New Models of Care Vanguard Site Details

New models of care ‘vanguard’ site details

Twenty-nine sites have been selected to be part of a national pilot programme – ‘the vanguard’ – for 3 of the new models of care outlined in the Five year forward view. This briefing contains some information on the 9 Primary and acute care systems and 14 Multispecialty community providers chosen. Information on the 6 Enhanced health in care homes sites is not included here. A map and list of all the vanguard sites can be found at annex 1.

Primary and acute care systems (PACS)

1. Wirral University Teaching Hospital NHS Foundation Trust/Wirral Health Partners Target patient group/population? Older people at potential risk of serious fracture following minor falls. Aims? Reduce readmissions; avoid serious fracture; support people to remain at home through primary/secondary care collaboration and expanded integrated care teams. Means? Identify older people at potential risk of serious fracture following minor falls that result in emergency admission; provide care plans, home assessments; technology enabled population health model. Partners? Wirral University Hospital NHS Foundation Trust; Cheshire and Wirral Partnership NHS Foundation Trust; Wirral Community NHS Trust; Wirral Clinical Commissioning Group; GPs on the Wirral; Wirral Metropolitan Borough Council; Cerner UK Ltd; Advocate Physician Partners ACO (USA based); The King’s Fund.

2. Mansfield and Ashfield and Newark and Sherwood CCGs/Better Together Programme Board Target patient group/population? Older people following acute episodes. Aims? Whole system integration of hospital, community, social and primary care within a single outcomes-based capitation contract. Help older (and other) people stay at home after an acute episode, rather than being admitted to a care home. Means? Home-based proactive care; single front door and integrated triage at ED; locality- based integrated care teams; specialist intermediate care teams, community-based crisis response teams; referral GP review and specialty triage for referrals; improved data sharing between Primary and Secondary care providers; integrated data sharing between ED and out of hours GP services. Partners? Mid Nottinghamshire Clinical Commissioning Groups (Mansfield and Ashfield and Newark and Sherwood CCGs); Aspirant Accountable Provider Alliance (Sherwood Forest Hospitals NHS Foundation Trust, Nottingham University NHS Trust, United Lincolnshire Hospitals NHS Trust, East Midlands Ambulance Service, Nottinghamshire Healthcare NHS Trust, Central Nottinghamshire Clinical Services, Circle); Voluntary Sector Special Purpose Vehicle (three District Council CVSs); General Practice Provider Clinical Cabinet (facilitated by the Local Medical Committee); Nottinghamshire County Council.

3. Yeovil District Hospital NHS Foundation Trust Target patient group/population? 1,500 South Somerset residents with multiple, long-term conditions. Aims? Provide integrated care in three hubs bringing together primary, secondary, community and social care in one place; less duplication, fewer delays; more proactive health and care services; prevent unnecessary admissions to hospital; enable independent and healthy lifestyle. Longer term benefits for the whole community through improved processes and networking with neighbouring trusts. Means? Hubs will provide care co-ordination, multidisciplinary teams, senior medical input and a single personalised care plan; remote monitoring of conditions, patients to use ‘Patients Know Best’ web platform to view their plan and keep in contact with the hub team. Single budget for the population; GPs provide ‘enhanced primary care’ such as health coaching to patients with less complex conditions.

Prepared by the BMA’s Health Policy and Economic Research Unit (HPERU) 2 Partners? Yeovil District Hospital NHS Foundation Trust, Somerset CCG, South Somerset Healthcare GP Federation and Somerset County Council.

4. Northumbria Healthcare NHS Trust/Northumberland Integration Board Target patient group/population? Entire adult population (?). Aims? Help communities to live long and healthy lives at home; prevent weekend visits to the Emergency Department. Bring together commissioning responsibility for acute, community and primary care. Means? Opening of Northumbria Specialist Emergency Care Hospital; primary care ‘hubs’ open seven days a week; enhanced access to community nursing services; fully-coordinated discharge and shared IT. Partners? The Northumberland Integration Board is made up of Northumbria Healthcare NHS Foundation Trust (Lead Partner); Northumberland Clinical Commissioning Group; Healthwatch Northumberland; Northumberland County Council; Northumberland Primary Care Practices; Northumberland Tyne and Wear NHS Foundation Trust and North East Ambulance Service.

