Our Dorset Sustainability and Transformation Plan 1

Our Dorset Sustainability and Transformation Plan for local health and care

Name of footprint: Dorset Number of footprint: 41 Region: South NHS England: Sustainability and Transformation Plans

In 2014 NHS England published the Five Year challenges1. This document, Our Dorset, is Forward View to provide a clear picture of our Sustainability and Transformation Plan. the scale of change that local health and care systems need to deliver by 2020/21. Detailed information about how Dorset is responding to the national ‘must-do’ New planning guidance requires all local priorities and key questions from NHS systems in England to create a Sustainability England are set out in each of our local and Transformation Plan setting out NHS organisations’ annual operating plans how they will address a list of national for 2016/17 (see Our Dorset Appendix priorities for 2016/17, as well as longer-term document).

Our Dorset health and care system is working together 13 to deliver our five-year plan. 2 1

750,000 3 1

1 6

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Over 750,000 people 6 district councils 97 GP practices 1 community and mental 13 community hospitals health provider 3 district general hospitals 1 ambulance trust 2 unitary local authorities 1 clinical commissioning 1 county council group

The local system is also supported by services provided by a range of private and voluntary sector organisations.

1 Delivering the Forward View: NHS planning guidance 2016/17 - 2020/21 (December 2015) Our Dorset Sustainability and Transformation Plan 3

Contents

Foreword 4

Executive summary 5

1 Our vision 8

Our bold ambition for how we want to transform health and care in order to meet the needs of people across Dorset.

2 Our challenges 9

Why we need to change because of our population growth, the changing profile of need, the difficulties in meeting quality standards, and limitations with our current workforce and finances

Health and well-being Care and quality Finance and efficiency

3 Our plans 13

How we intend to deliver our vision and in so doing tackle the gaps that exist in health and well-being, care and quality and finance and efficiency Prevention at scale 16 Integrated Community Services 21 One Acute Network of Services 29 Two Enabling Programmes of Work 36

4 A sustainable approach to funding 38

5 The national support we need 42 4 Our Dorset Sustainability and Transformation Plan

Foreword

Our Dorset sets out our ambitious five-year plan for radically transforming health and care in our area to achieve better health outcomes for local people, with higher quality care that’s financed in a sustainable way.

We’ve written this document for NHS England, as part of their requirement for each area to submit a Sustainability and Transformation Plan. It is also for everyone who lives in Dorset and everyone who works in health and care in Dorset – because we want to change so our local people benefit from a stronger, more successful and sustainable health and care system.

By focusing more closely on what, when and how local children and adults require health and care we have moved our thinking beyond how we currently deliver services, and the organisational boundaries about who delivers what. We are ambitious for Dorset, but big ideas This is important if we are to truly succeed will not be enough to realise our goal. at building a system that works for everyone We have to be clear about what needs to across our county. happen by when. That is why this plan is grounded in the practical reality of making We already have a successful track record change happen. and strong commitment to collaborative working across our health and care The road ahead is not without significant organisations, so that we act as one challenges. We have to change quickly and integrated health and care system. The last we have to involve and inform more than two years have seen increasingly effective 30,000 staff and over 750,000 local people. partnership working between our area’s We need to continue to deliver high quality GPs and primary care teams, the three local services at the same time as working to district general hospitals, our community transform the system. We will have to make and mental health service provider, the some difficult decisions that will affect the ambulance service, Dorset’s three local way things are currently done. But we are authorities, patient representatives and committed to making the changes that many others. It is this approach that has will enable us to fulfil our duty to deliver enabled us to build a plan of this scale the best possible health outcomes and the and ambition – and puts us in an excellent highest possible standard of services within position to deliver it. the budgets we have available. Our Dorset Sustainability and Transformation Plan 5

Executive Summary

Our Dorset has been shaped by the views of clinicians, staff and local people and developed by leaders from across our health and social care system.

Together, we have a successful track record Health and well-being gap and strong commitment to collaborative Much of our expected population growth working across our organisations, so that we will happen amongst the oldest with act as one integrated system. This has been corresponding increases in long-term fundamental to our ability to build a plan of conditions. This will result in an increased this scale and ambition – and puts us in an demand for our health and care services. We excellent position to deliver it. also have unacceptable inequalities between the health and life expectancy of different Our vision groups of people in Dorset, including those We want to change our system to provide with mental health problems. To improve services to meet the needs of local people the health and well-being of our current and and deliver better outcomes. This means future population we have to change. our plan has been built around the needs of the children and adults who live here - the Care and quality gap current population of over 750,000, as well There is too much variation in the quality of our as the additional 50,000 people we expect to health and care services. We do not always have serve by 2023 and those people from outside enough staff with the right skills in the right of Dorset that use the same services. place at the right time. Finding or accessing relevant patient information is also more Our ambition is to see every person in difficult than it needs to be. In most cases our Dorset stay healthy for longer and feel more local services are good, but we have some areas confident and supported in managing their of care that do not meet the national quality own health. We want everyone to have an standards. To improve the care and quality of equal standard of care regardless of who the services we provide we have to change. they are and where they live, delivered by health and care professionals with the Finance and efficiency gap appropriate skills. More of our services will If we carry on as we are now, we forecast be provided closer to home, with improved that in five years our health services will access seven days a week. We will have the have an annual shortage of £229 million a highest level of hospital-based services for year, this includes a shortfall of £20 million when people need them. This is how we can on NHS England specialised services. Our improve health outcomes and local people’s local authorities also face a significant drop experience of health and care services. in income, and together our nine councils will have to save over £70 million over the Our challenges next four years. As our funding cannot keep We must overcome three significant pace with growth in demands and costs, and challenges if we are to achieve our vision for to get the most from the money we do have, health and care in Dorset: we have to change. 6 Our Dorset Sustainability and Transformation Plan

Our plan requirement for health and care varies over Our plan sets out how we will achieve the course of their lives. our vision over the next five years. We We plan to deliver three programmes of have taken a ‘whole system’ approach to work over the next five years and beyond, addressing issues that impact on people’s with each programme contributing well-being and the development of health individually and collectively to close the gaps inequalities. We have also used a ‘needs we have identified in health and well-being, based’ approach to identify categories of care and quality, and finance and efficiency. need that reflect how children and adults'

Our three programmes of work

1 the Prevention at Scale programme will Supported by two enabling programmes: help people to stay healthy and avoid • the Leading and Working Differently getting unwell programme focuses on giving the 2 the Integrated Community Services health and care workforce the skills and programme will support individuals who expertise needed to deliver new models are unwell, by providing high quality of care in an integrated health and care care at home and in community settings system 3 the One Acute Network programme will • the Digitally-Enabled Dorset programme help those who need the most specialist will increase the use of technology in the health and care support, through a health and care system, to support new single acute care system across the whole approaches to service delivery county

We have developed our integrated programmes of work to radically transform our health and care system to address the differing needs of our population.

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The critical decisions we are looking to make

Our three key programmes of work will require us to make critical decisions around the following: • the resourcing and co-ordination of our systematic approach to prevention at scale • the organisation of our primary care services into larger groupings • the reconfiguration of our community hospitals to provide more integrated services at scale • the reconfiguration of our three acute hospitals in order to deliver the highest quality of emergency and planned care

What this means for local people How national support would help Delivery of our plan will see us provide local We are in a strong position, but national children and adults with: expert advice and investment would enable • improved health outcomes us to move faster to deliver the changes we • better patient experience are aiming for. In particular, we would like assistance to review and strengthen our • same standard of care across all health patient benefit case for the Competition and care settings and Market Authority alongside legal, • more care provided closer to home workforce and change management support. We will need access to sustainability • more information, advice and support to and transformational funding along with help people to stay well endorsement of our case to secure the • more choice about when and where to capital to undertake the acute hospital and receive treatment community services reconfiguration and • less travelling time to attend appointments information technology investment. Given the scale of the transformation we are proposing we also hope to be given political support before and during the forthcoming periods of transition so we can achieve our ambitions. 8 Our Dorset Sustainability and Transformation Plan

Our vision

Our vision is simple but effective: we want to change our system to provide services to meet the needs of local people and deliver better outcomes.

Local needs will be at the centre of all We want all children and adults in Dorset to: that we do across the whole health and • stay healthy for longer care system. Health and care services and • feel more confident and supported in resources will be organised in the best managing their own health possible way to meet the requirements of local people, rather than around existing • have an equal standard of care regardless organisational structures or facilities. of who they are and where they live • have a more joined up, seamless We will take a broad view of health and care experience of all services needs, with a focus on prevention as well as • be treated by a health and care treating ill-health. We will support people professional with the appropriate skills to stay well even from before they are born to deliver high quality care and take into account the broader factors that affect individuals’ well-being. • have more control over their own care • have more access to services seven days We will extend health and care services far a week beyond doctor’s surgeries and hospitals, into people’s homes and our communities • have more services delivered closer – the places where it is needed most. When to home people need hospital based specialist care • have access to the highest level of hospital we want this provided from centres of based services when they need them excellence.

