the system Delivered through Experience Led Commissioning, the ES End • 2.5% reduction in those reporting a poor experience (hospital We will make significant of Life programme and continuous monitoring and effective inpatient care) progress towards eliminating system management with Primary, Secondary, Mental Health + • 8% reduction in those reporting a poor experience (GP + Out of avoidable deaths in hospital Community Care Providers to ensure robust patient safety + Hours care) quality outcomes and maximising patient choice • 0 cases of MRSA in avoidable circumstances

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East Staffordshire CCG

East Staffordshire CCG is ambitious, its vision is to deliver high quality safe care and radically transform the delivery and outcomes for all non elective care. This will be achieved by maximising self care to the lowest point of dependency with care delivered in local communities through innovative services with clearly defined outcomes and better use of today’s technology. Innovative Commissioning and procurement approaches will drive the above, at scale and at pace. The East Staffordshire local health system recognises its significant financial challenge with an allocation of £140million pa for the healthcare of its 135,000 local people. At the start of 2014/15, this was £6.4m less than the target “fair share”, rising to £9.8m as at November 2014, and is a key cause of the financial challenge. The GPs have a long history of working together and our proud of their achievements: benchmarking indicates that on most domains the local system performs well in quality and efficiency; and is better than England average. However our ambition is to be at best decile in everything we do delivering the best possible quality, experience and value; focussing together and first on the poorly performing indicators listed above.

Local Context

East Staffordshire Clinical Commissioning Group (ESCCG) falls in the Staffordshire County Council area and is predominately covered by the area governed by East Staffordshire Borough Council with a small part of its population falling under Lichfield District Council. The CCG serves a population of 135,200 residents and has been formed by the 19 general practices within the East Staffordshire Borough Council Boundary which includes Burton on Trent and Uttoxeter. In East Staffordshire there are several characteristics of population health that will impact on the way we will need to plan and deliver our health and care services. Our patient population has a high level of smoking and hospital admission attributable to smoking. Consumption of 5-a-day is below average and alcohol admission rates and obesity levels are increasing. These characteristics translate into a set of specific health needs which we will be addressing over the next 5 years as laid out in this strategy document

 An ageing population with increased demand for Long Term Condition Management  Complex demographics with life expectancy for men being 14 months lower than the England average  Life expectancy for women is longer than average. Despite higher breast and cervical cancer rates we have made significant improvement in female life expectancy which now benchmarks higher than England average.  High levels of obesity

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 Higher than average Non Elective admissions for small cohort of ambulatory care sensitive conditions  Specific social care / demographic factors  The overall population is projected to grow by 9% with plans for building 7,000 new homes leading to an estimated 13,000 new population  There is a degree of population churn in Burton connected with European migrant labour  The 0-15 years population will grow by 11%.  Despite these overarching themes, diversity between areas within East Staffordshire is considerable and requires different approaches. For example, the CCG covers both urban and rural areas including areas considered to be deprived.  The CCG is fully supportive of integration and is proud of its national recognition with regard to its integrated organisational development in conjunction with its local CSU. It is now instrumental in the organisation development of the Integrating commissioning with other CCGs and public services to offer better integrated and better value public services which promote the philosophy of the Health and Well Being Board.  The CCG has a comprehensive Call to Action programme and will only Commission services which focus on the key Outcomes sought by fully engaged patients which are better enabling, more modern and more integrated in their approach.  We are encouraging of the acute Trust developing a role in providing the proactive and enabling prevention services we aim to commission to support this approach and are encouraging of the local acute Trust to develop strategic partnerships and alliances to sustain clinically and financially the maximum range of locally provided services, at the right quality and cost, where this is achievable. We will only commission acute hospital based services which meet the necessary clinical standards and where the pathways are no more complex and no more expensive that other providers.  We are positive about working with our providers to drive the right outcomes, quality, experience and value for patients and to develop “gain and risk share” arrangements within our contractual relationship to promote aligned ambition for the right patient outcomes.

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South East Staffordshire and Seisdon Peninsula CCG

Vision: “Improve the health and wellbeing of our population by commissioning high quality services”. Mission Statement: “Clinically led, quality driven needs focussed organisation. Working in partnership to reduce inequalities to transform and improve local healthcare within the available resources”.

Objective: People will receive Delivered through continuous quality improvement informed by patient/public Governance the right specialist service engagement: • Health & wellbeing Boards (County and District / supported by comprehensive The CCG is committed to refining assurance mechanisms with all providers. Borough level) care plans Innovative ways to capture issues that really matter to patients and professionals • Patients Council (further accountability mechanisms to are being tested, and rolled out, in order to build a rich information base to the community to be developed) support commissioning. • CCG Governing Body and relevant sub committees • CCG Clinical Delivery Group • Locality member forums

Objective: People will feel safe and supported in times of crisis Delivered through partnership working: The CCG will progress joint decision making through strategic partnerships, together with more formal agreements such as collaborative and integrated commissioning arrangements with neighbouring CCGs, local authorities and NHS England development of integrated care. Key measures • NHS Outcomes Ambitions and Framework delivered Objective: People will have • NHS constitution requirements and responsibilities met. access to safe, high quality, • Locally agreed health, QoL and service quality coordinated care which Delivered through the adoption of the ‘House of Care Model’: outcomes delivered provides support from diagnosis This will put person centred coordinated care at the heart of all commissioning • Clinically and financially sustainable health economy to the end of life work, of self-care/management and use of digital technology. The approach will • Evidence of true public and patient engagement support professionals and enable true multi-disciplinary working. Organisational throughout commissioning processes will be strengthened, from quality monitoring assurance to IT • Patients feeling safe in their receipt of care and are interoperability. Commissioning structures and mechanisms will be utilised, such as able to manage their condition the prime provider, to promote the development of seamless high quality pathways • Consistently high quality and efficient and effective Objective: People with of care. services, demonstrating value for money dementia and their carers will feel supported to manage the impact of the disease on their lives Delivered through the implementation of a ‘Service Improvement Model for Quality Improvement’: The CCG will implement a significant programme of transformational change. CCG values and principles General Practice Plus will support patients from diagnosis to the end of life. Rapid • Consider the patient voice throughout commissioning Objective: People will have Response Services and Specialist Services will provide short term interventions to • Work in partnership improved access to mental patients in time of specific need. The development of Mental Health Services and • Utilise evidence based commissioning health services and better Dementia Services will provide specialist support for patients over a longer term. • Commission safe, timely and effective services outcomes will be achieved for They will link into General Practice Plus to ensure that there is continuity of care • Focus on prevention individuals with mental illness and that all health needs are met. • Consider parity of esteem through all work and their families