5. Salford Together Target patient group/population? Entire adult population (230,000) Aims? Create an Integrated Care Organisation responsible for meeting the health and social care needs of the population through both direct provision and contracts with other local providers (Salford Royal will lead). Means? Transfer Adult Social Care services to Salford Royal and establish arrangements for adult and older peoples’ mental health services. New model of care comprising 1) multidisciplinary groups to identify people who are at most risk of becoming more unwell and to coordinate services around their needs 2) build supportive networks with the voluntary sector for individuals who are at risk of becoming socially isolated 3) create a single centre for people to contact to guide them to the right support or services, as well as providing health coaching for people with long term conditions. Partners: NHS Salford Clinical Commissioning Group, Salford City Council, Salford Royal NHS Foundation Trust and Greater Manchester West Mental Health NHS Foundation Trust. Plus active support and engagement from Salix Health, the local GP provider consortium.

6. Lancashire North/ Better Care Together Programme Target patient group/population? Morecambe Bay population of 365,000. Aims? Bring together responsibility for the whole health and social care needs of the population within a single budget. Keep individuals, families and communities healthy. Means? Smaller, more productive hospital service working; integrated out of hospital services; develop capacity in general practice and community services. Partners? University Hospitals Morecambe Bay NHS Foundation Trust; Cumbria Partnership NHS Foundation Trust; Blackpool Teaching Hospitals NHS Foundation Trust; Lancashire Care NHS Foundation Trust; North West Ambulance Service NHS Trust (NWAS) and two NHS Clinical Commissioning Groups: NHS Lancashire North Clinical Commissioning Group and NHS Cumbria Clinical Commissioning Group; Lancashire County Council and Cumbria County Council; the North Lancashire Medical Group and the South Cumbria Primary Care Collaborative (GP provider federations).

7. North East Hampshire and Farnham CCG Target patient group/population? 220,000 in North East Hampshire and Farnham. People with respiratory and cardiac problems and people who have fallen are specific local needs. Aims? Develop an integrated health, social care and wellbeing system which will put the person at the centre of their care; help people avoid hospital; improved wellbeing. Means? NHS and social care services will share resources and skills to support people to stay healthy and well at home; care provided by local multi-disciplinary teams working together, across physical and mental health services and in partnership with the voluntary sector to provide a personalised service.

Prepared by the BMA’s Health Policy and Economic Research Unit (HPERU) 3 Partners? Frimley Health NHS Foundation Trust; Southern Health NHS Foundation Trust; North Hampshire Urgent Care (OOH PC); Surrey and Borders Partnership Foundation Trust; Hampshire County Council; NHS North East Hampshire and Farnham CCG; primary care providers.

8. Harrogate and Rural District CCG Target patient group/population? Individuals in crisis 24/7 Aims? Prevent people in crisis 24/7 from using A&E as first point of contact. Provide support to remain independent, safe and well at home Means? Provide advice and information 24/7; care plans; community hubs; integrated team which includes GPs, community nursing, adult social care, occupational therapy, physiotherapy, mental health and the voluntary sector. Partners? Harrogate and District NHS Foundation Trust, Harrogate and Rural District CCG, North Yorkshire County Council, Tees Tees, Esk and Wear Valleys NHS Foundation Trust, Harrogate Borough Council, Yorkshire Health Network.

9. Isle of Wight/’My Life, A Full Life’ Target patient group/population? 140,000 Aim? Develop person-centred, coordinated health and social care services for the island; better outcomes for people, working with local communities to build capacity and resilience of people, families and carers. Means? Greater use of digital technology coordinated through a single point of access; patient-led monitoring; primary care led integrated locally based services, delivering care out of hospital right across the Island. Partners? Isle of Wight CCG, Isle of Wight NHS Trust, Isle of Wight Council and the GP collaborative One Wight Health (all 17 GP practices). Multispecialty community providers (MCPs)

10. Calderdale Health and Social Care Economy Target patient group/population? One urban and one rural locality, representing 50% of the population. Aims? Deliver integration across all services outside of a hospital setting, through a single point of access Means? Joint community-based, multi-disciplinary teams made up of community, social care, primary care, mental health and pharmacy services. Partners? Calderdale Pennine GP Alliance (represents 23 out of 26 Calderdale practices), Calderdale and Huddersfield Foundation Trust, Calderdale Clinical Commissioning Group, Calderdale Metropolitan Borough Council, South West Yorkshire Partnership Foundation Trust, Locala Community Partnerships (NHS), Voluntary Action Calderdale (represents 128 health-related 3rd sector organisations).

11. Derbyshire Community Health Services NHS Foundation Trust Target patient group/population? 97,000. Frail and vulnerable people mentioned specifically as well as those with LTCs (diabetes, chronic vascular disease and chronic lung conditions). Aims? Deliver population health service through local provider integration (health, social care, voluntary sector) and a capitated budget for populations of Erewash. Deliver services to people who do not require hospital services and can be treated for their conditions in a community or home setting. Means? Prevention team made up of health and care professionals including GPs, advanced nurse practitioners, mental health nurses, extended care support and therapy support. Care planning for people with LTCs; extend access to GP services; treatment plans for most vulnerable people accessible on A&E and Out of Hours computer systems.