Radical change

The health and care system in Dorset that we have in 2016 is not designed in a way that can support these ambitions. That’s why we’re embarking on this programme of radical change. Our Dorset Sustainability and Transformation Plan 9

Our local challenges

We have identified three main challenges that we must address if we want to achieve our vision for health and care in Dorset:

Health and Care and quality Finance and well-being gap gap efficiency gap

Variation in the health Differences in the The increasing pressure and well-being outcomes quality of care received on resources within the of different people by people across our system, with shortages across Dorset area and shortcoming of some staff and the in reaching national prospect of insufficient standards funds to maintain our health and care system in the way it currently operates

How these challenges affect • not meeting NHS Constitutional local people standards such as being seen in A&E within the 4 hour waiting time target and national waiting times for cancer All of the problems we have identified referrals and treatment within 31 have a direct effect on local people. and 62 days Examples include: • not being discharged from hospital • having to see different doctors, nurses in a timely way and other professionals and repeat their • not being able to access additional care story each time at home when needed • not being able to see a GP at the • not always being able to access good times they would like quality care homes when needed • having to travel for tests and • getting different messages and advice appointments in different places from the professionals that they see • having tests repeated because results are not available where they should be

Our understanding of local challenges draws on a substantial analysis of Dorset’s health services conducted in the winter of 2014/15 and ongoing scrutiny of a wide range of clinical quality and safety data, clinical audit measures, patient and carer experience feedback and finances. We continue to update and deepen our understanding of the range and depth of challenges we face across our health and care system so that our plans are firmly focused on delivering positive change. 10 Our Dorset Sustainability and Transformation Plan

Health and well-being gap

By 2023, the population of Dorset will when numbers are falling nationally. We have increased from around 750,000 to think this variation is unacceptable. over 800,000, with much of the growth happening among older people. Increased Many factors play a part in creating this longevity brings new challenges to health gap. The prosperity of an area is one factor. and care systems, because as we grow older Lifestyle factors are another big reason why more of us develop long-term conditions people may have more ill health. Based on such as diabetes and dementia. current trends, obesity will become an even more widespread problem by 2020, by which People in Dorset generally live healthier time we think 1 in 10 local people could have and longer lives compared to the average diabetes and 1 in 8 could have heart disease. for England, but this is not evenly spread across our population – the data reveals There is a difference of up to 20 years in unacceptable inequalities between different the life expectancy of people with mental groups. We must reduce the gap between health problems. We want everyone in the health of the poorest and richest. There Dorset to receive the same high quality of is a particularly wide health gap for men care, regardless of where they live, what living in Bournemouth, where those living in health condition they have, or any other more prosperous areas can expect to live for personal characteristic. We also know that 11 years longer than those living in the most people who act as carers are at high risk of deprived areas. Whilst there has been no experiencing worse health outcomes, having change in the numbers of people who die their employment or education disrupted early from heart disease in Poole and rural and becoming socially isolated, which in turn Dorset in the last five years, there has been impacts on their role as a carer. a rise in Bournemouth and this is at a time

Dorset has more older people and less Oer working age and eoe young people when compared to the England average

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Care and quality gap

In Dorset we are proud that recent Care Quality Commission inspections of local organisations have identified areas of good practice, despite the pressures in our system. However, they have also highlighted areas where we need to improve: areas where there is too much variation in the quality of services; where the standards being achieved do not meet the targets that we expect; where there are not enough appropriately-skilled staff where and when they are needed; and where finding or accessing relevant patient information is more difficult than it needs to be.

National quality standards are rightly high, and they are continuing to rise. In most cases our services are good, but in others the evidence shows we need to do more to meet these standards consistently. For example, when people are admitted as an emergency to hospital, they may end up staying longer than they need. Dorset is among Better care the five worst-performing areas in England for delays in getting people home. For for all older people in particular, a longer stay in We want everyone to have the hospital increases the risk of falls, infection, highest quality of care no matter increasing confusion and pressure ulcers. who they are or where they live, and whenever their health There are unacceptable variations in the need arises. quality of care across Dorset. For example, patients with diabetes at some GP practices are more likely to have better control of their condition, meaning they are less likely to develop further problems such as heart disease. Similarly, there are variations in immunisation rates and dental care among children who are in the care of each our three local authorities. We want everyone to have the highest quality of care no matter who they are or where they live, and whenever their health need arises. 12 Our Dorset Sustainability and Transformation Plan

Finance and efficiency gap

The NHS in England will have a national government £1.1 billion), and we need to shortage of £22 billion by 2020/21. In be sure that we use our resources including Dorset we forecast that in five years our our workforce, technology and buildings, health services will have a shortage of £229 in a way that brings the greatest benefit million a year, this includes a shortfall of £20 to local people. More than 30,000 people million on NHS England specialised services, work within our local health and social care if we carry on as we are now. Our local system. The way that services are currently authorities face a significant drop in income organised means that we don’t always have that sees a requirement to have to save over staff with the right skills where and when £70 million over the next four years. they are needed. We have gaps in some staff groups, particularly in domiciliary care, As our funding cannot keep pace with nursing staff and GPs. growth in demands and costs, and to get the most from the money we do have, we face We have made savings and have been a significant challenge of needing to bring working more efficiently. Our health our system back into financial balance. This providers have all saved around 2% to 4% means we have to be more efficient; we each year and local authorities have also need to organise and deliver our services in made significant savings. However, given the different ways to provide health and care scale of the financial gap, carrying on as we that meets our changing needs; and we are is not an option. To achieve our vision, need to invest more money in prevention. we need to make significant changes.

Together the NHS and local authorities in Dorset spend over £2.5 billion on public services (health spend £1.4 billion, local

Financial impact of doing nothing in Dorset

£229m

Expenditure £0m Forecast gap by 2020/21= £229m annual Underlying surplus

2013/14 Break even 2014/15 2020/21 point Our Dorset Sustainability and Transformation Plan 13

Our plans

Delivering our vision demands ambitious plans that 3 are bold in scope and grounded in evidence and local insight.

Our plans are underpinned by two A needs-based approach approaches to understanding health and People experience varying health and care care: the effect that different factors in needs over the course of their lives. We have people’s lives have on their health and to be able to design and deliver high quality, well-being, and the different levels of need safe and sustainable services that address experienced across local populations. the full range of health and care needs, including minor illnesses and injuries, long- The wider determinants of health term conditions, planned care, unexpected We recognise that there are many complex urgent and emergency requirements and and often interrelated factors that influence end of life care. By thinking about local people’s health and care needs. These children and adults as having categories factors include the quality of housing people of need, which is also known as ‘risk live in, the ability to find employment and stratification’ or ‘population segmentation’, how well schools are performing. Our plans we can make sure we are providing what is take into account these wider determinants required. This understanding allows us to of health and we are working with local think differently about how we organise our authorities, the voluntary sector and other services, workforce and finances to support partners to take a ‘whole system approach’ each segment of the population. to addressing issues that impact on well- being and create health inequalities.

Determinants of health

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A needs-based approach to our integrated programmes of work

We have three interconnected programmes of work to drive forward changes to our services in order that we better meet the differing health and care needs of local children and adults.

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Our programmes of work We have identified three programmes of work that are already underway, which we will continue to develop and accelerate to enable us to realise our vision for health and care in Dorset over the next five years.

Each programme contributes individually and collectively to close the gaps we have identified in health and well-being, care and quality, and finance and efficiency, to produce a truly integrated system that meets the needs of all our population. There is already a great deal of exciting work going on within these areas that we can learn from and build on.

1 Our Prevention at Scale programme will Local Government help people to stay healthy and avoid In developing our plans we have been getting unwell. mindful of the evolving government landscape. The Government has set out 2 Our Integrated Community Services the legal framework within which local programme will support individuals who authorities and the public, business and are unwell, by providing high quality care community sector partners can develop at home and in community settings. and deliver devolution opportunities. 3 Our One Acute Network programme will As part of the devolution proposals, the help those who need the most specialist structure of councils across Dorset is under health and care support, through a single review and it may lead to local government acute care system across the whole county. reorganisation during the lifespan of this To realise these ambitions we have two plan. These proposals have been prepared fundamental enabling programmes. in a context where local authorities in the area will be losing all Government Revenue • Our Leading and Working Differently Support Grant funding over the next five programme focuses on giving the health years and, in some cases, by 2019. and care workforce the skills and expertise needed to deliver new models of care in an integrated health and care system. • Our Digitally-Enabled Dorset programme will harness the power of technology and support digital innovation across the health and care system, to support new approaches to service delivery. Our plans for these two workstreams are outlined in the Our Dorset Appendix document. 16 Our Dorset Sustainability and Transformation Plan

Programme 1 Prevention at Scale

The Prevention at Scale programme forms the foundation of our plans and underpins all of the work we will do. Prevention work also runs through the upper tiers of the triangle – our Integrated Dt e Dorset e or eret Community Services and One oest ee er ol Prntion Acute Network programmes. oulation at sal

