DRAFT Ipswich and East Suffolk Alliance Delivery Plan 2020/21 and Forward View 2021/24
Our Alliance in Action Working Together with You Contents
Contents Page
Introduction 3
Plan on a Page 5
Our Communities 6
Challenges 8
Assets and Opportunities 9
Commitment to Actions 10
Our Governance 11
Summary of Highest Level Milestones 12
Risks 13
Connecting Actions 14
Service Transformation Actions 35
Enabling Actions 64
2 Working together with you Introduction - Our Mission, Vision, Outcomes and Values
Our Alliance – is a partnership with common purpose. We are: Suffolk County Council; East Suffolk and North Essex Foundation Trust; Norfolk and Suffolk Foundation Trust; Suffolk GP Federation; and Ipswich and East Suffolk CCG working with our District and Borough Councils, community and voluntary sector partners. Our mission is ‘to work seamlessly together with you – individuals, families and communities’.
Our plans have been built on discussions with the public and staff, together with partnership working between our organisations over many years. We have drawn on local evidence of need, understanding of national policy and the ambition of our wider Integrated Care System Partnership. Together we are bound by a vision of Ipswich and East Suffolk as a ‘place of strong communities in which everyone is able to stay well, take control over their mental and physical well-being and, when support is needed, receive joined up health and care’
Together we serve over 400,000 people.
The outcomes we want to achieve are directly aligned to those of the Suffolk Health and Well-being Board, of which all we are all members. They are:
1. Every child has the best start in life 2. People of working age are supported to optimise their health and well-being 3. Older people in Suffolk have a good quality of life 4. People in Suffolk have good mental health and well-being
The Suffolk Health and Well-being Board also identifies four principles or cross-cutting themes. These principles are very closely aligned to the ‘Connecting Actions’ which our Alliance described in its original strategy. For consistency, which enables focus and drive in planning, delivery and progress monitoring, our Alliance will now adopt the same language. The principles are listed first (with the original Alliance description in brackets):
• Prioritising prevention (Enabling you to stay well) • Reducing health inequalities (Addressing inequalities) • Promoting resilient communities (Joining up in our communities) • Working well together (Creating One Team)
3 Working together with you Introduction
This approach also enables a direct line of sight to the Integrated Care System’s (ICS) strategy and Higher Ambitions, in particular. The ICS’ Higher Ambitions are:
• Reducing the health gap • Zero suicides • Preventing and treating obesity • Improved end of life care • Ageing and living well alone • No patient diagnosed with cancer through an unplanned admission
The way we work together and with you, matters to us hugely. This is how we will ‘Work Well Together’
Together we have evolved six shared values - the six ‘Cs’: 1. Collaboration – Co-ordination 2. Compassion – kindness and care 3. Creativity; innovation 4. Community-focus 5. Creating One Team - Combined Clinical and Care Leadership 6. Cost effectiveness
The Alliance’s programmes of work in this Delivery Plan are at various stages of development and delivery. As we progress, we will: • Use the Outcomes Based Accountability Framework to guide us • Use information already available to us through Place Based Needs Assessments • Adopt emerging Population Health Management Tools • Broaden and deepen co-production with patients, the public, people working across our health and well-being services
This Delivery Plan focuses on 2020/21 but also includes milestones for the following four years. It is informed by our delivery to date which is described in our Progress Report, which can be found here: www.ipswichandeastsuffolkccg.nhs.uk/IpswichandEastSuffolkAlliance
4 Working together with you Our Plan on a Page – Note – further design work will be done to make this ‘easy read’ following approval of the Plan
Our Vision: Ipswich and East Suffolk is a place of strong communities in which everyone is able to stay well, take control of their mental and physical health and wellbeing and, when support is needed, receive integrated health and care services.
Our Mission: To work seamlessly together with you – individuals, families, communities.
ICS Ambitions and Alliance Outcomes Programmes of Work ICS Higher Ambitions Alliance Outcomes Transforming Services Connecting Actions Enabling Actions • Reducing the 1. Every child has the • Joined up care • Enabling you to health gap best start in life • Planned care stay well • Governance • Zero suicides 2. People of working • Mental health • Joining up in and management • Preventing and age are supported and Learning communities treatingobesity to optimise their Disabilities • Creating One Team • Workforce health and well- • Improved end • Cancer • Addressing inequalities • Digital being of life care • Estates 3. Older people in • Children and • Ageing and living Suffolk have a good Young People • Communication well alone quality of life • Primary care and engagement • No patient 4. People in Suffolk • Maternity • Resources diagnosed with have good mental • End of Life cancer through health and well- • Eye and Oral Health an unplanned being admission
Our Values: Collaboration – Compassion - Creativity - Community-focus - Creating One Team - Cost-effectiveness
Our Members: East Suffolk and North Essex NHS Foundation Trust; Suffolk County Council; Norfolk and Suffolk NHS Foundation Trust; Suffolk GP Federation, working with Ipswich and East Suffolk CCG, our wider district and borough councils, voluntary and community partners
5 Working together with you Our Communities
Our area is one of fast-paced change in our busy port, County Town and housing growth areas alongside gradual change in our villages and rural communities. Our area includes: • Ipswich, the County and University Town of Suffolk • Felixstowe, Britain’s largest container port next to Martlesham, a global centre for British Telecom • Stowmarket, home of the Museum of East Anglian Daily Life • Woodbridge and Wattisham Garrisons • Framlingham, Saxmundham, Aldeburgh, Leiston and our coastal communities • Eye, Mendlesham and rural mid-Suffolk • Hadleigh, Holbrook, Shotley and Constable Country of south Suffolk
Our Alliance is one of three within our wider Suffolk and North East Essex Integrated Care System, which provides strong leadership and support for the delivery of local plans. Our Alliance includes eight localities in which we are working to join up health and care with wider voluntary and community partners to deliver our vision of strong communities.
Ipswich and West Suffolk North East East Suffolk Alliance Essex Alliance Alliance
Ipswich waterfront and University Aldeburgh
6 Working together with you The Health and Wellbeing of Our Communities Today
By 2039, 1 in 3 55.7% of our 18.5% of people have Suffolk residents will be population has a Long a caring responsibility. aged 65 and that will mean Term Condition This is not just the ratio of people of (53.5% in England) parents working age and over 65 will be 1:1 The 3 biggest causes Ipswich has 12 of death for people areas in the top less than 75 are: 10% most deprived 32% of people are in semi- areas of England skilled or unskilled Cancer occupations in our area as (206.4 per 1000, 74.6 preventable) 21.6% of homes are compared with 25% in social rented in Ipswich Cardiovascular England as compared with 17.5% (102.2 per 1000, 40 in the rest of England preventable) 24.3% of people have no Respiratory qualifications compared 22% of children in (25.9 per 1000, 10.9 to 22.5% in England preventable) Ipswich live in poverty
7 Working together with you Challenges
We have identified four major challenges:
The care and quality gap - Demand for health and care services is growing. In the next 20 years, 1 in 3 people in our area will be aged over 65 and the ratio of non- working to working aged people will be 1:1. The number of individuals with Special Educational Needs and Disabilities is also rising.
The health and wellbeing gap - There are inequalities. The 2019 Index of Multiple Deprivation, published since our initial strategy, shows that our area ranks 124 out of 191 in England, where 1 is the most deprived area. Our deprivation score was 17.4 in 2015 compared to 17.7 in 2019. 5% of small areas are in the 10% most deprived nationally – this is the same as in 2015. The most deprived area is Priory Heath; the least deprived is Martlesham. The drivers remain, as before: living environment; education, skills and training; and barriers to accessing housing and other services. There is inequality in access, experience, and outcomes.
The finance gap - Our finances are stretched. Over the last eighteen months, we have learnt a great deal more about each organisation’s position through open-book accounting and a spirit of collaboration. Whilst our position remains exceptionally challenging, this understanding has helped us to manage our position.
The workforce gap - Our workforce is shrinking. In the next five years many members of our current workforce may reach or be over the retirement age and recruitment may be unable to match demand. Our plans and delivery to close this gap have progressed significantly within individual professional groups and in creating “One Team – Ipswich and East Suffolk” but workforce remains a top priority for us.
8 Working together with you Assets and Opportunities
These challenges are not insurmountable. Ipswich and East Suffolk has many assets and opportunities, which we have been building on: 1. The quality of our health and care services is generally good, in many areas outstanding, and there is a clear plan for services which need improvement.
2. Our towns and villages have many vibrant community and voluntary sector organisations who work actively with us and our local authority partners.
3. We have excellent clinical and professional leaders in all of our organisations who are increasingly working together collaboratively. 4. We have a strong track record in working, in partnership, across organisations and most importantly with local people to make services better whilst managing costs and cutting waste.
(copyright C Partridge)
9 Working together with you Commitments to Action
We have three major Commitments to Action to deliver our outcomes:
Service Connecting Transformation Actions Enabling Actions Actions Dedicated support to delivering the Principles
1. Service Transformation Actions: Joined up care, close to home; planned care (cardiovascular disease, diabetes, respiratory, stroke); mental health and learning disabilities; cancer; maternity; children’s and young people’s services; primary care; and end of life care
2. Connecting Actions, which involve every Alliance partner and are needed to deliver every transformation programme: i. Enabling you to stay well - prevention; self-care; re-enablement. ii. Joining up in our communities - physical, mental health and well-being. iii. Creating ‘One Team’ - joining up clinicians and professionals across our Alliance. iv. Reducing inequalities - in outcomes and experience.