Prepared by the BMA’s Health Policy and Economic Research Unit (HPERU) 4 Partners? Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, Erewash GP Provider Company, Derbyshire Health United (Out of Hours Service & 111) and NHS Erewash CCC.

12. Fylde Coast Local Health Economy Target patient group/population? 1,000 people, frail and elderly population. Aims? Create new models of care, wrapped around local people, spanning across all health and social care services. Means? Integrated teams of community nurses, allied health professionals, social care, mental health and third sector will be fully implemented by April 2016. ‘Extensive Care Teams’; access to one care record to support the patient in their treatment. Partners? Fylde and Wyre Clinical Commissioning Group (CCG), Blackpool CCG, Blackpool Teaching Hospital NHS Foundation Trust, Lancashire County Council, Lancashire Care NHS Foundation Trust and Blackpool Council.

13. Vitality (Birmingham) Target patient group/population? 70,000 Aims? Develop a health and social care system accessible through GP practices, with a care-coordinator to support patients on their journey. Means? Deliver medical services from a number of primary care centres across Birmingham and Sandwell; expand the range of social, mental, community and enhanced secondary care services on offer to patients by delivering community outpatient and diagnostic services. Partners? Single, local GP partnership called Vitality Partnership which operates from 15 practice sites across Birmingham and Sandwell and serves a registered population of 70,000 patients.

14. West Wakefield Health and Wellbeing Ltd Target patient group/population? 63,000 Aim? Fully-integrated, expanded and digitally-mature primary health and wellbeing system. Means? Improved 7 day service; improved integration of community workers with community pharmacy; create a team of care navigators; innovative digital technology. Partners? West Wakefield Health and Wellbeing Ltd (6 GP practices); NHS Wakefield CCG , Wakefield Council, Wakefield District Housing. Supported by South West Yorkshire Partnership NHS Foundation Trust, Wakefield Healthwatch, Mid Yorkshire Hospitals NHS Trust, Nova (VCS representative body), Yorkshire Ambulance Service and Local Care Direct.

15. NHS Sunderland CCG and Sunderland City Council/Better Health for Sunderland Target patient group/population? 284,000 Aims? Transform out-of-hospital and in-hospital care; enable self-care, person-centred, co-ordinated care; elderly patients will be encouraged to recover in their own homes, or be placed in supported accommodation including care homes if that better suits their needs. Means? Multi-disciplinary teams; focus on more proactive, patient-centred care and prevention. Partners? GP Federations – Sunderland GP Alliance and Washington Community Health Care, South Tyneside Foundation Trust (provider of Sunderland community services), City Hospitals Sunderland Foundation Trust (acute trust), Northumberland Tyne and Wear Foundation Trust (provider of mental health services in the city), Sunderland Care and Support Services (provide much of the previous Local Authority direct provision for adults), Sunderland Health Watch, Sunderland Local Medical Committee, Cumbria and North East Area Team, Voluntary and Community Action Sunderland.

16. NHS Dudley CCG Target patient group/population? 318,000 Aims? Develop a network of integrated, GP-led providers across health and social care; “teams without walls” taking shared mutual responsibility for delivering shared outcomes.

Prepared by the BMA’s Health Policy and Economic Research Unit (HPERU) 5 Means? Multi-disciplinary teams in the community including specialist nurses, social workers, mental health services and voluntary sector link workers; 24 hour rapid response and urgent care centre providing a single coordinated point of access. Partners? Dudley Clinical Commissioning Group; Dudley Metropolitan Borough Council, Black Country Partnership NHS Foundation Trust, Dudley Group NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust, Dudley Council for Voluntary Services and Future Proof health Ltd.

17. Whitstable Medical Practice Target patient group/population? 53,382 (registered GP population) – elderly patients mentioned specifically. Aims? Outcome focused, person centred, co-ordinated care that is easy to access and enables people to stay well and live independently for as long as possible. Means? Integrated community long term condition management service; community urgent care service; community elective service; enhanced rehabilitation and intermediate care service. Care planning; care workers with access to new technology; better trained care workers. Partners? Whitstable Medical Practice, Northgate Medical Practice and the Saddleton Road & Seasalter Surgeries working with local health, care and support organisations including Canterbury & Coastal CCG, Kent County Council, East Kent Hospital University Foundation Trust, Kent Community Health Trust, Kent Partnership Trust and AgeUK.