Prevention is not a new idea, but with more We are focusing on the following major and people developing long term conditions our growing influences on the health and well- approach to prevention is now as much about being of our population: promoting health and well-being as it is about • heart disease and diabetes contribute preventing disease. We are committed to the most to health inequalities in Dorset, working in partnership to tackle the wider and we know that early deaths from determinants of health – the complex and these causes are increasing in some areas. often interrelated factors that influence Many of the actions we take to reduce people’s mental and physical well-being, and the impacts of heart disease start early in the longer term impact on their health and - in pregnancy and early life. They will care needs. Our programme also aims to help also reduce the impacts of cancer and individuals take control of their own well- dementia, and will help to give the next being and make healthy choices that will keep generation a healthy start in life them well for longer. As we plan and deliver • musculoskeletal and mental health services we will consider what effects we can problems as they have a major influence have on health of all our population. on the quality of life for a large number of local people from childhood to the end of Our two Health and Well-being Boards will life be central to this work and are currently • alcohol misuse – the ill effects of this rapidly refreshing their Joint Health and Well-being increasing problem affect all parts of our Strategies to align with this plan. These society, and impact on all public services. will go out for consultation with the public We will take a comprehensive co-ordinated later in 2016. They will provide a common approach to reduce alcohol's harm framework and language so that all our partners from across health and social care, A comprehensive approach to prevention the voluntary sector and the independent Our Prevention at Scale programme will use sector, can understand how they can these focus areas to take a comprehensive contribute to this work. approach to prevention including a focus on promoting health and well-being and the wider determinants of health, as well as building on best practice in primary, secondary and tertiary levels of prevention. Our Dorset Sustainability and Transformation Plan 17

We will also build this approach into the Creating job opportunities and access to Integrated Community Services and One affordable housing: Dorset’s local authorities Acute Network programmes. have formed a single local economic partnership and produced a county-wide Promoting health and well-being and the strategic plan that focuses on building skills, wider determinants of health developing the local economy, increasing Local authorities in Dorset are already job opportunities and access to affordable delivering a range of initiatives that are housing. Bournemouth University and Arts designed to tackle the wider determinants University Bournemouth play a key part in of health. We will build on the experiences and contribute to the growing creative and and successes of these initiatives as we digital sector in Bournemouth. develop plans for the Prevention at Scale programme of work. Examples of work Revitalising communities: Each local authority already being done include: is leading projects to address housing needs, job opportunities, community facilities and Supporting children to grow and families cultural attractions in areas identified as being to thrive: Through the Joint Commissioning in need of regeneration. These areas include Partnership Board for Children, a Pan Dorset Boscombe, West Howe, Bourne Valley and Emotional Well-being and Mental Health Melcombe Regis. Strategy for Children and Young People has been developed. It emphasises the need for a Improving the quality of homes occupied focus on mental health and emotional well- by vulnerable people: Older, less energy- being and improved early access to support efficient houses can be difficult to keep across a broad spectrum of need. More use will warm and cold homes are linked with be made of schools and early years settings health problems such as respiratory disease, to provide low level support. Parents will be circulatory problems and increased risk of helped to become more self-reliant and build poor mental health. The Dorset Healthy the emotional resilience of their family. We will Homes programme is a collaboration across also ensure improved partnership working to the district, borough and unitary authorities identify vulnerable families and children who in Bournemouth, Poole and Dorset, which need extra assistance. aims to improve the quality of homes occupied by vulnerable people. The ambition is to deliver improvements to around 150 homes each year over the next three years.

NHS Five Year Forward View

“ The future health of millions of children, the sustainability of the NHS and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.” 18 Our Dorset Sustainability and Transformation Plan

Encouraging active travel: Dorset local Primary prevention - staying healthy authorities have a good history of working Primary prevention is about helping people together on sustainable transport projects, who are currently well to make these including the Local Transport Plan which changes in their lives that will help them highlights the importance of shifting stay healthy for longer. We will: commuter behaviour away from cars and towards healthier alternatives such as • extend our LiveWell Dorset service to walking or cycling. The most recent plans provide more people with help to quit include the Dorset-wide Partnerships for smoking, cut down on alcohol, exercise Active Travel initiative, which aims to more, lose weight and eat more healthily. promote walking and cycling as alternatives The service is currently being evaluated to car journeys, among businesses, so that our planned expansion will be employees, apprentices, job seekers and refined to ensure it reaches more people, students. There are direct economic benefits particularly in more disadvantaged areas, arising from switching to active travel and that it works to support people to (estimated to exceed £4 million over 10 make the changes they want to their lives years); there are also likely to be further • deliver training and advice in 2016/17 via health and well-being benefits from a LiveWell to help employers and voluntary reduction in future risk of developing organisations reach their employees and chronic diseases like cardiovascular disease, the communities they serve with tailored as well as effects on air quality by reducing health and well-being advice and support the number of miles travelled by car. Our Dorset Sustainability and Transformation Plan 19

• extend our work training teachers and Life, My Care staff across educational settings in Mental • ensure our health and care practitioners Health First Aid and Five Ways to Well- provide timely and high quality support being so they are better able to support to help people to consistently control pupils’ emotional health and well-being their blood sugar, blood pressure and Secondary prevention - staying well cholesterol, especially for people who Secondary prevention focuses on supporting have diabetes. This will help to address people who have already developed a the variations in health and well-being health problem such as high blood pressure outcomes across our area, reduce the or diabetes. It focuses on detecting these likelihood of patients developing further problems at an early stage and making problems and needing hospital based care sure that they are well controlled so that Tertiary prevention - staying independent the person stays well. An important part of The third type of prevention focuses on this is supporting people in developing the individuals who have more complicated or confidence, knowledge and skills to manage severe health problems. Tertiary prevention their condition. We will: aims to make sure that their condition has • extend the number of people receiving as little impact as possible on their quality of personalised support from our My Health life. We will: My Way initiative to be able to self- • continue to support people to find the manage their long-term conditions. We help they may need to live independently will also work closely with primary care at home with our My Life, My Care service to ensure patients are invited in regularly for check-ups and that a more proactive • continue to provide short-term intensive approach is taken for people who do not support to help people get back home attend appointments after a hospital stay, as part of our integrated community services programme • develop a ‘patient portal’ within the (see page 21) Dorset Care Record, as part of our 2020 Digital vision (see page 37). This will • provide more timely access to information provide people with access to better and advice to carers to help those they information and decision making support care for, as well as support to help them around how to self care. The portal will to maintain their own well-being. The also provide people with access to their 2011 census identified that we have 82,900 health records and link the information unpaid carers providing invaluable support held by the My Health My Way and the My to people at home 20 Our Dorset Sustainability and Transformation Plan

What our Prevention at Scale programme means for local people

Focusing on promoting health and well- • by becoming more physically active, being across the whole system will lead to a eating healthily and moving towards a wide range of positive health outcomes for more healthy weight, people will be less local people: likely to develop diabetes, heart disease • with improved housing conditions, fewer and mobility problems people will become unwell with lung • fewer people drinking more than is problems and fewer people will die early healthy for them will result in fewer from chronic lung problems or heart people admitted to hospital for alcohol disease related problems including stomach or • a focus on walking and cycling in local liver problems transport planning will mean a small increase in physical activity for most It will help people who already have a people, that overall will add up to fewer health problems to stay well by: deaths from heart disease • detecting more health problems at an • community-based obesity prevention early stage work that brings together different • building confidence and support to help approaches to help people eat well people take more control of their own will mean fewer people become obese care and therefore fewer people will go on to develop diabetes. Places where this • reducing the likelihood that they will approach has been tried have also found need to go into hospital because of their that people have a more positive outlook condition on life, which may mean they are less • creating an equal standard of care for prone to mental health problems all, with less variation in the quality • more children and young people experienced by advantaged and growing, developing and achieving disadvantaged groups their potential It will help people who have more It will help people to stay healthy by complex health problems stay making positive healthy choices: independent by: • reduced levels of smoking will lead to less • making sure that people are discharged heart disease, lung problems, cancer and from hospital as soon as possible dementia • providing more support to carers

“The plans we have for prevention at scale and to empower self-care, represent an exciting opportunity to shift from a focus on the treatment of ill-health to a focus on helping people keep well for longer. This will require a clear and enduring commitment from all partners to prevention as a central theme of all their work. ” Dr David Phillips, Director of Public Health, Public Health Dorset Our Dorset Sustainability and Transformation Plan 21

Programme 2 Integrated Community Services

Integrated Community Services form the middle tier of our plan. This programme will transform general practice, primary and oerte ee er community health and care Pol it ntratd modrat or ommunity services in Dorset, so that they rourin Sris alt nds are truly integrated and based Dt e Dorset on the needs of our local e or eret populations.