3. Enabling Actions: Governance and management; workforce; digital; communication and engagement; estates; and resources.
The Orwell Bridge Ipswich Marina
10 Working together with you Our Governance
IPSWICH & EAST SUFFOLK ALLIANCE – ORGANISATIONAL STRUCTURE
PCN/ PCN/ PCN/ PCN/ PCN/ PCN/ PCN/ PCN/ INTs INTs INTs INTs INTs INTs INTs INTs
East Suffolk & Norfolk & Suffolk District & Ipswich & East North Essex Suffolk NHS Suffolk GP Voluntary County Borough Suffolk CCG Foundation Foundation Federation Sector Council Councils NHS Trust Trust
Ipswich & East Financial Performance Alliance Quality Committee Suffolk Alliance Committee Board Community Clinical & Social Care Engagement Partnership ‘Council’? Executive Delivery Group
East and West Ipswich & East Ipswich & East Suffolk Suffolk Suffolk Only ICS Wide + North East Essex (ICS)
Elective Care Board Children Board Cancer Integrated Care Chair: Karen Lough Programme Board Programme Board
Mental Health Board Maternity Localities/INTs/Con Programme Board nect Development
ICS Suffolk Health and Wellbeing Board Essex Health and Wellbeing Board
11 Working together with you Summary of Highest Level Milestones 2020/21
Milestone
1. INT Core Leadership Teams established and operational
2. Social prescribing evaluated (and re-procured, as appropriate)
3. University of Suffolk Institute health and care developments progressed
4. Seven-day extended hours working in place for community services
5. Holistic End of Life model agreed
6. Primary Care Network Agreements signed; Care home and medication services operationalised
7. Urgent and emergency care centre plans fully approved
8. New outpatient model agreed
9. Phased implementation of new mental health model agreed
10.Continuity of maternity care teams established across the ICS
11. Faster diagnosis standard of 28-days from referral to diagnosis ruling out cancer
12. Next steps in Alliance governance for strategy and delivery agreed
13. Estates strategy developed and approved
14. Turf broken for Tooks’ Primary and Community Hub and Hawthorne Drive Development Plans agreed
15. Digital strategy agreed
12 Working together with you Risks
. Risk Mitigation
Inability to attract, retain and develop Delivery of local workforce strategy and workforce to scale of demand and pace plans required to deliver strategy
Organisational collaboration/integration Development and delivery of does not succeed at sufficient depth or Organisational Development Plan pace
Failure in performance or quality of any Transparent sharing of risk registers and one provider cannot be mitigated by collective mitigation strategies. other Alliance partners or bodies Development of Alliance Quality Committee.
Failure to achieve system financial Shared Financial Planning through balance Alliance Financial Strategy Committee; maximise external (to system) income sources; delivery of prevention and demand management strategies
Urgent in-year(s) demand jeopardises Maximise immediate investment capacity to invest in prevention and self opportunities; maximise technology; management with inability to ‘double- ensure prevention and self management, run’ is embedded into all transformation; secure all system approach by clinicians to prevention and self management; public engagement
Covid-19 Global Pandemic Covid-19 pandemic presenting risk to life, health and service delivery Robust mitigation and management in line with all national guidance and within the established structures and accountabilities
13 Working together with you Connecting Actions
We have developed priority Connecting Actions, which involve every Alliance partner. These are aligned to the Health and Well-being Board’s principles.
1. Enabling you to stay well (prevention; self-care; re-ablement).
2. Joining up in our communities - physical, emotional health and wellbeing.
3. Creating ‘One Team’ - joining up clinicians and professionals across our organisations.
4. Reducing inequalities - in outcomes and experience
ALL FOUR CONNECTING ACTIONS CONTRIBUTE TO ALL FOUR OF OUR OUTCOMES
Enabling you to stay well
Joining up in our communities
Creating ‘One Team’
Reducing Inequalities
14 Working together with you Connecting Action 1 Prioritising Prevention - Enabling you to stay well SENIOR RESPONSIBLE OFFICERS: Dr Badrinath Padmanabhan, Maddie Baker-Woods Our Ambition People living in Ipswich and East Suffolk live well for longer: A revolution in prevention, self-care and re-ablement.
Why is it important? The Suffolk Prevention Strategy identifies eight modifiable risk factors which can have the greatest impact of the six most common preventable diseases.
Modifiable risk factor CVD Diabetes Respiratory Frailty Dementia Falls
Smoking reduction
Alcohol consumption
Healthy weight
Physical activity
Social isolation
Vaccination
Support for carers
Blood pressure control
AF detect & manage
Diabetes detect & manage
Our indicators for success are (benefits): • Fewer adults (aged 19+) classified as overweight or obese • Higher average number of portions of fruit and vegetables consumed • More physically active adults and children • Fewer people report low satisfaction, worthwhile or happiness • Lower smoking prevalence
15 Working together with you Connecting Action 1 – Prioritising Prevention - Enabling you to stay well
Our high level milestones are:
MILESTONES: Enabling you to stay healthy 20/21 21/22 22/23 23/24 Priority 1: Improve early detection and treatment for hypertension, atrial fibrillation, chronic obstructive pulmonary disease (COPD), diabetes and “frailty”
Type 2 Diabetes Management: increase proportion of patients with optimal treatment to national good practice levels (general X practice and localities Falls and fragility fractures prevention in older people – Alliance X wide and localities Support for older people to achieve a healthy lifestyle to delay the onset of frailty by supporting them to stop smoking, be more X physically active, improve diet and reducing alcohol intake. Encouraging food business to promote healthier food and drink X choices: Eat Out, Wat Well and Take Out Eat Well campaign Priority 2: Improve direct and indirect support to those who wish to change their lifestyle
Support delivery of “Making Every Contact Count” (MECC), HLP, X veteran training Mental Health First Aid and health coaching.
Prevent suicide through the Suffolk Lives Matter strategy X Support healthy cooking classes for families, adults and older people living in poverty within leisure centres to support X alongside physical activity Healthy Towns Programme: bringing together the health sector with housing developers and local authority planning teams to X X design and build healthier communities Activity programmes within the workplace: Activity programme/menu options for businesses that meet the needs of X their business and staff Families and children ‘Get active and play sport together’ X Healthy Schools Rating Programme and Fit and Fed schemes in X schools
16 Working together with you Connecting Action 1 Prioritising Prevention - Enabling you to stay well
Our high level milestones are:
MILESTONES: Enabling you to stay healthy 20/21 21/22 22/23 23/24 Priority 3: Create Personal and Community Capacity and enhance Personal and Community resilience Connect with green spaces by developing park based activities that connect people with outdoors and build on relationships; X promote via app (similar to www.parksherts.co.uk) includes green gyms, pond dipping, tree trails, etc. Encourage self care and prevention by every GP practice to become Park Run friendly, stop smoking clinics in leisure X centres, health kiosks in community settings Expand children’s sports day camps beyond just summer – deliver healthy eating and living courses in primary schools and X expand the junior leisure centre programme to include the transition between school PE and outside club Increase healthy eating options in leisure centres X Healthier children and young people: Healthy Schools Rating Programme expansion X Activity programmes in care homes: opportunities to link care X homes together based on the Felixstowe Care Homes Network Older people have support to stay healthy: encourage people to live as healthy lifestyle as possible, through retirement planning, advance care planning, information and advice by broadening out to Borough and District council services including planning and housing teams. Active Schools Project: Healthy food awareness, extra curricular X X clubs, active classrooms and the daily mile Providing support to health and other professional key groups: GPs, dentists, optometrists, pharmacists, social care, schools to get involved and promote health campaigns through One You, X How Are You Suffolk campaigns
Continue to support and extend GP exercise on referral schemes X
17 Working together with you Connecting Action 2 – Joining up in our communities SENIOR RESPONSIBLE OFFICERS: Paul Little and Maddie Baker-Woods
Our Ambition People living in Suffolk will be aware of and able to access joined up health and care services as close to home as possible, in their community, so that the whole health and care system can focus on supporting people to regain or maintain their ability to live full independent lives.
Why it is important: Local community health and care services working together, to care for people in their own home wherever possible enables us to comprehensively understand and support the needs of the whole person and to reduce duplication. : We are focused on: 1. Fewer people needing unplanned care and support (reduction in crisis) 2. Greater numbers of people having access to and are supported by activity outside of statutory services 3. Resources in the delivery of community based health and care being used more efficiently 4. The on-going costs of supporting people being reduced as people’s independence is increased.
18 Working together with you Connecting Action 2 – Joining up in our communities
Our indicators for success are: • Improved health-related quality of life for older people • Reduced rates of severe frailty or increasing frailty • Fewer excess winter deaths index, people aged 85 and over • More older adult social care users and carers who say they have as much social contact as they would like • Fewer emergency hospital admissions due to falls in people aged 65 and over • More people who care for someone with dementia reporting good quality of life
Our baseline is: The eight Connect areas are established although not currently aligned fully to either Primary Care Network nor District/Borough Community Partnership boundaries. Joint social care and community health leadership has been established for all Integrated Neighbourhood Teams outside of Ipswich. Each area has a draft local plan. Co- location plans are in place for four areas. Social prescribing is operational in all eight areas. Some management support tools are in place.