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South East Staffordshire and Seisdon Peninsula CCG

Local Context

The CCG consists of 31 practices in total, representing a population of around 210,000 across two distinct localities, South East Staffordshire and the Seisdon Peninsula. The local population of SESSP has some specific issues which feature in the way we are addressing the five year strategy

 People are ageing at a greater rate than the national average  There are contained areas within Tamworth that are particularly deprived and have a relatively young population. There are also some very specific issues such as teenage pregnancy  There are a large number of rural areas across the CCG, particularly in South Staffordshire and Lichfield  Most patients (in excess of 60%) registered to the CCG receive their acute care outside of Staffordshire and a large proportion of the CCG registered population are resident outside of Staffordshire and vice versa. This is a particular issue when integrating services because of the differences in responsible commissioner definitions for health and social care

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Cannock Chase CCG – Organisational Strategic Plan on a Page 14/15 – 18/19

This plan represents a summary of the CCGs Strategic Vision for

‘Commissioning high quality safe services to ensure people live healthier longer lives’.

Objective: To continuously Delivered through effective quality monitoring and improvement Key measures improve quality and safety of Continual use of national tools and local performance matrix / quality dashboards to • NHS Outcomes Ambitions and Framework delivered all commissioned services. identify at the earliest opportunity those, providers who have safety and quality concerns. • NHS constitution requirements and responsibilities Responding effectively to unacceptably low quality of care in a robust and decisive met manner. • Locally agreed health, QoL and quality measures Objective: Services provided delivered through an integrated system, • Significant increase in the number of integrated Delivered through integrated commissioning at a number of levels services delivered through prime provider coordinated and personalised Integrated commissioning is taking place through the Staffordshire Health & Wellbeing arrangements so that patients receive a Board. The formation of an ‘extended BCF ’arrangement will have ensured commissioning • Proactive coordination and personalisation of care positive experience of care. is integrated for the following programme areas LTC’s. Cancer / End of Life, mental • Promoting health & wellbeing health, learning disability, long term conditions, community equipment and carers. • Ensuring fast, responsive access to emergency and Commissioning will be through patient outcome base service specifications and at the Objective: Primary care urgent care district, locality or county level. coordinating the care of • Ensuring consistently high quality and value of groups of patients, including care, effectiveness, safety and patient experience those with complex health Delivered through co-commissioning of primary care services and partnership working • Financially and clinical sustainable health economy needs, the frail elderly and The CCG will develop a collaborative approach to commission wider primary care services that continues to improve the quality of care, encourages innovation and produces a those with dementia Success criteria stronger focus on integration between primary and community services. Through this work • Parity of esteem Objective: Citizens having there will be reduction in the inappropriate use of acute hospital services. • Financial surplus 2018/19 access to a reliable • Delivery of system objectives consistent, high quality • 20% productivity gain in elective care Delivered through joint & partnership working emergency and urgent care • Increased number of integrated services Patient experience and clinical engagement will inform the commissioning of an commissioned through Prime Provider system in and out of hours integrated emergency and urgent care service that meets the model identified in the arrangements. should the need arise Keogh (Phase 1) Report. This will link to the work being delivered though the Better Care • Financially viable clinically effective and cost Fund. efficient use of resources Objective: To support A shift of resources into primary care, community and other ‘wrap around’ community services, will allow the CCG to develop its ambitions to enable and educate patients and individuals to take greater Overseen through the following arrangements responsibility for living well carers to play a more active role in staying healthy and have greater role to play in managing their own conditions bringing care closer to home. and staying healthy, co- External designing services that are • Co commissioning of Primary Care able to meet their needs Delivered through partnership with acute providers, community services and • Collaborative commissioning arrangements specialised services • Health & wellbeing Board (District / Borough / County) Objective Commission The TSA recommendations will have informed the service configuration delivered by a number of local acute providers. • Citizens & patients involved in patient service sustainable portfolio of design services that are providing Internal high quality care in an Delivered through continuous monitoring and effective system management • CCG Board Commissioning affordable and productive services that provide better outcomes for effective and efficient • CCG Quality Committee patients as well as value for money, ensuring that QIPPS are managed and delivered. manner, that meet the needs • Quality Finance and Performance Committee Decommissioning and disinvesting from services of relatively limited value. of the citizens • CCG Board Assurance Framework

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Cannock Chase CCG Local Context The socio-economic history of Cannock Chase is one of mining and industry, which has more recently moved into manufacturing. The area has been classified as a ‘Manufacturing Town’ as per the Office of National Statistics cluster groupings. A summary of the population’s health and current service utilisation demonstrates the current level of need and the demographic challenges facing the area over the coming years