Community based services will be led by • make sure our community services are able multidisciplinary teams of professionals, to support frail older people with long- working together to meet the needs of people term conditions so that more care can be of all ages who have short-term health needs, delivered closer to home individuals with long-term conditions and • improve personalised care for people with those requiring specialist care for severe or complex needs, including individuals with complex health needs. We will deliver all of learning disabilities these services in a way that makes it easier for people to access care when and where they • adopt new technologies that will support a need to, with a consistent and high quality high quality, consistent patient experience experience for patients as they move between throughout the health system, with different parts of the integrated system. standardised working practices and seamless communication between health and care professionals Our priorities are to: • support people to better manage their • create integrated teams of professionals own health, with access to appropriate with the right skill mix (including students) in information and support – we expect a 10% improved working environments, to support reduction in new outpatient attendances the delivery of the model of care as well and a 25% reduction in follow-ups as enhance skills acquisition and personal development opportunities • provide care that is based on the needs of our local population, with services delivered • make sure that our NHS buildings, resources at the times and places people need them and finances are used in a cost-efficient way, including by planning care on a larger scale • enable more people to receive care at home to achieve cost savings and in the community, and to self-manage long-term conditions, to avoid having to visit Creating a network of community hospital or being admitted as an inpatient services – we expect to reduce unplanned medical To deliver our priorities we intend to create admissions by 25% and unplanned surgical a network of community services hubs admissions by 20% throughout Dorset. These services will enable people to access a wider range of health 22 Our Dorset Sustainability and Transformation Plan

services, from routine care to urgent and contraception services and prevention advice specialist care, closer to their homes. • rapid same-day access to GP-led urgent care, Mixed teams of health and care professionals with on-site diagnostic testing including providing care for people who have physical imaging and x-rays and mental health needs will staff these • self-management support for patients with services hubs. They will offer services for long-term conditions children, adults and our growing older population. • outpatient appointments The health and care system will address a • urgent and unplanned care wide range of different needs of our local • secondary care consultations and minor population, including: procedures • people who are mostly healthy but with • rehabilitation and services to support some recurrent health needs, such as young recovery after periods of ill-health children, pregnant women and people with • specialist care and support for people with short-term illnesses complex needs, including 24/7 crisis support • people at moderate risk of requiring higher to help people receive the urgent care they sudden levels of care need, or sudden care need without going into hospital needs, including those with long-term Community service hubs: Many of these conditions, learning or physical disabilities, services will be delivered through our and frail older people proposed community service hubs. Some of • people with a very high risk of a the hubs will also offer community beds so deterioration in their health, who require that when appropriate, people can receive regular supervision and support, including care locally instead of being admitted to an people at the end of life and those with acute hospital. These community beds will multiple health and social care needs also be used to provide rehabilitation after an The services will include: acute stay, and to support people at the end • routine care including traditional primary of life. care, screening, baby clinics and checks, We have modelled the level of demand we expect for each of the core services that would be provided, and considered the facilities We will establish a network of community service hubs each providing a range of health and care services 1 1 Routine care 8 2 Rapid same-day access 2 3 Self-management support 4 Outpatient appointments 7 5 Urgent and unplanned care 3 6 Secondary care consultations 7 Rehabilitation 6 4 8 Specialist care and support 5 Our Dorset Sustainability and Transformation Plan 23

that would be required on each site, such as An integrated workforce: We know that we the number of consultation, treatment and already have most of the health workforce therapy rooms. We have identified a minimum that we need to deliver community care population catchment required for each hub, in these new ways, but we have yet to which will ensure use of the facilities for a understand the gaps in the social care minimum of 8 hours a day, 5 days a week, workforce. We expect there will be a need with some services being provided 14 hours a for some recruitment, changes in the skill mix day for 7 days a week, and use the workforce across staff groups and new ways of working, efficiently. Our plans for expanded integrated such as developing nursing and allied health teams could deliver more and better services professional roles across community and from a fewer number of sites than the 13 primary care services, including community community hospitals with beds and over 130 pharmacy and pharmacists in a range of primary care sites that currently operate across settings. Dorset. We will reorganise health and social care staff We have reviewed our existing community into teams with a greater diversity of skills hospital estate to identify options for locating and expertise, so that they are better able to the proposed community hubs. The options respond to specific health needs in community involve consolidating services on some existing settings. sites and repurposing or development of some For more information about our plans for the buildings to make better use of resources. workforce see page 36. We have taken into account criteria such as quality of care, access to care, affordability and Transforming General Practice value for money, workforce, deliverability and General practice is the fundamental building research and development. block for the delivery of health services. “Should General practice fail, the NHS will Following this review, our proposals are to fail” (Stevens 2016); ensuring long-term have 12 sites across Dorset; seven community sustainability of General Practice is therefore hubs with beds which will have a wide critical. range of facilities including outpatients and diagnostics. We will also have an additional Our analysis to date suggests that if we five hubs without beds which will have a continue with the current 97 GP practices range of outpatient services, co-location of delivering care in over 130 sites this will staff and could be used by a range of other over-stretch our workforce and finances; a local community resources. challenge compounded by the workforce crisis and our local ageing population. Dorset CCG's proposals for creating three centres of excellence (page 30), which include The ongoing engagement with GPs to a major planned care hospital with an urgent develop the Primary Care Commissioning care centre support our options for integrated Strategy has identified the key barriers to community services, as this site will also sustainability of General Practice: workload provide community beds. and workforce and this has shaped our thinking around enablers to overcome these During 2016/17 we will continue to test out barriers: adequate resourcing to facilitate our plans and seek assurance from local and transformation (financial and workforce), national regulators. These plans will be part common health record (with appropriate of our public consultation in late 2016. When information governance arrangements) to a final decision is taken and implementation minimise duplication and improve efficiency, begins, we expect that the services provided reducing unnecessary workload and improved within the hubs, where appropriate, will be responsivity of social care. jointly commissioned by the NHS and local authorities. 24 Our Dorset Sustainability and Transformation Plan

Our plan permits an opportunity to consider at a practice, locality and county-wide level the short, medium and long term stages to enable transformation and thereby establish sustainability. Our Primary Care Commissioning Strategy determines how general practice within Dorset will seek to evolve given the current challenges and to reflect the General Practice Forward View2, in particular to address workload and workforce whilst seeking to address the STP aims. The strategy outlines our vision for delivery of community based care and identifies the opportunities for how general practice could work at scale to strengthen delivery of the Transforming community based urgent and three key aims of our plan: emergency care 1. prevention at scale Our plan is to further strengthen the urgent 2. integrated community services care integrated advice and assessment service 3. appropriate use of acute services (see page 27) to create one clinical pathway A reduction in the number of GP sites and that provides timely access to the most development of community hubs will allow appropriate service. This will ensure Dorset more services to be consistently and more is best placed to meet the NHS England efficiently delivered across the county for Commissioning Standards for Integrated 3 more hours of the day and days of the Urgent Care by 2018 . We also want to week. However, there is no ‘one size fits all’ develop a high quality and consistent trauma approach to how general practice should care pathway that will support the proposed best be organised, and we recognise that we model of care for the One Acute Network will need to further invest and develop our (see page 29). Enhancing the provision of estate for delivery now, while we plan for community based urgent and emergency care future transformation. The solution depends is essential if we are to reduce inappropriate upon the needs of the local population and attendance at A&E, reduce hospital admissions our additional modelling work and on-going and deliver care closer to home. discussions across primary care will help to Transforming mental health services determine the right approach for each area We are committed to tackling mental health within Dorset. with the same energy and priority as we Community hubs are expected to be have tackled physical illness in order to supported by strengthened networks of GP deliver ‘parity of esteem’ in line with the Five 4 practices, offering patients a wider range Year Forward View for Mental Health . Our of universal and more specialist services, vision (see page 8) applies equally to people including urgent care seven days a week. with mental health problems and learning disabilities. The RCGP Ambassador and Local medical committee have indicated their support for We want to see more being done to prevent our approach and continue to be involved in the development of mental health problems, the consultation. and early intervention across primary care and other services to NICE standards and national 2 NHS England General Practice Forward View (April 2016) 3 Commissioning Standards for Integrated Urgent Care (September 2015) 4 The Five Year Forward View for Mental Health (February 2016) Our Dorset Sustainability and Transformation Plan 25

"The community teams have very capable expert staff in them. What they haven’t had previously is a way to access medical expertise and that means that managing complex patients often involved referring patients to different services. By making myself available to those teams easier, and often informally, they can continue to manage those patients and I can support the patients at home where necessary. And the patient has to do much less moving around of the healthcare system." Dr Riaz Dharamshi, Geriatrician, Dorset HealthCare University NHS Foundation Trust targets so that people get timely access to the The first phase of the review was to gather help that they need. We want our integrated views5 from local people, carers, staff, the community services to support as many people voluntary sector as well as our health, social as possible to stay independent and to provide care and public service partners. We gathered appropriate health and care closer to home. over 3350 pieces of feedback. We are now in We also want to improve the linkages with our the second phase, describing and shortlisting acute services and raise the quality of the care options for new models of care. The options that is provided at a time of crisis, including for were approved by Dorset CCG Governing Body people with anxiety and depression as a result in October 2016 before public consultation in of pain, living with a long-term condition or early 2017. following an acute physical health event, as The new model will reflect best practice well as those living with dementia. and national guidance, and will be focused To help to achieve our ambition, in 2015 we on improving patient outcomes. It will also began a Mental Health Acute Care Pathway take account of the work of the Integrated Review to understand how services such Community Service and One Acute Network as inpatient assessment and treatment, programmes. psychiatric liaison, crisis response and home When a final decision is made in 2017, treatment, street triage and community implementation will begin and will include mental health teams need to change. close partnership working with the third In line with ‘Implementing the Five Year sector. Forward View for Mental Health’, the co- We have also started a Dementia Services produced Acute Care Pathway review has Review jointly with our local authority developed options for: partners this year, in support of our • the delivery of safe spaces commitment to the 2020 NHS Mandate goals for dementia care. This will include looking • further development of peer support closely at how to improve the time it takes workers to access a diagnostic assessment and post • improving choice and access options for diagnostic support, our inpatient services and people with the aim of preventing crises and specialist dementia intermediate care. We expect to identify opportunities to deliver • enabling people to self-refer into some more services to reduce social isolation services when they feel that they need that could be provided from the proposed support. community hubs. We will also be working with We are also looking at the future demand for technology partners as part of our local digital acute inpatient beds to ensure these are fit for vision 2020 to trial innovative new ways of the future, sustainable, safe and best placed working. for people to access within 33 miles from their In 2017 we will start a review of the complex place of residence. care and recovery pathway of people with