Our Plan is:
We have a 10-point plan to support the development and delivery of each INT- Connect locality.
1. Development of core leadership teams for each connect area 2. Alignment and engagement of Primary Care Networks with INTs 3. Joint Strategic Needs Assessment, Population Health Management (currently being trialled) and development of locally focused delivery plans for each connect area (focused on our outcomes) 4. Delivery and evaluation of social prescribing 5. Provision of infrastructure – supporting the development of the core leadership team 6. Development of supporting management tools – in order to help deliver local delivery plans 7. Analysis of financial impacts of local plans 8. Estates development – enabling our integrated teams to operate from the same space 9. Organisational development – creating the one team ethos 10. Communications
19 Working together with you Connecting Action 2 – Joining up in our communities
Our Partners are: ESNEFT, Suffolk County Council, Primary Care, Care UK (111 and GP out of hours service), district and borough councils, Voluntary and Community Sector Partners, Healthwatch and Service Users
Our milestones are:
MILESTONES: JOINING UP IN OUR COMMUNITIES 20/21 21/22 22/23 23/24
1. Development of Core Leadership Teams to provide a focal point for planning and oversight of INT and X Connect teams 2. Alignment and engagement of Primary Care X Network Clinical Directors with INTs 3. Joint Strategic Needs Assessment for each INT X X progressing to use of Population Health Management 4. Delivery and evaluation of Social Prescribing for each INT X Re-procurement of social prescribing X 5. Appointment of business, administrative and programme management support to each INT X Complete 6. Provision of sample Terms of Reference for an INT and Connect Group to complement a Primary Care X Network’s Agreement
7. INT operational financial strategy X
8. Estates – delivering the next moves X X X X
9. Organisational Development Support Offer X X X X
10. Communications and access to information X X X X
20 Working together with you Connecting Action 2 – Joining up in our communities
Eye & North West Integrated Neighbourhood Team
Core Leadership Team INT Manager – Barry Gibson; PCN Director – Dr Pete Holloway; Community Development Lead – Elspeth Gibson; Social Prescribing Lead – Dominic Naysmyth-Miller; Community Mental Health Key Local Needs Lead – Liz Ellis Challenges to •Frailty face •Pneumonia prevention •AF detection • A diverse geography •End of life planning • Not pure PCN/INT •Asthma management alignment •Mental health management Eye and North West Priorities for Brilliance to build Action on • Frailty – • A broad based, comprehensive supportive Connect identification, partnership and set of assessment and community management partnerships • Diabetes prevention Enablers in Action • High intensity users • Estates – maximizing the asset of Hartismere Hospital; • Transport project (to be scoped)
21 Working together with you Connecting Action 2 – Joining up in our communities
Woodbridge Integrated Neighbourhood Team
Core Leadership Team INT Operations Manager – Jenny Blades; PCN Director – Dr John Lynch; Social Prescribing Lead – Jasmine Ross; Community Challenges to face Mental Health Lead – tbc Key Local Needs •New and large area with • Pneumonia diversity of population need • Prevention •INT/PCN not fully • Falls prevention aligned • High intensity users of services
Woodbridge Brilliance to build on Priorities for Action •Pneumonia vaccinations • Good single INT •Polypharmacy review for leadership and local those at high risk of falls relationships; •Identify high intensity Developing plan with users within primary and clear methods for community measuring success Enablers in Action •Population Health Management Pilot site •Estates – co-location plans for INT in place from March 2020
22 Working together with you Connecting Action 2 – Joining up in our communities
Felixstowe Integrated Neighbourhood Team
Core Leadership Team INT Operations Manager – Melanie Curle; PCN Director – Drs Paul Driscoll & Stephen Feltwell; Social Challenges to face Prescribing Lead – Hayley Stearn; Community Key Local Needs •Further team Mental Health Lead – Gail development work and Collyer •Care home engagement primary care forward with thinking (as part of one practice/community team); current plan needs nursing further focus and clear •Large order population measures. NB. No specific (high density of care inclusion of working age homes); peoples’ needs (in •Dentistry particular at the Port)
Felixstowe Priorities for Action •Direct access for Care Homes Brilliance to build on to nurse practitioner with prescribing capabilities to •Well established reduce / prevent admissions practical joint working in (8am–8pm daily) the area •Frailty Assessment Base •Prevention – Flu Vaccination and Dentistry Enablers in Action •Workforce development •Data – •Estates – further development / reconfiguration of Felixstowe Community Hospital site
23 Working together with you Connecting Action 2 – Joining up in our communities
Stowmarket Integrated Neighbourhood Team
Core Leadership Team INT Operations Manager – Michelle Chaplin; PCN Director – Dr Neil Macey; Social Prescribing Lead – David Grimmer; Community Mental Health Lead – tbc Key Local Needs Challenges to • Uptake of influenza & pneumococcal face vaccination in ‘at risk’ • INT/PCN alignment groups • Frailty management • AF detection
Stowmarket
Priorities for Action •Review data COPD LES from Brilliance to build scheme •Increase AF detection to aid on stroke prevention •Increase support to care • Engagement with homes to reduce unplanned PCN admissions Enablers in Action •Identify patients at risk of falls • Focus on prevention & suitable interventions to and team ethic in CLT •Workforce – recruitment by prevent Mid Suffolk PCN of Social •Continue Alcohol Awareness Prescriber with specific remit •Physical activity to increase physical activity levels •Data – focus attention on the needs of 2 areas identified in Stowmarket INT as ‘more deprived’; Explore strategies to prevent age-related diseases, especially frailty and dementia •Estates – co-location of INT planned for early 2020
24 Working together with you Connecting Action 2 – Joining up in our communities
South Rural Integrated Neighbourhood Team
Core Leadership Team INT Operations Manager – Cath Minchin; PCN Director – Dr Carrie Everitt; Community Development Lead – Robert Feakes; Social Prescribing Lead – David Grimmer; Community Mental Health Lead – tbc Challenges to Key Local Needs face • Falls and frailty • Capacity and • Dementia prioritising delivery management • Measures need • Management of UTIs further development
South Rural
Brilliance to build Priorities for Action •Proactive Falls INT Project on •Support people who are • One strong team socially isolated ethic and focus on •Drinking water awareness importance of VCS for everyone – help with Enablers in Action dental issues and UTIs • Well structured local •Embed trusted plan •Data – understand data around where people are assessment approach living i.e. care homes / patient homes to find out why there are high numbers of patients getting pneumonia •Engagement – invigorate connect meeting to include wider community membership •Comms – develop a wider communication plan and approach for the INT
25 Working together with you Connecting Action 2 – Joining up in our communities
Saxmundham and North East Integrated Neighbourhood Team
Core Leadership Team INT Operations Manager – Martin Hamilton; PCN Director – Dr Imran Qureshi; Community Development Lead – Nicola Jenner; Social Prescribing Challenges to Link worker– Jon Evans; Community Mental Health face Lead – Catherine Searle Key Local Needs • New INT leadership team • Frailty • Diverse population – • Mental Health affluence and pockets • Young adults – risky of deprivation behaviours • Unknowns – Sizewell C? Saxmundham and North
East Priorities for Action •Enhance the local frailty offer, including maximizing Brilliance to build the use of the resource at on Aldeburgh hospital •Mental Health Strategy • Strong one team ethic Early Adopter Site • Clear, focused plan •Further scope issue in relation to young adults – risky behaviours (identified Enablers in Action local concern) •Community Assets - •Workforce – develop integrated community nursing forum; improve access to domiciliary care and workforce development •Estates – Area based strategy required (OPE) •Community Development: ECC-led
26 Working together with you Connecting Action 2 – Joining up in our communities
Ipswich West Integrated Neighbourhood Team
Core Leadership Team Social & Community Health Manager – Miranda Walsh (Health) & Lisa Hill (ACS); PCN Director – Drs Alastair Flett & Balaji Donepudi; Community Development Lead – Simon Lanning; Social Prescribing Lead – Sally Oakley; Community Key Local Needs Mental Health Lead – Dean McMath •83% of population under 65 Challenges to •More deprived than the face Suffolk average and children in low income • Narrow focus of families activity •Levels of depression are significantly higher in Ipswich •Dental care for children Ipswich West
Priorities for Action •Establish funding for Brilliance to build on social prescribing scheme for young people (11- •Strong link to evidence 18yrs, base related to young •Reducing emergency people, wide system admissions related to self engagement and detail harm) and depth in plan •Increased numbers of referrals to VCSE Enablers in Action organisations • Partnership development • Estates – Tooks development site
27 Working together with you Connecting Action 2 – Joining up in our communities
Ipswich East Integrated Neighbourhood Team
Core Leadership Team Social & Community Health Manager – Beverly Chambers (Health) & Paula Springle (ACS); PCN Director – Drs Ayesha Tu Zahra & Mike McCullagh; Community Development Lead – Simon Challenges to Lanning; Social Prescribing Lead – Sally Oakley; face Community Mental Health Lead – Heather Balleny • Plans lack focus, Key Local Needs detail and measures • Actions are •Mental health exploratory and little •High intensity users for focus on attempted suicide prevention/VCS or wider Connect engagement
Priorities for Action •Patients identified from Brilliance to build Ipswich East GP system data – (Oct18- on Oct19) of intentional and unintentional attempts of • All partners engaged, suicide; consider deep plan has a focus on dive into data from one the development of general practice to new approaches understand scale of the issue; design revised pathway of care Enablers in Action Estates: Alliance wide feasibility plan for Hawthorne Drive
28 Working together with you Connecting Action 2 – Joining up in our communities
Social Prescribing Social prescribing - offering an alternative opportunity to medical or other statutory care in the local community - can help to prevent ill health or aid recovery. In Ipswich and East Suffolk a number of successful pilots have paved the way to a roll-out this year across our eight Integrated Neighbourhood Teams. Social prescribing link workers – known locally as Community Connectors – receive referrals, have a conversation with an individual and support to them in engaging in a local activity. Our Community Connectors are all hosted by voluntary sector organisations who are uniquely placed to understand someone’s need and to find the right opportunity for them. The hosting organisations were selected through a formal procurement process and include: Suffolk Family Carers, The Shaw Trust, Citizen’s Advice and Access Community Trust.
