Right first time 24/7
Our evolving clinical
and quality strategy
Stakeholder meeting
6 February 2014
www.cddft.nhs.uk
The story so far…
Integrated hospital and community services in 2011
During 2012/13 held discussions with staff and
stakeholders around key services as an integrated
provider:
Unscheduled care
Integration and care closer to home
Women and children
Centres of Excellence
Agreed that getting care right for the emergency patient,
especially the frail elderly, must be the priority
www.cddft.nhs.uk
National context: quality
Reviews published into care at Mid
Staffordshire by Robert Francis
Reports into patient safety by Don Berwick
and Professor Bruce Keogh
Professor Keogh report on emergency care
www.cddft.nhs.uk
National context: affordability
2014/15
2015/16
Total Affordability Challenge
3.1%
6.6%
Provider Efficiency
2.0%
2.5%
System Efficiency
1.0%
2.0%
Remaining Challenge
0.1%
2.1%
Tariff Efficiency
4.0%
4.5%
www.cddft.nhs.uk
Local context: resources 2014/2016
Local CCGs
2014/15
2015/16
CCG Growth
£17.9m
(+2.14%)
£14.5m
(+1.7%)
Tariff Deflator
£10.4m
£11.8m
Total Additional Cash
£28.3m
£26.3m
www.cddft.nhs.uk
Local context: Better Care Fund 2015/16
D/ton
DDES
N Durham
Total
Total Fund
Contribution
£7.2m
£22m
£17.2m
£46.4m
Supporting Existing
Health Services
£3.9m
£11.9m
£9.2m
£25.1m
www.cddft.nhs.uk
Right first time 24/7
www.cddft.nhs.uk
Our vision
Right person
Right place
Right time
First time
24/7
www.cddft.nhs.uk
Our principles
Deliver core acute specialties across
both acute sites
Specialty departments delivering care
across two acute sites and beyond
Consultant delivered care
Patients in homes not hospital,
clinicians to patients
Care closer to home where safe,
effective and efficient
Older person at the heart of service
delivery, supported in the community
www.cddft.nhs.uk
“We need to stop
thinking of ourselves as
a group of small acute
hospitals, merged with
community services,
and really create a
vision of one large
progressive integrated
provider.”
www.cddft.nhs.uk
“Getting care right for
the emergency patient
must be prioritised – in
hospital and in the
community, with a
particular focus on older
people. This is our core
business.”
www.cddft.nhs.uk
“Services will be
organised so that
consultant review,
clinical staff and
diagnostic and
support services are
readily available on
a 7-day basis.”
www.cddft.nhs.uk
“We need to ensure that
steps to keep patients
out of hospital and
support them in the
community are
clinically effective and
cost efficient at a time
when there are
pressures on budgets.”
www.cddft.nhs.uk
“Many of our rotas at
both junior and
senior level are
supported by locum
staff, which impacts
on continuity of care
and consistency of
quality.”
www.cddft.nhs.uk
“Our ambition should be
to host one of the major
emergency care centres,
envisaged in Sir Bruce
Keogh’s report, within the
Trust, and upgrade the
level of acute and
emergency care available
within County Durham
and Darlington.”
www.cddft.nhs.uk
“We must design our
future configuration to
make sure that we make
the best use of our
hospital sites and that
each site has a strong
portfolio of services.”
www.cddft.nhs.uk
“Our reserves can only
be spent once, so it is
important that we do
so wisely, on
investments and
capital schemes in
hospital and in the
community, that will
help us achieve our
vision.”
www.cddft.nhs.uk
“We need to work with our
commissioners, with primary
care, with other providers,
and with our local authorities
to provide a truly integrated
service which meets the
needs and expectations of
patients.”
www.cddft.nhs.uk
Progress so far
Intermediate care
Service transformation work in ED
ED/UCC integration at DMH
Locality focus for community services
Community pilots in telehealth and remote working
Electronic clinical document management
UHND - endovascular theatre
Bishop Auckland – cardiac CT, bowel cancer
www.cddft.nhs.uk
Purpose for today
Stakeholders meeting our clinical strategy
steering group
Listen and share experience, and views
Engage in developing plans:
Long term plans
What needs to change for next winter?