5 ACP Mental Health Acute Care Pathway – View seeking evaluation, full report, Bournemouth University MRG (October 2015) 26 Our Dorset Sustainability and Transformation Plan

For more information about the existing integrated workforce at Bridport Community Hospital and the Integrated advice and assessment centre watch this video www.youtube.com/watch?v=KHWWudtgaaU mental health problems, to include supported operates 8am to 6pm seven days a week, housing and employment. We aim to ensure and brings together a wide range of health that people are not held in restrictive settings and social care coordinators working as for longer than they need to be. This will one integrated team. It includes GPs with require ongoing support across the system in enhanced skills to manage chronic and acute supported housing and employment services illnesses, community nurses, social workers, as these are critical to prevention of mental an old people’s mental health worker, a health problems and the promotion of community rehabilitation team nurse, a recovery. community matron, a paramedic and an in- As part of the national Transforming Care reach nurse. Working collaboratively enables Programme we are progressing our plans the team to identify and respond to people to ensure that people who have the most at the highest risk of needing more health complex needs have appropriate and and care with the aim of providing support in personalised care and support. This will ensure the community and reducing the need for an we can reduce the numbers of people who are admission to an acute hospital. The staff use placed in specialist hospital provision outside anticipatory care plans and frailty registers, Dorset. Our three local authorities and Dorset and have close links to local practices to CCG are also developing The Big Plan, a joint strengthen care planning. The hub also has commissioning strategy for people with a access to local ‘step-up’ community beds. In its learning disability which will be implemented first four months the hub has had 500 referrals from April 2017. and the improved care pathways means only 32 people have needed to be admitted Integrated community services: the impact to Dorset County Hospital. Staff also report to date feeling more satisfied and motivated. Important foundations have already been laid towards realising our integrated community The modelling work we are undertaking to services vision, which will help us to increase identify the options on where to locate our the scale and pace at which we can deliver our community hubs will also be informed by the ambitious plan. existing work to locate services together in areas such as Blandford, Bridport, Shaftesbury Our existing Weymouth and Portland and Sherborne. These examples demonstrate Integrated Care Hub has the potential to act the benefits we can realise by using our estate as a blueprint for the rest of Dorset. The hub more effectively and supporting services and covers a network of nine local GP practices teams to work more closely together to meet whom together service 74,000 people. It patient need. Our Dorset Sustainability and Transformation Plan 27

An illustrative example of a Dorset

Vanguard Programme which looks to have a mixed team of health and care out etre t e professionals, as well as volunteers and peer re sre se t e s s e supporters, too provide orers care oter suort that is centred s e t t ees oo trsort seres e e around local people's physical and mental r D health care needs.outeers eer suorters

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An integrated workforce: the impact to date as working through networks or being co- The Better Together Partnership (Better located within hubs. Other practices are still

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frail and older people through robust multi- provisions is appropriate for local need. The agency care management arrangements. funding and planning support from the Local They have also enabled earlier discharge from Dorset Vanguard programme is helping to hospital, increased intensive rehabilitation and accelerate plans. reablement for patients such as those who Community based urgent and emergency have had a stroke, and improved end of care. care: the impact to date At Bridport Community Hospital this is an We have established a standalone urgent care integrated health and social care team integrated advice and assessment centre that working together to support the most handles enquiries from across the county 24 vulnerable local people. Our plan is to create hours a day, seven days a week. It is operated similar integrated health and care teams that by the ambulance service and sits alongside reflect local need across the whole of Dorset. the 999-call centre, NHS 111 control centre GP services: the impact to date and GP out of hours services. It also operates Launched within the last six months, the Local as a ‘single point of access’ through which all Dorset Vanguard programme has provided health and care professionals can organise CCG funding and additional planning support follow-up appointments for individuals in to six GP federations covering all of Dorset, need. By having up to date details of what to help them think how they can work services are available at every hour of the day differently to provide care to local people the hub can ensure local people are supported that meets their needs seven days a week. to access the right care at the right time. Since Some of our GP practices have chosen to work April we have also introduced a new Dorset- together across bigger localities and combine wide labour line that is available directly primary care services with community, social through NHS 111 and provides support for care, voluntary and acute care services to plan women in labour or who have concerns about to deliver services in a range of ways, such their pregnancy. 28 Our Dorset Sustainability and Transformation Plan

Mental health services: the impact to date home treatment services as an alternative Since 2013 there has been important work to hospital admission; and the additional taking place to ensure there is more equitable investment made to establish a recovery house treatment and outcomes for people with to provide an alternative choice of place of mental health problems. care for people in crisis. To improve prevention and increase emotional In winter 2016 a female Psychiatric Intensive resilience more mental health well-being Care Unit will be opened in the county, as education is being delivered in educational currently local people have to travel out of settings with training support for teachers the area. We have also worked in partnership (see page 17). We also have in place Child and with 16 organisations on the development Adolescent Mental Health Service liaison roles and on-going delivery of the Dorset Crisis Care as part of our psychiatric liaison service. Concordat. Our Dorset talking therapy service, Steps to We have commissioned the Alzheimer’s Well-being, is consistently delivering high Society to deliver an innovative pre and post recovery rates that are above the national diagnostic support service for people who target. are concerned about their memory. Dorset In 2013 acute mental health services HealthCare Mental Health acute wards for changed in line with national models and adults of working age and psychiatric intensive developments, which meant that there care unit is one of only two Trusts in the was a reduction in inpatient bed numbers country to be awarded outstanding for acute accompanied by development of crisis and inpatient mental health services.

What our Integrated Community Services programme means for local people

• More choice about when and where to • Easier access to health records and receive treatment information about their treatment • Less travelling time to attend Integrated community services will benefit appointments everyone in Dorset, but there will be • Less time waiting for appointments, particular benefits for older people, who diagnostic tests and test results make up a large and growing proportion of our population (see page 10). Making • Improved health outcomes, with more a wider range of health and care services opportunities to be cared for at home and available closer to home will help people to in the community rather than in a hospital stay in their own homes for longer; avoid setting unnecessary hospital stays which can lead • Better patient experience, with the same to additional health problems and a loss of high standard of care across all health independence; and regain independence and care settings and effective sharing of following a stay in hospital with the help information between health professionals of home-based support and the use of technology. • Support to return home after a stay in hospital, or closer to home, as quickly as possible Our Dorset Sustainability and Transformation Plan 29

Programme 3

One Acute Network est ee er Pol it n aut of Services oml nds ntor of sris One Acute Network is the top tier of our plan. This programme will transform acute services in Dorset so that they meet the complex and specialist needs of Dt e Dorset e or eret our local population.

The network will assign specialist roles to each of hospital and reduce the need for an of our three district general hospitals and inpatient stay, including the provision of create a single skilled network of clinicians more urgent and emergency care who will provide a consistent, high quality • invest over £100 million in refurbishments experience for patients. and enhancements, including a new maternity and paediatric unit in east Dorset Our priorities are to: • establish centres of excellence for patients • provide an integrated frailty service and who need hospital based services improved mental health care, working closely with the Integrated Community • develop a Major Emergency Hospital to Services and supporting the Mental Health provide more urgent and emergency care Acute Care Pathway review (see page 25) 24 hours a day, seven days a week where evidence shows it makes a difference to • deliver a range of primary and community clinical outcomes, including across major services from our acute hospital sites trauma, hyper acute cardiac, stroke, • adopt new technologies that will emergency surgery support a high quality, consistent patient • develop a Major Planned Care Hospital to experience throughout the health system, provide high quality and timely care for with standardised working practices and planned (elective) and day case surgery seamless communication between health professionals • maintain a Planned Care and Emergency Hospital to provide urgent and emergency • join our workforce across Dorset into a single alongside planned and specialist care network working together to support the delivery of more 24/7 services across our • establish single acute networks for services hospitals and the Integrated Community such as cancer, heart disease and stroke, Service programme, as well as enhance so that consistent services are provided for skills acquisition and career and personal people across Dorset development opportunities • support integrated community services to treat where appropriate more people out 30 Our Dorset Sustainability and Transformation Plan