Over the next 12-months Social Prescribing will continue its development and delivery in each locality. An evaluation is being undertaken by the University of East Anglia. This will inform development of our forward strategy, taking account of our local ambition, outcomes for individuals, return on investment and system workload management, national policy and funding requirements.
Pictured: some of the Community Connector teams now working in Ipswich and east Suffolk
29 Working together with you Connecting Action 3 Working Together Well – ‘Creating ‘One Team’ SENIOR RESPONSIBLE OFFICERS: Dr Mark Shenton, Dr Crawford Jamieson, Lisa Nobes
Our commitment is to invest in the people who work with you; to retain, develop and attract the best talent.
Our Ambition Seamless care delivered by seamless teams.
Our indicators for success are (further development required): • Improved patient and customer experience of health, care and well-being services • Improved staff recruitment, retention and satisfaction rates
Our Baseline is: We have made significant progress in specific in the recruitment of joint roles with: six of the eight Integrated Neighbourhood Teams being led by a single community/social care Manager; Join Children’s Service Transformation Leads between the CCGs and Suffolk County Council (SCC) and between SCC and NSFT;
Our Plan is: Our plan has five key strands: • A shared mission and set of values • Joint roles • Shared leadership development • Joint teams • Co-location and communication using digital tools
This programme of work is inextricably linked with our workforce, governance and locality plans. All Alliance partners are currently or will be engaged in this programme of work.
30 Working together with you Connecting Action 3 – Working Together Well - Creating ‘One Team’
MILESTONES: Creating One Team: 20/21 21/22 22/23 23/24
Shared mission and set of values X
Joint roles X X X X
Shared leadership development X X X X
Joint teams X X X X
Co-location and communication using digital tools X X X X (See digital and estates enabling actions)
31 Working together with you Connecting Action 4 – Reducing Inequalities SENIOR RESPONSIBLE OFFICER: Stuart Keeble
Our Ambition People will be treated fairly. Outcomes will be equal.
Why it is important and what is our baseline? The Marmot Review, published in 2010 as Fair Society Healthy Lives re-stated the causes of health inequalities and six domains for action: • Early child development – 22% of children in Ipswich live in poverty • Education and life long learning – 32% of people in our area are in semi or unskilled jobs compared with 255 nationally • Healthy and sustainable environments in which to live and work – 21.6% of homes are social rented in Ipswich as compared with 17.5% in the rest of England • A social determinants approach to prevention – addressing the causes of the causes – the Social Mobility Index ranks Ipswich 271 out of 324 local authorities
Our indicators for success are (benefit):
• Less statutory homelessness • Fewer people living in fuel poverty • More adults with qualifications that will help them into work • Fewer children in low income families, aged under 16 • Fewer 16-17 year olds not in education, employment or training (NEET) • Increased uptake and delivery of health services to reduce health inequalities experienced by groups with protected characteristics • More employment among people with mental illness or learning disability • More unpaid carers identified and supported
32 Working together with you Connecting Action 4 – Reducing Inequalities
Our plan has four planks:
1. Using our role as ‘anchor institutions’ in our community: o As employers – in our recruitment, training and progression; and in creating healthy workplaces; o As purchasers – using local supply chains and building our values and expectations into our contracts o As land and asset owners and in new developments o In how we behave as leaders and partners – upholding our values
2. Using a potential matrix of decision making which prioritises actions, which support a reduction in health inequalities;
3. Continues investment community developed and community delivered actions
4. Harnessing the knowledge, skills and drive of Integrated Neighbourhood and Connect Teams to reduce inequalities within their areas
Our Key Partners are: Community and voluntary groups, district and borough councils, Suffolk County Council, wider statutory partners, ESNEFT, NSFT, CCG.
33 Working together with you Connecting Action 4 – Reducing Inequalities
MILESTONES: REDUCING INEQUALITIES 20/21 21/22 22/23 23/24
1. Development of SMART Alliance Plan to deliver our commitments as Anchor Institutions with early focus on X major health and care developments
2. Development of decision-making tools which prioritise aiding a reduction in health inequalities X
3. Community-developed; community delivered action (NB – the following programmes are not exhaustive; they all involve multiple voluntary, community, health, care, district, borough, wider statutory partners. They are focused on: Food; Housing; Education; Income; Safety; Vulnerable groups. and are considered to make a significant contribution to our shared outcomes. A further workshop of Alliance partners is planned to consider whether these are the correct cohort of priorities for inclusion in this plan). Access to affordable healthy food: Fit and Fed Summer Activities Programme, Ipswich Food Plan and Suffolk bid X nutrition for children and families
Warm Homes: People will be supported to access resources that can make their home more heat efficient X
Housing First programme and Making Every Adult Matter - People who are homeless will have the right support to X improve their health and wellbeing
People from vulnerable groups are supported to access and remain in Employment: Youth Employment Service X (YES) in East Suffolk delivered by INSPIRE
People have income that enables them to meet their health and wellbeing needs including money advice, benefits and support: Funding to CAB from Alliance X Partners: SCC; Districts, Boroughs and CCG and Low Income Family Tracker (LIFT) software pilot
34 Working together with you Connecting Action 4 – Reducing Inequalities
MILESTONES: REDUCING INEQUALITES cont’d 20/21 21/22 22/23 23/24 Community Safety Partnership including Gangs and County Lines training and initiatives including preventing violent extremism, Domestic Abuse forums X and Town Pastor schemes in Ipswich and East Coast
Lifelong learning - Encourage people to continue lifelong learning within work and community facilities X e.g. Men’s Sheds, Meet up Mondays, inter- generational activities Support further development of dedicated, community developed and based BAME health and X well-being programmes Intergenerational health and care programmes - Dementia and blue badge health walks, roll out of “Grandmentor” programme for care leavers in East Suffolk, Suffolk Family Focus Programme for young X people who are vulnerable and at risk of being in contact with the youth justice system
Armed Forces Covenant – on-going Alliance wide support for delivery of commitments to veterans and military families 4. Support INT Core Leadership Teams working with wider Connect partners to develop plans to address X X inequalities within each of their areas
35 Working together with you Service Transformation Actions
Particularly contributing to Joined up care, close to Outcome 3: ‘Older People have a good quality of life’ home
Contributing to all outcomes for all ages Urgent and Emergency Care
Contributing to Outcome 2: People of working age are supported Planned Care (CVD; Stroke; to optimise their health and wellbeing Outcome 3: Older people have a good quality of Diabetes; Respiratory) life
Contributing to Outcome 1: Every child has the best start Children and Young People in life
Contributing to Outcome 4: People have good mental Mental health health and well-being
Contributing to all Outcomes for all ages Primary Care
Contributing to Outcome 1: Every Child has the best Maternity start in life
Contributing to Outcome 2: People of working age are supported to optimise their health and Cancer well-being Outcome 3: Older people have a good quality of life
36 Working together with you Joined-up care, close to home Out of hospital and community care SENIOR RESPONSIBLE OFFICERS: Richard Watson, Paul Little
Why it is important: Local community health and care services working together, to care for people in their own home wherever possible is essential everyone in Suffolk and North East Essex is to live well and age well.
Our indicators for success are:
• Reduce delayed transfers of care from hospital • Long term support needs of older people (age 65 and over) met by admission to residential and nursing care homes, per 100,000 population • Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation • Reduction in readmission rates • Increases in mortality in out of hospital setting – hospice, care homes, patients home
Our baseline is:
Members of the REACT and DIST team
37 Working together with you Joined-up care, close to home Out of hospital and community care
Our plan is: • Proactive care to enable you to stay well in your community and keep your independence, health and well-being; to avoid crisis or unexpected ill-health, for example, by falls prevention, long term condition management and end of life care. • Reactive care to ensure that when you do experience a crisis, trauma or medical emergency you receive timely care, where possible in your community, or that you are able to return home as soon as possible. We will do this with the new Integrated Urgent Care service and set of admission prevention and re-ablement services.
