CLINICAL SERVICE STRATEGY H ERTFORDSHIRE C OMMUNITY NHS T RUST
2012/13 – 2016/17
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1
V5
Trust Board
29 November 2012
Hemal Desai
Executive Team
November 2012
November 2014
HCT Board

H ERTFORDSHIRE C OMMUNITY NHS T RUST CLINICAL SERVICE STRATEGY
Version Date Summary of Changes
DRAFT
V1
DRAFT
V2
7 May
2012
12 May
2012
DRAFT
V3
DRAFT
V4
DRAFT
V5
31 May
2012
18 Nov
2012
21 Nov
2012
Initial Draft following Board Briefing on overview of Clinical Service Strategy on 26 th
April 2012.
Second Draft. Updated to reflect comments from Executive and post feedback from presentation at HV CCG Board Meeting on
7 th May 2012.
Third Draft. Updated following comments received from Trust Board presentation.
Fourth Draft. Reviewed in line with changes to other strategies and minor edits.
Fifth Draft. Reviewed following comment from Executive Team
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Author(s)
Hemal
Desai
Distribution
(Group /
Committee)
Executive
Team
Hemal
Desai
Hemal
Desai
Hemal
Desai
Hemal
Desai
Executive
Team
Executive
Team

Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
1.1 The clinical service strategy outlines the strategic direction for Hertfordshire
Community NHS Trust and underpins all of the other key strategies to deliver services in the future. It forms the basis on which HCT will deliver outcomes and focus resources. The Trust is keen to develop its services at pace over the coming months and years and has initiated discussion to gain support from commissioners to undertake the programme of work required to deliver the strategy.
1.2 At the heart of our strategy we have a number of key objectives, relating to our three main areas of services provision:
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To keep patients in their homes where possible by coordinating a range of services that meet their needs
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To develop a single integrated service which is closely aligned with both general practice and social care and to coordinate care around a patient across health, social care and voluntary sector
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To deliver services which promote optimal health and wellbeing for children, to provide the best possible start in life, and a sound foundation for a healthy future
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To develop a single integrated service which co-ordinates care around children and families
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To provide innovative and responsive ambulatory services in community based settings, which meet the needs and expectations of patients
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To work closely with primary care and align to local priorities for long term conditions and 'wellbeing'
1.3 We have developed the programme to support the transformation of each of these three main areas of care and also have some generic developments around workforce development and project management that span some of the projects within the programme.
1.4 Our strategy provides a proposition that goes beyond the narrow confines of 'keeping people out of hospital' and is about maintaining health, helping people to live their lives optimally, living independently where they choose to do so. We will:
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Take a broad view of what we can achieve as a Trust;
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Act as the element of the system which links primary care, social care, acute and mental health services with the wider community; and
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Provide an alternative vision of managing care, which will offer choice for commissioners and for patients.
1.5 The clinical services strategy builds on the existing capabilities within HCT but intends to provide a systematic approach to the provision of a continuum of care, especially for older people and children's services, and allows for a framework upon which service developments are assessed from a clinical perspective as part of the overall process for business development.
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
3.1 There are several drivers that have an impact on the way HCT delivers its services. To react to the impact of these drivers HCT will need to build on its existing strengths and use its considerable expertise in delivering services to children and older people. In 2012/13,
HCT is forecast to have 1.89 million patient contacts. Of these on year to date performance
, 48% will be for those people over 65 years and 29% are to children up to 18 years.
3.2 HCT also has significant experience in providing many other services including diseasebased models, such as diabetes or musculoskeletal services, or specialty-based models such as dermatology services. These services tend to replace aspects of those previously provided in outpatient settings within the acute hospitals. The drivers impacting on HCT can be summarised as:
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Demographic changes - there will be a significant increase in those above the age of 65 years over the next few years and an increase in the number of children below the age of 19 years.
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Public health needs - there will be a substantial rise in the prevalence of long term conditions and the need to ensure healthy children
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Commissioners priorities - these will focus on care in the community, streamlining care pathways, reducing non elective activity, preventing admissions, management of people with long term conditions and establishing a single point of contact for health & social care
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GP expectation - GPs want greater integration with practices, easier access to HCT services (along with social care), ensure that district nursing and health visiting are responsive and information about the use of services
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Technological advances - substantial advances in technology enable care to be delivered more safely, effectively and efficiently
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Local Health Economy Other important drivers include the strategic objectives of local organisations (such as the adjacent commissioners, acute Trusts, local authorities and schools) and the increasing financial constraints impacting on future sustainability as a Foundation Trust
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Finance - Public sector finances are under considerable pressure and this will remain for the foreseeable future. Healthcare will have to be provided more effectively and efficiently to greater numbers and this Transformation programme is aimed at aligning HCT services in a way that will allow them to deal with increasing demand and maximise the benefits of health spend in Hertfordshire.