Creating three centres of excellence beds, from a level of 1,810 in 2013/14. The Our plan is to reconfigure the organisation major change will result from shifting beds of our existing three district general hospitals to the planned Major Emergency Hospital into three centres of excellence with better and a reduced number being required at the defined and more specialist roles, to enable Major Planned Hospital. Population changes them to deliver rapid, high quality healthcare would have increased demand for beds to an as part of one collaborative network. estimated 2,465. We want to: Our plan aims to achieve a 25% reduction in • establish a Major Emergency Hospital in the unplanned medical admission by improving east of the county at Poole Hospital or Royal the management of urgent and emergency Bournemouth Hospital, to provide more cases and people with long term conditions, specialist emergency services for the whole and 20% reduction in unplanned surgical of Dorset, with hyper-acute specialist services admissions through the Integrated Community provided at the region’s tertiary centre, Services programme. University Hospital Southampton During 2016/17 we will continue to test our • establish a Major Planned Care Hospital in plans for reconfiguration. We will aim to the east of the county at Poole Hospital or hold a public consultation in late 2016 and Royal Bournemouth Hospital, to provide seek assurance from our local and national higher quality elective services and a 24/7 regulators. Urgent Care Centre (as part of Dorset’s A&E Dorset CCG’s governing body will not make Network) a final decision on the site-specific locations • maintain planned and emergency services until 2017, following the completion of the at Dorset County Hospital in the west of the assurance and public consultation process. We county expect the implementation of the early stages Across the three hospitals we will increase to begin in 2017 and continue over a number the amount of consultant-led care, including of years. an ambition to deliver 24/7 consultant care An integrated workforce in some specialities at the Major Emergency We want our workforce to work across Hospital. This aligns Dorset’s plan with the hospital sites and beyond organisational model of care set out in the Keogh Urgent and boundaries in a single Dorset wide network Emergency Care Review (2013) which evidence of skilled professionals. Our plan is to shows saves more lives. improve the leadership and organisation of Integrated Community Services, in particular our workforce so that there will be a single community hospitals and hubs that form a culture and aligned behaviours. This will help single health and care system for Dorset, will to ensure that local people receive a more support our acute network. Organising our consistent experience of our health and care services in this way – so that they are delivered services. By working more closely together, we as part of a single system of health and care in can plan and deliver a single clinical pathway Dorset, transcending traditional organisational across the county for each specialty rather boundaries – will help us develop a than having variation because different types sustainable, coherent system for current and of services are provided by different hospitals. future generations. A single network, supported by an enhanced use of technology (see our Digitally-Enabled As a result of the proposed One Acute Dorset programme plan on page 37) will also Network we expect the bed capacity in Dorset allow our clinicians to share their skills and to reduce to around an estimated 1,570 expertise more effectively. Our Dorset Sustainability and Transformation Plan 31

Detailed modelling has taken place, alongside an assessment against the six evaluation criteria of quality of care, access to care, affordability and value for money, workforce, deliverability and other issues such as research and development. As a result, Dorset CCG is planning to consult the public on two options for reconfiguring Poole Hospital and Royal Bournemouth Hospital. Dorset CCG's preferred arrangement is Option B.

Dorset County Poole Royal Bournemouth Hospital Hospital Hospital

Option A Planned Care and Major Emergency Major Planned Hospital Emergency Hospital Hospital with with Urgent with A&E services A&E services Care Centre (as part of Dorset A&E Network)

Option B Planned Care and Major Planned Hospital Major Emergency Emergency Hospital with Urgent Care Centre Hospital with with A&E services (as part of Dorset A&E services A&E Network)

Transforming cancer services Transforming maternity and paediatric A key element of our plans for establishing services One Acute Network is to deliver improved We have ambitious plans to improve the outcomes for cancer patients by delivering maternity and paediatric services that are locally the Achieving World Class Cancer delivered in our acute hospitals and in the national strategy and the Wessex Strategic community. We intend to offer a larger Vision for cancer services. By working more and higher quality range of services in the closely with all our partners we will be able community to reduce the need for local to address the fragmentation of the current people to have to attend hospital. This care pathway so that patients experience will include the development of a Dorset- a seamless service. Working in partnership wide children’s community nursing service. with the Wessex Cancer Alliance there will For pregnant women we will increase the be a significant opportunity to strengthen provision of midwife-led care across the and support our local work, in particular county, which will enable more women to around research and clinical trials, as well as be able to choose a home birth, and create prevention. a single team of midwives, health visitors and nurses.

One network

" We want to support our workforce to work across hospital sites and beyond organisational boundaries in a single Dorset wide network of skilled professionals." Paula Shobbrook, Director of Nursing, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust 32 Our Dorset Sustainability and Transformation Plan

We will reorganise hospital based care by • the One NHS in Dorset Acute Vanguard implementing the Royal College review programme being led by our three acute recommendation to consider 'by exploring provider foundation trusts the integration of services between Dorset Clinical Services Review County Hospital and Yeovil District Hospital In 2014, the Clinical Services Review was such that there could be one site delivering started to help us to identify a future model consultant led obstetric care and one site of care to better meet the needs of our local with a midwifery led unit'. If the feasibility population. The project has been managed of this is not agreed within the next six by Dorset CCG with leadership from a months, we follow the recommendation of 6 representative group of senior clinicians, the independent Royal College review for a nurses, allied health professionals and our Dorset-wide network. If implemented, this health and care system’s chief executive, chair will see us move to a midwifery led unit and and lead councillors. paediatric assessment unit at Dorset County Hospital with a high-risk obstetric unit and The work to date has been shaped by consultant delivered paediatric inpatient site the regular and active involvement and at the Major Emergency Hospital in the east of engagement of hundreds of clinicians working the county. in primary care, acute, community, mental health and children’s services, voluntary sector One acute network: the impact to date organisations, our workforce and local people. We have two aligned work streams to develop Alongside input from our Patient, Carer and deliver our transformation plan for the and Public Engagement Group, Supporting One Acute Network: Stronger Voices and Health Involvement • the Clinical Services Review being led by Network. It has also been subject to valuable Dorset CCG scrutiny and assurance from NHS England,

6 Royal College of Paediatrics and Child Health Invited Reviews Programme - Design Review, Dorset CCG (April 2016) Our Dorset Sustainability and Transformation Plan 33

29,000 525 100

Pieces of feedback used Attendees at our public Different forums, meetings to inform our Need to meetings to help design and events to inform and Change. the models of care. engage thousands of local people including staff.

12 3,900 18

Meetings with our Clinical Members of our Health Meetings with our Pan-Dorset Services Review Patient, Carer Involvement Network and 150 Engagement Leads Forum to and Public Engagement Group representatives of Supporting plan and deliver a consistent of representatives. Stronger Voices have received approach to communications regular information and been and public involvement across involved. our health and care system.

Wessex Clinical Senate and our local Joint parts of the NHS and internationally, to help Overview and Scrutiny Committee, as well as shape our ambitions the independent advice of a Royal College • considered the services offered outside of Review that we commissioned to examine our Dorset, such as specialist services delivered maternity and paediatric services. from Southampton, patient flows into This collaborative approach has enabled the Dorset from surrounding counties such as programme to make significant progress Hampshire, and Dorset patients receiving towards making both our One Acute services from non-Dorset hospitals including Network and Integrated Community Services Yeovil and Salisbury programmes a reality. We have: • designed the model of care for One Acute • analysed current and future demand for Network as detailed on pages 29-32 and our services alongside our existing supply, Integrated Community Services as detailed to identify the challenges Dorset currently on pages 21-28 faces – our health and well-being, care and • produced detailed finance, activity and quality and finance and efficiency gaps are 7 workforce modelling to explore the outlined in Need to Change , which involved feasibility of the model of care examining over 29,000 pieces of feedback from the public 8 • undertaken extensive communications and engagement activity with the general public, • reviewed evidence on good practice and patients and carers (see box above) considered service reconfigurations in other

7 Dorset CCG Clinical Services Review Need to Change (January 2014) 8 Reference The Big Ask and Bournemouth University report 34 Our Dorset Sustainability and Transformation Plan

Having obtained Stage 1 assurance in 2015, pace before, during and beyond the external and Stage 2 assurance in summer 2016, Dorset scrutiny of our site specific reconfiguration CCG are now seeking the support from NHS plans. England's Investment Committee. We have recently set out the timetable for Alongside this we have been working closely the delivery of this programme of work and with the Wessex Clinical Senate to address this includes: their detailed valuable independent feedback. 2016 In late 2016 the CCG intends to hold a public • Agreeing the priority activities which will consultation to obtain views of local people include determining where to realign with on our plans, including the site-specific other existing or planned activity. reconfiguration options for our acute and • Agreeing the contracting and financial forms community hospitals. Once the consultation with the CCG along with the framework for and assurance has been complete, Dorset the joint partnership decision. CCG’s Governing Body will then make a decision in 2017. We expect to phase in the • Completing the common IT strategy and implementation of the plans over five years workforce strategy and implementation plan. with the early stages beginning in 2017. 2017 - 2020 One NHS in Dorset Acute Vanguard • New joint partnership will be embedded and programme delivery locations will be organised in line One NHS in Dorset is an early adopter site with the Dorset Clinical Services Review. as part of NHS England’s National Acute • Implementation will have been undertaken Care Collaboration Vanguard Programme. and a significant contribution made to It is focused on delivering the workforce improved patient outcomes, clinical and and organisational cultural and behavioural financial sustainability. changes to have a single network of clinical The intention is to support the development services across Dorset providing higher of one or more Accountable Care Partnerships standards of care in a more consistent way, who will manage and deliver integrated irrespective of where local people live and health and social care to patients across what service they access. By driving more Dorset. This will enable us to incentivise effective leadership and organisation of our patient outcomes and support a collaborative workforce it is therefore the vital mechanism approach across organisational boundaries. to accelerate the implementation of our new models of care, and it can proceed at