Our Key Partners are: ESNEFT, Suffolk County Council, Primary Care, Care UK (111 and GP out of hours service), district and borough councils, Voluntary and Community Sector Partners, Healthwatch and Service Users
Our high level milestones are:
Members of the REACT and DIST team
38 Working together with you Joined-up care, close to home Personalised care SENIOR RESPONSIBLE OFFICER: Lisa Nobes Why it is important: Choice and control over our own health and care are essential if everyone in Suffolk and North East Essex is to live well
Our indicators for success are: • Increase in active personalised care and support plans from an estimated 323 in 2019/20 to 17,476 in 2023/24 • Increase in the number of personal health budgets in place, from 308 in 2018/19 to 3,300 in 2023/24 • Increase in the number of social prescribing link workers from 0 in 2018/19 to 41 in 20123/24 • Increase in the number of referrals into social prescribing link workers from 1,668 in 2018/19 to 15,881 in 20123/24
Our baseline is:
Our plan is: • To build choice for individuals in the ways in which they access and receive health, care and well-being information and services to meet personal needs, drawing on local innovative practice across our Alliance as well as national policy and experience.
Our Key Partners are: ESNEFT, NSFT, Suffolk County Council, Primary Care, VCS and Service Users
39 Working together with you Joined-up care, close to home Personalised care
Our high level milestones are:
MILESTONES: PERSONALISED CARE 20/21 21/22 22/23 23/24 Personal Health Budgets become the default delivery X model for Wheelchair service users
Personal Health Budgets become the default delivery X model for individuals under S117
Identify groups where update of Personal Health Budgets X is low and work to expand
Personalised care and support plans in place for 82% of X maternity service users
Personalised care plans in place for 80% of End of Life X patients (last 12 months)
40 Working together with you Urgent and Emergency Care SENIOR RESPONSIBLE OFFICER: Neill Moloney
Why it is important: The best urgent and emergency care, when and where people need it, is essential if everyone in Suffolk and North East Essex is to live well.
Our indicators for success are: • Reduction in the rate of emergency incidents where at least one patient was transported to an emergency department, from 58.5% in 2018/19 to 57% in 2023/24 • Preventing increases in the average number of patients with delayed transfers of care per day, currently at 69 per day in 2018/19 • Reduction in the average number of patients staying a hospital bed for 21 days or more, from 232 in 2018/19 to 173 in 2023/24
Our baseline is:
Our plan is: • Development of Urgent and Emergency Treatment Centre • Expansion of admission avoidance services • Further development and embedding of High Intensity User schemes
Our key partners are: Ipswich and East Suffolk CCG, Care UK (111 and GP out of hours service), ESNEFT, Healthwatch Suffolk, District and Borough Councils, Norfolk and Suffolk Foundation Trust, Suffolk County Council, Suffolk Community Foundation, Suffolk GP Federation, East of England Ambulance Trust and Voluntary and community partners and Service Users
41 Working together with you Urgent and Emergency Care
Our high level milestones are:
MILESTONES: URGENT AND EMERGENCY CARE 20/21 21/22 22/23 23/24 Redesign urgent and emergency care pathways linked to front door transformation and mobilisation of an Urgent X Treatment Centre within Ipswich. Deliver 70 hours a week acute frailty assessment within X ED within 30 minutes of arrival. Develop plans to re-provide admission avoidance services (REACT) at a locality level within the community whilst X keeping a central core function.
Develop a roll out plan for Ageing Well and embedding this within each INT including 2-hour urgent community X response and 2-day re-ablement response. Develop and mobilise proactive frailty service at a locality level as part of national ageing well anticipatory care agenda, determined by place based needs assessments X and frailty identification. Realignment of integrated therapy resources across the X care pathway to provide a model of care closer to home. Develop and embed processes for High Intensity Users X across primary and community care.
42 Working together with you Planned Care SENIOR RESPONSIBLE OFFICERS: Richard Watson, Karen Lough, Dr Crawford Jamieson
Why it is important: The best planned treatment and care, when and where people need it, is essential if everyone in Suffolk and North East Essex is to live well
Our indicators for success are: • Shorter times between referral and treatment, eliminating 52- week waits and reducing waits overall • Reduction in face to face follow ups • Capacity Alerts in place and reduced waits for 1st outpatient waits
Our baseline is:
Our plan is: Working with clinical leads, we will take a holistic approach to planned care, in particular to the transformation of outpatient services whilst continuing our focus on key specialities at ICS level: (1) Cancer; (2) Maternity; (3) Stroke, CVD, Neuro- rehabilitation; (4) Respiratory; (5) Diabetes
43 Working together with you Planned Care
Our Key Partners are: ESNEFT, Suffolk County Council, Primary Care, VCS and Service Users
Our high level milestones are:
MILESTONES: 20/21 21/22 22/23 23/24 PLANNED AND NON-EMERGENCY CARE
Support the development of a revised model of care across East Suffolk and North Essex NHS Foundation Trust for the provision of some inpatient surgical work to be specialised x x on one of its two acute sites. This will give patients better access to the right expertise, at the right time, and enable surgery not to be cancelled when more urgent cases arrive.
Focusing on reducing the need for people to attend hospital for routine first outpatient appointments through a much greater use of advice and guidance between clinicians, more x x x x effective clinical triage of referrals to all clinical specialties and alternative referral options such as physiotherapists and optometrists all by April 2021. Giving people access to their own information about their own health, how to improve it and in a format that is available when they want to use it. This will empower x x x people to have more control over their condition and their care. Implementation of the Capacity Alerts to reduce waiting x times for planned surgery Give people who have waited six months for treatment an alternative choice of provider, by April 2020. People should x x not have to wait excessive periods for treatment. Widening access to services helps manage demand more effectively. Expanding the availability of MSK first contact practitioners across primary care, so patients receive timely, local access x x to care.
44 Working together with you Cardio Vascular Disease
Why it is important: The best care and quality of life for people with cardiovascular disease are essential if everyone in Suffolk and North East Essex is to live well.
Our ICS wide outcomes for Cardiovascular Disease are: • People have the information and support they need to reduce the risk of developing cardiovascular disease • People with cardiovascular disease have the right treatment and support to manage their condition.
Our indicators for success are: • Increase in the cumulative percentage of the eligible population aged 40-74 offered an NHS Health Check who received an NHS Health Check • Increase in QOF prevalence (all ages) • Reduction in mortality for coronary heart disease rate per 100,000 for under 75 years of age • Reduction in emergency hospital admissions for Myocardial Infarction (heart attack), standardised admission ratio
Our baseline is: • People have the best possible treatment and care for survival and recovery from cardiovascular disease
Our plan is: • Design and deliver a single point of access for cardiac failure • Design a one stop shop approach for cardiac failure diagnosis • Development of a Furosemide community pathway to prevent hospital admission
Our key partners are: ESNEFT, GP Practices, Community Services
45 Working together with you Cardio Vascular Disease
Our high level milestones are:
MILESTONES: CARDIOVASCULAR DISEASE 20/21 21/22 22/23 23/24
In primary care, improving uptake of health checks and x improve awareness of CVD for high risk groups.
In primary care, to case find and treat people with x x x x high-risk conditions
To help people access diagnostic tests more quickly will improve the early detection of Heart Failure and x x x x Heart Valve Disease.
Provide more multi-disciplinary integrated community- based teams will bring together acute and community clinicians working with primary care networks to x provide more co-ordinated services, improving diagnosis and treatment.
Provide rapid access to heart failure nurses for patients not staying on a cardiology ward. People will receive x the support they need regardless of the function of the ward they are admitted to.
Scale up and improve marketing of NICE recommended x cardiac rehabilitation intervention
To implement the recommendations of the Congenital x Heart Disease review, by April 2022.
46 Working together with you Diabetes
Why it is important: The best care and quality of life for people with, or at risk of, diabetes is essential if everyone in Suffolk and North East Essex is to start well and live well.
Our two indicators for success are: • Increase in the number of people supported through the National Diabetes programme from 145 in 2018/19 to 3408 in 2023/24 across the ICS. • Increase in number of people with type 2 diabetes who achieve all three treatment targets across the ICS.
Our baseline is:
Our plan is threefold: • Promotion and delivery of prevention • Access to high quality treatment as close to home as possible • Support with self management
Our key partners are: WSFT, ESNEFT, Suffolk GP Federation, Primary Care, Diabetes UK, OneLife Suffolk, DPP Provider (Currently ICS Health and Wellbeing), VCS and Service Users
47 Working together with you Diabetes
Our high level milestones are:
MILESTONES: DIABETES 20/21 21/22 22/23 23/24
Eclipse rolled out to all practices and using perfect patient x data
3% more patients achieving their three NICE Treatment x targets
3% more patients completing their nine Care Processes x
Achieving the wave 5 NHS DPP annual numbers x x x (milestones)
Complete ICS DM website and regular communications to x patients and clinicians
Roll out the GDM pathway x
48 Working together with you Respiratory Disease and Air Quality
Why it is important: The best care and quality of life for people with respiratory disease and cleaner air is essential if everyone in Suffolk and North East Essex is to start well and live well.
Our two indicators for success are: • Reduction in smoking prevalence in adults (18+) • Reduction in non-elective admissions for COPD, Asthma and Pneumonia
Our baseline is:
Our plan is four-fold: • Prevention, in particular, through clean air • Early diagnosis • Access to high quality services • Support to self care; maximising tech-based opportunities
Our Key Partners are: ESNEFT, Primary Care, VCS, Breatheasy, British Lung Foundation, Service Users, One Life Suffolk, Provide, Suffolk County Council and Public Health Suffolk.