 132,000 population and health budget of £151.8m  Overall population growth is estimated to be 8% between 2010 and 2035, with a 73% rise in the number of people aged 65 and over, and 103% rise is people aged 75 and over  Life expectancy is lower than National average as is all age all-cause mortality  Healthy life expectancy is estimated to be 67 years for men and 70 years for women in Cannock Chase. Both men and women live significantly more time in ill or poor health compared to the national average of 69 and 72 years respectively  Around 4,500 (21%) people aged 60 and over in Cannock Chase are deemed to be living in income deprived households. This is higher than the Staffordshire (15%) and England averages (18%)  Overall Cannock Chase is ranked in the second least deprived quartile nationally  The CCG was above the national average in both 2010/11 and 2011/12 for unplanned hospitalisations for patients with chronic ambulatory care sensitive conditions. Whilst there was an improvement in performance between the two years, performance has declined in 2012/13  Unplanned hospitalisations for asthma, diabetes and epilepsy in the under 19s was worse amongst the CCG population than the national average for both 2010/11 and 2011/12. Following initial improvement, performance has deteriorated in 2012/13  The CCG was above the national average for Emergency Admissions for Children with Lower Respiratory Tract Infections for 2010/11 and 2011/12. Following initial improvement, performance has declined significantly during 2012/13  The CCG was above the national average for emergency admissions for alcohol related liver disease during 2011/12, with the rate increasing from 2010/11  Patient experience of GP out of hour’s services has improved in the latest survey and is now better than the national average.

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The population demographic profile of an aging population and the lower than average health life expectancy emphasises the need for the CCG to focus its efforts on meeting the needs of an aging population, with poor health outcomes, whilst reducing the demand for services. The over reliance on acute hospital based services will need to be addressed at a number of different levels our approach will include citizen empowerment, the provision of integrated care, improving patient access and convenience and a greater emphasis on primary care. Where appropriate the CCG will continue to work in partnership to address the health inequalities associated with the high levels of income deprivation that currently exist across Cannock Chase. Integrated local commissioning with the District Council, County Council and third sector will be used to target services into areas of deprivation in order to reduce health inequalities and improve healthy life expectancy. This approach will complement the proposed large scale integrated commissioning described in the Better Care Fund. CALL to Action The CCG undertook a number of Call to Action consultation events in order to inform its longer term Plans, it recognises that a continued process of engagement is required to ensure that our patients and public are fully involved in shaping the changes required across the health system and in the future.

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Stoke-on-Trent CCG – Organisational Strategic Plan on a Page 14/15 – 18/19

Our Vision is to be an organisation that has quality at the heart of what we do, works with partners to reduce health inequalities, delivers best value for taxpayers money and is trusted by local people.

Objective 1: Delivered through: Governance Improve the • Understanding our population needs and commissioning services to address and care for • Health & Wellbeing Boards health outcomes our patients • Cross Economy Leaders Group for the people of • Setting and measuring ourselves against specific and ambitious improvement trajectories • Patients Congress and PPI structure • CCG Governing Body and b committees Stoke-on-Trent to ensure improved outcomes • Locality membership structures Delivered through: • Undertake equality analysis impact assessments for all of our commissioned services • Work with public health and general practice quality improvement scheme to ensure the Key measures NAO cost-effective interventions are implemented to best effect • NHS Outcomes Ambitions and Framework delivered • Ensure that we have a strategy and strategic delivery plan to deliver parity of esteem, • NHS constitution Objective 2: underpinned by increased budget for mental health • Local system outcomes Reduce Health • Increasing coverage through integrated local care teams based on discrete populations • Financially sustainable health economy Inequalities in and prioritisation based on principles of case management and risk stratification • Evidence of true public and patient engagement throughout Stoke-on-Trent commissioning • Patients feeling safe in their receipt of care and are able to Delivered through: manage their condition • Robust quality monitoring mechanisms which take into consideration: • Consistently high quality and effective services − Clinical Effectiveness − National Reviews and recommendations − Patient Safety − Patient Experience (inc feedback from Family and Friends test) CCG values and principles − Compassion in Practice Objective 3: • Patient centred with a commitment to quality of care, − Staff Experience and feedback improving lives and working together with patients, carers Ensure quality of − Safeguarding and the public for the benefit of patients services across • And putting in robust CQUINs and contractual measures to ensure quality improvement • Delivering what we say we will deliver, working as a team Stoke-on-Trent • Embracing change, striving for continual improvement and Delivered through: learning from the past Commissioners and providers across Northern Staffordshire have agreed on an agenda of • Using the best available evidence where we can and where focused, radical change across all parts of the system. This programme of cross-economy there is none we are developing it, promoting research and development will result in a real shift of activity, capacity and resource from the acute evaluation sector to the community and is based upon Integrated Local Care Teams using a case • Flexible, creative and innovative and are prepared to take management approach, improved intermediate care, a different approach to frail and legitimate risks (and mitigate against them) in order to achieve sufficient gains Objective 4: complex care and a system co-ordination and capacity ‘hub’ and is premised on: • Prevention and self-care • Prepared to make difficult decisions and are able to justify Ensure appropriate them access to • Primary Care at scale • Better integrated care including better long term conditions management • Valuing people for their knowledge, competence and healthcare across • Improved urgent and emergency care contributions rather than status and position Stoke-on-Trent • A real change in the way that acute care is delivered including better delivery of • Communicating well; we share information, make ourselves planned care and delivery of the NHS Constitution measures visible and accessible to others even when things get tough • Integrated care for Children and Young People and world class maternity services • An organisation that people want to work for and other • Seven day services organisations want to work with

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Stoke-on-Trent CCG

Local Context

Stoke-on-Trent CCG has a GP registered population of 290,000 people. ONS data from 2013 states a CCG population of 258,000. Out of the 326 local authorities in England - Stoke- on-Trent is the 16th most deprived, with a number of areas within the city that are among the top 5% of the most deprived areas in the whole of England. We have a lower than average life expectancy and higher mortality. Average life expectancy for males in Stoke-on-Trent is 76.2 years (national average 78.6 years) and for females is 80.2 years (national average 82.6 years). The overall death rate in the city is 21% higher than the national average. 72.8% of all deaths in Stoke-on-Trent occur as the result of three main areas