One NHS in Dorset

The nine acute hospital based services that have been identified as the priorities for our Acute Vanguard programme. • Cardiology • Paediatrics • Imaging • Pathology • IT and other transaction related services • Stroke • Non-surgical cancer services • Women’s health • Ophthalmology Our Dorset Sustainability and Transformation Plan 35

" These are exciting plans for Dorset’s hospitals that will ensure we have the most modern, high quality and safe hospital based health services for local people. By having more consultant-led care the evidence shows that patient outcomes will be improved. A more consistent quality of service will be enabled by teams working together in a single clinical network. This will also help staff to develop their skills, share best practice and feel more supported." Dr Robert Talbot, Medical Director, Poole Hospital, NHS Foundation Trust

Acute Hospital@Home The Dorset County Hospital Acute Hospital@ What our One Acute Network Home service has been delivered as a pilot in programme means for local people west Dorset to provide aspects of inpatient care in patient’s own homes, to reduce the • Improved health outcomes, including need for additional admission to hospital. The more lives saved by having more care service operates 7.30am to 11pm seven days provided 24/7 by consultants. a week, with access to the admitting medical • Better patient experience, with the same and surgical teams outside these hours. By high standard of care for people across working as part of an integrated team and the county and more effective sharing of improving communication with primary and information and health records between community care teams (including the use health professionals. of an electronic discharge summary), Acute Hospital@Home is helping to ensure frail and • Less waiting time for access to urgent older people as well as those with long-term and emergency care and planned care conditions are provided with safe, high quality operations. care that does not require them to travel. To • Reduction in cancelled planned care date there has been an increase in referrals to operations because of emergency care wider community teams and positive patient needing to take priority. feedback, the intention is to extend the service and embed this work within the Integrated • Less travelling time to attend Community Services programme. appointments as more diagnostic tests, outpatient appointments and rehabilitation will be provided closer to home in community settings. • More support to return home after a stay in hospital as quickly as possible. 36 Our Dorset Sustainability and Transformation Plan

Two enabling programmes of work

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Enabling programme 1 Nursing and Midwifery. We will also build Leading and working differently on the work of our established Primary We will organise our workforce of over 30,000 Care Workforce Centre and our recruitment people more effectively, so they are better campaign www.doorwaytodorset.nhs.uk able to deliver high quality, safe, We have a single integrated leadership team timely, accessible and sustainable health who have already been working together for and care services. two years and includes lead cabinet members This will require closer working between (including the portfolio holders who chair and across teams to deliver an integrated the Health and Well-being Boards), NHS non- seamless service, and to maintain and develop executive chairs and chief officers (including professional skills. the pan-Dorset Director of Public Health). We Our plans for our workforce will help to will continue to develop the capability of this establish Dorset as an exciting place to work, team to work across organisational boundaries so that we can attract the highest calibre of and lead the transformation of our system. We staff into our local communities. We intend expect this to lead to more partnerships within to create more innovative roles, and develop and between organisations and meaningful clear development pathways and placement relationships that are capable of sustaining opportunities across primary, secondary and collaboration alongside competition. To social care for a range of professions working oversee delivery of Our Dorset we have also closely with our education providers. agreed to move towards having an aligned system wide programme management This work will be delivered by implementing approach. our Leading and Working Differently Strategy that has been created with director level To make these major service changes we will leadership from across Dorset’s health and support the development of Accountable social care organisations together along Care Partnerships. These build on existing with Health Education Wessex and Thames partnerships between health, social care Valley and Wessex Leadership Academy, and voluntary organisations in particular the deanery, Skills for Care and the Wessex localities, and will shift the focus to delivering and Regional Workforce Strategic Board for the best outcomes for patients regardless of organisational boundaries. Our Dorset Sustainability and Transformation Plan 37

We are planning to develop Accountable Care This will see us align the digital strategies of Partnerships in Dorset which may reflect the local health and care providers into a single outcome of the current Local Government digital plan for our area. We will implement Review. the Dorset Care Record, a unified record of Practical, early wins for each of the local people’s interaction with services, with Accountable Care Partnerships in the coming a priority focus on clinical record integration year include implementing a single, integrated and record sharing between health and social hospital discharge team, improving integrated care practitioners. This will improve safety care at the end of life and developing and care for patients, by giving professionals integrated care pathways and developing more timely access to the right information to real-time care capacity management systems inform their decision-making. to help reduce unnecessary delays as people We will also provide more information and move from one care setting to another. support, along with expanded access to Enabling programme 2 telehealth and innovative technologies to Digitally-Enabled Dorset enable local people to better manage their We intend to harness the power of technology own health. and support digital innovation by rolling out This digital plan is being developed and the plans in our Digital Vision 2020 strategy delivered by our established Dorset Informatics for a Digitally-Enabled Dorset. Group made up of senior clinical, social care and technical leaders including Chief Information Officers and clinical leaders.

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The governance arrangements for the programme are provided in the Appendix, page 5. 38 Our Dorset Sustainability and Transformation Plan

A sustainable approach to funding Delivering improvements to our health and care system at a time of increased demand but with a lower growth in resources demands a sustainable approach to funding. This underpins all of our programmes of work.

programmes will have on services provided Dorset health economy £m by our local authority and the risks associated The scale of our financial challenge 229 with this. Our solution: How we will jointly We have undertaken financial modelling work achieve our ambitions to calculate the impact of implementing our • Managing demand together 83 plan and to determine that we can close the health economy financial challenge gap by • Provider system efficiencies 100 working together to jointly deliver the Dorset Sustainability and Transformation Plan. • Re-investment in community services -16 • Health system stretch target 34 Managing demand together: £83 million Through working together as one Dorset • Nationally managed programmes 28 health system: • Dorset Sustainability and 229 • NHS RightCare – Reducing unwarranted Transformation Plan variation to improve peoples health: £28 The scale of our financial challenge has been derived from million the 2016/17 planned outturn position with our solutions derived for the period 2017/18 to 2020/21 inclusive. Every health economy in England is expected to embed the NHS RightCare In March 2016 we calculated that a ‘do approach at the heart of their nothing’ scenario would create an annual transformation programmes. It is a financial gap in the local health system by programme committed to improving 2020/21 of £158 million, with a further £32 people’s health and outcomes. It makes million shortfall on NHS England specialised sure that the right person has the right services. Over the summer we have updated care, in the right place, at the right time, our figures based on the latest guidance making the best use of available resources. and modelling and taken into account the We will implement this as part of our total financial position of our NHS providers ongoing work in order to contribute £28 in Dorset. As a result of this our annual million. financial gap over the five year period 2016/17 • Secondary prevention and active to 2020/21 has increased to £229 million. management: £27 million This includes a shortfall of £20 million on Through our Prevention at Scale and specialised services. Integrated Community Service programmes Meanwhile, local authorities in our footprint we expect to invest more in community have identified a funding gap of over £70 and home care services, improve secondary million in the same period and of this, the prevention and active management and potential amount attributable to social care develop enhanced management of long is £37 million. This is in addition to a further term conditions. As a result of this we £13 million of savings on social care already expect to reduce the demands on our planned for the period. We are continuing to hospitals to the value of £27 million. model the impact that our NHS transformation Our Dorset Sustainability and Transformation Plan 39

• Outpatients: £8 million the 2016/17 financial framework, with We have identified many opportunities to a further contribution of £81 million modernise and develop outpatient services. required across the remaining four year Some outpatient appointments may no period 2017/18 to 2020/21. The Acute longer be required, some may be delivered Care Collaboration (Vanguard) has through alternative delivery models, some ambitious plans for strengthening Dorset may be delivered by different staff skill mix clinical networks, pathology services and some may be delivered closer to the and efficiencies associated with business person’s home –which is the cornerstone support services, which will be key to how to our Integrated Community Service this scale of ambition is delivered. programme. Overall, this could contribute • Acute hospital reconfiguration; £19 million up to £8 million. Once the proposed acute hospital • Specialised services; £20 million reconfiguration is fully operational By working jointly with NHS England we (2020/21), it is estimated that this will will jointly identify an appropriate plan contribute annual efficiencies of over for specialised services, which would be £19 million each year. Our clinically- expected to directly offset the estimated led discussions set out that this would shortfall of £20 million against these be achieved through a 30% increased services. This will include business as efficiency associated with having all usual efficiencies at approximately 1% planned services on one site, and a 20% and transformational activities for the increased efficiency from bringing our remainder supported by the production emergency services together. of an outline vision for specialised services This ambitious acute transition programme delivered within Dorset. requires capital investment of between Provider efficiencies: £100 million £148 million and £189 million in order • Cost improvement plans across all four to improve the existing hospital estate NHS foundation trusts: £81 million and to create new wards and units where Our local providers have agreed to required, for the Major Emergency Hospital contribute at least 2% savings on their and Major Planned Care Hospital in the existing cost base, supported by the east of the county. This capital investment national Lord Carter work programme. would be spread be over a five year period This would see the delivery of more with the savings contribution only realised appropriate services with better outcomes at the end of the transition period. for less money by maximising effectiveness This investment decision is subject to public across the workforce and in areas such consultation under the Dorset clinical as supplies, information technology and services review, and would require a full estates. During the current year plans business case. are already underway to deliver within 40 Our Dorset Sustainability and Transformation Plan