49 Working together with you Respiratory Disease and Air Quality
Our high level milestones are:
MILESTONES: 20/21 21/22 22/23 23/24 RESPIRATIORY DISEASE AND AIR QUALITY
To ensure that quality assured spirometry is X X undertaken to enable early and accurate diagnosis
Healthcare professionals will follow national and local prescribing guidelines and will teach people the correct X X X X inhaler technique Expand awareness of, and access to pulmonary X X X X rehabilitation
MyCOPD App made available in primary care as well as acute and Pulmonary Rehab to enable people to self- X manage own condition
To ensure increased access to smoking cessation X X support and completion of programmes Supporting staff to recognise early signs of lung cancer, so that patients can attend screening and testing where X X X X needed
50 Working together with you Stroke
Why it is important: Preventing strokes and providing high quality treatment and support to recover after a stroke are essential if everyone in Suffolk and North East Essex is to live well
Our two indicators for success are: • Increase in the proportion of patients with a stroke who are directly admitted to a stroke unit within four hour from 73.6% in 2018/19 to 81.1% in 2023/24. • Increase in the percentage of applicable patients who are assessed by the NHS at six months from 68.2% in 2018/19 to 74.1% in 2023/24
Our baseline is:
Our plan is four-fold: • Improved awareness through public communication and health checks to help people stay health and avoid a stroke • Rapid diagnosis • Access to high quality and timely treatment for all diagnoses, with close working across our system • Integrated and high intensity community-based rehabilitation
Our Key Partners are: ESNEFT, Primary Care, Stroke Association, VCS and Service Users
51 Working together with you Stroke
Our high level milestones are:
MILESTONES: STROKE 20/21 21/22 22/23 23/24
In primary care, improving uptake of health checks and X improve awareness of stroke for high risk groups.
To help people access diagnostic tests more quickly, we will use technologies such as stroke app and build on our X recent mobile stroke unit trial.
Meeting NHS 7 day standards for stroke care and National X Clinical Guidelines for Stroke in all stroke units. Delivery of high quality hyper-acute stroke care, including brain scanning and thrombolysis in dedicated units as part of a networked 24/7 service. Our three units will work X much more closely together through the planned Suffolk and North East Essex Integrated Stroke Delivery Network. Provision of mechanical thrombectomy and thrombolysis X on specialist stroke units. Providing more integrated and high intensity community- based rehabilitation, including community-based X therapies and home adaptations where appropriate.
52 Working together with you Children and Young People SENIOR RESPONSIBLE OFFICER: Allan Cadzow
Why it is important: The best possible physical health for children and young people as they grow and develop is essential if everyone in Suffolk and North East Essex is to have a good start in life.
Our indicators for success are: • Increase in the percentage of children immunised • Reduction in emergency admissions for children • Increased access to Mental Health services • Development of a 24/7 mental health crisis response service
Our baseline is: The evidence tells us that around 9% of 5-16 year olds have a mental health disorder, and a further 3.5% have an emotional disorder. Children and young people with poor mental health or emotional difficulties often don’t get the help they need as quickly as they should. As a result, difficulties such as anxiety, low mood, depression, conduct disorders and eating disorders can stop some young people achieving what they want in life (Suffolk Annual Public Health Report 2019). The 2016 health needs assessment of CYP mental health analysis of unmet need from the available data (pp34 – 36), indicates that two thirds (1,890) of 2,800 children who require Tier 3 service are referred to these services after assessment process, however one third of children in East and West Suffolk who might have needed to access specialist provision in Tier 3 were triaged as not requiring assessment by these services. Whilst not all CYP experiencing a level of emotional of mental health distress require a specialist mental health response and many are supported well by educational settings, children’s services and voluntary and community services, referrals to mental health services have increased over recent years and it is clear that capacity within our specialist services is insufficient to meet the need.
Our plan is: • To understand and anticipate families’ needs – including a single assessment • To reach out and responding – early help focused on individuals • To join-up a single point of access With a focus on: (1) emotional health and well-being; (2) physical health and well- being; (3) special educational needs and learning difficulties; (4) speech, language and communication; (5) neurodevelopmental pathways; (6) community services; (7) urgent need.
53 Working together with you Children and Young People
The East and West Suffolk System wide transformation of mental health support and treatment for children and young people will address this situation by increasing the capacity, knowledge and skills across all our children’s workforce, embed collaborative assessment and delivery of care and provide a needs based, holistic approach that is available at the right time, in the right place, by the right worker and with the right intervention. Whilst this is a five year process of delivery we will already see the inception of an under 18 24/7 crisis response team in place by the end of 2020 and school based mental health support teams in two high schools and their associated primary schools in West Suffolk with planned rollout to all schools over the next three years.
Our Key Partners are: WSFT, ESNEFT, NSFT, EPUT, NELT, Suffolk County Council, Essex County Council, Primary Care, VCS and Service Users
Our high level milestones are:
MILESTONES: CHILDREN AND YOUNG PEOPLE 20/21 21/22 22/23 23/24 New Suffolk mental health model phased implementation started by September 2020 with full implementation 09/20 including growth by 2024 Mental Health access targets – minimum requirements 35% 37% 39% 41% Perinatal model implemented and meeting access targets – 7.1% 8.2% 10% 10% minimum requirement Neurodevelopmental pathways introduced for Suffolk 09/20 24/7 Mental Health Crisis support model in place within 09/20 Suffolk Review CYP Mental Health provision for NE Essex and 09/20 develop revised model Re-procure CYP Mental Health provision across Essex with 10/21 new service in place Implement recommendations from SEND written statement of action for Essex including revised SALT and 11/21 Neurodevelopmental pathways
54 Working together with you Mental Health SENIOR RESPONSIBLE OFFICERS: Richard Watson, Stuart Richardson
Why it is important: The best possible mental health and resilience is essential if everyone in Suffolk and North East Essex is to live well
Our key indicators of success are: • More people receiving psychological therapies (IAPT), increase access to 25% interventions for those in need by 31.03.21 (from 20,575 in 2018/19 to 28,428 in 2023/24 (needs to include NSFT and H&P FT cumulative activity); and provision of IAPT Long Term Conditions services • Increase in proportion of people with a severe mental illness receiving a full annual health check and follow-up interventions, (from 35.4% in 2018/19 to 82% in 2023/24) • More people with severe mental illness accessing Individual Placement and Support that operate in line with fidelity to the established evidence based model, from an estimated 559 in 2021/22 to 969 in 2023/24 • Increase in Early Intervention in Psychosis services reaching NICE standards at Level 3 or above, from 0% in 2018/19 to 100% in 2021/22, including providing a service that covers age range of 14-65 years and has a provision for people with an At Risk Mental State (ARMS) • Increase in proportion of mental health liaison services within general hospitals meeting the ‘core 24’ service standard, from 0% in 2018/19 to 100% in 2021/22 • More people over 18 with severe mental illness receiving care from new models of integrated primary and community mental health services, from 0 in 2018/19 to 6,520 in 2023/24 • Increasing the number of people accessing Specialist Perinatal Mental Health services from 4.5% to 10% by 2023/24 inclusive of maternity outreach clinics and extending periods of care from 12 -24 months. • Maintaining the dementia diagnosis rate national target (67%) with suitable post diagnostic support services within the community
55 Working together with you Mental Health and Learning Disabilities
Our plan is: • Our current priorities will focus on delivery of: (1) well-being services; (2) improvements to access and assessment; (3) integrated delivery teams; (4) psychiatric liaison in our hospitals; (5) suicide prevention.
Our baseline is:
Our Key Partners are: NSFT, ESNEFT, Suffolk County Council, Primary Care, VCS and Service Users
56 Working together with you Mental Health and Learning Disabilities
Our high level milestones are:
MILESTONES- All three ICS Alliances unless stated. 20/21 21/22 22/23 23/24 MENTAL HEALTH AND LEARNING DISABILITIES Maintain/Deliver national dementia diagnosis rate (67%) and embed post diagnostic support services amongst X dementia friendly communities
Deliver physical health checks for patients with Severe Mental Illness (SMI) and develop new integrated community models of care incorporating mental health X X X X into primary care/community services including the new Suffolk model Develop system wide services to support Personality X Disorder and Eating Disorders Deliver national Improving Access to Psychological Therapies (IAPT) intervention and recovery rates X X including increasing support for Long Term Conditions Deliver enhanced crisis mental health service provision including Psychiatric Liaison Services (PLS) at core 24/7 fidelity level at Ipswich, Colchester and West Suffolk X sites and development of alternative crisis provision (crisis café) in Suffolk and North East Essex Increasing access to EIP services and achievement of X Level 3 rating Inappropriate acute out-of-area mental health X placements will be ended by December 2021.
57 Working together with you Primary Care SENIOR RESPONSIBLE OFFICERS: Maddie Baker-Woods, David Pannell
Why it is important: 90% of all healthcare is delivered by GP-led primary care.