 Cancer (31.7%) Whilst the number of people (under 75) who died from cancer in Stoke-on-Trent has fallen in 2008-2010, the mortality rate remains significantly higher than England  Circulatory Disease (25.1%) Mortality for coronary heart disease (48.6%) remains the main cause of death within circulatory diseases and the mortality rate remains significantly higher than the England average  Respiratory Disease (16.0%) The number of deaths from respiratory disease in Stoke-on-Trent has decreased and is at the lowest level since 1998. However, the mortality rate remains significantly higher than the England average and the gap in the mortality rate between Stoke-on-Trent and England has increased.

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North Staffordshire CCG – Organisational Strategic Plan on a Page 14/15 – 18/19

Our Vision: “Quality care, best value, better outcomes” Quality is our guiding principle and underpins everything we do. By quality care, we mean that the health services we commission for the people of North Staffordshire will be safe; the interventions will be clinically effective, delivering a positive outcome and the patient experience will be a good one. Our focus on quality will realise a quality premium – by doing things right the first time, we will secure best value from the resources we invest and achieve better outcomes for our patients.

Goal: Delivered through improving quality and outcomes Governance Increase life • Understanding our population needs, commissioning services to address these and care for our patients • CCG Governing Board and sub committees • Setting and measuring ourselves against specific and ambitious improvement trajectories to ensure improved • Locality membership structures expectancy and reduce outcomes. Targeted improvements will include increasing smoking quitters, reducing premature CVD and cancer • Cross Economy Leaders Group inequality mortality, focusing on prevention and interventions of underlying causes of childhood obesity, improving health • Patient Congress and PPI structure outcomes through Transforming Cancer and End of Life Programme • Health & Wellbeing Boards

Delivered through partnership working • Work with Public Health and General Practice quality improvement scheme to ensure the NAO cost-effective Key measures interventions are implemented to best effect • NHS outcomes ambitions and framework delivered • Ensure that we have a strategy and delivery plan to deliver parity of esteem, underpinned by increased budget • NHS Constitution for mental health. • Financially sustainable health economy • Working with partners on the Health and Wellbeing Board and neighbouring clinical commissioner group partners Goal: • CCG Outcomes to align commissioning strategies, develop integrated commissioning and support the implementation of • public and patient engagement throughout Improve prevention, integrated care initiatives through the Better Care Fund commissioning early detection and • Working with providers to develop innovative service developments eg • patients feeling safe in their receipt of care and are effective management able to manage their condition of those at increased Delivered through continuous quality monitoring and improvement including user / carer feedback • consistently high quality and effective services risk • Robust quality monitoring mechanisms which take into consideration • Clinical effectiveness • National reviews and recommendations CCG Delivery Priorities: • Patient safety We will… • Patient experience • Commission safe, effective and high quality • Compassion in practice sustainable services • Staff experience and feedback • Deliver better patient outcomes through effective, Goal: • Safeguarding federated and collaborative arrangements with • Parity of esteem key partners Enhance quality of life • Robust CQUINs and contractual measures to ensure quality improvement • Improve patient experience, through engagement, and improve health • Involving patients in the decision about their care feedback and involvement in decisions throughout outcome for people • Robust patient/public engagement through, patient participation groups, patient congress, insight database, the whole commissioning cycle public board meetings and diseased specific focus groups • Reduce health inequalities and inappropriate with LTCs clinical variation Delivered through Service Redesign • Achieve all the above while remaining in financial Commissioners and providers across Northern Staffordshire have agreed on an agenda of focused, radical change balance and achieving best value across all parts of the system. This programme of cross-economy development will result in a real shift of activity, CCG Key Principles: capacity and resource from the acute sector to community and is based upon integrated local care teams using a Out decisions will be made… case management approach, improved intermediate car, a different approach to frail and complex care and a • As locally as possible and in collaboration with key Goal: system co-ordination and capacity ‘hub’ and is premised on: partners • Prevention and self-care • That seeks to meet the needs of patients, while Ensure people receive • Primary care at scale balancing the needs of clinicians and partners the right care in the • Better integrated care including better long term conditions management • In line with defined prioritisation process and with right place at the right • Improved urgent and emergency care regard to the relevant evidence • Real change in the way that acute care is delivered including better delivery of planned care and delivery of the • In order to achieve better outcomes time NHS constitution measures • In light of the available resources • Integrated care for Children and Young People and world class maternity services • In an open and transparent manner • Seven day services

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North Staffordshire CCG

Local Context

North Staffordshire Clinical Commissioning Group (CCG) is a relatively new organisation, now authorised and established as a statutory body from 1 April 2013. We were established in shadow form in April 2011 and have grasped with enthusiasm the task of commissioning high quality, safe services for our 213,000 population, delivering the very best health care we possibly can within the resources made available to us. We understand the health challenges that our patients and population face and the very real and marked inequalities that exist between our communities

 We have a gap in life expectancy of nearly 10 years between people living in our most affluent and disadvantaged localities  Much higher than average numbers of our population die prematurely from largely preventable illness and disease, such as circulatory disease, cancer and respiratory conditions  Whilst significant improvements have been made, we still have relatively high levels of infant mortality in parts of Newcastle-under-Lyme  We have an ageing population with an increasing prevalence of long term conditions, some of which remains undetected  We have an urgent and emergency care system that is not delivering the right care at the right time in the right place for many of our patients

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Stafford & Surrounds CCG

Our vision for ‘Commissioning first class care leading to a high quality patient experience and excellent outcomes’.

