Cambridgeshire & Peterborough North Alliance Integrated Neighbourhoods Implementation Plan
December 2018
Confidential Draft: work in progress Scope and Geography Wisbech population: 48,000
Peterborough population: The North Alliance can broadly be sub-divided 277,000 into three areas; • Greater Peterborough • Huntingdon Huntingdon population: • Wisbech 240,000
Based on the populations of these areas, the North is likely to have up to 12 Integrated Neighbourhoods.
The approach for defining the geography for the Integrated Neighbourhoods is currently being explored and is considering: • Current service provision • Population health data • Population economics • Knowledge of natural communities
The North Alliance aims to agree the geography of the first 3 Neighbourhoods by January 2019. This map is a visual representation and the actual boundary lines will be confirmed when the neighbourhood coverage is 2 Confidential Draft: work in progress agreed Key Milestones: Overview
2018/2019 2019/2020 2020/2021
Formation of Integrated Neighbourhoods Programme Greater Peterborough Greater Peterborough remaining Accelerator Sites (3) coverage (3)
Huntingdonshire Huntingdonshire remaining coverage (3) Accelerator Site (1)
Wisbech
3 Confidential Draft: work in progress Key Milestones: 2018/2019
Jul-Sep Oct-Dec Jan-Mar
Q2 18/19 Q3 18/19 Q4 18/19
Agree NADG Appoint 3 Form Integrated Away Clinical NADG N’hoods as Day Leads NADG priority
Establish IDB Complete Ask & Offers to Develop project brief and plan for Implementation of operational for generate operational ideas 10 operational workstreams workstreams in G.P’borough G.P’borough
G.P’borough N’hood groupings N’hoods identified agreed for across all of PB G.P’borough
N’hood Events for early adopters to develop local programme based on population need Heat map of N’hood readiness groupings Hunts n’hood completed for agreed for 1 identified Hunts Hunts
Assess Wisbech’s readiness
4 Confidential Draft: work in progress Key Milestones for North Alliance Integrated Neighbourhoods 2019/2020 Apr-Jun Jul-Sep Oct-Dec Jan-Mar
Q1 19/20 Q2 19/20 Q3 19/20 Q4 19/20
Implementation of operational workstreams in G.P’borough
Remaining N’hood Events for N’hood Leadership Implementation of local work programme for G.P’borough N’hood early adopter G.P’borough rest of PB sites to meetings established site (3). This will be decided by the Integrated Neighbourhoods, based on N’hoods develop local for G.P’borough (3) population health data and community insight. identified programme based on population need
Review current operational Develop Hunts Establish IDB workstreams and Implementation of operational programme plan for for Hunts complete ask & offers to workstreams in Hunts operational workstreams generate local ideas
N’hood Event for Hunts 1 N’hood Leadership Implementation of local work programme for Hunts 1. This will to develop local meetings established for be decided by the Integrated Neighbourhood, based on programme based on Hunts 1 population health data and community insight. population need
N’hood Event for Implementation of local work Wisbech to programme for Wisbech This will be Link Wisbech develop local decided by the Integrated with GPN IDB programme based Neighbourhood, based on population on population health data and community insight. need 5 Confidential Draft: work in progress Key Milestones for North Alliance Integrated Neighbourhoods 2020/21 Apr-Jun Jul-Sep Oct-Dec Jan-Mar
Q1 20/21 Q2 20/21 Q3 20/21 Q4 20/21
N’hood Leadership meetings established Implementation of local work programme for G.P’borough N’hood 4,5,6,7. This for G.P’borough will be decided by the Integrated Neighbourhoods, based on population health 4,5,6,7 data and community insight.
N’hood Events for N’hood Leadership Hunts N’hood Implementation of local work programme for Hunts N’hood 2,3,4. This meetings established Hunts N’hood 2,3,4 to develop will be decided by the Integrated Neighbourhoods, based on population for Hunts 2,3,4 2,3,4 identified local programme health data and community insight. based on population need
Implementation of local work programme for N’hood Leadership Wisbech. This will be decided by the Integrated meetings established Neighbourhood, based on population health for Wisbech data and community insight.