3.3 The impact of these drivers inevitably means that HCT needs to transform the way in which it delivers services to be sustainable in the future and to meet the demands of those that pay for, use and refer in to HCT services.
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
4.1 The Strategic Developments are broken down across the three core areas of our business:
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4.2 This strategic development arises from transforming the way in which services are provided to adults and older people. It builds on the services to HCT's core market of those aged over 65 years.
4.3 The Community Service for Adults and Older People will transform and facilitate a systematic approach to meet the needs of those with long term conditions and, in particular, older people with complex needs and multiple co-morbidities in Hertfordshire. It will transform the existing, complex provision of services with multiple entry points and variable outcomes into a systematic streamlined model of care focusing on outcomes and partnering with older people to address their health, social and psychological needs.
4.4 HCT aims to lead a multi-agency approach with Hertfordshire County Council and
Hertfordshire Partnership NHS Foundation Trust to develop a system that promotes proactive, risk-based and co-ordinated model of care for those most in need of care, particular those aged over 85 years, to prevent rapid deterioration of health requiring emergency health or social care.
4.5 This systematic approach is shown graphically in the model for Community Services for
Adults and Older People (Figure 1). It sets the foundation to enable HCT to provide a continuum of care stretching from avoiding unnecessary admissions to acute services, based on risk stratification, to the delivery of care to individuals with complex needs (subacute) but are not acutely unwell. The use of telehealth will be a critical enabler for HCT to deliver this care effectively and efficiently and will allow us to integrate with the local authority and their use of telecare.
4.6 The model for Community Services for Adults and Older People includes developing the following services across Hertfordshire:
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Liaison Team for Older People - will provide a point of contact and useful resources to help with daily activities and to signpost to appropriate health, social and voluntary services
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Integrated Point of Access / Single Point of Contact (IPA / SPOC) with Joint Rapid
Triage Team - will provide easy access for those referring in to the service and will handle navigation through the service
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Dedicated Assessment and Care Planning Team - will provide rapid assessment of the patient with early decision making and initiation of care plans
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Integrated Care Team - will provide a multi-disciplinary team to manage most patients within their home or care setting with allocation of a key worker for every patient
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HomeFirst - will provide a virtual ward with case management for those with the highest risk of deterioration and those most likely to require emergency care
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Home Care - will provide intensive peripatetic nursing and therapies in the home or residential care setting providing an alternative model to community hospitals
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
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Enhanced Care - will provide an advanced level of inpatient care in the community focusing on complex rehabilitation, complex nursing and managing those with infective illnesses in the community
4.7 The HCT Community Service for Adults and Older People will aim to:
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Prevent emergency admission to acute hospitals for those with long term conditions
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Promote faster recovery from illness through active rehabilitation and achievement of goal related outcomes
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Support discharge following a hospital admission by reducing acute hospital length of stay for those with cellulitis, pneumonia and urinary tract infections
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Help a person remain in their own home living as independently as possible
Figure 1. Model for Community Service for Adults and Older People
4.8 The objectives of the Community Service for Adults and Older People are:
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To deliver the best outcomes for patients by delivering evidence based healthcare
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To keep patients in their homes where possible by coordinating a range of services that meets their needs
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To coordinate care around a patient across health, social care and voluntary sector
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To deliver a service that enables patients to make informed and self-management decisions
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To work in partnership with carers supporting them to meet their own needs
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To deliver a role for patients over 85 years as a lead professional assessing and coordinating their health and social care needs
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To provide an easy access route for referrers and patients and carers
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To provide a response that is timely and appropriate for the caller, flexibly meeting their needs, whether requiring advice, sign posting, assessment or an intervention
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
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To deliver a coordinated health and social care service that is efficient in its use of resources
4.9 HCT intends to transform Children's Services, which currently account for 29% of HCT's activity.
4.10 HCT will use its capability to work with children and families to implement the Healthy Child
Programme in a systematic way that aims to ensure children receive a healthy start in life and remain healthy in adulthood.
4.11 Over the last two years the DH has outlined its aim to improve services for children. It launched a new service model to improve care for children, families and communities with the Healthy Child Programme for those up to 5 years. This was followed with the launch of
Getting It Right for Children, Young People and Families, a programme for maximising the contribution of the school nursing service and the Healthy Child Programme for those between 5 and 19 years.