Objective: To continuously Delivered through effective quality monitoring and improvement Key measures improve quality and safety of Continual use of national tools and local performance matrix / quality dashboards to • NHS Outcomes Ambitions and Framework delivered all commissioned services. identify at the earliest opportunity those, providers who have safety and quality • NHS constitution requirements and responsibilities concerns. Responding effectively to unacceptably low quality of care in a robust and met decisive manner. • Locally agreed health, QoL and quality measures Objective: Services provided delivered through an integrated system, Delivered through integrated commissioning at a number of levels • Significant increase in the number of integrated services delivered through prime provider coordinated and personalised Integrated commissioning is taking place through the Staffordshire Health & Wellbeing arrangements so that patients receive a Board. The formation of an ‘extended BCF ’arrangement will have ensured • Proactive coordination and personalisation of care positive experience of care. commissioning is integrated for the following programme areas LTC’s. Cancer / End of • Promoting health & wellbeing Life, mental health, learning disability, long term conditions, community equipment • Ensuring fast, responsive access to emergency and and carers. Commissioning will be through patient outcome base service specifications Objective: Primary care urgent care and at the district, locality or county level. coordinating the care of • Ensuring consistently high quality and value of care, groups of patients, including effectiveness, safety and patient experience those with complex health Delivered through co-commissioning of primary care services and partnership • Financially and clinical sustainable health economy needs, the frail elderly and working those with dementia. The CCG will develop a collaborative approach to commission wider primary care services that continues to improve the quality of care, encourages innovation and Success criteria produces a stronger focus on integration between primary and community services. • Parity of esteem Objective: Citizens having Through this work there will be reduction in the inappropriate use of acute hospital • Financial surplus 2018/19 access to a reliable services. • Delivery of system objectives consistent, high quality • 20% productivity gain in elective care emergency and urgent care Delivered through joint & partnership working • Increased number of integrated services system in and out of hours Patient experience and clinical engagement will inform the commissioning of an commissioned through Prime Provider arrangements. should the need arise. integrated emergency and urgent care service that meets the model identified in the • Financially viable clinically effective and cost Keogh (Phase 1) Report. This will link to the work being delivered though the Better efficient use of resources Objective: To support Care Fund. individuals to take greater A shift of resources into primary care, community and other ‘wrap around’ services, responsibility for living well will allow the CCG to develop its ambitions to enable and educate patients and carers Overseen through the following arrangements and staying healthy, co- to play a more active role in staying healthy and have greater role to play in managing their own conditions bringing care closer to home. External designing services that are • Co commissioning of Primary Care able to meet their needs. Delivered through partnership with acute providers, community services and • Collaborative commissioning arrangements specialised services • Health & wellbeing Board (District / Borough / Objective Commission The TSA recommendations will have informed the service configuration delivered by a County) sustainable portfolio of number of local acute providers. • Citizens & patients involved in patient service design services that are providing Internal high quality care in an Delivered through continuous monitoring and effective system management • CCG Board effective and efficient Commissioning affordable and productive services that provide better outcomes for • CCG Quality Committee manner, that meet the needs patients as well as value for money, ensuring that QIPPS are managed and delivered. • Quality Finance and Performance Committee of the citizens. Decommissioning and disinvesting from services of relatively limited value. • CCG Board Assurance Framework

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Stafford & Surrounds CCG Local Context Stafford and Surrounds is considered to be a Prospering Smaller Town (ONS cluster groupings) The health of the population is good; men in Stafford have similar life expectancy to the national average whilst women have longer life expectancy. Overall healthy life expectancy is significantly higher than national averages. This may be a reflection, in part, that the population of the CCG is within the least deprived quartile nationally. The most influential demographic feature is the significant rise in the over 65 and 75 year old population and their inevitable need for healthcare services. The consumption of healthcare is already high when compared with similar populations and the cost of services at the present level are neither appropriate nor sustainable and hide additional problems. A summary of the population’s health and current service utilisation demonstrates the current level of need and the demographic challenges facing the area over the coming years

 There are pockets of deprivation where health outcomes are less favourable with one Ward (Littleworth) in the 10% most deprived quartile in England and three Wards in the top 20% of most deprived quartile in England (Penkside, Highfields and Western Downs),  The CCG is above the national average for emergency admissions with higher than expected levels of growth over the last three years particularly in respiratory and gastroenterology, and alcohol-related liver disease,  Higher rates of elective activity for a range of services when benchmarked against other comparable CCG’s  High levels of unplanned hospitalisations for patients with chronic ambulatory care sensitive conditions The population demographic profile of an aging population and high than expected utilisation of services emphasises the need for the CCG to rebalance the local health economy focusing its efforts on meeting the needs of an aging population whilst reducing the demand for services. This will be addressed at a number of different levels, our approach will include citizen empowerment, the provision of integrated care, improving patient access and convenience and a greater emphasis on primary care. Where appropriate the CCG will continue to work in partnership to address the health inequalities associated with the local pockets of deprivation. Integrated local commissioning with the Borough Council, County Council and third sector will be used to target services into areas of deprivation in order to reduce health inequalities and improve healthy life expectancy. This approach will complement the proposed large scale integrated commissioning described in the Better Care Fund. CALL to Action The CCG undertook a number of Call to Action consultation events in order to inform its longer term Plans, it recognises that a continued process of engagement is required to ensure that our patients and public are fully involved in shaping the changes required across the health system and in the future.