www.cddft.nhs.uk
Views of commissioners
and local authorities
www.cddft.nhs.uk
A CCG View- Planning priorities
and commissioning intentions
Right First Time
Stakeholder Engagement Event
Thursday 6 February 2014
HIGH QUALITY CARE
FOR ALL, NOW AND FOR
FUTURE GENERATIONS
6 System Characteristics
The 6 characteristics of high quality, sustainable
health and care systems in 5 years time are:
• Citizen inclusion and empowerment
• Wider primary care, provided at scale
• A modern model of integrated care
• Access to the highest quality urgent and
emergency care
• A step-change in the productivity of elective care
• Specialised services concentrated in centres of
excellence
Challenges for Commissioners/providers/the system
• Rising Demands on Health Care –demography; LTCs;
elderly, dementia
• Unprecedented constraints on public sector
budgets – NHS £30bn gap between 2013/14 and
2020/21
• Expectations of the public
County Durham & Darlington Clinical Programme Board
• Purpose to harness the resources across the health
economy to develop proposals for recommendation
to the CCG and FT Boards to improve outcomes for
patients
• Comprises senior clinicians and leaders from all
sponsoring organisations
County Durham & Darlington Clinical Programme Board
Outcomes
The Clinical Programme Board will deliver the following
tangible outcomes in the health system:
• No unnecessary waits
• No 0 day lengths of stay
• No outlying patients, including out of area
placements
County Durham & Darlington Clinical Programme Board
Key Agreed Priorities
•
•
•
•
Elderly/frail elderly
Urgent Care
Mental Health and Dementia
Long Term Conditions
Emerging Priority areas for Darlington
• Support creation of a “Healthy Darlington” – where people eat well, move
more and live longer and ensure every contact counts
• Frail and Elderly – Extend care home project; model for community stroke
services; End of Life Strategy and action plan; HELS model to support
outside of hospital care
• Urgent Care –co-location and integration of UC and ED; Confirm the vision
for urgent care in Darlington;
• Long Term Conditions – invest in care of the elderly with complex
(multiple)conditions and others with long term health conditions including
dementia
• Mental Health and Learning Difficulties- Deliver a shift in the delivery of
care and support centred around primary care and community services
• Primary Care - Invest in primary care infrastructure and wrap care and
services around practices; improve access and 7 day services
Rising Demands on Health Care
• 80% of deaths from major diseases are
attributable to lifestyle risk factors (smoking,
alcohol and poor diet)
• One quarter of the population has a long term
condition. LTCs account for 50% of GP
appointments; 70% of days in a hospital bed
• The number of older people likely to require care
is predicted to rise by over 60% by 2030
• Around 800,000 people nationally are now living
with dementia - this is expected to rise to one
million by 2021
• Continuing with the current model of care will
lead to a national funding gap of around thirty
billion between 2013/14 and 2020/21
Challenges for Darlington CCG
• All of above!
• Financial resilience
• Achieve strategic shift (15%) acute activity to outside
of hospital via transformational schemes; BCF
• Capacity – delivery against plan
• Strategic partnerships with a focus on Darlington;
establish planning unit/transformational hub
Better Care Fund….
• The £3.8 billion Better Care Fund (BCF), (formerly the
Integration Transformation Fund) was announced by the
Government in the June 2013 Spending Round, to support
transformation in integrated health and social care.
• A single pooled budget to support health and social care
services to work more closely together as a response to
growing demand and constrained resources across the health
and social care.
• The BCF is not new money - it is funding already
allocated to services/contracts with providers.
• Key driver to reduce the use of acute beds by providing
outside of hospital services which are cost effective and
provide better outcomes for patients and service
users.
• The BCF supports the stated intentions of both the
Council and Clinical Commissioning Group (CCG) to
deliver services which are value for money and improve
outcomes through closer integration of the two
organisations.
BCF for Darlington
Darlington’s allocation of the fund totals £7.8m made up of the
following for 2015/16:Funding
£
Setting up of new services
417k
Transfer from Health to Social Care
1.8m
CCG reablement funding
626k
Carers break funding
208k
Capital funding
900k
CCG identified funding
3.9m
Total
7.8m
• £400k identified for transformation in 2014/15 has been
identified from CCG baseline funding.
• The remainder is money already included in previous
allocations to DBC and to the CCG.
• The total allocation of £7.8m can only be realised by
taking £3.9m of spend out of acute provision in Darlington
in 2015 to use instead for the development of new
services.
Emerging Schemes
•
•
•
•
•
•
Delayed transfers of care
People at risk of admission/readmissions
Reducing A&E/UC attendances
Support for those with LTCs
Elderly people who are frail
Multi agency teams; named care coordinator; wrap around ( levels of) care
including VCS
• IT systems which communicate and support joint assessment and planning
• Information governance which enables appropriate and proactive sharing of
data – ensuring safeguards are in place
• Integrated support to care homes with a linked GP; joint assessment and
reduction in admissions from care homes
An Opportunity……. and a Risk
• If the new services fail to reduce acute activity then the
CCG will not have the funds required to cover the cost of
the provision.
• Need to design credible, convincing alternatives to acute
admission
• Engagement and involvement of CDDFT/TEWVFT
essential
Views of commissioners
and local authorities
www.cddft.nhs.uk
Table discussion
What should unscheduled care look like
in two and five years’ time?
Where should we invest and where
should we disinvest?
What would this mean for service users
and families?