4.12 HCT aims to lead a multi-agency approach with Hertfordshire County Council to develop a system that provides a comprehensive, co-ordinated universal service to improve the health and wellbeing of children through the expert skills of health visitors and school nurses. The universal service will be supported closely by targeted services, which will tackle inequalities, and specialist services, which will provide integrated therapies and expert medical support when required. This model will allow a co-ordinated approach to dealing with major challenges such as childhood obesity facing Hertfordshire over the next few years.
4.13 The Universal MDT and Multi Agency Team will be the key component of the Children &
Family Service. It will be a flexible and responsive service that includes health visitors, school nursing teams, family nurse partnerships and the thriving families team who will work with GPs, schools, Children's Centres and voluntary organisations to deliver the
Healthy Child Programme by focusing on the importance of early intervention. The Service will reduce the obstacles by working across the age ranges as a multi-skilled team that delivers evidence based interventions to best support families to ensure that children reach their full potential.
4.14 In addition HCT will work to utilise the expertise within specialist services to equip the wider children’s workforce to identify children with additional needs as early as possible and provide advice and intervention reducing the need to access specialist services and improving outcomes for children. By ensuring service provision is delivered as soon as possible, at the lowest tier of service possible, coordinating services across health, social care and education and by ensuring the most appropriate levels of clinician delivers each service, HCT will strive to deliver effective services that are value for money and an excellent experience for children and their families.
4.15 The service will use the latest technology to make sure that its service users can access help and support promptly and at a time and venue that suits them.
4.16 The HCT Children & Family Service will aim to:
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Prevent disease through improved uptake of the immunisation programme
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Support the reduction in childhood obesity
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Drive reductions in teenage pregnancy
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Ensure readiness for school
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
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Undertake screening programmes such as hearing, vision and bloodspot.
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Promote good mental health
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Increase rates of breastfeeding
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Support the most vulnerable families through evidenced based services such as
Family Nurse Partnership and Thriving Families
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Promote good physical and mental health in pregnancy
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Enable access to the Universal Team in the evening and weekends to reflect GP provisionDevelop a Family Nurse Partnership team in West Hertfordshire
4.17 The Service will help to deliver one of the priorities of the Health & Wellbeing Board to help families facing multiple problems to thrive and fulfilling lives for people with learning disabilities.
Figure 2. Service Model for Children's Service
4.18
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To deliver services which promote optimal health and wellbeing for children, to provide the best possible start in life, and a sound foundation for a healthy future
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To reduce inequalities in the experience of children, deploying resources accordingly
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To support the effective management of children with disabilities or long term conditions to optimise their life experience
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To tackle childhood obesity effectively
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To develop further the partnerships which support these objectives and ensure effective use of resources
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
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To be focused on meeting the needs of children and families
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To provide information to support families access the services they need
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To deliver a coordinated health and social care service that is efficient in its use of resources.
4.19 A further development opportunity arises from ambulatory services, either disease-based or specialty based-models of care. HCT would like to develop this area to support commissioners to reduce non-elective activity in secondary care and shift this into a more accessible and cost-effective community setting, particularly, for long term conditions. HCT sees this is as an area of growth in the future and is keen to invest resources to develop this further with commissioners and GPs.
4.20 For disease-based models, HCT proposes the development of pathway hubs for long term conditions in key priority areas for CCGs such as diabetes and COPD. HCT has already successfully developed a community-based service for diabetes that provides accessible and effective services. HCT would like to extend this model to include other aspects of the diabetes pathway becoming the lead provider for diabetes care outside general practice.
4.21
HCT are keen to work with commissioners to develop the “Year of Care” funding model in
Hertfordshire to facilitate the shift of care from acute based settings. Across Hertfordshire in
2011/12 over £4.5m was spent on unplanned emergency care for those diagnosed with diabetes and chronic lower respiratory disease alone. Pathway hubs would aim to achieve better outcomes resulting in reduction in spend on emergency attendances for these conditions. HCT’s proposed model for a pathway hub is shown in Figure 3.
Figure 3. Service Model for Ambulatory Care
4.22 For specialty-based models, HCT proposes further scoping with commissioners in several key specialties to understand whether there is an appetite for this level of change. HCT would like to focus on the areas that have been shown to have an evidence base for
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY community-based services delivered through improving the skill mix. The development of the non-consultant led tariff could provide a framework to identify target specialties.