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APPENDIX 2 – INDEPENDENT ENGAGEMENT REVIEW

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APPENDIX 3 – KEY LINES OF ENQUIRY

Correlations between requirements and our strategy document

Key Line of Enquiry Response

Which organisation(s) are completing this submission? East Staffs CCG, South East and Seisdon peninsula CCG, Cannock CCG, Staffs and Surrounds CCG, North Staffs CCG, Stoke-on-Trent CCG

In case of enquiry, please provide a contact name and contact details Name Rita Symons Title Accountable Officer Email [email protected] Merlin House, Etchell Road, Bitterscote, Tamworth B78 3HF t 01827 306111 f 01827 306193 www.sesandspccg.nhs.uk

What is the vision for the system in five years’ time? Strategy Document Section A1 How does the vision include the six characteristics of a high quality and sustainable system Ensuring that citizens will be fully included in all aspects of service design and change and transformational service models highlighted in the guidance? Specifically Strategy Document Section C9 Ensuring that citizens will be fully included in all aspects of service design and change, and Patients will be fully empowered in their own care that patients will be fully empowered in their own care Strategy Document Sections B3 B5

Wider primary care, provided at scale Strategy Document Section B3 A modern model of integrated care Strategy Document Section B4 Access to the highest quality urgent and emergency care Strategy Document Section B6

A step-change in the productivity of elective care Strategy Document Section B7 Specialised services concentrated in centres of excellence (as relevant to the locality) Strategy Document Section B8

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Key Line of Enquiry Response

How does the five year vision address the following aims a) Delivering a sustainable NHS for future generations? a) Delivering a sustainable NHS for future generations? Strategy Document Sections A1 B3 - B8 b) Improving health outcomes in alignment with the seven ambitions b) Improving health outcomes in alignment with the seven ambitions See appendix 5 c) Reducing health inequalities? c) Reducing health inequalities? Strategy Document Sections B3 – B8 and appendix 1

Who has signed up to the strategic vision? How have the health and wellbeing boards been Strategy Document Sections A1 B3 B4 B5 C9 involved in developing and signing off the plan? How does your plan for the Better Care Fund align/fit with your 5 year strategic vision? Strategy Document Section A1

What key themes arose from the Call to Action engagement programme that have been Strategy Document Section C9 and appendix 2 used to shape the vision? Is there a clear ‘you said, we did’ framework in place to show those that engaged how their Strategy Document Sections A1 C9 and appendix 2 perspective and feedback has been included? Has an assessment of the current state been undertaken? Have opportunities and Strategy Document Sections B3 – B8 and C9-11 challenges been identified and agreed? Does this correlate to the Commissioning for Value packs and other benchmarking materials? Do the objectives and interventions identified below take into consideration the current Yes state? Does the two year detailed operational plan submitted provide the necessary foundations to Yes deliver the strategic vision described here? At the Unit of Planning level, what are the five year local outcome ambitions i.e. the Strategy Document Section B3 – B8 and appendix 1 aggregation of individual organisations contribution to the outcome ambitions? How have the community and clinician views been considered when developing plans for Strategy Document Section B3 – B8 and C9 improving outcomes and quantifiable ambitions? What data, intelligence and local analysis was explored to support the development of plans Distressed Economy Review

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Key Line of Enquiry Response

for improving outcomes and quantifiable ambitions? SUS SLAM

How are the plans for improving outcomes and quantifiable ambitions aligned to local Strategy Document Section B5 JSNAs? How have the Health and well-being boards been involved in setting the plans for improving Strategy Document Sections A1 B3 B4 B5 C9 outcomes? Are the outcome ambitions included within the sustainability calculations? I.e. the cost of Yes implementation has been evaluated and included in the resource plans moving forwards? Are assumptions made by the health economy consistent with the challenges identified in a Strategy Document Section C9 and appendix 2 Call to Action? Can the plan on a page elements be identified through examining the activity and financial Strategy Document Section a2 and appendix 1 projections covered in operational and financial templates? Please list the material transformational interventions required to move from the current state Strategy Document Sections B3 – B8 and D and deliver the five year vision. For each transformational intervention, please describe the • Overall aims of the intervention and who is likely to be impacted by the intervention • Expected outcome in quality, activity, cost and point of delivery terms e.g. the description of the large scale impact the project will have

• Investment costs (time, money, workforce)

• Implementation timeline

• Enablers required for example medicines optimisation

• Barriers to success • Confidence levels of implementation Strategy Document Sections D13 – 18 The planning teams may find it helpful to consider the reports recently published or to be published imminently including commissioning for prevention, Any town health system and the report following the NHS Futures Summit. What governance processes are in place to ensure future plans are developed in Strategy Document Sections A1 B3 – B8 C9 -11 and D16

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Key Line of Enquiry Response

collaboration with key stakeholders including the local community? Please outline how the values and principles are embedded in the planned implementation Strategy Document Sections B3 – B8 and C9 – 11 of the interventions

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APPENDIX 4 – GLOSSARY

7 day working Across the NHS providers, commissioners and providers are now charged with ensuring that key skills and services are available each day of the week. This has major implications for staffing hospitals and GP services during the weekend /holidays . Acute care Short term care in response to an unpredicted or urgent need. Term use to distinguish from care given as part of a planned admission or procedure or long term care, although escalations in conditions of those with long term needs may result in acute requirements. Allied Health Professional Health care professionals other than doctors, nurses and midwives. Most commonly used to describe physiotherapists, podiatrists, occupational (AHP) therapists, psychologies and speech and language therapists.