Re-investment in community services: -£16 built up commissioner surplus above the million nationally required 1%. As part of our Dorset health economy plan Nationally managed programmes: £28 to develop community services, we would million re-invest community provider savings made • Sustainability and Transformation Fund; as part of the above cost improvement plans £53 million in developing community services. This is an As part of the confirmed national essential part of delivering our Integrated NHS funding allocation to 2020/21, a Community Services plans for integrated sustainability and transformation fund community teams and community hubs. (STF) has been earmarked. Whilst there Health system stretch target: £34 million is limited detail as to how this will be We jointly expect to be able to significantly distributed over the final two years 2019- expand and develop Dorset-wide working in 21, the Dorset system has been advised clinical and non-clinical areas from 2018/19 indicative non-recurrent allocations for onwards. There is scope to utilise our the next two years 2017-19 of £18.9 resources and estate much more efficiently million per annum. By 2020/21 it has been by working as one NHS in Dorset, enabled by assumed that the Dorset health system our ‘Digitally Enabled Dorset’ and ‘Leading would receive £53 million recurrently and Working Differently’ programmes. as a contribution to achieving financial In addition as a system we are looking sustainability for health services across to work differently to mitigate expected Dorset and support investment in growth in demand. These plans are still nationally sponsored programmes. being developed in order to determine the • National programmes; -£25 million programmes of work to deliver the required In closing the financial gap through contribution. the other programme areas identified Included within this to close the gap is above it has enabled us to protect the the use of £2m per year from the historic transformational element of the STF fund, noted above, we have estimated a

The recent publication of the STP indicative allocations has suggested £53m that Dorset should receive a £53 million sustainability and transformation fund by 2020/21. Our Dorset Sustainability and Transformation Plan 41

programme delivery cost of £25 million. Prevention at Scale These programme areas support the There are additional expected finance and delivery of the five year forward view to efficiency improvements that will be delivered close the care and quality gap including by addressing the wider determinants of prevention, childhood obesity, diabetes, health, undertaking: dementia, cancer, GP access and national maternity review areas. • Smoking prevention programmes in schools can return as much as £15 for every £1 spent, There are two programmes that underpin as can anti-bullying interventions. our savings plans, Integrated Community Services and Prevention at Scale, which are • Getting one more child to walk or cycle to looked at here in slightly more detail. school could pay back as much as £768 or £539 respectively in health benefits, NHS Integrated Community Services programme costs, productivity gains and reductions in air reconfiguration pollution and congestion. We are at an early stage of determining • Housing interventions to keep people warm, the financial implications of the model of safe and free from cold and damp could save Care for the Integrated Community Services the NHS £70 over 10 years for every £1 spent. programme. We know that workforce costs make up around 70% of our local revenue • Every £1 spent on befriending services saves costs. We need to deliver care in new ways, £3.75 in reduced mental health spending our workforce will need to be reorganised and improvements in health. to deliver services in the right place and • Every prevented visit to an NHS service with the appropriate skill set. The finance results in a saving: £31 for a GP visit, £114 working group will be reviewing the proposed for an A&E attendance and £3283 for an options for how the public sector estate across inpatient stay in hospital. Dorset could be better organised to deliver We will be continuing to refine and check community services by considering value for our assumptions and savings plan based on money, capital requirements, feasibility and national funding allocations and efficiency deliverability. requirements, while also closely monitoring There will be a transition period where we how our plans are delivering the required need to run some services in tandem, while savings. Overall, we will spend more in 2020/21 we train staff and develop new care pathways when compared with current levels but we that will require temporary additional running will be ensuring more efficient use of our costs and investment in parts of our estate. available resources to meet the needs of our Our plans will ensure that the funding of population. services will reflect patients’ need, to ensure Given the leadership we have in place and our that the whole Dorset system will remain in changing culture we are confident that these financial balance. finance and efficiency interventions will see us We expect to be investing in our ICS deliver a financially balanced health system, programmes and for the programme to alongside improvements in quality and safety enable savings to be released in the other for all those who use Dorset's health and care programmes we have identified above services. 42 Our Dorset Sustainability and Transformation Plan

The national support 5 we need

We are proud of Our Dorset and the scale of our ambitions to deliver a transformed health and care system focused on meeting the needs of our local population. We have a vision that we all support; a plan that we all agree will close gaps in health and well-being, care and quality, and finance and efficiency gaps; and some immediate priorities that we are all focused on delivering. We are all committed to working hard and at pace to realise our plans over the next five years.

Our Dorset already has important foundations patient benefit case so that it is likely to be in place. Crucially, there is a positive supported by NHS Improvement and the relationship between the organisations across Competition and Market Authority. our health and care system and we have a As part of our Acute Vanguard programme, track record of working together to devise we would like legal expertise to help and deliver services. Recently strengthened determine the format and structure of the leadership and governance arrangements ‘vehicle’ that will be established to deliver our will help us to accelerate the delivery of single clinical network and workforce. Support our plans. Our Clinical Services Review and with shaping workforce models, building skills Acute Vanguard programmes mean we are and developing our training plans would also not at a standing start: much of the analysis help to ensure we grow the right workforce to and modelling work is complete and we are meet our future care models. quickly moving towards the implementation phases. We can also build on existing good Our local authorities are seeking peer support practice such as the Weymouth and Portland to understand the approach of other health Hub, the integrated health and care teams and care systems and to share the learning, operating in a number of community hospitals particularly from those who are have been and the Acute@Home service. early adopters of new ways of working. We would welcome national support to help us We are in a strong position, but national set reasonable expectations about the scope support and investment would enable us to and pace of partnership working, as well as move faster to deliver the changes we are assistance to develop appropriate outcome aiming for. measures. Expert advice and support We would like support from our local MPs and Receiving national expert support and elected members for our plans, particularly assistance around patient benefits would around best use of our estate and our site- strengthen our plan. While our modelling specific reconfiguration plans. National work has indicated how our proposals will support could help local politicians to feel benefit local people, we will be working with they can confidently back the need for change strict national regulations around maintaining and proposed plans for the Dorset health and patient choice and quality standards when care system. This will be particularly important hospitals are reconfigured. We would like before and during the forthcoming periods of assistance to review and strengthen our transition as we embed the changes. Our Dorset Sustainability and Transformation Plan 43

Our specialised services are commissioned We will also require investment in our nationally by NHS England using national community hospitals and primary care estate, guidance and service specifications across a to make sure our estate is appropriate for geographical footprint that is different to the planned community hubs and improved the area covered by our Dorset health and integrated community care services. As part care organisations that have developed our of our ICS plan, current modelling suggests plan. While we have been working with that this can be funded from existing capital NHS England on the commissioning of these allocation. services it has been difficult to identify the We would like national support for our capital specific plans and opportunities that address requirement of our acute plans, to help with the needs of our local population. Assistance obtaining assurance from the investment from NHS England to define the health and committee so that we are in a position to well-being, care and quality and finance and bid for transformation funding and that efficiency gaps within these specialist services our Foundation Trusts are successful in their would be welcomed. application to the Independent Trust Financing Investment support Facility. There are important elements of our plan To date, our Acute Vanguard programme has that require financial investment, especially received approximately 10% of the original to deliver the proposed reconfiguration funding request. This is going to make it of our acute hospitals. If following public difficult for the leadership and workforce consultation and national scrutiny we progress across our hospitals to allocate the time to with the site-specific option, from 2018 we are develop the clinical networks we need. The going to need between £147 and £189 million Health Foundation and The King’s Fund spread over five years or more. These capital state that transformation on the scale we estimates are based on national best practice have outlined will require a period of double and we anticipate that actual build costs running. To be able to deliver our plan at pace could be 20-30% cheaper. The £19 million cost we will need the £10million Acute Vanguard savings come from the reconfigured hospitals funding that has already been committed. will mean that the capital investment pays for We also recognise that additional transitional itself in four to seven years depending on the funding in the region of £6 million will final costs. be required to cover double running/ non This investment will be required in tranches recurrent costs, across all our programmes over a five-year period as we extend and during the five year period (this has not been enhance our hospitals. For instance we would built into the financial modelling). propose to develop our joint pathology We are confident that investment now will capacity first at an initial cost of around help to realise the estimated financial saving £11 million. and other patient benefits of the the Dorset Sustainability and Transformation Plan.

9 Making change possible: a Transformation Fund for the NHS. The Health Foundation and The King’s Fund Research report (July 2015) 44 Our Dorset Sustainability and Transformation Plan