What would this mean for our
organisations and services?
www.cddft.nhs.uk
Feedback – table 3
People will only come to hospital when required. If they turn up at A&E in
many cases it should be seen as a system failure!
More integrated work – especially involving 3rd sector!!!
UCC and A&E will be combined! GPs will also be changing what they want to
do
24/7 services in place – including community matrons, and specialist nurses
More GP access – surgeries open 8am-8pm
Access for GPs to intermediate beds
More care planning
Ambulances will be seen as places of treatment
www.cddft.nhs.uk
Feedback: table 2
Voluntary sector will build more provision into community services
More emphasis on independence and self management
Disease specific support, often voluntary, will help support patients in the community
More focus on care planning
Ambulance staff deciding who they can see and treat, andwho needs to come to hospital
More co-ordination between GP practices – federated arrangements
Systems in place to support good navigation of the system
8am-8pm GP services – however, patients appreciate UCC, so change will not be popular,
and funding for 8-8 services will not be popular
We need to take the public and politicians with us
For many patients “access overrides safety”
www.cddft.nhs.uk
Feedback: table 4
There will be credible alternatives for unscheduled care – ambulances for
treatment
IT systems supporting good information sharing
Service users will have increased confidence if they see the right person
in right place
Effective care closer to home will require excellent case management
and more carer support – possibly by phone, by outreach team
Workforce development: how do we encourage people to take on new
roles in community and locality based models?
www.cddft.nhs.uk
Feedback: table 1
“Pathway across the garden”: patients take the shortest route to a service. Our response is often to put a wall up round the garden,
rather than build a path through it.
Some good news around elderly care physician recruitment to improve services in North Durham
We need to have developed effective alternatives to admission – there is a big gap between the GP and hospital
A lot of acute emergency pathway doesn’t need to happen in hospital
If someone comes to hospital, for many it should be for an assessment, rather than for admission
We need care planning across organisational boundaries
Culture and behaviours need to look very different in 5 years
People accept what is already there even if not very good! We need to take the public with us, and make clear what change means
in experience and outcomes.
Healthcare professionals need to work differently and in teams – there needs to be improved clinical accountability
Disinvest – changing culture and system is the way to drive this. There are some hard decisions we need to take together.
Don’t forget the planning for the things we need to do in the future
We need to engage with younger people differently – might telecare be a solution for young people -
www.cddft.nhs.uk
Table discussion
How can next winter be different?
What are the priorities for change?
Are there short term solutions which
may differ from long term objectives?
www.cddft.nhs.uk
Feedback: table 4
We need to commit to action: there may be difficult decisions to make, and staff
groups who may not want to change
We need to plan early for discharge
We need to move ahead with colocation of UCC and A&E – there are issues
around estate – so have we agreed what our priorities are across services
We need to redesign acute medicine (underway)
We are reviewing 450 over 7 day patients – although evidence so far suggests
most are not ready for discharge
We need more capacity for antibiotics in community
We need to address the patients awaiting care home assessment
Sue – “We have capacity for change if we stay together”
www.cddft.nhs.uk
Feedback: table 2
We need to provide information for patients and public about where to
access services such as pharmacy, flu clinics
We need more access to GP practices, but there is also high demand
there, so it is not a solution for everything
We need to look at opportunities for telehealth – could access to GP
advice be available without visiting the practice?
Ambulance service: we need to use paramedics differently this year
Discharge: we need to make sure we mobilise the right services
We need to learn lessons quickly! Eg from ISIS
www.cddft.nhs.uk
Feedback: table 1
This is about surge planning, not winter planning. Can we get the
capacity right across the health/social care economy?
How do we use the information that is available – could surge be
predicted?
We must show leadership and change what we do.
We must press on with action plans that are already in place.
We need to address issues that are holding us back, such as recruitment
and other HR issues
www.cddft.nhs.uk
Feedback: table 3
We need a public campaign about information available for patients
We need better working with mental health – esp dementia
We need to complete work on intermediate care
We need to build on our use of 3rd sector – there are small but valid
projects which could benefit at scale – keeping people well, keeping
them nourished
We need to stop talking, and take a leap of faith, accepting that some
benefits will be difficult to quantify beforehand.
www.cddft.nhs.uk
Next steps
Staff workshops and roadshows
Working with partners on Better Care Fund proposals
Submitting 2 year and 5 year plans
Developing a robust winter plan for 2014/15
Meeting required national and local standards (SeQuIHS)
www.cddft.nhs.uk
Staying engaged
Council of Governors and membership
Clinical programme board
Urgent care board
Health and well being board
Overview and Scrutiny
www.cddft.nhs.uk
Staying engaged
Your Trust magazine
Right First Time 24/7 newsletter
Email: rightfirsttime@cddft.nhs.uk
www.cddft.nhs.uk
www.cddft.nhs.uk