Ambulatory Care Ambulatory care sensitive conditions are chronic conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital Sensitive Conditions admission through active management, such as through vaccination; better self-management, disease management or case management; or lifestyle (ACSC) interventions. Examples include congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension. AnyTown A tool kit produced by NHS England, which using high level health system modelling, allows CCGs to map how interventions could improve local health services and close the financial gap. Area Team (AT) NHS England has 27 local Area Teams. The Area Team responsible for Stoke-on-Trent and Staffordshire is the Shropshire and Staffordshire Area Team. Average length of stay The actual length of a hospital stay from admission to discharge (in days). (ALOS) Better Care Fund (BCF) The Better Care Fund (BCF) is a single pooled budget to support health and social care services to work more closely together in local areas. Call to Action A series of activities across the NHS initiated by the publication of "The NHS belongs to the people: a call to action" in January 2014. This calls on the public, NHS staff and politicians to have an open and honest debate about the future shape of the NHS in order to meet rising demand, introduce new technology and meet the expectations of its patients. Carers A carer is a person who is unpaid and looks after or supports someone else who needs help with their day-to-day life because of eg their age, a long- term illness, disability, mental health problems, substance misuse etc.

Case Management The integration of services around the needs of an individual with long term or complex needs. CCG Clinical Commissioning Group - responsible for commissioning the majority of hospital and mental health care for people in their area. There are 6 CCGs

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in Stoke-on –Trent and Staffordshire. Co morbidity More than one condition affecting an individual. Many people will experience more than one long term condition leading to additional complexities in self care and management. Commissioners/ Commissioning is the planning and purchasing of NHS services to meet the health needs of a local population. Most hospital and mental health services Commissioning in Stoke-on-Trent and Staffordshire are commissioned by Clinical Commissioning Groups. NHS England is responsible for commissioning primary care and specialised services. CPAGs Clinical Priorities Advisory Group - comprising local clinicians and public health experts who advise the commissioners on the impact of commissioning plans and decisions. There are separate CPAGs for Northern and Southern Staffordshire. CSU Commissioning Support Units (CSUs) provide commissioning support services to NHS commissioners, including local CCGs, NHS England and local government. The CSU providing support to local CCGs is the NHS Staffordshire & Lancashire Commissioning Support Unit. Diagnostics All services that help clinicians reach a diagnosis or to make an appropriate referral decision. These include a range of imaging services, endoscopy etc. Distressed health NHS England has identified 11 health economies in England which are serious challenged financially and is providing expert help with strategic planning economy to secure sustainable quality services for local patients. Staffordshire/Stoke-on-Trent is one of the 11 "distressed economies". ED Emergency Department - an alternative term to A&E. Elective care Planned care resulting for a referral from a GP and a decision to undertake a planned intervention /operation/hospital stay. EoLC End of Life Care - care (health and other care) in the final period leading to an expected death. Experience-Led An innovative approach to commissioning which focuses on the experience of the patient and carers. ELC builds on the principle of co design of Commissioning (ELC) services and care and engages local people who use services as equal partners in commissioning. Federation of GPs A group of GPs working together to provide primary care at scale. FLO "Florence" - a telehealth app that enables mobile phone users to report on their health, being introduced on a wide scale in Staffordshire. General Practice Plus Additional services and approaches that could be added to the traditional approach of general practice that offer both greater quality for patients and satisfying careers for those working in general practice and primary care. Generalist care The level of care that has traditionally been provided by a GP to his/her patient - providing the point of first contact for any health concern, the management of many long term conditions, dealing with co morbidity through a holistic approach to the individual and referring on to a range of other disciplines as required. Healthwatch Healthwatch Staffordshire is the, independent consumer champion for health and social care in the local area, with statutory powers to Listen, Act,

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Challenge and Feedback. It is part of the national network of Healthwatch groups. HEE Integrated Where bodies with separate commissioning responsibilities come together to commission to ensure that all efforts are aligned and the most effective Commissioning services can be provided. This is facilitated by the pooling of resources as in the Better Care Fund. Intermediate care A short-term intervention involving re-enablement to ensure that a person can be discharged from hospital avoiding a prolonged hospital stay or discharge to a residential home. It is delivered by an integrated team providing a range of skills. Assistance with social care may be provided for a limited period only. Joint Strategic Needs A process undertaken led by local authorities that identifies current and future health and wellbeing needs in light of existing services and informs future Assessment (JSNA) service planning taking into account evidence of effectiveness. JSNAs define the big picture on which planning should be based. LET LMC Local Medical Committee - LMCs are local representative committees of NHS GPs and represent their interests in their localities to commissioners and other planning services. Long term conditions Conditions, such as diabetes, asthma and arthritis that cannot currently be cured, but whose progress can be managed and influenced by medication, self management and other therapies. LOS The actual length of a hospital stay from admission to discharge (in days). NEL Non-Elective; patients who attend hospital with an urgent, unplanned health need NHS England NHS England is responsible for commissioning specialised services, primary care. NHS England has 27 local Area Teams but acts as one single organisation operating to a common model with one board Commissioning of public health services is carried out by Public Health England (PHE) and local authorities, although NHS England commissions, on behalf of PHE, many of the public health services delivered by the NHS. NHS Outcome Framework Sets out the outcomes and corresponding indicators used to hold NHS England to account for improvements in health outcomes.

NHS TDA Trust Development Authority provides support, oversight and governance for all NHS Trusts (as opposed to NHS Foundation Trusts who are overseen by Monitor). Non elective care (NEL) Urgent/emergency attendance at A&E or admission to hospital. Our of Hours Out of hours - eg GP services in the evenings and at weekends. Outcome In essence, an improvement to health status - usually used to describe the changes caused by an intervention or service provision. Parity of esteem Recognises that people with mental health issues have had a poorer experience of healthcare.. This is an underlying principle of health care that promotes the careful attention to both mental and physical health regardless of which care environment the person is accessing services.