6 Confidential Draft: work in progress The Problem The Intervention The Mechanism The Outcomes
MODERATED COST OF DELIVERY Ageing population, more complex Inputs Outputs Workforce upskilled to manage complex needs needs in the community Reduced length of stay in hospital and GOVERNANCE. An agreed model of MDT decrease in DTOC working Reduced emergency admissions to Financially challenged system System Leadership – HCE, System-wide commitment to GPs supported by MDTs to manage complex hospital North Alliance patients in the community MDT working Increased referrals to non-medical Greater Peterborough interventions People not connected to help and Integrated Delivery Board MOU – how roles/ functions work together support early enough Joint accountability for care management in Reduced paperwork – multiple Neighbourhood Leadership the community assessments, hand-offs Teams Shared care plan template Recruitment and retention of aligned to summary care record Reduced admissions to residential and workforce difficult Practice monthly face-to-face nursing care MDTs Effective MDT approach in primary, Communications plan IMPROVED HEALTH AND WELLBEING community and secondary Lack of clinical capacity Virtual weekly MDTs Patient engagement and Increase in care plan/meds reviews involvement Help and support needs identified, people Proactive case finding, Map of 30k-50k connected to community assets for prevention Increase in MDT working with care Multiple providers helping the same identify and refine at risk Neighbourhoods built around and self-management homes person – not co-ordinated cohort GP practice lists Patients/carers signposted to other Patients at risk supported to manage their support Refer patients for MDT Health needs/priorities at own condition and learn how to access Reliance on urgent and emergency working/support/intervention Neighbourhood level support Reduction in falls services Establish shared care plan Resource map each that all parties have access to Neighbourhood Team People supported to recover and be re-abled More patients supported to self-care People requiring ongoing care for at home – stay independent for longer preventable reasons, e.g. falls Deliver care plan – ensure Neighbourhood dashboard - IMPROVED QUALITY OF CARE holistic approach metrics of success More people have a new or revised Multiple governance, contractual, Relationships and trust – Commissioner intentions Shared, accessible care plan that links to care plan performance measures driving MDT working becomes the 2019/20 summary care record . behaviour norm Increased staff and patient satisfaction
Shared training opportunities Issues, risks, lessons learned Patient/carer connected to non- No shared definition of MDT working medical services and support Increase in range of services in community Greater Peterborough Integrated Teams Logic Model (DRAFT)
7 Confidential Draft: work in progress Approach & Methodology for Identifying the Primary Care Networks
Groupings are based on geography and population demographics, supported by Public Health (SK), considering: • Deprivation / Ethnicity / Disease Prevalence / Activity Data
Deprivation Risk Factors Broad measure of health Principal diseases 3 Primary Care Population % population Population % 18 to 74 IMD score IMD Rank in % non white Smoking Under 75 % population in Life Life expectancy % population Emergency Elective Admission CHD Prevalence COPD Prevalence Respiratory CVD 1 1 1 2 6 4 4 1 7 7 Network <18 years <18 years >= 75 years Greater British Prevalence Mortality good or very good expectancy - - female >= 75 years Admission Rate per Rate per 100,000 premature premature 3 5 4 9 4 4 Peterborough health male 100,000 patients patients 9 mortality Mortality