Our key indicators of success are: 1. New models of care including working at scale through collaborations to enable resilience and transformation and in new partnerships with other providers. 2. New consultation types with GP-led multi-disciplinary teams. 3. Development of prevention and self-management programmes. 4. A set of workflow efficiency measures to release time to care - 10 High Impact Actions. 5. Recruitment, retention and returner programmes for GPs and Nurses, and growth of a wider multi-disciplinary team.
Our baseline is: • All practices currently within a Primary Care Network • 120,000 patients (over ¼ of our total) are served by the single partnership, Suffolk Primary Care • A growth in non-GP clinical roles above trajectory • 100% practices offering on-line consultations • All practices currently rated good or outstanding by the CQC and achieve an average of 98.8% of Quality Outcomes Framework targets
Our plan is: • To enable GPs to have ‘time to care’, diagnose and manage risk most effectively • To deliver prevention programmes effectively • To facilitate GPs to manage patients who are acutely ill; and oversee the care of patients with long-term conditions but with most of the care delivered by other members of the team • To support and enable patients to practice self-care including the increased the use of technology
58 Working together with you Primary Care
• To extend the system leadership role (integrated model) including developing ways of working that encompasses the whole extended community health team including social care • To plan that all services are provided in a primary care setting unless they must be provided in another setting or for safety or other reasons • To provide continuity of care (not always continuity of professional) • To increase the pace of transition of care from a secondary to a primary care setting with appropriate transfers of resources • To facilitate practices working in groups, where it enables resilience, transformation and high quality service provision • All practices, Suffolk GP Federation and wider local Integrated Neighbourhood Team and Connect partners
Our key partners are: All practices, Suffolk GP Federation, Suffolk LMC, wider Alliance Partners, PPGs
Our high level milestones are:
MILESTONES: Digitally-enabled Primary Care 20/21 21/22 22/23 23/24 Secure full sign up to the new PCN DES and support X new models of care Maximise recruitment of additional roles in line with X X X X guidance Work with PCNs to deliver national service X X X X requirements Continuously improve rates of QOF, dementia diagnosis, LD healthchecks, SMI healthchecks and X X X X vaccination
Practices offer on-line consultation 100% 100% 100% 100%
Practices offer online video consultation 100% 100% 100% 100%
Patient records available to be shared 98% 98% 98% 98% Additional information available on Summary Care 40% 50% 60% 70% Record
59 Working together with you Maternity (ICS-wide with local delivery) SENIOR RESPONSIBLE OFFICER: Lisa Nobes
Why it is important: Healthy pregnancies, healthy births, healthy parents and a healthy first two years of life are essential if everyone in Ipswich and East Suffolk is to have a good start in life
Our four indicators for success are: 1. Reduction in the neonatal mortality rate, from 1.3 per 1000 live births and still births in 2016 to 0.77 in 2023/24 2. Increase in the percentage of women with continuity of midwife from 34.3% in 2018/19 to 100% in 2023/24 3. Reduction in the rate of infants with a brain injury during or soon after birth from 5.33 per 1000 live births in 2017 to 3.37 in 2023/24 4. Increase in the proportion of women accessing specialist community perinatal mental health services from 2.3% in 2018/19 to 10% in 2023/24
Our baseline is:
60 Working together with you Maternity (ICS-wide with local delivery)
Our plan is focused on: • Providing easy access to evidence based information to help people make choices • Continuity of care as close to home as possible • Provision of specialist intensive and mental health care, when needed
Our Key Partners are: WSFT, ESNEFT, Tertiary Neonatal units, NSFT, EPUT, Primary Care, Suffolk County Council, VCS and Service Users
Our high level milestones are:
61 Working together with you Cancer (ICS-wide with local delivery) SENIOR RESPONSIBLE OFFICER: Richard Watson
Our Ambition shared with the ICS is that: No patient is diagnosed with cancer through an unplanned hospital admission. 100% of patients take up the offer of breast, bowel and cervical screening.
Why it is important: The best quality cancer treatment, care and support is are essential if everyone in Suffolk and North East Essex is to start well, live well and die well.
Our two indicators for success are: • An increase in proportion of cancers diagnosed at stages 1 or 2 across the regional Cancer Alliance, from 54.5% in 2017 to 62.6% in 2023/24 • Increased 1 year and 5 year survival rates
Our plan is: • Rapid access to diagnostics • Best quality treatment • Personalised support to live well
Our baseline is: • Proportion of people that survive cancer for at least 1 year: 2017 71.9% • Cancers diagnosed at early stage: 2018 56.9% (1 year rolling average)
Our Key Partners are: WSFT, ESNEFT, Primary Care, Macmillan, CRUK, VCS and Service Users
62 Working together with you Cancer (ICS-wide)
Our high level milestones are:
MILESTONES: CANCER 20/21 21/22 22/23 23/24
Development of Primary Care Networks that enable locally designed interventions to help improve early X diagnosis of cancer by responding to local needs and challenges
Implementation of a new Faster Diagnosis Standard of X 28 days from referral to diagnosis/ruling out of cancer
Implementation of rapid diagnostic centre pathway X
Everyone with cancer having personalised care including needs assessment; care plan; and health and wellbeing information and support, and where X appropriate, protocols in place for personalising follow-up and systems for remote monitoring of patients on supported self- management.
More people will be supported to take part in clinical X trials, where appropriate Review of current cancer workforce and development X and implementation of a local plan. Macmillan Cancer Care Navigators rolled out across X the ICS and pilot evaluated
63 Working together with you Enabling Actions
Governance and Programme Management
Workforce
Digital
Working in Partnership
Estates
Financial Resources
64 Working together with you Enabling Action 1 – Governance and Programme Management SENIOR RESPONSIBLE OFFICER: Maddie Baker-Woods
Why it is important: Good Alliance governance provides the structure and processes for efficient and effective decision making, to drive outcomes. It enables confidence and safeguards and reputation of all partners and ensures accountability to the people with serve and staff we support.
Our Indicators for Success are: • Secure, shared system wide understanding and application of governance arrangements which enable our functions to be delivered • Efficient and effective ‘programme’ management to enable delivery
Baseline: • The Alliance is a partnership of health, care without legal form. • The Alliance is supported in co-ordination of its overall planning and management functions by a small number of individuals on a part-time basis • Each organisation provides leadership, individual programme management and delivery resources
Our Plan is: • Assessment of current governance and management arrangements by all partners (using maturity matrix, completed in 2018) • Development of options to ensure continuous improvement and agreement of future models • Development of detailed plans • Implementation of plans
65 Working together with you Enabling Action 2 – Workforce SENIOR RESPONSIBLE OFFICER: AMANDA LYES, LISA LLEWELYN
Why it is important: Strengthening our health and care workforce is a key priority if we are to deliver the benefits to the people living in Ipswich and East Suffolk described in this plan. We will adopt an integrated approach to workforce, working closely with performance and finance to make sure our workforce plans are realistic and meet the needs of the local population. Our Indicators for Success are: • Improved staff retention rates • More providers’ Care Quality Commission ratings are ‘Well-led’ • Lower nurse, GP and other clinical vacancy rates • Reduced sickness absence rates • Positive annual NHS Staff Survey feedback Increase in apprenticeships • More young people recruited into health and care pathways • Improved supply and quality of pre-qualifying student placements • Successful e-rostering • Closing of gender and race pay gaps • Increased diversity of employees with protected characteristics at all levels • Improved support to NHS Boards to review their Workforce Race Equality Standards and Disability Equality Standard and implementation
Our baseline is: • Ageing workforce – imminent retirements/loss of experienced staff (NHS: 18% by 2021) • Insufficient supply, especially adult, mental health, learning disabilities and primary care nurses, A&E doctors and GPs • Over-reliance on international recruitment and agency recruitment • Ensuring supply timelines and a consistent quality of education.
66 Working together with you Enabling Action 2 – Workforce
Our plan is: We do not yet have a holistic strategy; this is a priority but meanwhile are vigorously pursuing a set of initiatives within and across our organisations focused on: • Workforce planning – from daily rostering to long-term needs assessments • Addressing specific skills and role gaps in primary care, mental health, social care, acute medicine; introducing new roles • Delivering 21st century care – growing our overall workforce, introducing more varied and • Developing a new ways of working for delivery of new models of care • Building TeamEast – One Team (see this section)
Our Key Alliance Partners are: Ipswich and East Clinical Commissioning Group (CCG), Suffolk GP Federation, East Suffolk and North East Essex Foundation Trust (ESNEFT), Suffolk County Council (SCC), Suffolk Borough Council, Norfolk and Suffolk Foundation Trust (NSFT), East of England Ambulance Service Trust (EEAST), voluntary sector partners
Our high level milestones are:
MILESTONES: WORKFORCE 21/21 22/23 23/24 24/25 Health and Care Academy X Health Ambassadors X Retention Strategy X OD strategy X Health and Wellbeing programme X Leadership training X System Apprenticeship approach X Introduce a staff charter/kite mark X
67 Working together with you Enabling Action 3 – Digital SENIOR RESPONSIBLE OFFICERS: Dr Shane Gordon, Amanda Lyes
Why is it important?/ Our Ambition We want to develop infrastructure to enable all health and care professionals to be able to easily access relevant and timely information at the point of care and to enable all residents to be able to access key information about their care digitally.
