Northern Lincolnshire Sustainable Services
Quality Services for all
May 2013
Commissioners have laid out their vision for a new
model of care for Northern Lincolnshire
Self care
independent living
Primary care
Community based care
Secondary / Tertiary
Secondary / Tertiary care
Healthcare providers should provide a comprehensive service, from supporting prevention and
self-care, through community provision, to specialist and tertiary care.
Providers of these services should take an integrated approach, so that local people have access
to a seamless service
Higher quality
The result will be higher-quality care, with more lives saved and more people returned to full health
A further result will be a service that is affordable in the years to come
Case for Change for Sustainable Services
NHS and Social care partners in Northern Lincolnshire are looking at ways of improving
quality of care for residents
As part of this case for change process we have started to identify the quality standards we
want to achieve.
We have also started to look at a number of service areas where we hope to set out a case
for change, including:
• Primary Care, Intermediate Care, Urgent & Acute Services
The final solution will deliver sustainable care across all health and social care services
As this process continues we will be talking to a wide range of stakeholders including:
• Managers and frontline staff of local services
• Relevant oversight bodies and adjacent services
• Public representatives, and a wider range of people, if appropriate
As part of the Case for Change process, options are being
developed which increase primary and community based care
Self care
independent living
Primary care
Community based care
Options to increase
primary and community
based care,
....which will support ...
Secondary / Tertiary
Secondary / Tertiary care
Options to reduce
secondary and tertiary
These are some options for primary and community based services
(focusing on services which reduce demand for secondary care)
demand for
N Lincolnshire
NE Lincolnshire
Integrated care model
Integrated care model
Step down
Step down
Step up
Step up
Primary ambulatory
Primary ambulatory
Complex case management
CCGs adopting same service approach
with common delivery model
Emergency ambulatory
local need)
Improving Access to Psychological
End of Life Strategy
End of Life strategy
Primary Care Triage in A&E
Unplanned care pathway
Diagnostic support in Primary Care
GP risk based tool
Expert patients programme
CCGs undertaking different additional
services in response to local needs
and priorities
But all options will have to be assessed against the ‘Hurdle Criteria’
• Option must meet all current best practice guidelines and
national standards with no overall reduction in quality of services
• Primary and community options must reduce unnecessary
hospital admissions
• Primary and community options should increase patient choice
for services
Clinical effectiveness
Patient experience
• Option must meet acceptable standards for access to
urgent treatment
• Option must not introduce unacceptable health
inequalities for patients
Distance and time to access services
Patient choice
• Option must be affordable to health and social care
Net present value
Capital cost to the system
Transition costs
Commissioner affordability
Provider viability
• Option must be deliverable within a five year
Deliverability timeframe without creating increased risk to high
quality care during that period
1. Northern Lincolnshire: Commissioner Visions for Sustainable Services; 2. RCOG (2007) Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour ; ROCG (2011) High Quality Women’s Health
Care: A proposal for change ; RCOG (2012) Tomorrow’s Specialist 3. College of Emergency Medicine / BMA (2009) "The Consultant Contract and Job Planning for Emergency Medicine Consultants" ; 4. RCPCH (2011)
"Facing the Future: Standards for Paediatric Services"; 5. 'Blue light' travel time is calculated to be 1/3 shorter than non-blue light journeys. Source:
Explaining Community Based Care
What is Complex Case Management?
• Intensive casework with selected patients at high risk of A&E attendance / acute admission
• Area wide assessment identifies patients using highest resource
• Intervention co-ordinated through single multi-agency team
What is different from now?
• Targeted patients receive bespoke assessment followed by intensive, wrap around services, co-ordinated by a single key
How many people will benefit?
• ~200 patients consuming highest healthcare resource
What is the Integrated Care Model?
• Multi-agency integrated teams delivering joined up services to higher risk patients
• Typically teams include district nurses, social care, mental health services and are aligned to GP practices
• Focus on elderly/frail and patients with long term conditions
What is different from now?
• Patients with multiple needs have single, integrated assessments; receive a single care plan and often have a named lead
How many people will benefit?
• Differs depending upon particular groups targeted, but typically 2-5% of patients
Ambulatory care
What is Primary Ambulatory Care?
• Enhanced primary, community and self management of conditions most effectively managed within the community
• Ambulatory care sensitive (ACS) conditions include COPD, asthma and diabetes1
What is different from now?
• Active management of patients with ACS through vaccination; better self-management, disease-management; or lifestyle
interventions – prevents acute exacerbations, reducing need for emergency admissions
How many people will benefit?
• Depends on initiative. Nationally 28% of the population have long term conditions
What is Emergency Ambulatory Care?
• Clinical care for conditions perceived as urgent and requiring prompt clinical assessment
• Undertaken within hospital through less intensive route (e.g. reclining beds)
• Patients typically either low risk or of specific targeted diagnoses that can be released same day
What is different from now?
• Significant focus on reducing overnight admissions through effective management of identified case mix
How many people will benefit?
• Typically, ~5% of A&E attendances or 20% of emergency admissions
1. Full list of 19 ambulatory sensitive conditions are: COPD, angina (without major procedure), ENT infections, convulsions and epilepsy, congestive heart failure, asthma, flu and pneumonia (>2 months old), dehydration and
gastroenteritis, cellulitis (without major procedure), diabetes with complications, pyelonephritis, iron-deficiency anaemia, perforated/bleeding ulcer, dental conditions, hypertension, gangrene, pelvic inflammatory disease, vaccinepreventable conditions, nutritional deficiencies.
Source: ; Department for Health; ; NHS Institute of Innovation "Directory of Ambulatory Emergency
Care for Adults" ; NHS Institute for Innovation & Improvement "The health coaching experience in NHS Midlands and East"
Short Term Step Up / Step Down Care
What is Step Up Care?
• Non acute beds for additional medical support to patients who would otherwise go into hospital;
– or, who have been discharged from an acute episode, but have other outstanding health conditions
(e.g. UTI)
• Targeted at frail patients who, due to illness or injury, are unable to safely remain at home
• Short stay with target of swift return home
What is different from now?
• Lack of provision, particularly step up
• Bridges care at home and in hospital, avoiding admissions and re-admissions
How many people will benefit?
• Proposal for additional 27 beds
1. Source: South East Essex 'Intermediate Care' –
Source: NHS Institute of Innovation "Directory of Ambulatory Emergency Care for Adults"
The ‘Case for Change’ Engagement Approach …
• 12 week high profile campaign
• Using multiple tactics across both CCG localities
• Engagement with key stakeholders and the wider public
Key aims:
• Raise with the public and stakeholders the appreciation that change is
• Obtain views on future healthcare needs
Next Steps
Describe current
status and vision
and define options
and define options
and response
(if necessary)
Dec 12- Feb 13
Feb -Apr
• Develop
commissioner vision
• Develop case for
change & baseline
• Engage key clinicians • Wider engagement
with broad range of
and wider provider
• Identify shortlist
potential options
• Develop criteria for
assessing options
• Detailed assessment
and development of
preferred options