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Patient Activation Patient activation is a measure of a person’s skills, confidence and knowledge to manage their own health. The Patient Activation Measure (PAM) produces a score of 1-4. Personalised care Care designed around the needs of an individual and planned through engaging, empowering, hearing, listening, responding to patient needs. In social care, this is increasing facilitated through the use of personal budgets. Planned care See elective care. PPI Patient public involvement. Primary care at scale The ability to offer a wider range of services and expertise through practices working together. Prime Providers A single provider who is commissioned to provide a range of related services along a pathway that would previously have been delivered through a number of different contracts with different providers. Procurement The actual process of contracting and obtaining the services identified through commissioning. PROM/PREM metrics Patient Reported Outcome Measures/ Patient Reported Experience Measures. Quality Innovation The national programme of work using projects addressing Quality, Innovation, Productivity or Prevention aspects to raise the effectiveness and Prevention and efficiency of health and social care Productivity (QIPP) Programmes Rapid Assessment A specialist multidisciplinary mental health service, working within an acute hospital to ensure the needs of those with mental health issues are properly Interface and Discharge addressed. (RAID) Service RDGP Reablement/ Support to enable a return to independent living eg as part of intermediate care. Rehabilitation REM ROI Return on investment - the benefits (however measured) that are created by an investment. Specialised services Also known as prescribed services these are services provided in relatively few hospitals, accessed by comparatively small numbers of patients but with catchment populations of usually more than one million. These services tend to be located in specialised hospital trusts that can recruit a team of staff with the appropriate expertise to enable them to develop their skills. They are commissioned through national specifications by NHS England. Specialist services Services requiring certain skills and facilities that may mean they may not be provided at each hospital/practice.

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Telemedicine/ Telehealth/ Methods that make use of telecommunications to diagnose and make treatment decisions (telemedicine), monitor and help in self management Telecare (telehealth) and provide assistance in other care situations eg monitoring, alarms etc (telecare). TELS The Care Bill The Bill brings together existing care and support legislation into a new, modern set of laws and builds the system around people’s wellbeing, needs and goals. It sets out new rights for carers, emphasises the need to prevent and reduce care and support needs, and introduces a national eligibility threshold for care and support. It introduces a cap on the costs that people will have to pay for care and sets out a universal deferred payment scheme so that people will not have to sell their home in their lifetime to pay for residential care. Triage Deciding the priority of the order of treating patients based on the severity of their condition TSA Trust Special Administrator for Mid Staffordshire NHS FT - has two roles - to oversee the running of the Trust and to develop and consult locally on a draft report about what should happen to the organisation and the services it provides in the future so that high quality, sustainable health services are delivered to the local communities. UCWG Urgent Care Working Group, formed to specifically improve the patient pathway for those with urgent needs Unit of Planning As CCG sizes and local configurations differ, a larger unit of planning is required for the development of consistent and integrated long-term strategic plans. The 6 CCGs of Stoke-on-Trent and Staffordshire are planning together as one Unit of Planning. Unwarranted Clinical Variation in the quality, and by implication the outcome, of clinical practice and/or variation in the amount of service delivered to different populations Variation which cannot be explained by differences in the population's needs. UOP Unit of Planning; the group of six CCGs working together to produce this strategic plan for their combined system Urgent and emergency Care which is not planned and is accessed through out of hours GP services, ambulance services, minor injury units, A&E or other emergency unit eg care (UEC) hospital medical assessment unit. Virtual ward team A team delivering care in the community to those with complex requirements - the team maintains close team working without necessarily being co- located making good use of telecoms and information systems to ensure that care is integrated and is delivered by those with the right skills. WENWBS

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APPENDIX 5 - REFERENCES

The NHS Confederation, The Academy of Medical Royal Colleges, National Voices (2013) , Changing Care, Improving Quality - Reframing the debate on reconfiguration Professor Nigel Mathers, Royal College of General Practitioners (2013), Improving General Practice – Call to Action Analysis of UK Long Term Care Market, Technology Strategy Board (2013) OECD, National Statistics, Population Trends, Dementia UK, London School of Economics & Institute of Psychiatry at King’s College London, Department of Health, NHS, British Heart Foundation, National Audit Offce, The Health Foundation, Diabetes UK includes Frost & Sullivan extrapolations and analysis. Securing the future of general practice new models of primary care

The Kings Fund & Nuffield Trust - Research report

Judith Smith, Holly Holder, Nigel Edwards, Jo Maybin, Helen Parker, Rebecca Rosen and Nicola Walsh, July 2013.

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APPENDIX 6 – CROSS REFERENCING BETWEEN THIS STRATEGY AND “EVERYONE COUNTS”

5 Year Strategic Plan components

The 10 Seven Ambitions The 5 Domains The 6 Characteristics (Critical indicators) (Measures of success)

Securing additional years of life for treatable B5 table.pdf mental and physical health conditions. - Preventing people from dying Modern model of integrated care. B3 data prematurely B5 - Improving health related QoLfor people with B3 LTCs incl. mental health.

Wider primary care at scale. B4 Reducing avoidable hospital admissions (more Enhancing quality of life for people

integrated care out of hospital). B3 B6 with LTCs B3 B5 mework measures mework Increasing proportion of older people living at New approach to ensuring people are home after discharge.

included in service design and change and B3 Helping people to recover from content/uploads/2012/12/oi fully empowered in own care. B5 episodes of ill health or following - injury More people with mental and physical health B3 B5 conditions having positive experience of hospital. B3 B4 B5 Access to highest quality urgent and Ensuring people have a positive emergency care. B6 As above but outside of hospital, in general practice and community. B3 B4 B5 experience of care fra Outcome National NHS B3-8 Eliminating avoidable deaths in hospital caused Specialised services concentrated in by problems in care. ? Treating and caring for people in a centres of excellence.

B8 safe environment and protecting http://www.england.nhs.uk/wp Improving health. B5 them from avoidable harm B3-8 Reducing health inequalities. B4 A step-change in productivity of elective

151 care. B7 Parity of Esteem. B3-8 C10-11 Appendix1