Indicators for Success • Higher levels of digital health literacy and inclusion • Improved patient access including signposting • Reduction in unnecessary face to face appointments • Higher levels of security and public trust
Our Baseline • Multiple patient record systems within our organisations with limited interoperability • Increasing on-line access for individuals to their records and/or key information about their care • Increasing safe remote access for professionals to records to enable care • My Care Record has supported sharing patient information within health and care services • Growing use of digital applications to support individuals with self care and prevention but without an overarching strategy
Our Plan Our Plan has three key strands: 1. Front-line health and care professionals are easily able to access relevant and timely information at the point of care 2. All people in Ipswich and east Suffolk are easily able to access key information about health, care and wellbeing services digitally 3. People involved in health and care can easily access information about services digitally
68 Working together with you Enabling Action 3 – Digital
Our high level milestones are:
Milestones: Digital 20/21 21/22 22/23 23/24 All health and care professionals are easily able to access relevant and timely information at the point of care Adopt My Care Record (GP, mental health, community, X social care, hospital)
National information governance framework adopted X and in active use across Alliance
Digital Workforce capacity and capability assessment X and quick wins implemented
Alliance-wide connected and secured wireless network X live
Frontline practitioners have access to key information X about presenting individual to deliver safe care
All Alliance organisation digitisation plan established X
Alliance wide data systems are secure, resilient and recoverable through system design, monitoring and X education
Implement Time to Care capabilities (current list, X X X X evaluation and wider adoption)
Everyone can easily access key information about their care digitally
Digital First services implemented in priority areas for X GP and Outpatients
30% people using digital first NHS services by 23/24 X
Develop connectivity insight map and improvement X plan
100% people have a digital first GP service options X available
69 Working together with you Enabling Action 3 – Digital
Milestone: Digital cont’d 20/21 21/22 22/23 23/24 People are involved in health and care can easily access useful information and services digitally Plans, procurements and adoption of new Digital First services in place X X X X Communication, skills development in place for staff and public E-rostering and e-job plans in place for major NHS X bodies Core Information Standard adopted across care setting priorities for integrated records X
Increase support for people to manage their own health by adopting digital services Forerunners – diabetes, respiratory, maternity and X X parenting, mental health (adults and children) Followers – Pain, frailty, end of life Trialling of smart devices such as remotely monitored X inhalers
Re-procurement of Infolink X
East Coast - Smart Towns (Framlingham and Felixstowe X – launch Transformation projects • Development of a Master Patient Index at ESNEFT • Development of the Strategic Outline Business Case for ESNEFT’s Electronic Patient Record • SystmOne for acute and physiotherapy X • NHS Mail support for care homes • SystmOne links to Suffolk County Council • SystmOne for Social Prescribing
70 Working together with you Enabling Action 4 – Working in Partnership Involving, Engaging and Informing SENIOR RESPONSIBLE OFFICER: Lisa Nobes
Why it is important? Co-production or working in partnership is shown to improve the quality, uptake, experience and outcomes of services. It is also shown to improve staff’s motivation and satisfaction in developing and delivery improved services. Clear, concise, accurate and aligned communications by all Alliance partners increase reach and ensure that communities are able to make safe, personal decisions about how to prevent ill health, access services and to manage their conditions. As multiple channels evolve and the risk of ‘fake news’ grows, our collective approach grows in importance.
Our baseline is: Each partner within our Alliance has its own approach to working in partnership with patients, the public and staff; some major programmes of work have been undertaken together or between two or more partners. Alliance wide approaches include development of our mental health and emotional wellbeing strategy and now delivery plan. We have an established Alliance-wide communication network, which has worked together on joint messaging over the past 12-months.
Our indicators of success are: • Local communities will have a clear way to work in partnership with the Alliance in the development, delivery and review of our work • Local communities will be well informed about how to prevent ill health and manage their own health and care • Our staff will have clear ways to engage in development of plans and feel the benefits of working in partnership and excellence in receiving information themselves and to the people we serve
Our plan is: We now need to build an holistic forward plan for our whole Alliance, each locality and transformation programme. This will be underpinned by excellence in: • Working in partnership • Involving • Engaging • Informing . . . the public, people who use our services and people who work in our services.
71 Working together with you Enabling Action 4 – Working in Partnership Involving, Engaging and Informing
It will be based on principles previously agreed that we will: • reach out to people • seek out new technologies - push our normal boundaries . . . to get people involved and provide information.
Whilst this holistic strategy and plan is developed in partnership, we will continue our current actions in individual programmes of work.
Our Key Partners are: All Alliance partners working with patients and the public, voluntary and community sector groups
Our high level milestones are:
MILESTONE: Working in Partnership Involving, Engaging and 20/21 21/22 22/23 23/24 Informing Development of Alliance partnership working (co-production) strategy X Development of Alliance partnership working (co-production) delivery plan X
Develop Alliance-wide community engagement partnership X
Evolve communications group X Work with lay and elected members to develop further engagement with us X Develop Alliance branding and messaging X
Collate stories X Produce multi-channel and format, accessible annual ‘report’ X Deliver key communication campaigns including Coronavirus, Elective Care Centre, Mental health services X
72 Working together with you Enabling Action 5 – Estates SENIOR RESPONSIBLE OFFICER: Amanda Lyes
Why it is important: Our estate is critical to delivery of our goals. An ICS-wide strategy is currently being developed in line with the Naylor Review and local One Public Sector Estate principles. We are keen to play a highly active role in its development; ensuring we address local critical challenges.
Our Outcomes are: Delivering an estate where people can access services at the right time, in the right place and be seen by the right person. Delivering an estates that is sustainable for the future both finically and in terms of meeting the growing population Delivering an estate which is flexible to enable it to meet with the changing service delivery models and patient needs
Our indicators for success are: • Capital and revenue costs which fit with current and future budgets and are finically sustainable • Current and forecast population growth are able to access healthcare services and access them in locations convenient to them • Providers are able to offer the variety of services and service models that are required to meet their population needs at a locality level
Our baseline is: • Limited flexibility within the current estate due to constraints imposed by existing buildings • Limited opportunities to develop truly integrated teams and service delivery models due to funding and building constraints. • A current estate which does not have sufficient capacity to meet the current population size or the proposed growth over the short to medium terms
73 Working together with you Enabling Action 5 – Estates
Our plan is: We are focused on: • Alignment with local clinical strategies, specifically including service integration in localities. • Maximising value for money, specifically including our plans to eradicate waste and to change our investment profile from urgent and acute care to primary and community care and prevention. • Addressing backlog maintenance.
Our Key Partners are: GP providers, East Suffolk and North East Essex Foundation Trust (ESNEFT), Norfolk and Suffolk Foundation Trust (NSFT), East Suffolk District Council, Babergh & Mid Suffolk District Council, Ipswich Borough Council, Suffolk County Council
Our high level milestones are:
MILESTONES: ESTATES 20/21 21/22 22/23 23/24
Delivery of capital schemes to increase clinical capacity of GP X X X X Surgeries Development of Primary Care Estates Strategy to align with X priorities of Long Term Plan and Alliance Priorities Completion of feasibility studies in a number of areas to assess X X system development opportunities Continued negotiation for Section 106 and Communality Infrastructure Levy funding from housing developers where new X X X X housing is developed Opportunities to co-locate primary and community care teams are X X being explored
Continued capital support to address infection control issues within X X X X GP Surgeries
Reduction and management of Void space within premises X X
74 Working together with you Enabler 6 – Financial Resources
Our key Enabling priorities for the Alliance include the following: • Development of organisational, alliance and system plans to deliver the financial control total requirements in each of the financial years, and the improvement trajectory outlined in the Strategic System Plan. • Monitoring of financial performance and management of the financial position at organisational, alliance and system level, in line with the system control total management process. • Financial evaluation of health investment opportunities to support investment decision-making. • Diagnostic analysis of system efficiency, and potential for improving efficiency. • Support to the process for development of efficiency/productivity plans, and performance monitoring against those plans at organisational, alliance and system level.
Our baseline is: NHS acute bodies and the CCG will meet their control totals in 2019/20
Our Key Partners are: All Alliance partners and their regulators. Our Alliance has established a financial committee to ensure shared understanding and facilitate shared decision-making.
Our high level milestones are: Milestone 21/21 22/23 23/24 24/25 Alliance Financial Control Totals (£m) Baseline IES -21.003 -16.846 -14.937 -12.975 NEE -18.232 -14.561 -12.872 -11.136 WS -8.419 -5.694 -4.103 -2.336 SNEE System -47.654 -37.101 -31.912 -26.447 Alliance Financial Control Totals (£m) inc FRF, MRET IES 2.676 2.792 2.909 3.024 NEE 2.599 2.714 2.827 2.939 WS 1.696 1.770 1.844 1.917 SNEE System 6.971 7.276 7.580 7.880 Efficiency/Savings targets (£m) IES 21.467 20.025 19.567 20.063 NEE 20.364 17.073 16.710 17.186 WS 18.360 15.820 15.417 15.645 SNEE System 60.192 52.918 51.694 52.894
75 Working together with you Thank you to contributors
For further details, please contact:
Maddie Baker-Woods Chief Operating Officer Ipswich and East Suffolk Clinical Commissioning Group and Alliance
01473 770000 [email protected]
76 Working together with you 77 Working together with you