4.23 Indicatively, Table 1 below shows the specialties that could each result in savings over £1m if pursued through non-consultant led models especially in those specialties (in green) where they may be more scope to develop innovative models. This information covers the following local acute hospital trusts at West Hertfordshire Hospitals NHS Trust; East and
North Hertfordshire NHS Trust; The Princess Alexandra Hospital NHS Trust; Barnet and
Chase Farm Hospitals NHS Trust; Bedford Hospital NHS Trust; and Luton and Dunstable
Hospital NHS Foundation Trust.
Table 1. Table showing potential savings identified using NHS Reference Costs comparing Consultant led services to Non-Consultant led services in six local acute hospital trusts
Potential Saving
Specialty First (£) Follow Up (£) Total (£)
Obstetrics
Paediatrics
2,364,545
2,294,858
2,338,547
1,900,982
4,703,092
4,195,840
Cardiology
Ophthalmology
Rheumatology
Clinical Haematology
Gynaecology
Respiratory Medicine
General Surgery
Geriatric Medicine
Genito-Urinary Medicine
ENT
Gastroenterology
Urology
Dermatology
Medical Oncology
1,490,579
548,591
804,225
699,163
1,060,668
561,407
856,878
911,643
777,992
795,970
816,694
526,880
612,062
278,954
1,541,485
2,002,042
1,720,418
1,752,162
888,845
1,010,421
698,145
585,660
623,823
546,887
469,797
576,559
466,562
771,248
3,032,064
2,550,633
2,524,643
2,451,325
1,949,513
1,571,828
1,555,023
1,497,304
1,401,814
1,342,857
1,286,491
1,103,440
1,078,624
1,050,201
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
5.1 Our strategy is based on delivering a very different experience of community services for the population and for the organisations we work closely with, specifically general practice and social care.
5.2 Our plans will:
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Deliver a significant shift in services to the community for those with long term conditions and, in particular, older people with complex needs and multiple comorbidities with a systematic approach to managing people with complex needs across organisational boundaries
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Deliver the Healthy Child Programme whilst creating a wider system of care that will be able to deal with all aspects of children’s health and wellbeing. This will include the significant challenges resulting from inequalities in early life and startling rates of childhood obesity
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Develop further innovative models of ambulatory services especially in areas that have supportive evidence base to use increased skill-mix in the community to deliver cost effective services with better health outcomes, which provide an alternative choice for commissioners
5.3 We will:
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Make it easier for GPs and patients to use our services by developing a comprehensive front of house contact point
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Focus on developing consistent standards and responses across the county
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Work closely with partners to ensure there is a co-ordinated approach to patient care
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Continuously improve our clinical outcomes
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Reduce system costs, particularly for older people's and ambulatory services
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Deliver high levels of patient satisfaction
6.1 This Strategy sets out our Clinical Service Strategy over the next five years. It aligns with our Integrated Business Plan.
6.2 The next steps are to create more detailed action plans for the service developments that build on this strategy with defined timescale, deliverables, and measurable outcomes over a five year period. It is important that this strategy is shared with partners and other stakeholders to inform the evolution of the service developments.
7.1 The Clinical Service Strategy is a supporting strategy of the Integrated Business Plan and has dependencies to a greater or lesser extent with all other strategies.
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Hertfordshire Community NHS Trust CLINICAL SERVICE STRATEGY
MDT
NCB
NHSLA
NMET
OD
ONS
OT
QIPP
RR
SaLT
SIP
SPOC/A
SWOT
TWWW
VW
HCC
HCP
HCT
HF
IBP
ICS
IM&T
IPA
LTC
LTFM
Monitor
AfC
(C)FT
CCG
COPD
CQC
DH
EDS
EIS
EWTD
GP
Acronym /
Abbreviation
ADO
Description
Assistant Director of Operations
Agenda for Change
Community Foundation Trust
Clinical Commissioning Groups
Chronic Obstructive Pulmonary Disease
Care Quality Commission
Department of Health
Equality Delivery System
Early Implementation Sites
European Working Time Directive
General Practice / General Practitioner
Hertfordshire County Council
Healthy Child Programme
Hertfordshire Community NHS Trust
HomeFirst
Integrated Business Plan
Intermediate Care Strategy
Information Management & Technology
Integrated Point of Access
Long Term Conditions
Long Term Financial Model
Independent Regulator of Foundation Trusts
Multidisciplinary Team
National Commissioning Board
NHS Litigation Authority
Non-Medical Education & Training
Organisational Development
Office of National Statistics
Occupational Therapy
Quality Innovation Productivity Prevention
Rapid Response
Speech and Language Therapy
(Hertfordshire’s) System Integrated Plan
Single Point of Contact / Access
Strengths Weaknesses Opportunities Threats
“Transforming the Way We Work” – HCT Transformation programme
Virtual Ward
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