18. Stockport Together Target patient group/population? 300,000 - people with complex conditions or at the end of life mentioned specifically. Aims? Build on the GP registered list; integration at GP practice level (20-30,000 population), at locality level (80,000 population) and at borough level (300,000 population). Means? Redesign hospital urgent care; single point of access integrated with community teams; care plans. Partners? Stockport Metropolitan Borough Council, NHS Stockport Foundation Trust, NHS Pennine Care Foundation Trust and NHS Stockport CCG.

19. Tower Hamlets Integrated Provider Partnership Target patient group/population? 270,000 Aims? Straightforward easy to access health and social care services; positive patient experience. Social care, primary, community and acute health services to truly co-ordinate their services around the patient. Means? New model of community care; single shared assessment and plan for patients. Partners? Tower Hamlets GP Care Group Community Interest Company (representing primary care); Barts Health NHS Trust (the local acute and community health services trust); East London NHS Foundation Trust (local mental health trust) and London Borough of Tower Hamlets (local council and social care).

20. Southern Hampshire Target patient group/population? 220,000 – older patients mentioned specifically. Aims? Improve the health, well-being and independence of people living in Southern Hampshire; support people to take a more active role in self-managing their care and offer access to improved care when needed. Means? Deliver higher quality, more accessible and more sustainable out-of-hospital care; care plans after acute episodes; regular check-up appointments at local practice or hospital; integrated care record. Partners? Southern Health NHS Foundation Trust; 16 local NHS, local government and voluntary sector organisations.

Prepared by the BMA’s Health Policy and Economic Research Unit (HPERU) 6 21. Primary Care Cheshire Target patient group/population? 330,000 - particular focus on young children, managing long-term conditions and supporting elderly patients. Aims? Better and more integrated support from different local health and care services. Means? ‘Starting Well’ ensure the best start in life for babies, children and young people in the local area; ‘Being Well’ will enable greater collaboration between local services and the several clusters of GP practices, supported by integrated teams, to help people manage long-term conditions, and; ‘Ageing Well’ will focus on excellent care for the frail/complex wherever they are living (including those in care homes). Partners? NHS West Cheshire CCG and Primary Care Cheshire (a single entity); Cheshire & Wirral NHS Partnership Foundation Trust; Countess of Chester NHS Foundation Trust; Cheshire West and Chester Local Authority.

22. Lakeside Surgeries/Lakeside Healthcare Target patient group/population? 100,000 – plans to expand to 300,000 Aims? Offer patients a number of new services. Means? New services (i) a nationally acclaimed and respected Urgent Care Model (the ‘CorbyCare’ model – delivered both in community and front-of-hospital locations); (ii) an Ambulatory Care service, particularly designed to relieve pressure at the ‘front door’ of hospitals; (iii) a bespoke and effective long-term condition management service for the frail elderly and other vulnerable patient groups which might include admission to short-stay community beds managed by Lakeside; (iv) a highly focused GP- led complex-care management service; and (v) a number of hospital outpatient and planned care services, including dermatology, ophthalmology, MSK, geriatric medicine and mother & baby services. ‘Extended primary care services’ to most patients; multidisciplinary teams 7 days a week; most vulnerable will receive ‘extensivist primary care services’ (longer, in-depth consultations with enhanced continuity of care); work alongside hospital consultants to provide better and more integrated access to specialist care; employ its own consultants in key specialties. Partners? GP ‘super-practice’ (four practices merged so far, further mergers intended) working in close partnership and collaboration with several local NHS providers (including: Kettering General Hospital; Peterborough & Stamford Hospital; University Hospitals Leicester; Northampton General Hospital and Northamptonshire Healthcare Trust), and also with key elected authorities (Northamptonshire County Council and Corby Town Council), and with Celesio (Lloyds Pharmacy), local social service providers and the voluntary and community sector.

23. Principia Partners in Health Target patient group/population? 126,000 – elderly population mentioned specifically Aims? Take contractual responsibility for the health, quality and costs of care for the local population within the capitated resource allocated. New model of integrated care focussed on early intervention, living well at home and avoiding unnecessary use of the hospital; reduction in fragmentation, delays, duplication and inefficiencies experienced by patients and carers. ; Means? Care will be delivered closer to patients’ homes; capitated outcomes-based contract covering health and social care; proactive care planning. Partners? Principia is constituted as a Community Interest Company and has three stakeholder classes: Rushcliffe GP practices; Rushcliffe community services providers; and the 126 000 registered population of Rushcliffe. Working with health and social care partners as part of the local South Nottinghamshire transformation work. NHS Rushcliffe CCG is the sponsor.

Prepared by the BMA’s Health Policy and Economic Research Unit (HPERU) 7

Prepared by the BMA’s Health Policy and Economic Research Unit (HPERU)