PCN1 2,598 23.5% 1,184 65.7% 9.6 28 8.2% 11.0 216.8 85.8% 82.9 86.1 10.7% 73 123 3.6 2.0 11.2 60.3 PCN1 1,423 18.5% 726 72.0% 13.4 26 6.1% 11.8 235.1 85.3% 81.3 85.3 9.5% 77 121 3.4 2.5 15.4 50.2 PCN1 3,551 21.9% 1,075 71.4% 12.2 27 9.2% 15.0 247.0 84.8% 83.6 85.5 6.6% 92 129 2.7 2.1 17.4 63.0 PCN1 1,135 24.4% 260 70.0% 20.4 20 20.0% 12.7 315.0 83.0% 79.9 83.7 5.6% 99 131 2.4 1.8 16.3 87.1 PCN1 1,045 20.6% 280 73.9% 16.6 24 13.8% 14.1 296.4 82.9% 80.8 86.9 5.5% 81 125 2.2 1.4 44.0 36.5 PCN2 712 25.6% 120 70.1% 25.5 16 45.7% 19.7 466.1 81.0% 76.8 80.1 4.3% 98 69 2.1 2.3 11.0 120.1 PCN2 1,615 23.1% 412 71.0% 21.2 18 33.2% 13.6 224.5 81.7% 93.8 88.2 5.9% 78 119 2.0 0.9 16.0 28.1 PCN2 1,354 25.6% 228 70.0% 38.0 2 33.6% 28.4 462.0 80.1% 78.0 83.0 4.3% 109 102 2.0 1.8 35.6 118.7 PCN2 1,269 29.8% 114 67.5% 39.4 1 46.9% 29.0 504.1 78.9% 74.7 77.4 2.7% 97 68 2.5 2.0 28.0 151.2 PCN2 3,600 25.7% 726 69.2% 29.3 15 20.4% 24.2 394.4 80.7% 78.5 82.7 5.2% 86 83 2.3 1.5 28.1 95.5 PCN2 1,215 30.2% 116 66.9% 35.9 6 46.1% 22.6 505.2 80.3% 79.4 82.2 2.9% 108 99 2.2 1.7 70.6 149.4 PCN3 1,939 27.6% 225 69.2% 20.0 21 23.5% 19.3 333.0 84.3% 80.7 85.4 3.2% 73 101 1.3 1.2 34.8 105.0 PCN3 3,268 24.7% 772 69.4% 30.5 10 19.4% 22.6 499.2 81.4% 76.0 80.7 5.8% 94 105 2.7 1.9 45.0 109.1 PCN3 2,663 21.5% 1,036 70.2% 24.3 17 21.4% 22.8 346.6 80.9% 80.5 87.7 8.3% 86 101 3.1 1.7 50.7 72.3 PCN3 1,357 25.2% 280 69.6% 32.0 8 18.6% 24.8 396.2 80.8% 78.4 83.3 5.2% 98 71 3.1 1.9 77.5 69.7 PCN3 3,014 32.3% 284 64.7% 15.5 25 24.7% 15.3 419.5 89.4% 77.6 79.0 3.0% 93 74 1.2 0.5 30.1 64.2 PCN4 4,923 19.5% 2,567 70.3% 30.3 11 37.1% 21.9 343.6 80.2% 80.5 83.2 10.2% 100 102 3.8 2.7 39.4 86.9 PCN4 412 21.7% 241 65.6% 29.8 12 40.7% 16.1 339.6 80.5% 78.3 - 12.7% 96 103 3.5 1.9 24.7 85.1 PCN4 807 19.4% 424 70.4% 29.7 14 35.0% 20.3 278.0 80.5% 80.6 85.6 10.2% 90 105 3.9 2.6 30.9 52.5 PCN4 2,129 23.0% 700 69.4% 30.8 9 40.9% 18.5 344.0 80.6% 79.0 83.1 7.6% 98 98 3.7 1.7 56.2 76.8 PCN4 1,723 22.1% 665 69.3% 29.8 13 36.7% 21.0 355.2 80.3% 78.5 81.7 8.5% 97 97 3.7 2.0 28.3 88.5 PCN5 2,885 24.1% 654 70.5% 36.1 4 26.5% 26.1 349.6 80.5% 79.5 83.6 5.5% 85 82 2.7 2.2 49.3 92.6 PCN5 3,468 28.5% 260 69.4% 38.0 3 56.9% 32.6 431.7 80.3% 78.5 82.2 2.1% 107 80 1.6 1.0 72.6 120.0 PCN5 6,259 25.6% 408 72.7% 35.9 5 47.0% 39.9 340.0 80.3% 80.8 84.8 1.7% 88 87 1.3 0.9 27.0 98.5 PCN5 3,009 21.3% 542 74.8% 35.3 7 45.3% 29.1 345.4 80.4% 80.1 85.3 3.8% 84 82 1.4 1.2 45.0 60.4 PCN6 1,291 16.9% 904 71.3% 18.9 23 5.0% 17.6 325.7 79.6% 79.7 81.4 11.8% 93 119 4.2 2.6 31.5 97.9 PCN6 1,683 20.5% 720 70.7% 20.5 19 8.5% 17.4 297.6 81.7% 81.2 81.6 8.8% 89 104 3.4 1.6 32.6 56.6 PCN6 4,296 22.2% 1,500 70.0% 19.7 22 10.6% 18.3 290.0 79.6% 81.6 84.5 7.8% 88 114 3.0 2.1 26.1 69.8 8 Confidential Draft: work in progress Key Next Steps
• Recruitment of Clinical Leads (1 x Peterborough, 1 x Hunts, 1 x Wisbech)
• Confirm the 3 accelerator Neighbourhoods for Greater Peterborough
• Be able to narrate the compelling story; how the groupings emerged
• Assess readiness of Integrated Neighbourhoods in Huntingdonshire and associated timetable
• Create project brief for 10 operational workstreams for Greater Peterborough and assess scale, feasibility and potential impact (timeframe dependant on resources)
• Continue to strengthen the links with the prevention work as this aligns well
• Strengthen the links to the Think Communities programme
9 Confidential Draft: work in progress